One bright, sunny day, you lose your balance and fall from a ten foot ladder. You land on the ground with a thud and hear a sickening crunch. You've fractured your legs. That's awful for you, but considered normal, after all you fell from such a great height, didn't you?

But when you slip over the loose edge of a rug inside your house and put your hand out to steady yourself and end up with a wrist fracture? That's not normal. While you may call it a freak accident, in reality it's a red flag for a condition called osteoporosis or porous bone.

Dr. Alan Froehling, orthopedic surgeon, at the Nueromuscular Orthopedic Institute in Mt. Vernon says he's been a real champion of getting the word out there and helping in the fight against osteoporosis.

"The tragedy is that most people aren't diagnosed with osteoporosis until they fracture something and are debilitated in some way. Sometimes they could be in spinal pain from collapsing vertebra. In most cases, the reason they are here to see me is that they have osteoporosis and they just don't know it as yet."

What is Osteoporosis?

Osteoporosis predisposes a person to having a fracture. A disorder of the skeleton, it results in decreased bone strength.

Dr. David Kelley, board certified internal medicine doctor, at Crossroads Community Hospital, in Mt. Vernon says there are two components to bone strength. "First there's quality - you know, good bone and bad bone. Second, there's mineralization and bone density, which is measurable at the hospital."

As you lose bone strength and bone mass, cross structures start breaking down. "What happens when you cut the legs off a stool?" asks Kelley. "The stool falls down of course! The same thing happens with osteoporosis."

"Osteoporosis can be a symptom or a sign of some other disease," says Dr. Raymond Estrella de la Rosa, an endocrinologist, at Lourdes Hospital, in Paducah, KY. "With osteoporosis, your bones are getting thinner than they should be and before we can start treating it, we need to find out what's causing it."

"It's extremely important to prevent that first fracture," says Kelley who sees about 30 patients a day; 80 percent of whom are 50 years of age or over - all possibly at risk for osteoporosis.

Dr. Suzanne Kaarsberg, family practitioner, at Heartland Regional Medical Center, in Marion, agrees, "Once someone fractures, their bones are frailer and their risk of future fractures goes up dramatically. If someone came in with a fracture from a simple trauma - for example, a compression fracture in the back - it sends alarm bells because it's just not normal in a healthy person."

Osteopenia

A precursor to osteoporosis, osteopenia is a medical condition of the bone, characterized by decreased calcification, decreased density and/or reduced bone mass.

"When you're diagnosed with osteopenia, you're halfway there," says De la Rosa. "You need to have a talk with your doctor and find out what can be done to prevent it from progressing to full scale osteoporosis."

Kelly cites the figures released by the National Osteoporosis Foundation, in 2002. "They found that 30 million people had abnormal bone densities. Out of this number, 22 million had osteopenia and eight million had osteoporosis. Because of all this, we have an average of 1.2 million fractures every year, which is a lot."

Who's at risk?

Osteoporosis is more common in women, since their bone density at its peak is less than men. "Most women in their 20's have the highest bone density they will ever have and then it all starts to decline from that age on," says Kaarsberg.

Several years later, women start going through menopause. "As they lose estrogen, their bones become frailer. While we do see it in men too, they don't lose testosterone as early as women lose their estrogen," she adds.

Once a woman fractures in the back, Kelley says she has an increase of five times the risk of fracturing within the year and twice the risk of hip fracture. One in five women over the age of 50, has had at least one back fracture. In fact, statistics indicate that 50 percent of the time a woman may have a fracture of the vertebra and might not even know it, says Kelley

"The sad fact is we all lose bone mass as we grow older," shares Froehling. "Some people lose a lot of bone mass. Women lose it after menopause and men start losing it in their 50's and 60's. Men do get osteoporosis, but the number is significantly less in comparison to women."

Research indicates that the figures are considerably lower for males, since men tend to have a larger bone mass than women. But experts point out that men have also been under diagnosed and under researched, since the bulk of the literature out there concerns women and osteoporosis.

"Ironically enough, the larger you are the lower your risk," says De la Rosa. "If you are female and weigh over 300 pounds, it's next to impossible to get osteoporosis. However, being large, while possibly eliminating you from osteoporosis comes with its own set of health complications."

Statistics imply that around 40 percent of women over 65 have osteoporosis. "By the time they reach 80 years of age, most women will have it, whereas only about 10-15 percent of men will develop osteoporosis at that age," says De la Rosa.

"Menopausal women form just a small part of it," admits De la Rosa. People who've had prostrate surgery, brain tumors, kidney stones and gastric bypass surgery can be at risk for osteoporosis. "For example, you could lose a hundred pounds with gastric bypass, but then you will have a hip replacement in six years!" says De la Rosa, cracking up at his own sense of humor.

Kaarsberg adds to the list, "Anyone who had eating disorders at a young age, has low activity levels, has rheumatoid arthritis or thyroid problems, is at risk for osteoporosis."

Some of the other factors include women over 45 who have suffered a fracture, hyperparathyroidism, excessive use of alcohol and tobacco and those with a family history of osteoporosis.

According to Froehling, who sees an astonishing two-three broken hips every week, osteoporotic people in their 50's start losing height and commonly develop fractures in the spine, when their bones crack and compress.

In their 70's and 80's, osteoporotic patients commonly have falls, when they slip over a loose rug and end up breaking their hip or wrist. "We take care of the fracture first and then test them for osteoporosis," says Froehling.

Prevention

Vicki Seeburger and Amanda McKee are family nurse practitioners who run the Osteoporosis Clinic at the Orthopaedic Center of Southern Illinois, in Mt. Vernon and Centralia. They bring patients in, review all risk factors and individualize each case, before going ahead with the bone density scan, which is also known as the DEXA scan. Open on Tuesdays and Fridays, the clinic sees an average of 37 patients on both days put together.

"Prevention is really the key," stresses Seerburger. "Weight-bearing exercises coupled with lifestyle changes, which include intake of calcium and vitamin D supplementation will go a long way in the fight against osteoporosis."

"Just follow the kind of advice your mom would give you," chuckles Froehling. "When you don't use your bones, they get weaker. Hence exercise is important."

Keeping your body weight close to ideal really helps in the long run, says Froehling. In fact post-menopausal women are now discovering that they can reduce their risk for future fractures, by taking preventative measures early on.

Bone density screening

The general rule of thumb is the denser the bones, the stronger they are. Hence bone mass or density can predict the likelihood or risk of fracture

According to De la Rosa, "You have the heel ultrasound available in drugstores, where you just stick your foot in and it tells you your bone density. If you have a low score, then its time to get a real test. The heel ultrasound is really not very good for picking up minor disease."

Froehling tends to agree, "The heel scan is not very reliable, as the heel is not normally the bone to break; it's more like the hip or the spine."

When it comes to bone density screening, all doctors seem to agree that the most exact way to measure bone density and find out if you are at risk for a fracture is by a DEXA (also known as DXA) scan. DEXA stands for dual-energy x-ray absorptiometry and is considered the gold standard when it comes to bone density screenings.

If you already have a fracture and the doctor suspects osteoporosis, the DEXA scan can confirm the diagnosis. It's the test against which all other tests are measured, but it can be expensive.

"The DEXA machine we have now allows us to do vertebral assessments, in addition to bone density screenings, for you can't always see micro-fractures on film," says McKee. Known as VFA (Vertebral Fracture Assessment) or IVA (Instant Vertebral Assessment) this exciting new technology helps physicians evaluate the likelihood of a vertebral fracture in the thoracic and lumbar areas in addition to getting the regular scores from the DEXA scan.

However De la Rosa stresses that the DEXA scan is not enough. "You need a qualified person, trained in bone densitometry, possibly certified by The International Society for Clinical Densitometry (ISCD) who can read and interpret them reliably."

Dr. Jackie Treschuk-Bahn, chief radiologist at Crossroads Community Hospital, Mt Vernon says she often sees vertebral, forearm and hip fractures that are routinely associated with osteoporosis.

"People may have different rates of loss in bone density in different places," she says. "Fractures of the spine and the hip can be extremely debilitating, since people move into a downward spiral where they lose their mobility and then become bedridden. I can't stress enough about the importance of screening. It really is vital."

When to get scanned?

Froehling advises women in their 40's-50's and men aged 50-55 to get a DEXA scan done, so that they can find out where they're at.

Kelley recommends a bone density screening for women going through menopause, and younger women who suffer from rheumatoid arthritis or have had a hysterectomy or are on steroids - since they are all at risk for osteoporosis.

Everyone agrees that for peace of mind, you really want to get your bone density scan done, especially if you are over 60 years of age or are at risk for developing osteoporosis.

Drugs for osteoporosis

According to Kelley, drugs for osteoporosis can be divided into three segments. "There is a group of medications to prevent bone loss; another builds bone and a third group mixes the two."

"How long you continue taking these drugs is a matter of controversy," says Froehling. "People need to remember that they still need calcium and exercise in addition to pills."

Biphosphonates

"Biphosphonates are the primary course of treatment that is most widely used for people with osteoporosis," says Tim Jennings, densitometrist certified by ISCD, physician's assistant and physical therapist, who runs the Osteoporosis Clinic at Southern Illinois Orthopedic Center in Herrin. Open to the public on Wednesdays, the osteoporosis clinic develops a comprehensive treatment plan that includes a weight bearing exercise program, diet and nutritional counseling, medication and follow-ups for people with osteoporosis, once they have been completely evaluated and scanned with the DEXA machine.

"Bisphosphonates like Fosamax and Actonel, bind permanently to the surfaces of the bones and slow down the osteoclasts (bone-eroding cells)," says Kelley. "This allows the osteoblasts (bone-building cells) to work more effectively." Taken once a month to stop bone loss, biphosphonates coat the bone; they don't grow bone.

According to McKee, relatively new drugs for osteoporosis include Boniva - an oral bisphosphonate and IV medication. "With Boniva, the patient takes a 3mg injection on an outpatient IV status, once every three months," she says.

Selective Estrogen Receptor Modulators (SERMs)

Another method of treatment, reserved for women with osteoporosis, involves a serum based estrogen receptor modulator called Evista (Raloxifene) that Kelley calls, "simply fascinating." He says it decreases the activity of the osteoclasts and is not quite as strong as biphosphonates.

"It does not affect the uterus, but works on the breast receptor," says Kelley. "It's associated with a deceased risk of breast cancer. But the downside is it increases the risk of blood clots just like estrogen does."

Forteo

A relatively new drug in the market is Forteo, which seems to be receiving mixed reviews from doctors. "Forteo, actually builds bone," says De la Rosa. "Let's say you're a woman aged 40-55 years old, you will suffer an approximate 30 percent bone loss within the first two years of menopause. While Fosamax could slow it down by 10-12 percent, Forteo doubles whatever you'd have gained."

Kelley tends to agree, "With Forteo, I see an amazing increase in bone density with a significant decrease in fractures. I'm very impressed with the results I see in my patients." However he acknowledges that Forteo is not meant for everyone, especially not someone who is classified as having an increased risk of bone cancer.

A self injection that needs to be taken everyday, for two years, Forteo tends to be very expensive and therefore out of reach for most patients, Seerburger notes.

Jennings concurs, "I have a limited number of patients on Forteo and I must say the results haven't been as stellar. Of course this could be due to patient compliance issues since it's a daily injection. But then there are those who are fearful of the needle or those who find it too costly."

"Forteo is really for those who've done poorly on biphosphonates and it does have its own set of side effects - like upsetting the GI tract," says Jennings.

Hormone Replacement Therapy (HRT)

An effective treatment option - in use for over 60 years - for women with menopausal symptoms, hormone replacement therapy is also being used in women to prevent osteoporosis. The medication is made up of one or more female hormones; commonly estrogen and progestin, and as an added benefit even helps reduce the risk of heart disease.

However hormone replacement therapy became controversial because of the Women's Health Initiative (WHI) that came out in 2002 that followed a total of 161,808 women, aged 50 to 79 who were either on a combination of progestins and equine estrogens or a placebo. The study found that the measured risks of this combination outweighed its measured benefits.

"It essentially said that it puts women at risk for breast cancer, Alzheimer's disease and stroke," says Kelley. "But it was the combination of estrogen and progesterone that seemed to be the culprit - as they had bad outcomes."

Experts agree that the WHI results were almost universally misreported as risks and problems associated with HRT in general, rather than with the specific proprietary combination of progestins and equine estrogens that were actually studied.

As a result of all the controversy, Kelley admits that a lot of doctor's started shying away and began to look at alternatives. "But it must be noted that if a woman has no uterus, she can be treated with estrogen alone," he says. "Estrogen helps balance bone density and bone breakdown. Something is not in sync when a person is estrogen deficient."

According to McKee, most OB/GYNs try to leave an ovary inside women who are having hysterectomies, so that they have some estrogen replacement occurring naturally.

"It's a double edged sword," says Froehling. There's a protective effect of estrogen on the bone. For example, women who take Premarin, which is conjugated estrogen look younger and see a lot of beneficial effects on the system. But if they have a family history of breast cancer and suffer from any other problems, then you determine if the risk is acceptable.

Other treatments

Other treatment options for osteoporosis include calcitonin - a synthetic compound taken as an injection or a nasal spray, and synthetic parathyroid hormone, which is taken as an injection. Several medications are currently under investigation for the treatment of osteoporosis and these include new forms of bisphosphonates, additional SERMs, Strontium Ranelate, Osteoprotogerin, and many other small proteins that appear to stimulate bone.

To reduce the risk of osteoporosis without hormones, dietary changes that increase calcium uptake, phosphorous and vitamin D, in a healthy diet, exercise, and drugs such as biphosphates, SERMs or calcitonin have been tried by various doctors.

The impact

"The incidence of osteoporotic fractures in women is far greater than the incidence of heart attacks, strokes, and breast cancer combined," reveals Seerburger. "Osteoporosis costs Americans 18 billion every year and the real need of the hour is to educate people on how they can prevent it and fight it."

People can often underestimate the terrible impact of hip fractures and broken bones. "It's not just a broken bone; it's more serious than that," says Froehling. "Your risk of dying of a hip fracture is very similar to that of breast cancer. A hip fracture reduces your mobility, puts you at risk for pulmonary embolisms and studies have shown that a large number of people just never walk again or function at the level they used to before the incident."

"There are things we can't control like genetics, but what we can control is diet and lifestyle, in addition to taking the right medication," says Froehling.

Jennings agrees wholeheartedly, "With treatment, we definitely see an improvement in bone density over time. Even if we formally stop treating patients with medication, preventative measures still need to be taken over a lifetime to maintain what they gained."

Sidebar 1:

Calcium and Vitamin D supplements

Widely available without a prescription, adequate calcium and vitamin D are absolutely essential for reducing bone loss.

Dr. Suzanne Kaarsberg, family practitioner, at Heartland Regional Medical Center, in Marion says calcium carbonate is one of the more common over the counter calcium supplements available today.

"But it can have side effects. So some people choose coral calcium. Mostly it comes down to cost," says Kaarsberg. "What can they afford? Some who have side effects from one supplement may be fine with another and vice versa."

Stephanie Wood, registered dietician, at Southern Illinois Orthopedic Center in Herrin says the body needs calcium everyday as a nutrient. "If you don't have enough, the body will take it from where it can find it - which is how the bone starts eroding." That's why the simple act of taking calcium is important as it helps stop active bone break down.

Wood says there are two major kinds of calcium. "Calcium carbonate needs to be taken with food, while calcium citrate can be taken anytime in the day. However the latter does not have as much elemental calcium per pill, so you might end up taking more pills per day, which in turn could be more costly."

"A lot of people use antacids as a source of calcium," says Wood. "I would recommend that you don't do that, since the purpose of antacids is to suppress the acid in the stomach. So the calcium may not be absorbed to the degree you think it is."

Wood says the body absorbs around 500 mg of calcium at a time. "So if you take two calcium pills a day, space them apart - one in the morning and one in the evening - for maximum absorption." She recommends that people take calcium C supplements with vitamin D.

Experts recommend that if you drink a lot of milk everyday, then your calcium and vitamin D supplements can be adjusted accordingly to take that into account.

Sidebar 2

Am I at risk?

Dr. David Kelley, board certified internal medicine doctor, at Crossroads Community Hospital, in Mt. Vernon says you might be at risk if you fit any of the following criteria:

* Post menopausal

* Advanced age

* Low bone mass

* Family history of osteoporosis

* Estrogen deficient

* Early menopause / hysterectomy

* Low calcium in diet

* Of Caucasian or Asian descent

* Slender body build

* Smoke cigarettes

* Use alcohol excessively

* Lack exercise