Raising awareness of this widespread silent condition

Many people do not realize they have osteoporosis – until they suffer a fracture. Around 80 risk factors are known, and increasing numbers of physicians now work together in interdisciplinary networks to treat their patients early and preserve their mobility. Dr. Christiane Karrenberg, Orthopedist, Trauma Surgeon and Osteologist based in Rösrath/Germany and her specialist colleague Prof. Dr. Uwe Maus from Düsseldorf University Hospital are working on raising awareness of osteoporosis.

life: As an office-based physician, you see a wide variety of osteoporosis symptoms. What developments have you noticed?

Dr. Christiane Karrenberg: One thing is clear: osteoporosis is a widespread condition, even though it’s still underestimated. Every year, 380,000 osteoporotic bone fractures occur in Germany. That is a dramatic number. And numbers are increasing in our aging society. Medical associations estimate about five million¹ people living with osteoporosis.

What does an osteoporosis patient’s typical treatment path look like in a specialist practice?

Dr. Karrenberg: I often observe that female patients come to me whose mothers or sisters are suffering from severe osteoporosis, and they want to be checked themselves. Other patients who have already been through menopause come to see me because their gynecologist is aware of the condition and has recommended an appointment. A lot of others only come once they have suffered a fracture. Of those approximately five million affected, not everyone will know that a process characterized by bone loss has begun. Overall, however, awareness of the subject is increasing.

How do you proceed in terms of diagnostics when you suspect bone loss?

Dr. Karrenberg: I initially work with a specific osteoporosis questionnaire for female patients with relevant risk factors. The current treatment guidelines published by Dachverband Osteologie (tri-national umbrella association for osteology), which were adopted in June at the Osteology Convention, list numerous risk factors. This may be an existing predisposition in the family. It can include chronic inflammatory bowel disease as well as rheumatoid arthritis, asthma, COPD, thyroid conditions, type 1 diabetes, dialysis dependency or breast cancer. Oftentimes, it’s the medication for the relevant condition that attacks bone mineral density, such as steroids or aromatase inhibitors. We then carry out osteoporosis-specific laboratory diagnostics to determine the bone parameters, such as calcium, and optionally, Vitamin D levels. When I see a clear osteoporotic fracture, a vertebral fracture for example, I wouldn’t even have to wait for the results of the bone densitometry. But densitometry is part of the initial examination, and it provides important data for monitoring the course of treatment.

What treatment method will you then implement?

Dr. Karrenberg: That will always depend on how pronounced the osteoporosis is, on possible comorbidities, what medication a patient is taking and the patient’s general state of health. In general, if required, Vitamin D levels will be supplemented. Specific medication only makes sense afterwards. If needed, pain medication will be prescribed.

Is treatment the same for women and men?

Dr. Karrenberg: Basically yes but the range of medication for men is not as comprehensive as that for post-menopausal women because not all medication approved for women is also approved for men. 

“In general, it would be good if osteoporosis were
considered more often as a cause of fractures.”

Prof. Dr. Uwe Maus

Prof. Maus, I imagine you see a different category of patients at your hospital …

Prof. Dr. Uwe Maus: I would estimate that 95 per cent of our patients come to us because of fractures. Many of them are affected because of age-related trauma, they take various kinds of medication, and their muscles are generally weaker. After treating the fractures, we will quickly look at the bone metabolism. If the patient has well-balanced Vitamin D levels, we will start specific treatment straight away. However, in eight or nine cases out of ten, this is not possible immediately. These patients are given a recommendation for medication that will take place later. But we don’t start it right away.

What kind of improvements would you like to see in terms of the current discharge management after fractures?

Prof. Maus: In general, it would be good if osteoporosis were considered more often as a cause of broken bones. Ideally, these patients should leave the hospital with an appointment at a specialist practice or with an osteologist. Unfortunately, some patients fall through the cracks after leaving the hospital – when waiting for an appointment, because they simply forget or because they are overwhelmed and not mobile. This would not be acceptable with a heart condition …  

Dr. Karrenberg: Exactly. It’s all about showing the way. A clever concept would be to have a coordinator who could compile a folder for patients while they’re still in hospital, briefly listing everything in the discharge papers: diagnostic and laboratory findings, complemented with a risk questionnaire, easy-to-understand educational material and addresses of practices close to the patient’s home. If this is left up to often aging patients without any help, there will be an increased risk that nothing will happen, and the next time you see the patient, it’s with another major fracture. 

Widespread conditions usually have a lot to do with lifestyle habits …

Dr. Karrenberg: As is often the case: a healthy diet and a lot of exercise can moderate the progression of a condition or delay its onset. The activity component in particular is crucial – yet hard to improve in older patients. They become less and less confident, especially if they’ve had a previous fall. Then it’s hard to motivate them even to go for a ten-minute stroll. Using a brace that straightens the spine cannot be overestimated, as also recommended by guidelines. A brace helps both with pain therapy, and it also supports posture and straightening, which can prevent a fall. A feeling of confidence is really important for patients; it can preserve their mobility.

How well do older patients manage with a brace?

Dr. Karrenberg: They need to be instructed properly in how to don the brace. This is taken care of by the treating medical supply retailers. Standard treatment following a vertebral fracture takes about three months, but I recommend to my patients that they continue to wear their brace, at least when subjected to strain. Conversely, I also hear my patients saying themselves that the brace is beneficial and that they wear it every now and then. One thing is always important: most patients don’t want to look old and frail. So it’s handy when the brace is unobtrusive and can be worn underneath clothing.

Prof. Maus: I also believe that braces are very important and effective. They can even be prescribed at the hospital as part of discharge management. Nevertheless, braces play a more minor role in hospitalized care compared to outpatient care because our percentage of patients undergoing surgery is much greater than in an outpatient setting.

What are the consequences of osteoporosis when it is left untreated?

Dr. Karrenberg: Fractures are a primary concern. If the shoulder joint is fractured, for example, independent living will be affected. Just think of getting dressed, shaving, brushing your hair… vertebral fractures or fractures of the femoral neck can result in a significant restriction in quality of life, and even to increased mortality. Another consequence could be a hunched back, also known as hyperkyphosis. This increases the risk of falling, but excessive curvature of the thoracic spine can also lead to restricted breathing and impact the digestive system.

“A feeling of confidence is really important for patients –
it can preserve their mobility.”

Dr. Christiane Karrenberg

How important is interdisciplinary cooperation when treating osteoporosis?

Dr. Karrenberg: It’s an incredibly important factor. As we mentioned before, patients are often also suffering from other conditions that can affect bone mineral density. But there are also highly complex cases where it can offer value to access additional treatment expertise. These experts can include endocrinologists, rheumatologists, geriatricians or nephrologists. Sometimes, it’s a bit like doing a jigsaw puzzle.

Preserving mobility with the Spinova Osteo

Correction of posture and strengthening the back muscles are important approaches to osteoporotic conditions in the spine. The Spinova Osteo back brace has been specifically designed to provide individually adjusted support for straightening the upper body and to stabilize posture. This alleviates pain and corrects incorrect posture as well as impaired gait. The risk of falling can thus be reduced, which is important in older patients in particular to preserve their mobility for as long as possible. Improved, straight posture helps with better lung function and relieves the internal organs. The brace is easy to put on, lightweight and barely shows under clothing.

A comprehensive network

Knowledge increases when it is shared. This is the philosophy of REKO, the regional circle of osteology experts in Germany. Under the umbrella of REKO Deutschland e.V., physicians from different disciplines cooperate in order to promote and share know-how related to osteology, for example via research, symposia and now even a podcast. 

This interdisciplinary exchange between hospitals, practices and rehabilitation centers as well as healthcare policymakers and service providers is designed to provide the best possible care. Dr. Christiane Karrenberg is the first chair of REKO.  

For more information, please visit www.reko-deutschland.de

More about the German REKO Podcast about osteoporosis.

^{1 Fragility Fractures in Germany. Burden, management and opportunities: EU6 Summary Final Report 2018-06-26.}

Images: Bauerfeind, Michael Bause