Osteoporosis is not just a problem for old women

Most men do not spend much time thinking about their bones.

We think about muscles, waistlines, blood pressure, cholesterol, testosterone and whether we can still lift what we used to lift.

Bones are simply assumed to be there, quietly holding the whole operation together.

Until one of them breaks.

Then they suddenly become extremely interesting.

As an orthopaedic surgeon, I have treated many fractures associated with osteoporosis, such as fractures of the hip, wrist and vertebrae in the spine.

It is not only hip fractures that can change the life of an older person. A wrist fracture may determine whether somebody can continue dressing, cooking and managing alone at home. Spinal fractures can cause persistent pain, loss of height and reduced mobility. A fracture does not have to threaten life directly to take away a substantial part of someone’s independence.

One of my older medical teachers used to suggest that, in some cases, the hip might break first and the fall follow—not necessarily the other way around.

That is difficult to prove, and it certainly does not explain every hip fracture. But the comment stayed with me. It was a reminder that weakened bone may be part of the reason for the fall rather than merely an innocent victim of the floor.

Most men still think of osteoporosis as a disease affecting very old women.

Women are affected more frequently, particularly after menopause. But osteoporosis is not exclusively a female problem, and it does not suddenly begin when somebody becomes old.

Roughly one in five men over fifty will suffer an osteoporosis-related fracture during his remaining lifetime.

Those are not particularly comforting odds.

Bone Is Very Much Alive

It is easy to imagine the skeleton as a dry internal coat rack: a rigid frame from which the rest of us hangs.

That is completely wrong.

Bone is living tissue. It has a blood supply and nerves and is constantly being repaired and renewed. It changes in response to hormones, nutrition, illness, medication, physical activity and the forces placed upon it.

Bone also acts as a storehouse for minerals, particularly calcium and phosphate. The body needs these minerals for many purposes, including normal muscle and nerve function.

If it needs them elsewhere, it may take them from the bones.

The body does not ask whether we were saving them for retirement.

Inside bone, one group of cells removes old or damaged tissue while another builds new bone. There is a demolition team and a construction team, both permanently at work.

For much of our lives, they maintain a reasonable balance.

As we grow older—or become inactive, ill or affected by hormonal changes—the demolition team may gradually begin to work faster than the builders.

Nothing may be felt while this is happening.

The building still looks fine from the street.

It Begins Earlier Than We Think

We generally reach our greatest bone mass during early adulthood. After that, the balance slowly begins to change.

Some types of bone loss may start surprisingly early in both men and women, long before anyone would describe them as old.

Women often experience faster loss around menopause. Men usually lose bone more gradually, which may help explain why we pay less attention to it.

But gradual does not mean harmless.

Smoking, excessive alcohol, poor nutrition, prolonged inactivity and low testosterone can all contribute. So can several chronic illnesses and some medications.

Corticosteroids are an important example.

These are not the anabolic steroids associated with bodybuilding. They are powerful anti-inflammatory medicines, such as prednisolone, used to treat many different conditions.

They can also weaken bone.

I learned this personally.

For approximately one year, I needed maintenance treatment with corticosteroids. I did not feel anything happening to my bones. There was no warning light on my forehead and no sensation of calcium quietly leaving the building.

A bone-density scan later showed mild bone loss.

Fortunately, it was detected at an early stage. But the experience made osteoporosis considerably less theoretical for me.

That is one of the problems with bone loss: it is usually silent.

The first message from the skeleton may arrive in the form of a fracture.

Bones are not always skilled at sending polite reminders.

What Does a Bone-Density Scan Actually Tell Us?

A DXA scan measures the amount of mineral in certain bones, usually the hips and lower spine.

The scan is quick and painless. You lie on a table while the machine does the measuring. There are no tunnels, dramatic noises or demands that you demonstrate courage.

The result gives useful information about bone density.

But density is not exactly the same as quality.

The strength of a bone also depends on its internal architecture, the condition of its collagen, microscopic damage, the rate at which it is being renewed and how forces travel through it.

A building is not safe merely because it contains a certain number of bricks.

Their arrangement and condition matter as well.

As an orthopaedic surgeon, one occasionally gets a very direct impression of bone quality. When drilling into bone or inserting a screw, some bone feels strong and dependable. Other bone feels very different.

That is not a scientific measurement, but it reminds us that one number cannot describe everything.

The DXA scan is useful.

It is not the entire story.

A previous fracture, long-term corticosteroid treatment, family history, smoking, alcohol, low testosterone, loss of height and repeated falls may all add important information.

Doctors should therefore look at the man, not just his scan.

Medicines Are Only Part of the Picture

Medicines used for osteoporosis can reduce the risk of fractures. Some slow the breakdown of bone, while others encourage the formation of new bone.

They can be important and, for people at substantial fracture risk, may be necessary.

But every effective medication can also have side effects.

Another major problem is that many people do not remain on treatment.

That is understandable. Osteoporosis usually does not hurt before a fracture. A man takes medicine but does not wake the next morning feeling that his skeleton has become twenty per cent stronger.

If the treatment causes inconvenience or side effects, it is easy to stop.

Success is also strangely invisible. If the medicine works and no fracture occurs, it may look as though nothing happened.

Treatment therefore needs explanation, follow-up and individual assessment. It should not consist merely of handing somebody a prescription and hoping that both the patient and his bones remain cooperative.

Medication may be part of the answer.

It is rarely the whole answer.

Muscle and Bone Belong Together

Bones respond to the way we use them.

When muscles contract, they pull on bones. When we stand, walk, lift, climb, jump or change direction, forces travel through the skeleton. Repeated loading stimulates bones to maintain and strengthen the areas being used.

If we stop placing reasonable demands on the body, it adapts to that as well.

Unfortunately, it does not maintain large amounts of muscle and strong bone purely because they might be useful one day.

Walking is valuable, but it may not be enough on its own. Strength training places different demands on the skeleton and also helps preserve muscle.

Balance and coordination matter just as much.

There is little advantage in improving bone density while becoming steadily more likely to fall over.

This is particularly important for men as they grow older. Muscle loss can begin much earlier than most people realise and may accelerate later in life.

Weak muscles, poor balance and weaker bones make an unpleasant team.

Exercise must, of course, be adapted to the individual. A man with advanced osteoporosis should not read this article and immediately begin jumping off boxes with a barbell across his shoulders.

The purpose is to challenge the body intelligently, not to arrange an early demonstration of the problem we are trying to prevent.

Adequate protein is important for muscles and bones. Calcium and vitamin D matter, particularly if intake or vitamin levels are low.

But supplements cannot do the work of muscles.

A cupboard full of tablets is not strength training.

Smoking should stop, alcohol should remain within reasonable limits and hormonal problems such as low testosterone should be considered when appropriate.

Bone health is not created by one pill, one food or one exercise.

It is the result of what we repeatedly do.

Dalibor Krpan and the Skeleton as One Organ

One man who has strongly influenced my thinking about osteoporosis is the Croatian physician and researcher Professor Dalibor Krpan.

Krpan is an internist, endocrinologist and nephrologist who has devoted much of his professional life to metabolic bone disease.

His experience is not based only on bone-density measurements or numbers appearing on a computer screen.

Over the years, he has taken, prepared and examined thousands of bone biopsies.

A bone biopsy makes it possible to study the actual structure and activity of bone under a microscope. It can reveal features of bone formation, breakdown and mineralisation that cannot be seen on an ordinary bone-density scan.

When you have personally examined thousands of samples of living bone, it is understandable that you may become reluctant to define an entire disease by one number.

This experience helped lead Krpan to an idea that is central to his work: the skeleton should be regarded as one large and complex organ, not merely as a collection of separate bones, joints and body parts.

The bones, joints, cartilage, muscles, tendons, ligaments and fascia influence one another.

A problem in the knee does not necessarily remain politely confined to the knee. It may change the way we walk, alter the forces travelling through the hips and spine and gradually affect other parts of the skeleton.

Weak muscles, poor balance and changed movement can also alter the forces placed on bones.

Krpan incorporated this way of thinking into what he calls the BaR concept:

• B — Biomechanics

• a — Analgesia

• R — Regeneration

The idea is that chronic problems of the skeleton should not be treated by looking only at one painful joint, one weak bone or one number on a scan.

The way the whole body moves matters. Pain matters. Muscle strength matters. Balance matters. The ability of tissues to repair and renew themselves matters.

The BaR concept is not one treatment or one machine. It is an attempt to look at the musculoskeletal system as a connected biological whole.

That broader view makes sense to me.

Doctors divide the body into specialties. Orthopaedic surgeons look after certain structures, endocrinologists deal with hormones and metabolism, and physiotherapists concentrate on movement and rehabilitation.

The body itself has never shown much respect for the borders between our departments.

From Taekwondo to Tae Do

Krpan also brings an unusual background to this work.

He holds a seventh-degree black belt—7th Dan—in Taekwondo. For readers unfamiliar with martial arts grading, that is a very senior master rank representing decades of training and experience.

He served as president of the Croatian Taekwondo Federation for many years and has also been active within the international Taekwondo movement.

This is relevant because the Tae Do exercise system he developed was not simply a doctor borrowing a few impressive-looking kicks from martial arts.

It grew out of both his medical knowledge of bone and his lifelong practical knowledge of Taekwondo.

Tae Do uses controlled movements partly derived from Taekwondo. They are intended to produce carefully directed muscle contractions, involve much of the body and improve balance, coordination and movement control.

The purpose is not to prepare somebody with osteoporosis for a fight in the car park.

The movements can be adjusted to a person’s health and physical ability. The important elements are control, repeated muscle contractions and the interaction between the nervous system, muscles and bones.

Krpan’s basic point is simple: exercise for osteoporosis should do more than burn calories. It should send useful mechanical signals through the skeleton while remaining safe enough for people to continue doing it.

Even the finest exercise programme ever designed is useless if nobody wants—or is able—to perform it.

MBST: Interesting, but Not the Answer to Everything

Another part of Krpan’s work has involved MBST, a treatment based on magnetic resonance.

MBST is based on the same general physical principles as MRI, but it does not produce images. It uses much weaker magnetic fields and radiofrequency signals in repeated treatment sessions, with the aim of influencing biological activity in tissues such as bone and cartilage.

The treatment is painless and has no known clinically significant side effects or interactions. There are also relatively few contraindications, although every patient should still be assessed before treatment.

Krpan’s research and clinical experience have led him to believe that MBST may have beneficial effects on bone formation and bone quality. His work has produced encouraging observations and results that deserve further investigation.

That does not yet prove that MBST prevents fractures or that it should replace established treatment.

The most important question is not only whether a number on a scan changes. It is whether people actually break fewer bones and remain healthier and more active.

That requires larger and carefully controlled research.

There is nothing wrong with being open to a promising idea. Many advances in medicine began because somebody was prepared to question the accepted approach.

But curiosity should travel with caution.

We do not need to reject every new treatment.

Nor do we need to turn it into a new religion.

The skeleton is complicated enough without asking one machine, pill or exercise system to become its alpha and omega.

What Can a Man Do for Himself?

A man over fifty does not need to become an expert in bone biology.

But he should give the subject some thought—particularly if he has suffered a fracture after a relatively minor injury, used corticosteroids for a long time, lost height, developed unexplained back pain or has several other risk factors.

He can begin with the things he can influence:

• Use his muscles regularly.

• Include sensible strength training.

• Work on balance and coordination.

• Eat enough protein.

• Make sure calcium and vitamin D intake are adequate.

• Stop smoking.

• Avoid excessive alcohol.

• Discuss important risk factors, hormonal problems or previous fractures with a doctor.

• Have bone density assessed when there is a reasonable indication.

If treatment is recommended, he should understand why and what it is intended to achieve.

Most importantly, he should not wait for a fracture before remembering that he has a skeleton.

Bones Keep Their Own Records

For most of our lives, bones tolerate what we do to them without complaint.

They adapt to work and exercise.

They also adapt to inactivity.

They respond to hormones, illness, nutrition, medication and ageing. They record years of loading—or the absence of it—without sending us monthly reports.

Then one day, sometimes during an ordinary fall, they may reveal the result.

Osteoporosis is not just a problem for old women.

It can affect men, begin developing long before old age and remain invisible until something breaks.

Bone density matters, but so do bone quality, muscles, balance, movement and the function of the skeleton as a whole.

Medication may be necessary, and MBST may prove to be a valuable non-pharmacological addition to treatment. Neither medication nor a machine, however, can lift the weights, improve our balance, stop smoking or choose what we eat.

That part remains ours.

Men often take pride in being difficult to break.

That is fine.

But it might be wise to make sure the bones agree.