Osteoporosis

Image ID 25447568 © Rob3000 | Dreamstime.com

Complaints with osteoporosis

Osteoporosis is a silent disease, because there are no visible symptoms. Sometimes you might notice a loss of height by noticing your clothes are not fitting right. Other times it may come to your attention only after you break a bone. When you have this condition, a fracture can occur even after a minor injury, such as a fall.
The most common fractures occur at the spine, wrist and hip. Spine and hip fractures, in particular, may lead to chronic (long-term) pain and disability and even death.
The main goal of treating osteoporosis is to prevent such fractures in the first place. Osteoporosis gradually develops without symptoms. If the doctor diagnoses osteoporosis in time, osteoporosis can be treated at an early stage. This can improve the bone density.

Bone fractures due to osteoporosis usually only occur at a higher age. For example, a vertebra can break and/or collapse, making you curved or smaller. As the vertebrae collapses, the spine becomes shorter. You can thereby be 5 to 15 cm smaller. You can check for yourself if this is the case: compare your current length with the length you used to have. You get wider flanks through the collapsing vertebrae. Sometimes your lower rib is touching the edge of your pelvis (the pelvic crest). You can also get an exaggerated, forward rounding of the back, such a posture is called a kyphosis.

Which three stages do we see in osteoporosis complaints in the spine?
● stage 1: normal vertebra: the bone mineral density is not more than 1 standard deviation (SD) lower than the average density in a young adult female (‘peak bone density’ or ‘peak bone mass’).
● stage 2: osteoporotic vertebra: this stage consists of 2 steps:
step 1: osteopenia (the preliminary stage): the bone mineral density is reduced, but there is still no question of osteoporosis. The bone mineral density is between 1 and 2.5 below the average density in a young adult female.
step 2: osteoporosis: bone mineral density is more than 2.5 below the average of a young adult female.
● stage 3: osteoporotic fracture: severe osteoporosis is associated with osteoporotic fractures.

Image ID 29338770 © Rob3000 | Dreamstime.com

Risk factors for bone fractures

Osteoporosis is a condition in which collapses of the vertebrae can be accompanied by chronic back complaints. Precisely because there are usually no or only a-specific complaints, vertebral fractures often do not come to the attention of the doctor. In some people, a curvature and the shortening of the spine is the only sign of vertebral fractures.

When the vertebra is collapsed, we speak of a vertebral fracture, a compression fracture in the vertebrae or vertebral deformation.

The most common osteoporotic fractures are fractures of vertebra, wrist and hip. Of course, wrist and hip fractures are not always the result of osteoporosis and occur mainly as a result of a fall or other accident.
If you are over age 50 and have broken a vertebra or another bone less than two years ago, the chance of a subsequent fracture is greater than with someone who has never had a broken bone.

Recognizing major osteoporosis risk factors, that you may influence:
• cigarette smoking.
• drinking a lot of alcohol (over two glasses a day).
• having a low body weight: less than 60 kg or BMI lower than 20.
• having the eating disorders anorexia nervosa and bulimia.
• having a sedentary (inactive) lifestyle or immobility due to illness.
• not being enough outside during the day (lack of sunlight).
• having low calcium and vitamin D from low intake in your diet starting during your teens and in your 20’s or inadequate absorption in your gut. A vitamin D deficiency is a risk for getting osteoporosis, as vitamin D is necessary for the absorption of calcium from food. Vitamin D is included in margarine, butter, milk, eggs and fatty fish and your body also makes vitamin D when you are outside. If you do not spend much outdoors or in the sun or if you have dark skin, you may need extra vitamin D.
• if you fall easily (for example, if you fell twice in the past year, if you have joint complaints, see less well, are confused, dizzy, drowsy or sleepy due to medication).
• having a bowel disorder such as chronic malnutrition, malabsorption, celiac disease.
• having poorly functioning kidneys.
• having liver cirrhosis.
• having low levels of sex hormone, mainly estrogen in women (menopause). This hormone estrogen is important for building new bone tissue. After the transition, bone decalcification and bone breakdown are therefore going faster. The levels of estrogen can be raised.
• having osteopenia.
• use of glucocorticoid drugs (corticosteroids), such as prednisone (Deltasone, Orasone and so on) or prednisolone (Prelone). For example if you use more than 7.5 mg of prednisone per day for more than 3 months.
• if you use excess thyroid hormone replacement when taking drugs for low thyroid or hypothyroidism.
• use of heparin, a commonly-used blood thinner.
• if you use certain medications such as antidepressants, anti-epileptics and anti-hormonal therapy in breast and prostate cancer.

Recognizing osteoporosis risk factors, that you cannot influence:
• having a small bone structure.
• if you have a father or mother who has broken a hip before.
• if many people in your family have osteoporosis.
• being of an advancing age above 60 or in the menopause.
• having had a prior fracture due to a low-level injury, particularly after age 50
• having an early transition. If you have had the ovaries removed and are in the early transition. If you have never been pregnant, you also have a higher risk of developing osteoporosis.
• having had an organ transplant.
Having a disease, that can affect bones:
• having Diabetes mellitus type 1.
• having a bowel disorder such as Crohn’s disease and ulcerative colitis.
• having COPD (lungs).
• having Cushing’s syndrome. (endocrine (hormone) disease)
• having thyroid (hyperthyroidism, hyperparathyroidism) disorders (endocrine (hormone) diseases).
• having a metabolic disease that disrupts the production of bone.
• having osteogenesis imperfecta, a bone disease.
• having spondyloarthritis/ankylosing spondylitis (inflammatory arthritis).
• having systemic lupus erythematosus (SLE) (inflammatory arthritis).
• having psoriatic arthritis (inflammatory arthritis).
• having rheumatoid arthritis (inflammatory arthritis).

Chronic joint inflammations affect bone quality. With rheumatoid arthritis you have twice as much chance of osteoporosis as a healthy person. Although less well studied, the same probably also applies to people with spondyloarthritis, psoriatic arthritis and systemic lupus erythematosus (SLE).

Diagnosis osteoporosis

Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

Anamneses
At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your working conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?

If you have complaints, the doctor will have several examinations done. This is necessary to confirm the diagnosis.

Diagnosis of osteoporosis
The diagnosis of osteoporosis is based on measuring the bone mineral density. The bone mineral density is determined by examining the amount of minerals in the bone (especially calcium) that absorb X-rays. The bone mineral density is then calculated as the bone mass, divided by the area of the irradiated bone. You have osteoporosis if the ‘bone density’ is much less than one might expect from someone of your age.
• A test that measures your bone mineral density is BMD. The Bone Mass Measurement (BMD) is measured at different parts of your body. Often the measurements are taken at your spine and your hip, including a part of the hip called the femoral neck, which is situated at the top of the thighbone (femur). The bone mineral density is determined by examining the amount of minerals in the bone (especially calcium), that absorb X-rays. The bone mineral density is then calculated as the bone mass is divided by the area of the irradiated bone. You have osteoporosis if the ‘bone density’ is much less than you would expect from someone of your age. The test can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is called a central dual-energy x-ray absorptiometry or DXA test.
• Dual energy X-ray absorptiometry (DXA/DEXA) is the best current test to measure the BMD. A DEXA bone density measurement can be made of your hip, spine and lower back. It is measured with the aid of X-rays how much calcium your bones contain (bone density). The DEXA is similar to an X-ray, but uses much less radiation. The DEXA test results are scored compared with the BMD of young, healthy people. This results in a measure called a T-score. The scoring is as follows:
DXA T-score Bone mineral density (BMD): Normal – Not lower than –1.0.  Osteopenia (mild BMD loss) – Between –1.0 and –2.5. Osteoporosis – 2.5 or lower. If your T-score is below 2.5 (osteoporosis) then you will most likely need treatment.
• If your T score is between -1.0 and -2.5 (Osteopenia) a FRAX score (Fracture Risk Assessment Tool) is used to see if you need treatment. Because of the bone-weakening effects of the menopause, 1 out of 2 women over the age of 50 will have a fracture related to osteoporosis. Men are also more likely to fracture a bone as they age. To help determine your risk for such an injury, the Fracture Risk Assessment Tool (FRAX) was developed. In case of osteopenia and absence of one or more vertebral dissections or lack of vertebral fracture assessment (VFA) or imaging of the spinal column, the FRAX score may be calculated. Your FRAX score is your risk of having an osteoporosis-related fracture in the next 10 years.
• A DEXA measurement can be supplemented with a Vertebral Fracture Assessment(VFA). This is a vertebral height measurement, in which the height of the individual vertebrae is determined and which maps the risk of a bone fracture. The doctor compares the outcome of the measurement of your current height with your height at a younger age, for example with the length on your passport. This way he determines whether you have become smaller. If you also have an exaggerated, forward rounding of the back or bent posture, this indicates that you have collapsed vertebrae.
• An X-ray of your back can be made to show the position of your vertebrae. The magnetic resonance makes it easier to see the fracture, whether there is an edema, whether the fracture is recent and what causes the pain.

Importance of a risk assessment
Falling can quickly lead to a fracture, so your doctor will ask you if and how many times you have fallen in the past year. The doctor will also perform physical examination to find out how your muscle strength is and whether you can stay well balanced. If necessary, you can receive physiotherapy or a referral for a fall prevention course.

Secondary osteoporosis in certain disorders
The doctor will have your blood, calcium (urine) and phosphate levels, kidney function, liver enzymes, hormones, presence of bone breakdown products (released when there is increased bone loss), vitamin D levels in the blood and traces of diseases that promote or worsen osteoporosis examined. It is important, if you have another disease, to know if there is a risk of osteoporosis, as this is an important predictor for bone fractures.

Treatment of osteoporosis

The treatment of osteoporosis is aimed at pain control, prevent further bone loss and prevent bone fractures. If you have osteoporosis, your doctor will advise to take vitamin D (necessary to help your body absorb calcium from foods you eat or calcium pills you take) and calcium and to exercise every day.
• Vitamin D. Get adequate amounts of vitamin D in your daily diet, which is important to help your body absorb calcium from foods you eat. If you are regularly in the sun, you’re body produces enough vitamin D itself. If that is not so, you might take vitamin D as a supplement. The recommended daily dose is 400 to 800 International Units (IU) for adults younger than age 50 and 800 to 1.000 IU for those age 50 and older. Your doctor can measure your vitamin D level with a blood test. If necessary, you may need a different dose depending on your blood level of vitamin D. The doctor will prescribe this.
• Calcium. Make sure you are getting enough calcium in your diet or you might need to consider taking supplements. The recommendation is 1.000 milligrams (shortened as mg) per day for most adults and 1.200 mg per day for women over age 50 and for men over age 70.
• Physical activity. Be sure to exercise every day, especially weight-bearing exercise, such as walking.

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side effects and can be easily combined with other medications.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
• Bisphosphonates. In case of osteoporosis or High FRAX scores, treatment with bisphosphonates will be necessary. This class of drugs (often called “anti-resorptive” drugs) helps slow bone loss, and studies show they can decrease the risk of fractures. Bisphosphonates are drugs that attach to bone tissue and thereby inhibit bone breakdown and make the bone stronger. These drugs inhibit the breakdown of bone tissue by binding to the bone-breaking cells, the osteoclasts. The drug ensures that calcium is absorbed better in the bone. The bone breakdown and bone production then come into balance again. When bisphosphonates are used, bone density may even increase slightly. Research has shown that the chance of a bone fracture halves if you use bisphosphonates. This applies especially to your spine, but also to your hips and to other bones, such as your wrist.
The best known bisphosphonates used in osteoporosis are alendronate and risedronate, which ensure that bone destruction is less rapid, but there are more bisphosphonates approved by the FDA. Alendronate, risedronate and ibandronate are pills that you must take on an empty stomach with water only or else your body will not properly absorb the drug. These drugs sometimes can irritate the esophagus (the tube that goes from the throat to the stomach). Therefore, you should remain upright for at least an hour after taking these drugs. Bisphosphonate drugs, approved by the FDA, for osteoporosis (OP) include:
– alendronate (Fosamax) – prevention and treatment of postmenopausal OP in women – treatment of OP in men – treatment of OP due to use of glucocorticoid medicines in women and men – dose: once daily or once weekly pills.
– risedronate (Actonel) – prevention and treatment of postmenopausal OP in women – treatment of OP in men – prevention and treatment of OP due to use of glucocorticoid medicines in women and men – dose: once daily, once weekly or once monthly pills.
– ibandronate (Boniva) – prevention and treatment of postmenopausal OP in women – once monthly pills or every three months by intravenous infusion (IV) given through a vein.
– zoledronic acid (Reclast) – same use as for risedronate – once a year by IV.

There have been reports of rare side-effects that may be linked to use of bisphosphonates. These include osteonecrosis of the jaw (jaw osteonecrosis or ONJ) and atypical femoral fractures.
– Osteonecrosis of the jaw. There have been reports of permanent damage of the bones of the jaw (ONJ) resulting after use of bisphosphonates, mostly in people who recently had a dental procedure or had dental disease. Most cases were in people who received high-dose IV bisphosphonates for cancer treatment. The risk of this problem in people taking these drugs at doses recommended for osteoporosis management seems to be very low. Still, doctors recommend that anyone taking a bisphosphonate have good oral hygiene and regular dental care. So report the dental treatment to your doctor and tell your dentist that you are taking a bisphosphonate.
– Atypical femoral fractures. Uncommon types of thighbone fractures have occurred in a small percentage of people using bisphosphonates long term for their osteoporosis. Again, this risk appears to be very low, especially compared with the number of fractures that bisphosphonates prevent.

• Denosumab (Prolia). This new class of ‘anti-resorptive’ drug is a fully human monoclonal antibody, a type of immune therapy. It works against a protein that interferes with the survival of bone-resorbing cells. If you are not allowed to use aledronate or risedronate because of side-effects, the doctor can prescribe denosumab as an alternative to bisphosphonates. Denosumab is a drug against bone breakdown and is used for an increased risk of bone fractures. The active ingredient is an antibody that is directed against the human molecule that stimulates bone destruction.
This treatment is approved for use in postmenopausal women who have osteoporosis and are at high risk of fracture. Another approved use is for women and men at high risk of bone loss and fractures from hormone-depleting medications used to treat breast and prostate cancer. Patients receive this drug as an injection under the skin every six months.
This drug can make your calcium levels go very low, so your calcium and vitamin D levels should not be low when you start to take this drug. There may be an increased risk of infections when using this drug. There have also been rare reports of ONJ linked to use of Denosumab. This drug is also approved for the treatment of cancer involving the bones (XGEVA).

• Other bisphosphonates, which are not FDA approved for osteoporosis treatment, are used to treat other bone diseases and to treat cancer that has spread to the bones, include clodronate (Bonefos), etidronate (Didronel), pamidronate (Aredia) and tiludronate (Skelid). The dose used, is often much higher than for osteoporosis. Zoledronic acid used in cancer treatment is marketed as Zometa.
• Clodronate (Bonefos) is a bisphosphonate, which is not FDA approved for osteoporosis treatment. But in some other countries however, clodronate is approved for osteoporosis treatment.

Parathyroid hormones
In our body there are four small parathyroid glands (parathyroidids) next to the thyroid gland. They have an important function for the calcium metabolism in your body. The parathyroid glands produce parathyroid hormone (parathyroid hormone or PTH). The PTH plays an important role in the calcium and phosphate balance of the body. It ensures the absorption of calcium from the intestines and the excretion of phosphate by the kidneys. In case of an overproduction of the parathyroid hormone (hyperparathyroidism) you have one or more overactive, enlarged, parathyroid glands that produce too much PTH. This makes the calcium content in the blood too high and the phosphate level in the blood too low. An excess of vitamin D use can also cause these deviations in the metabolism of calcium and phosphate. Due to the overproduction of parathyroid hormone and increased calcium levels, there is a risk of kidney stones and bone abnormalities (usually osteoporosis). Hyperparathyroidism is also often characterized by high blood pressure, abdominal complaints and sometimes psychological symptoms as well as fatigue, symptoms of thirst, increased urine production, constipation, nausea and sometimes gastric ulcers.
Your doctor can prescribe a parathyroid hormone, if you develop severe osteoporosis after menopause, still break a bone despite the use of a bisphosphonate, if treatment with bisphosphonates, denosumab or raloxifene does not work or if you cannot use these drugs.
• Calcitonin (Calcimar, Miacalcin). This drug is a hormone made from the thyroid gland and is given most often as a nasal spray or as an injection (shot) under the skin. It is FDA- approved for the management of postmenopausal osteoporosis and helps prevent vertebral (spine) fractures. It also is helpful in controlling pain after an osteoporotic vertebral fracture.
• Teriparatide (Forteo) is a drug that mimics the function of hormones and stimulates bone formation so that bone density increases. Hormones that play a role in the development of osteoporosis are parathyroid hormone (PTH), thyroid hormone (calcitonin), estrogen and progesterone. Parathyroid hormones are produced in the body by the glands in the parathyroid gland. They have an important function for calcium metabolism in your body. Teriparatide is a form of parathyroid hormone that helps stimulate bone formation. It is approved for use in postmenopausal women and men at high risk of osteoporotic fracture. It also is approved for treatment of glucocorticoid-induced osteoporosis. It is given as a daily injection under the skin and can be used for up to two years. If you have ever had radiation treatment or your parathyroid hormone levels are already too high, you may not be able to take this drug.
• Estrogen or hormone replacement therapy. Estrogen treatment alone or combined with another hormone, progestin, has been shown to decrease the risk of osteoporosis and osteoporotic fractures in women. However, the combination of estrogen and progestin can increase the risk of breast cancer, strokes, heart attacks and blood clots. Estrogen alone may also raise the risk of strokes. Consult with your doctor about whether hormone replacement therapy is the right treatment for you.
• Selective estrogen receptor modulators (SERMs). These drugs mimic the good effects of estrogen on bones without some of the serious side-effects such as breast cancer. However, there is still a risk of blood clots and having a stroke with the use of SERMs. The SERM raloxifene (Evista) decreases the risk of spine fractures in women. It is approved for use only in postmenopausal women. It works a bit like estrogen but does not affect the breasts or the uterine lining. Like oestrogens, raloxifene inhibits bone breakdown, allowing the existing bone mass to be maintained.

Other drugs
• Tramadol. In case of acute collapse of the affected vertebra, you might be prescribed morphine or a morphine-like painkiller for the pain. Tramadol is a morphine-like painkiller. This drug is used in moderate to severe pain. Doctors prescribe Tramadol when paracetamol and anti-inflammatory painkillers do not have enough effect.
• Strontium ranelate. This drug is approved for managing postmenopausal osteoporosis in several countries around the world, but not in the U.S. (Protelos, Protos, Osseor, Bivalos, Protaxos and Ossum). Studies show it lowers the fracture risk in postmenopausal women. The drug comes as a powder, which women dissolve in water and take daily. Because of an increased risk of blood clots, it should be used with caution in women who have a history of or risk of blood clots such as deep venous thrombosis or pulmonary embolism.

Percutaneous vertebroplasty and kyphoplasty
Pain is the most common symptom of osteoporotic vertebral compression fractures (VCF). A compression fracture is a bone fracture which is common (mainly in women) due to osteoporosis. The bone is compressed, as it were, in a compression fracture. Vertebral augmentation procedures, percutaneous vertebroplasty and balloon kyphoplasty, are indicated when there is evidence of an acute (>4-6 weeks) or subacute (< 6 months) vertebral body compression fracture with associated pain that does not respond to the conservative treating measures. The procedures are indicated for painful osteoporotic or vertebral compression fractures. Both vertebroplasty and balloon kyphoplasty have consistently shown a significant improvement in pain scores after the procedure.
Contraindications to vertebroplasty and balloon kyphoplasty include α-symptomatic stable fractures, clinically effective medical therapy, osteomyelitis or other local infection of the target vertebrae, uncorrected clotting disorders, allergy to any required component and a local or systemic infection.
– Percutaneous vertebroplasty (PVP) is a percutaneous vertebral augmentation procedure that has grown to be an effective treatment for painful vertebral compression fractures (VCFs), often in the setting of advanced osteoporosis. It is used in the treatment of painful, broken or collapsed vertebrae and osteoporotic or malignant fractures. Vertebroplasty is a minimally invasive outpatient procedure in which the compression fractures are stabilized by the injection of bone cement, polymethyl methacrylate (PMMA), through the skin. The doctor injects a small amount of bone cement into a collapsed vertebra under X-ray guidance with a needle. The bone cement strengthens the vertebra. This procedure reduces pain from a VCF, may restore vertebral body height and correction of deformity, has a low complication rate and improves function and quality of life.
Women are affected three times more often as men (15% versus 5% lifetime incidence). Women: 25% of women age 75 and 50% of women age 80 have at least 1 vertebral compression fracture.
– Balloon Kyphoplasty (BK) is a variation in which orthopedic balloons are used to gently elevate the fractured vertebra in an attempt to return it to the correct position and to create a cavity that is subsequently filled with bone cement.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drug prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drug regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side-effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different drugs.

Side-effects
• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first if you want to use less drugs or want to stop.

Pregnancy and osteoporosis

If you are young and have risk factors for osteoporosis and fractures, you need to carefully consider the medication options if you plan a pregnancy. There are not enough safety data available on the drugs for osteoporosis on using them when pregnant or breastfeeding.
Bisphosphonates can stay in your body for a long time, even after you have stopped taking them. In animal studies it has been shown that bisphosphonates cross through the mother’s placenta and enter the fetus. The risk of harm to the fetus in humans is not known. This means that if you want to become pregnant later on, you should weigh the expected benefits of using bisphosphonates against the possible risks.
When you have taken a bisphosphonate and become pregnant, you should have your blood calcium levels regularly checked. This to prevent that the blood calcium levels in your body drop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the operation of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or better helps to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks.

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.

Supplements

You must first of all ensure that you have a normal healthy diet. You must have sufficient minerals, vitamins, proteins, carbohydrates, fats and fiber in the food you consume daily.

If you still have a deficiency of calcium and vitamin D, your doctor may prescribe supplements for this. The combination of vitamin D and calcium provides stronger bones and greater bone density.
Vitamin D ensures that your body absorbs enough calcium from the intestines or from calcium pills you take. The amount of vitamin D in your body increases due to sunlight on your skin. If you are not often in the open air, if there is no sun or if you are always covered (with hat or headscarf), your doctor may decide to prescribe vitamin D.
Calcium provides strong and healthy bones. If you have to take calcium pills, the amount of calcium in your blood increases. Your body then has more calcium for the production of bone mass. Vitamin D is needed for your body to absorb enough calcium.

Living with osteoporosis

Lifestyle changes may be the best way of preventing osteoporosis. But when you already have osteoporosis, lifestyle changes are very important. A fracture is the biggest serious health consequence of osteoporosis. Spine and hip fractures may lead to chronic pain, long-term disability and even death. If you have osteoporosis, it is important to help prevent a fracture and further bone loss.
• Regular movement (at least 30 minutes per day) ensures strong bones. Active exercise ensures the development of stronger muscles and a better balance, making you firmer and more stable. So be physically active and do weight-bearing exercises, like walking, on most days each week. Aim for at least 2½ hours a week (30 minutes a day five times a week or 50 minutes a day three times a week). Exercises that can improve balance, such as Tai Chi or yoga, may help prevent falls.
• Avoid excess alcohol intake and have no more than two drinks a day.
• Stop smoking, because it has an unhealthy effect on bone formation. Every patient with an increased fracture risk is advised to stop smoking.
• Healthy food contributes to the building of strong bones. It is important that your diet is well balanced. Get enough vitamin D (400 to 1.000 IU/day, depending on your age and your blood level of vitamin D measured by your doctor). Make sure you get enough calcium in your diet or through supplements (roughly 1.000 to 1.200 mg/day, depending on your age).
• Underlying medical problem. You also should get treatment for any underlying medical problem that can cause osteoporosis. If you are on a drug that can cause osteoporosis, ask your doctor if the dose can be lowered or changed to another type of drug. Never change the dose or stop taking any drug without speaking to your doctor first. If you are at severe risk because of medication you have to take, then some of the above mentioned treatments might be appropriate for you.

Fall prevention
1. Make sure there are no loose rugs or wires or cables lying around on your floor. Remove or secure them, preventing you from tripping over.
2. Provide good lighting at home and leave a nightlight on in the hallways leading to the bathroom at night so that you can see enough, when getting out of bed.
3. Install grab bars in the bathroom and nonskid mats near sinks and the tub.
4. If you get dizzy when standing up in the morning, first sit on the edge of the bed and wait till the dizziness has subsided.
5. Turn your reading glasses off when walking around, otherwise you will not see the floor or steps of the stairs properly.
6. Put on a pair of glasses to see in the distance, before you walk for a better view of thresholds, stairs and curbs.
7. Certain exercises (balance and strength training) can help you to stand firmer.
8. Sleeping tablets make you (even during the day) drowsy. This means that you can fall easily, especially if you get out of bed at night.
9. Use a walking aid. If you are unsteady, use a cane or walker.
10. Get help carrying or lifting heavy items. If you are not careful, you could fall or even suffer a spine fracture without falling.
11. Wear sturdy shoes with soles that grip. This is above all true in winter or when it rains.

Videos sources

Amgen I Introduction to Bone Biology I https://youtu.be/inqWoakkiTc
Amgen I Osteoblasts and Osteoclasts I https://youtu.be/78RBpWSOl08
Amgen I Bone Remodeling and Modeling I https://youtu.be/0dV1Bwe2v6c
Amgen I Regulation of Osteoclast Activity I https://youtu.be/GpMV197xZXc
Amgen I Sclerostin I https://youtu.be/ajsioxRrf1I
Amgen I Postmenopausal Osteoporosis I https://youtu.be/c5tc01WFYks
Amgen I Anatomy of a Fracture as a Result of Systemic Bone Loss I https://youtu.be/P5HwYWShBhw
Intelecom Learning I Development of Bone I https://youtu.be/xXgZap0AvL0