Monday, September 25, 2017

DX Severe Osteoporosis: Part V -- A Race of a New Kind

This is Part V of a multi-part essay about my own personal experience with osteoporosis. I will be taking you through the diagnostic and treatment phases of my care in hopes that it provides you a better understanding of osteoporosis in general, and pearls that you can use to better your own bone health. 

"Without struggle, without enduring pain, there can be no full awareness of one's being."
           Crucibles of Will

I had never lost my self-image as an athlete, even as I approached middle age. It's natural for most men in the prime of their life to think they are fairly invincible. I certainly did. My time as an Olympian and decades of competing in triathlons and road races erased any sense of mortality that I may have had. Osteoporosis--my bones dissolving from the core--just didn't fit.

The best thing that could ever happen to me was someone doubting my ability to do something. Ben (not his real name) a close relative of mine once said, "You won't ever make the Olympic Team." And there was another time when I wanted to get into horse racing and he said, "You won't even get a horse to the track, let alone win a race." His words would cut deep; they would linger in the pit of my gut, in the deep recesses of my bones. From that point on, you could try, but you couldn't stop me. I might not be the best in the Olympics and my horse might not have the legs of Secretariat, but I wasn't about to fail and I would just about die trying to succeed.

When I started searching for the causes of my osteoporosis I began to wonder if this trait of mine, my intensity, could have somehow contributed to the severity of the bone loss. Many serious health disorders are caused by multiple factors; life style and stress are certainly major contributors to disease. Whether from emotional or physical causes, stress stimulates a huge release of cortisol from the adrenal glands and it weighs heavy on the immune system. Just a cursory internet search into the causes of bone loss brings up the damaging effects of excess cortisol, the stress hormone, and the involvement of the immune system in bone remodeling.

Many different aspects of who you are and how you live either contribute to health, or lessen its hold. The daily patterns of ones life as it is seen over the span of years can often shed light on who we are...who we have become. Since childhood the dominant pattern for me--and, coincidentally, the cause of why I had to go seek the help of an orthopedist for my hip pain when this whole mess started--was that of my athleticism. I was a hard grinding athlete who believed that it wasn't just the quality of the effort that mattered but it was the quantity of miles that would make me the best. With this erroneous training method, I racked up way to many miles and was constantly in a state of over-training. A ten-mile run usually wasn't good had to be twenty. And a 75 mile training session on my bike probably wouldn't do when thoughts of my competitors somehow getting an advantage over me during the night as I wasted valuable time sleeping. No, that just wouldn't be enough. I HAD to go 110 miles instead. Usually, this was with no food and minimal fluid and electrolyte replacement. That is how I trained and lived, for decades. It wasn't that I was trying to be foolish or irresponsible; it was just that back then (forty years ago) there weren't a lot of athletes putting in the miles I was and there had been minimal research and awareness into the detrimental effects of over-training and the need to refuel and allow the body to rest. Rest was just a dirty word to me. I was simply totally focused on training hard...not on taking note of the needs of my body. Recovery wasn't in my vocabulary. If I wasn't totally flogged by the end of a training day (and days off were non-existent) then my competitors might be getting a jump on me...or at least that is what I thought.

Throughout high school I ran on the cross-country and track teams, swam on two different swim teams, and rode hunters and jumpers at our farm and in horse shows. Three run workouts a day, even during the "off" season, were more the norm than the exception. A two- or three-hour run, making a bee-line to a distant hill on the horizon, was my fun for an afternoon. Eating, replenishing my bones, was not on my radar. 

Each mile I ran felt like it fueled some magical fire that was deep within me. It was as if my body was
a furnace built to carry this fire and that my earthly life was a burning. I didn't really see my body as a furnace that sometimes needed repairs and maintenance, I only looked forward to the burning. I only knew that the harder and longer I ran the hotter that fire seemed to get until an alchemy of sorts would take place. With the intensity of each run I became a crucible that got hotter and hotter until an amalgamation of all the forces within me and all the natural forces that surrounded me, came together, as one. I knew only one thing as I ran, that the intensity by which I ran nurtured that small burning coal that was in me. A coal that we all have within us, that we are all born with, and which will take us where ever we want to go. When I ran, ran hard, I would blow those coals into flame...into what I thought would be an inextinguishable fire.

Now, it looked like I might have been wrong about the inextinguishableness of that fire. Now I was at the starting line of a new race, one to figure out why I had osteoporosis, and it was a race against time. Sooner or later things were going to start crumbling, and I needed to find a way not only to stop the disintegration but to reverse the damage before the infrastructure started breaking down. And there were bigger threats. Early osteoporosis has a high correlation with other diseases such as diabetes, cancer, heart disease, and Alzheimer's. Once you're caught in an avalanche, once cramps seize up your muscles during a race, once a fire starts's usually all over. The stage was being set in my body; it was easy to see what would happen if I couldn't change the course it was on.
With a T score of -4.3 my spine looked worse than a 100-year old's, but I was determined to put out this metabolic fire that was consuming my bones, and find a way to help them heal, if I could.

Bone densitometry is the gold standard for defining bone loss and determining fracture risk. If your density is low, you are at a greater risk for breaking a bone. When really low, like -4.3, it doesn't take much trauma to break something. A T score of -1.0 or better is normal. Between -1.1 and -2.4 is osteopenia and -2.5 or worse is considered osteoporosis. Anything below -3.5 is considered severe osteoporosis. At -4.3 and as a 46-year-old, I knew I was in for a rough ride.

The next few months were, indeed, bumpy. I had difficulty finding ways to educate myself in depth about the disease, and about all the bodily processes skeletal health, or lack there of, seemed to be involved in. I also had to identify the lab tests that would help lead me to the cause of my bone loss and to monitor progress. Then there was the treatment plan, one I felt would have a good chance of success because it would be tailored, individualized. A plan based on healing my whole body, not one relying only on drugs that built up bone density while ignoring or compromising overall health. My plan would be comprehensive, fine-tuned, based on how my particular body works, paying attention to its underlying functional patterns. I wanted to get this ALL figured out before I really started breaking things...but that didn't happen.

The Medical Scene:

After the two rib fractures while cross-country skiing, I sustained a mild compression fracture of a mid thoracic vertebra. In retrospect (isn't that always the way it is) I guess I shouldn't have been lifting that couch. In a medically inquisitive way of thinking, it was an "interesting" experience. It "felt" like a "pfffst" air rushing out of a blown tire when the vertebra broke. From a personal way of thinking--it wasn't actually interesting at all--just painful and distressing. When I told the endocrinologist about the fracture he wanted to see me right away. I didn't know why. As a chiropractic physician who has seen lots of compression fractures in patients over the years, I knew there wasn't much a medical doctor could do to help. But I went in to see him anyhow.

Health care should be a little less like processing cattle and more of an investigation of what is happening to real people with real hearts and real feelings. You have probably sensed the same, especially at the beginning of each doctor's visit. Each appointment always begins with allegorical weigh-in and measure. As if they are saying, "Yes, you are NOW at the doctor's office."

Being a doctor, the medical scene was completely familiar to me. (Although I don't weigh and measure patients at every visit unless it is warranted.) At the same time, the assumption was that now I was the patient and I would go along passively with whatever my doctor recommended. In general, this is the expectation of what patients should do, and it works out well much of the time. Most patients either don't actively engage in their own health are, or they just ask a few questions and look up some articles on the Internet. The medical jungle is daunting to the lay person. The amount of information available and the technical language it's encoded in shuts down just about any attempt to engage with it. For most people, it is hard to explore this territory and stay oriented. Amidst the confusion and complexity, it is easier to get lost than to stay on the trail. But I had a major jump on the game. I didn't know much about osteoporosis, but I could speak the language.

The endocrinologist that I had found at UConn seemed more like a coach than a guarded, emotionless physician. Of course he still had his nurses weigh and measure me at each visit--we couldn't do without that--but from the beginning he let me know he was on my bench. He was direct and told me he had never seen anyone with the extreme low bone density that I had who did not have multiple fractures. He never seemed to be rushed and would always take time to listen to my thoughts and concerns. Best of all, he didn't have those invisible blinkers strapped to the side of his head. He was willing to consider things from all angles, and to help me take this to any level of investigation that I wanted. Now with this compression fracture, I realized that he wanted to see me because he wanted to reassure me that we would find the underlying cause of this mystery and that I wasn't alone in this mess. He also explained the surgical procedures, vertebroplasty and kyphoplasty.

Once a person has sustained one compression fracture, the chances of them sustaining another within a year increases 4- to 6-fold! This phenomena is referred to as "vertebral fracture cascade" and he wanted to avoid this at all costs. Once several vertebra collapse a person's posture becomes kyphotic, bent forward, and this can eventually compromise heart and lung function when the kyphosis becomes severe.

Compression fractures of the spine can result from major trauma such as falling backwards onto the buttocks, or from minor traumas such as bending, lifting, coughing, or twisting. When bone is EXTREMELY fragile, fractures can result from simply walking around or, as with the second compression fracture I sustained, bending forward to pick up a stick when running. When the spine structure is severely weakened, it doesn't take much strain at all for the vertebrae to simply collapse.

Both of my compression fractures gave me a fair amount of pain for about a year. But it is not unusual (nearly 50%) for vertebral compression fractures to cause minimal or no pain and may go undetected. In fact, many of these fractures are discovered as "secondary findings" when radiological procedures are being performed for other medical reasons. (Tip: if you have had radiographs taken and read at a medical facility, it is a VERY good idea to have your chiropractor double check them.)

So how do you know if you have sustained a vertebral compression fracture? Typically your chiropractor or medical physician will be able to find a localized area of tenderness when they are examining your spine. He or she may also notice an increased kyphotic or forward angulation in your spine if there is a fracture in the thoracic area. Thoracic and lumbar spine fractures are the most common areas of the spine to sustain compression fractures although they can occur in the cervical region also. If your doctor suspects a fracture, x-rays will be ordered. A bone scan, CT (computed tomography), and/or MRI (magnetic resonance imaging) may also be indicated to determine if the fracture has occurred recently or if it is old and occurred months or years ago. These tests can also help your doctor evaluate any neurological involvement and also to rule out any suspicion of cancer.

The endocrinologist explained to me that if the compression fracture was severe enough they could inject cement directly into the vertebral body to reduce the pain and stabilize the fracture, a procedure called a vertebroplasty, or use a balloon to expand the fracture prior to injecting the cement. This second procedure, a kyphoplasty, attempts to bring the collapsed vertebra back to its original size. After assessing the fracture, he determined that it was not in need of either procedure. (Whew!)

At that time, 18 years ago, these surgical procedures were becoming a common treatment for compression fractures. But more recently, they have come under considerable scrutiny, not only due to the significant risk of adverse effects such as bleeding, infection, allergic reactions, and leakage of bone cement into the surrounding tissues, but also regarding questions concerning their long-term benefit. In fact, many believe that these procedures may increase the risk of the fracture cascade by placing undue mechanical stress on adjacent vertebrae.

In 2010, the American Academy of Orthopaedic Surgeons actually recommended against using vertebroplasty and only gave a weak recommendation for kyphoplasty.(1) In 2013, a study by Martinez-Ferrer et al.(2) published in the Journal of Bone and Mineral Research showed that there was a 30% chance of sustaining another compression fracture after a vertebroplasty. They also found that leakage of cement into the disk beneath the vertebra being repaired contributed up to a six-fold increased risk for developing a new vertebral fracture. When hard cement leaks into the disk this places increased mechanical pressure on the vertebra below. The authors state that other comparative studies indicate a similar problem with kyphoplasty.

As a chiropractor, I wasn't too keen on surgical procedures or drugs. Certainly in the case of the vertebroplasty or kyphoplasty, these would not have been my first choice even if they had been recommended by the endocrinologist. Chiropractors as a general rule are dedicated to the goal of genuine healing. We are not satisfied with eliminating symptoms by suppressing them or by short-circuiting the body's patterns of functioning. Chiropractors support the body's innate ability to heal, and feel that drugs and surgery should be used only as a last resort. Sometimes these interventions are a necessary part of treatment, but even then, there is a lot that can be done to strengthen the body through conservative means. In my case, I wanted to try to find the underlying causes of my disease and to address them. I wanted to give my body the best possible chance to heal itself. Most of the other doctors I saw had different ideas so I always had to reel them back in and get them headed in the right direction...the direction I CHOSE for treatment.

Genetically speaking we humans were only designed to live for thirty-five years or so. After that, after we have procreated, we really didn't have much reason to live...genetically speaking that is. Bone density follows this script and only actively increases up to about age 35; after that bone is still actively replaced, but only maintains the density it achieved earlier. Eventually this density starts to decline, and my density had been declining for years--possibly decades. In terms of nature's plan for my bones, there was nowhere to go but down. I, on the other hand, had other plans in mind.

               "This is why I run: for the sake of the fire; for the burning."

1) The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures ̴ Guideline and Evidence Report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, September 24, 2010. and

2) Martinez-Ferrer, A. et al. 2013. Risk factors for the development of vertebral fractures after percutaneous vertebroplasty. Journal of Bone and Mineral Research 28(8):1821-1829.

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