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keeping your back straight

I’ve been working hard to learn to move with my back straight.  I knew that forward bending was something to avoid –  small fractures in the front of the spine lead to more fractures– a cumulative process that is hard to stop once started.  I had thought it was ok to bend backwards, and have been doing this everyday as part of a modified balance exercise on the Wii.

I just found this diagram on the National Osteoporosis Foundation website: back straight

Looking through the ‘Yoga for Osteoporosis’ book by Loren Fishman and Ellen Saltonstall I see they don’t include poses with back bending.  They do have something called ‘Upward Bow’ (Urdhva dhansurasana) (p122) but is for prevention only.  The other poses come with three variations for those preventing osteoporosis, for those with osteopenia (at risk bones) and those who already have fragile bones.

If anyone has ever watched an infant get frustrated at being trapped in a car seat – I can empathise.

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Posture, posture, posture

yoga with Wii

The osteoporosis guides are full of exhortations to manage your posture to reduce your risk of fracture.  The aim is to prevent your back from curling forward (imagine cuddling a kitten/slouching on a sofa) as this increases the risk of spine fractures.  The spine is a series of stacked bones, and they get little fractures without people noticing, they crumble a little, form a wedge shape…and the wedge encourages curling forward, which increases the pressure and increases the fractures, and before you know it you are walking along unable to look at anything but the ground.

I’ve been teaching myself to put on my shoes with a straight back (don’t forget the neck!), but haven’t been able to figure out any way to cut my toenails without curving.  Maybe I’ll have to put up with lacquered toenails the rest of my life.  I got my nails cut by a nail salon person when I first broke my wrist as I could not do them myself, and the technician was so distressed at the idea of my just having my nails cut and no polish that I let her put polish on. Even though it was a nothing colour it was still weird, and I couldn’t open the very ancient pack of nail polish remover I had in the studio so it just wore off gradually over the next month.

A useful guide is to get a broomstick, place it along your spine, and learn to bend while keeping your vertebrae aligned with the pole.  At least it is a useful imaginary guide…it is actually really hard to tell what your back is doing in detail, and holding the pole top and bottom is difficult, especially with a fractured wrist.  Need a mirrored gym and a video camera and a physical therapist of my own.

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Ouch!  still haven’t figured out how to catch a sneeze ahead of it happening.  I’m supposed to support the small of my back or brace a hand against a thigh to reduce risk of fracture when sneezing…but my sneezes are unhelpful and they explode without enough warning.  Plus, of course, one should be grovelling for a tissue at the same time and not dropping whatever else is being carried and clenching (sorry) the pelvic floor muscles..

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I looked into devices to help one to develop and maintain a good posture.  Most of them are things you strap on and wear a measuring and notifying device in the small of your back.  The straps look awkward to manage and rather obvious, and most of the devices make an audible sound, so not good for discretion.  One US version allowed a sound or a vibration.

While I was looking at these I came across a device called Lumo Lift.  With the wonders of modern technology and delivery systems I found out about it the 23rd of December, and on the 24th I was presented with it as my (slightly early) christmas present by Bestbeloved.  It is very easy to use, very discrete, can be told what posture you are aiming at.  Two little taps in a new position tells the device that is what you are aiming at.  I sit straight at my desk on my Swopper chair but my back angle is slightly different from walking, and you can tell it to ‘coach’ you, where the thing buzzes whenever you go out of the desired posture, or just to monitor.  In the monitoring mode the thing gives five short buzzes if you have been out of the target posture for a length of time you can set for yourself.

An extra benefit is that it also tells you how many steps you have done.  I got an email this morning congratulating me on having walked the equivalent distance to swimming the English Channel over the past nine days.  It synchronises with your smart phone, which records the data.

The whole thing is tiny, discrete, and just clips onto your shirt or bra strap with a little magnet.  So far I am impressed with it as a way to remind me all the time to think about the shape of my back.  It measures what it calls ‘slouchy’ posture, and it is based on the angle of the device, so if my back was very straight but at an angle to the floor – as in the straight back bend I’m supposed to be learning, it would give a warning buzz.  What would be very useful would be to have two, one on the lower back and one on the upper, and for it to give a warning if the distance between these two reduced, because that would mean that the spine was curling.  I’ll write to the company and see if there is any way to do this.

I’ve already written to the company to see if the sensitivity can be altered.  While I am sitting, actively, on my lovely red Swopper stool, I register steps when I bounce…ok, I don’t bounce that vigorously a lot, but it is fun to do now and then.  The stool has made a considerable difference to my neck pain as well as keeping me moving the whole time I am at my desk, so I am very pleased with it. Fortunately I can still use the foot control of my sewing machine while on the stool, so for those of you that are envisaging a very wobbly unstable thing, it isn’t like that.  Stable with movement, like those animals on springs in children’s playgrounds.

We also retrieved the ancient Nintendo Wii from the attic and set it up in the living room.  Reducing the risk of falls is a big thing with osteoporosis, as even a hardly noticeable fall (even turning over in bed!) can lead to fractured bones.  I’ve been having fun on the balance games.  It is difficult to be sure what activities are safe to do- I’d like to do the hula hooping as it gets me out of breath and makes me laugh, but, while my back in straight the hip rotation must alter the angles of the vertebrae…until I can get a definitive answer I’ve banned that from my activities.   I’m surprised, with the numbers of people with osteoporosis and the use of the Wii with the elderly to reduce falls that I couldn’t get a list of which activities to avoid and modifications on others.  I’ll keep hunting.  Plenty of research papers available on the impact on balance and whether these balance activities equate to the tests used in other research, but no basic guide.  I wrote to the National Osteoporosis Society about one of the exercises they recommend that everyone else says not to do, but just got a (Facebook) message back saying I should phone.  I like the use of Facebook for generalisable advice as lots of people can learn from queries.

Enough sitting…January is the time for group challenges on my fused glass Facebook groups, so I’m off to do a Sgraffito drawing a day and a painting a day.  Started these to get myself out of the frit frolics I’ve been doing the last few months when I couldn’t handle sheet glass.  Still tricky, but getting my dexterity and strength back…frayed thumb tendon not fully recovered so opening jars still difficult, but making progress.

 

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BMD, fracture, Krege, Nature, prediction

numbers, numbers….and the mysteries of the invisibility of spinal fractures

The last post looked at the scores on the scans.  These show how my bones compare to other women’s bones, both young and fit, and the same age and fit.  If everyone had great bones and never got osteoporosis, someone would still be the worst.  They don’t tell you anything about what the risk of fracture is by themselves.  I’d like to know if my spine already has the small wedge fractures that lead to dowager’s hump, but I can’t tell that from anything in the current data.

The hip figures are used in an easy to use calculator called FRAX, which you can use at this link sitehttp://www.shef.ac.uk/FRAX/.  You do need to have your hip bone mineral density to work this out.  Based on my score I have a very low risk of fracture in the next ten years, even if I add in the chronic malabsorption caused by my problems with gluten (family history of coeliac disease, don’t know if I have it or one of the other gluten sensitivities).    Action for me would be some general lifestyle advice about eating well, reducing risk of falls by tidying the house, changing style of shoes etc.   With that as the sole bit of data I’d probably stop skiing (which I hardly do anymore) and try to be a bit less chaotic around the house. I already wear very sensible lace-up shoes and never wander around in my socks.

Malabsorption problems like coeliac disease are important in considering bone health.  If you don’t absorb nutrients properly, eating well and exercising properly in the bone building years to thirty will not be as effective in giving you long lasting strong bones.  I had a quick look at some current trials on osteoporosis drugs currently recruiting in the UK, and they all  excluded subjects with malabsorption issues.

So, if the spinal figures are so much worse for me, how likely am I to have a future spinal fracture?  Hard to say…the simple figure says high risk, and that is why I am taking the drugs and trying to learn to move in a way which protects my spine.  One thing that even a small amount of reading tells me is that these spinal fractures are strange and odd things.  I’ll write about what happens shortly, but for the moment a piece of research on the importance of spine imaging for identifying vertebral fracture and for identifying people at high risk for fracture makes an interesting point.

” Among 947 subjects with morphometric vertebral fracture, 66 reported a history of vertebral fracture by questionnaire and 881 did not. Thus, 93% of subjects with a morphometric vertebral fracture were unaware of the fracture. Additionally, among a total of 84 subjects with a history of clinical vertebral fracture by questionnaire, 66 (79%) were found to have a vertebral fracture by morphometric analysis of radiographs, whereas 18 (21%) were found not to have a vertebral fracture.”

http://www.nature.com/bonekeyreports/2013/130904/bonekey2013138/full/bonekey2013138.html

Fracture risk prediction: importance of age, BMD and spine fracture status

John H Krege, Xiaohai Wan, Brian C Lentle, Claudie Berger, Lisa Langsetmo, Jonathan D Adachi, Jerilynn C Prior, Alan Tenenhouse, Jacques P Brown, Nancy Kreiger, Wojciech P Olszynski, Robert G Josse, David Goltzman & on behalf of the CaMos Research Group)

What this shows is that people often don’t know if they have any spinal fractures.  That seems odd, but the individual bones in the spine are held in place by the other vertebrae, the ribs, other bits of tissue, and you can have a lot of fractures and still wander around getting on with life.  If you have ever seen those people, usually elderly women, who are out doing their shopping but walking along with a very bent back so they can only see the ground, they probably have spinal fractures that are visibly disabling but don’t prevent them from getting about.

I would like to know if I had spinal fractures already.  I’ve had years of back problems caused by my extremely pronating feet (flat feet) which I didn’t start correcting until my thirties, and I have used a programme of new prescription orthotics every year since then, combined with very controlling shoes (I found Ariat riding boots excellent, as the stiffness in place for the stirrups held my heel on the orthotics very well) and chiropractors and massage therapists helping to keep me aligned.  For the last six years or so it hasn’t mattered what podiatrist I have been to, I still can’t get rid of the neck pain, and the last two massage therapists I saw left me in pain for weeks.  Something has clearly changed.

It’s not a simple matter to know what state your spine is in.  You need access to complex imaging equipment, expert assessment of the images, and someone in the health system who decides you need to know.  It’s not like deciding to have a dental check up.  It is, of course, completely unnecessary to know if any of my spinal vertebrae are already showing compression fractures, but I’d like to see how the treatment and lifestyle choices I make now affect my spine over the next few decades.  A baseline measure would be good.

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Understanding the diagnosis

We asked the surgeon about a test for osteoporosis.  He said to ask the GP.  It looks as if, from the general reading I have done, that the bone team assume that bone density scans are initiated by GP’s and the GP’s assume that the bone team consider whether they are needed.  It is easy for a patient to slip through this assumption gap.

We asked for a scan. The GP agreed, and a couple of weeks later I was seen in a clean, calm, spacious room, and a week after that the GP had the results.  I have a vague recollection that the GP (who is really lovely and friendly), said she didn’t know what the numbers meant, but the single score prompts an osteoporosis drug and calcium and Vit D supplements if wanted (my scores on calcium and Vit D were fine but I always buy own – it seemed simpler to get the higher dose offered by prescription).

Got the pills, read all the data on the slip inside the packet, read around about side effects and effectiveness…more on that in another post.

 

We took a snapshot on a phone of the scores sent through by the DEXA people.   The hip scan shows that there is an increased risk of fracture (osteopenia) and the spine that there is a high risk of fracture (osteoporosis).  There are lots of numbers but you really only need to look for the summary at the bottom – WHO classification.

 

spine scan

hip scan

Of course, that is sufficient to decide to treat given the current guidelines, but I like to understand what is happening.  The first thing to bear in mind is that these scores are relative -they compare the amount of bone to a fit health thirty year old woman.  They tell you information about the likelihood of a fracture from a very minor fall, or, in the case of the spine, from normal activities like turning over in bed. These scores tell you how you differ from others, and I’ll write about the relative risks they indicate in another blog.

My sister sent me an excellent book called “Yoga for Osteoporosis” by Loren Fishman and Ellen Saltonstall.  The first few chapters of the book contain the best explanation of the statistical tools of Standard Deviation and T and Z scores that I’ve come across and I have three social science degrees and have spent a lot of time in statistics classes.  I’ll refer to this book several times- there’s a great section on how bones behave which I’ll write about later.

I was curious to understand the reports because I’m just generally curious, and the reading I did suggested that it was completely normal to be given a diagnosis of osteoporosis and a medical treatment without any form of explanation. Not surprising then that so many people stop taking the pills.  You get to find out about the side effects (they are described in every single packet of pills) even if you don’t experience them yourself, but you don’t know what is happening to your bones and what you might be able to do to help reduce the chances of disabling injuries. You also don’t get to know if you are improving your bones by the measures you take, unlike things like cholesterol lowering drugs where you can get almost immediate feedback on how effective you are being with lifestyle, diet and medication changes.

So, lets start with T scores.  Presuming the information in this source book (written in the USA) is the same as the UK, the T score tells you how many standard deviations your score is away from that of a healthy 25-30 year old woman.  So, that is how much you differ from someone in their prime.  The Z score tells you how many standard deviations you are away from healthy women of your age, height and weight.  We all lose bone mass from about thirty on- just some lose it a lot faster than others, and the menopause, with its change of hormone levels, makes the whole process speed up.  Men – you aren’t immune to this bone loss either, so don’t think you’re safe from fractures.  A positive score means you have denser bones than average, a negative score less dense.

So the next thing you need to know about is standard deviations – don’t worry, quick and simple explanation.  You need to know if almost everyone is about like you (say if you were an inch shorter than the average height) or if you are very different from the average ( your annual earnings if you are a top movie star).  One standard deviation around the mean includes 68.2% of people – so over two thirds of people will be in that group.  Two standard deviations include 95% of people. Only one percent of people are more than 2.5 standard deviation from the mean. If your bone density is over -2.5 standard deviations from the mean then you have osteoporosis – your bones are less dense than 99 percent of healthy young women.  Between -1 and -2.5 standard deviations from the mean indicates osteopenia – thinning bones but not yet at such a high risk of fracture.

So, peering carefully at my figures, I can see the Z and T scores for both the spine and hip.

Spine  T score    Z score

L1      -3.7            -2.8

L2      -3.0           -2

L3      -3.8           -2.8

L4     -3.9            -2.9

total  -3.6           -2.6

 

Hip

neck   -2.2        -1.2

total   -2.3        -1.7

The other numbers are the density readings the statistical comparison uses.  They would be meaningful to bone specialists.  I don’t need to know to figure out what the scans mean for me.

You’ll notice that the numbers in the second column are smaller than the numbers in the first column.  My bones are much less dense than those of young healthy women, and not quite so much worse than women of my age and build.  One of my lumbar vertebrae scored less than the minus 2.5 standard deviations worse than other women my age (yay!  Go lumbar vertebra 2!).  They average out to -2.6, which puts my lumbar spine in the osteoporotic range- only this area is scanned so I have no idea what the rest of my spine looks like. My lumbar vertebrae are less dense than about 99% of healthy women my age.

 

The hip bone is more dense- I score in the osteopenia range, where the bone has begun to thin and efforts should be made to reduce the onward thinning, but the risk of fracture is not so high. My hip bones are less dense than about 90% of healthy women my age and build.

 

So, why should I care what this means?  I got the pills- why not just take them and hope for the best?  Well, partly because the side effects listed are pretty gross.  Partly because compliance with the medication offered is so poor- so many people stop taking the drugs within the first two years when the risks will only get greater over the rest of their lives.  Partly because it looks as if  postural and exercise changes can make a significant difference, and partly because I’m just chronically nosy.

 

 

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