Prakash Chandran (Host): The word osteoporosis means porous bone. It's a disease that weakens bones. And if you have it, you're at greater risk for sudden and unexpected bone fractures. Today, we'll learn more about what it is, common symptoms and how to treat it. Joining us to discuss is Dr. Mary Breckel. She's a physical therapist with Jefferson Healthcare.

Host: Here is To Your Health, a podcast brought to you by Jefferson Healthcare. I'm your host, Prakash Chandran. So Dr. Breckel, thank you so much for joining us today. I really appreciate your time. Let's get started with the basics today. What exactly is osteoporosis?

Dr. Mary Breckel: Osteoporosis is a condition where the hardness of the bones is basically reduced compared to an otherwise healthy person. So, bones all have minerals like calcium that make them really strong and hard. So, what we're looking at is a loss of calcium and other minerals in the bone, and that's what makes someone have osteoporosis.

Host: Okay. And what are some of the risk factors for developing osteoporosis? And more broadly, does this affect certain age demographics that are worth noting?

Dr. Mary Breckel: Yeah. So, there are some genetic risk factors. And then, there's of course some lifestyle risk factors. Just a basic list is increased age, right? So, anyone over 60 and 65 in particular is a lot more likely to have this problem. Females are more likely to have this problem. Men with lower testosterone levels can get osteoporosis. Anyone who's white or Asian, having diabetes, kidney disease, IBS, so other health conditions can contribute to osteoporosis. Another thing is just having a smaller frame. So, having low body weight, in particular less than about 125 pounds, if someone has like a low body mass index or BMI, smoking and heavy drinking. And there's also some medications that can contribute to osteoporosis too. So, there's some high risk medications such as corticosteroids that would increase the risk.

Host: Okay. That's helpful. I'm curious like how someone might know that they have osteoporosis or are developing it. Are there common symptoms that people should be aware of?

Dr. Mary Breckel: So, it's really like a silent disease. It does not hurt, like your bones don't suddenly start to hurt when you go from normal to osteoporosis. But other related conditions can be painful. Often people that have osteoporosis might have arthritis or, God forbid, a fracture where they have a fall and they actually have a fracture that hurts. Then, they go in and they're told, "Oh, that bone actually had osteoporosis. So, the reason why screening tests are so important is that you really don't know that you have it unless you, let's say, had a family member who had it, and so you're getting screened early.

Host: Okay. So, let's talk about screening and just more broadly how osteoporosis is diagnosed.

Dr. Mary Breckel: So, it's diagnosed with a special imaging called a DEXA scan, which looks at how many of those minerals your bones have, and it gives you a score. So, comparing you to a healthy young adult, there's a T-score that your doctor will report back to you. And your scan results will either be normal, osteopenia or osteoporosis, depending on the density of the bone. So, scores ranging from like 0 to -0.9 are normal. Scores between -1 to -2.4 are osteopenia, which is basically mild osteoporosis. And then, scores -2.5 or below, like more negative, are osteoporosis.

Host: Okay. And one of the things that I want to expand on that you mentioned was a doctor might say like, after a fracture, that that bone had osteoporosis. Does it generally start in one area of the body and spread? How does it normally represent?

Dr. Mary Breckel: That's a good question. I think because we don't start testing this on young children, we really don't know. If we were doing DEXA scans on little kids and could track the progress, we would have a better idea of how it evolves. But sometimes we see someone that has osteoporosis of their lumbar or low back, their spine, but their hip is completely normal. Other times we see that their hip is osteoporotic and their spine is normal. And what I tend to see is that activity can make that difference. So if someone is a walker, they might have less hip osteoporosis and more spine osteoporosis because they have given theirselves some protective bone density through their walking compared to their genetics of their spine.

Host: I'd love to learn if there's any treatment options for osteoporosis.

Dr. Mary Breckel: So, medical treatment usually starts with offering medications to either help reduce the body's tendency to break down the bone or improve the body's ability to inherently build bone. So, ensuring the person also gets enough calcium and vitamin D is also critical. So, your doctor might talk to you about supplements. And then, additionally, physical therapy, which provides exercise guidance, maybe pain and balance treatments, education and lifestyle strategies, that's also offered. And in Port Townsend where we are, a lot of people want that more kind of holistic care, not just medication. So, depending on the person, it might be a range of other specialists and services, such as a dietician as well.

Host: Okay. So, we talked obviously about maybe some treatment, but let's talk about prevention. So, you mentioned earlier that if someone's a walker, for example, their hips might be okay because they've developed more protective bone density. So, I'm assuming exercise is extremely important for prevention, but maybe talk more broadly about that.

Dr. Mary Breckel: So when I think of prevention, I think of children, right? Wellness behaviors in children help prevent a diagnosis from occurring later in life, or it delays the start of the diagnosis and reduces how severe it will be later in life. So, supporting children and providing a healthy diet with enough calcium such as like dairy, nuts, leafy greens, whole foods and having them participate in weightbearing activities and the recommendation is one hour a day for children, that's critical, right? So, that means that there's less soda and juice and screen time, so that they can have healthier bones because we build our bone bank before we are 30. And the bigger our bone bank is, the longer we can pull from it later in life without becoming frail.

Now to answer your question, what should someone do when they're 60 and get diagnosed, right? And how to prevent it from worsening. It's the same as the other treatment I would provide to someone who came into the clinic, which is exercise, maybe working on sleep and stress management because that also disturbs our bone health. And again, that idea of getting enough calcium from someone's diet can be super important. Because no matter how much you exercise, if you're pulling calcium from your bone, because you don't have enough in your body to run your heart, that's going to be a problem.

Host: So, let's say that person over 60 or even 50 comes in and they get the instruction to kind of manage through exercise and diet. I'm curious if osteoporosis in them can be reversed or at least improved with these lifestyle changes.

Dr. Mary Breckel: I have seen that. So, I have had multiple patients that come in with either an osteopenia diagnosis, hoping to go back to normal or an osteoporosis diagnosis, hoping to go back into osteopenia. And when people get a repeat DEXA scan, if they've been like walking with their weighted vest and doing specific hip or back exercises that are strength training, I've seen up to an 11% or 12% improvement in bone density in two years. So, not only can you hold your bone from continuing the age decline, which it should decline as we age normally, but if you're doing these specific exercises, not only will it hold, it can actually get better.

Host: Wow. That's pretty reassuring to hear. And are there like specific exercises that you recommend for doing that?

Dr. Mary Breckel: Yes. If someone has hip osteoporosis, it's going to be using a weighted vest while they're walking and doing heavy hip strengthening exercises with like ankle weights or resistance bands. And that really targets the neck of the femur, which is where it tends to break if people have a fall causing a fracture related to hip osteoporosis. That being said, I also work a lot with people that have chronic pain. A lot of people with osteoporosis can't tolerate walking with a weighted vest because of their chronic pain. So, you're kind of unraveling this onion where you need to get the pain out of the way and the balance better to where someone is safe and successfully walking with a weighted vest to even get the bone density to budge.

Host: Before you talked about some of the medical treatments that reduce the body's tendency to break down the bone, what are those treatments and are there any other medications that are worth mentioning for treating osteoporosis?

Dr. Mary Breckel: Yes. So, there are a few classes of medications and I will leave it to the medical doctors to discuss them with patients on a case by case basis because there are multiple classes. Overall though, the benefits include that you can see an improved T-score on DEXA compared to a non-medicated patient. There are an array of side effects depending on the medication that might affect some people and not others. And this was more of a concern, I would say, 10 and 20 years ago where people would not even consider prescribing a medication because of concern of side effects. But there has been research done in the last 20 or so years to prescribe meds in a way to minimize the side effects. So, I always encourage people to report side effects to their doctor. You don't need to live with those obviously. But I also have a lot of patients who need counseling on being open to considering a medication their doctor recommends if the only reason they don't want to take it is because their neighbor had a side effect.

Host: We've talked a couple times about getting screened and the DEXA scan. Is there a certain age that you recommend that people start doing this?

Dr. Mary Breckel: I believe that Medicare pays for it when someone is 65, right? No matter someone's family history, that's really when we start screening this and it's covered. If someone has a family history, they can discuss with their doctor the possibility of getting a scan sooner, if there are reasons that they should do that. For example, let's say someone notices that they have some imbalance or they notice that they're losing inches in height, right? They might say, "Wow. Is this because of osteoporosis?" And they might get a scan before they're 65.

Host: Okay, understood. But as I'm understanding this, as you're explaining it, osteoporosis does seem like something that is progressive. Like if you are not necessarily exercising or doing some of the stuff that we discussed, it's going to get worse. So for example, I know there's obviously the Medicare coverage. But you know, given the fact that you build your bone bank, I think you said before 30, does it make sense, especially if you have a family history, to try to get in a little sooner?

Dr. Mary Breckel: Yes. So before I was a physical therapist, I was a dance teacher. And if I had a student who fractured a bone in their foot for no good reason, I would definitely say there's something not right here, right? Where this is a 15 or 16 year old that's breaking their foot for an injury that is not traumatic, just because let's say they're dancing on point or something like that. And so, there's a lot of reasons why I wish we would do DEXA scans earlier in life. Ultimately though, what it comes down to is if we all got the normal aerobic exercise and strength training that's already recommended in wellness recommendations, I mean, I could fill in the blank with any disease process, you're going to reduce it. So, do we want to scan everybody all the time? No. Would it motivate some people to do the wellness behaviors better if they saw their numbers dipping? Probably. So like, where's the balance on that? I don't know.

Host: Yeah. Well, amen to that. I think we all need to be a little bit more active, focus on that weight resistance training, functional fitness. Totally agree. Are there any ongoing research or advancements in the field of osteoperosis treatment that are worth discussing?

Dr. Mary Breckel: It's funny, I actually was just sent an article by a patient a couple days ago that was all about standing on one leg for like three minutes a day. And that those people actually had a notable improvement in balance, which you would think reduces the tendency for something to fracture. So, you're not going to see a change in the DEXA number, but you're going to see a reduction in fractures because you're not going to fall.

Host: Yeah. And as you get older, I'm told that one of the biggest culprits for really taking people down later in life and causing more of these more severe breaks is balance, right?

Dr. Mary Breckel: Right. So, it comes down to, unless your balance is very awful, you're probably not going to have your doctor go, "You have to go to PT for your balance." But people fracture their hip before their balance is awful all the time, right? So, that little feeling of like, "I just turned around in my kitchen counter to counter, and I had to take a corrective step to like get my footing," that's not normal, but we normalize it all the time, like, "Oh, this person's just old." And then when someone like that comes into my office and I'm actually doing tests on them, we see, "Hey, that's why you keep losing your balance to that side," and my hope is we can prevent a hip fracture if we can treat that imbalance.

Host: So Mary, we've talked about a bunch of things here today with regards to osteoporosis and ways to prevent it, ways to treat it. Out of all the experience, all the patients that you've seen, if there is one thing that you know to be true that you wish more people knew, what would that be?

Dr. Mary Breckel: So, I think it's very important that when people are being assessed for osteoporosis, that the entire person is being considered. So if someone has unregulated stress, that can cause cortisol to flood the body, and that can be the person's bone density problem. If someone has a poor diet, that can be the person's bone density problem. If someone's not walking or ever doing any strengthening activities or heavy work, that can be the problem. If someone's not sleeping, that can be the problem. So if someone comes into an office and they're not being asked about all of their pains and all of their problems and their behaviors, you're not going to get down to optimizing treatment for osteoporosis, is my opinion.

Host: I think that is very well said and the perfect place to end. Dr. Breckel, thank you so much for your time.

Dr. Mary Breckel: Okay. Thank you for having me.

Host: That was Dr. Mary Breckel, a physical therapist with Jefferson Healthcare. For more information about osteoporosis education and management, you can visit us at jeffersonhealthcare.org/services/rehabilitation-services.

If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks again for listening to this episode of To Your Health by Jefferson Healthcare. My name's Prakash Chandran. And until next time, stay well.