Osteoporosis is a skeletal disease characterized by low bone mass, and the deterioration of bone architecture leading to bone fragility and increased risk of fracture. Bone normally rejuvenates itself through a process of bone absorption and formation called bone remodeling. Osteoporosis occurs when bone breakdown, or absorption, occurs at a rate greater than bone formation.      

Osteoporosis has been called "the silent thief" because bone loss often causes no symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a bone fracture. An X Ray may reveal a seriously deteriorated vertebra. Once a vertebral fracture has occurred, symptoms can include severe back pain, loss of height, and spinal deformity.

The specific causes of osteoporosis are not known. However, risk factors that increase the likelihood of developing osteoporosis have been identified. A few of the risk factors are:
» Postmenopausal
» Ethnicity-Caucasian and Asian
» Family history
» Petite, small frame
» Eating disorders
» Caffeine
» Smoking
» Excessive use of alcohol
» Vitamin D deficiency
» Inactivity
» Thyroid disease
» Chronic steroid use

Bone density testing (DEXA Scan) is a quantitative estimation of Bone mass and is a readily available test to demonstrate whether Bones are Osteoporotic (Low Bone mass) or not. The test is recommended for all women over 65 years old. In addition, women with risk factors other than menopause, postmenopausal women with a history of a fracture are also advised to undergo the test. 

It is a noninvasive test wherein an x-ray can show bone loss in the spine and hip area. The test takes about 10-20 minutes.

• How can I prevent/treat osteoporosis?
  Early diagnosis and treatment is the best approach to preserve bone mass. For those who already have osteoporosis, medical treatment can slow bone loss and decrease the risk of fracture. Currently available therapies include calcium and vitamin D. Estrogen, calcitonin or bisphosphonates can be added to calcium and vitamin D. A rehabilitation program designed to reduce pain, increase mobility, and minimize risk of falling is an important part of any therapeutic regimen.
  
  A comprehensive, individually designed exercise program is especially important for:
  » increasing muscle strength and endurance
  » increasing flexibility
  » improving bone health
  » improving balance and stability
  » improving posture and body mechanics
  
  People with osteoporosis also benefit from education about self-care techniques, independent living skills, methods of conserving energy, and strategies for minimizing risk of injury. Surgical procedures are indicated usually in case of Osteoporotic Fractures.

Calcium should be taken after meals in divided doses of no more than 500mg (Elemental Calcium). Calcium should preferably be be taken with vitamin D 400-800 IU. The table below lists the recommended dose based on age.

There are many excellent sources of calcium namely milk and milk products like yoghurt and cheese, eggs,ragi, fish meat, almonds, spinach and fenugreek leaves, banana etc

There are many excellent sources of calcium namely milk and milk products like yoghurt and cheese, eggs,ragi, fish meat, almonds, spinach and fenugreek leaves, banana etc

Exercise stimulates the bone remodeling cycle. Weight bearing exercises such as weight training, running, walking, biking and cross country machines will provide both aerobic and weight bearing exercise. Consult your physician before beginning an exercise program.

Exercise stimulates the bone remodeling cycle. Weight bearing exercises such as weight training, running, walking, biking and cross country machines will provide both aerobic and weight bearing exercise. Consult your physician before beginning an exercise program.

There are several medical treatments for osteoporosis. Estrogen therapy has been used to treat osteoporosis especially in post menopausal females for many years. Newer non hormonal treatment options are now available; these are the bisphosphonates like alendronate and risedronate, raloxifene, a selective estrogen receptor modulator (SERM), calcitonin and newer bone forming molecules like Teriparatide. Always Talk to your Orthopaedic Surgeon/Health Care Provider to determine the best treatment option for you.

It is a common degenerative joint disease in aged population. In this disease, the surface of the joint gets damaged (i.e. degeneration of joint cartilage) and the surrounding bone gets thicker.

1. Primary Osteoarthiritis (idiopathic)
A. Localised
» Hands : Nodal osteoarthiritis more than three joints involved.
» Hip : Eccentric, concentric, diffuse.
» Knee : Medical tibiofemoral, lateral tibiofemoral, patello femoral.
» Spine : Apophyseal, intervertebral, spondylosis

B. Generalised
» Small (peripheral) joints
» Large (central) joints
» Mixed and spine

C. Erosive Osteoarthiritis

2. Secondary
» Congenital & developmental disorders, bone dysplasias.
» Post surgery/ injury – meniscectomy.
» Endocrine: diabetes mellitus , acromegaly, hypothyroidism, hyperthyroidism, hyperparathyroidism, cushing syndrome.
» Metabolic: haemochromatosis, ochronosis, marfan's syndrome, ehler-danlos syndrome, paget's disease, gout, pseudogout, wilson's disease, hurler's disease, gaucher's disease.
» Rheumatologic: Rheumatoid arthritis.
» Neurological: Charcot joints.
» Hematological: haemoglobinopathies.
» Iatrogenic: Intra-articular steroids.

Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.

Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.

Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.
Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected.

Financial effects include
» The cost of treatment
» Wages lost because of disability

Lifestyle effects include
» Depression
» Anxiety
» Feeling of helplessness
» Limitations on daily activities
» Job limitations
» Trouble participating in everyday personal and family joys and responsibilities.

Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following:

» Pain relief medications
» Rest and exercise
» Patient education and support programmes
» Learning self-care and having a "good-health attitude".

Apart from a detailed medical history and physical examination, the doctor will recommend various tests to evaluate and diagnose the condition. These include :

» Blood test for C-reactive protein (elevated in Osteoarthritis). It is also a good predictor of progression of Osteoarthritis.
» ESR and test for Rheumatoid factor to exclude Rheumatoid arthritis.
» X-ray of the affected joint which may show loss of joint space, bony marginal lipping and bony projection (spurs)
» Synovial fluid examination to rule out infection. Presence of cartilage cells in synovial fluid is an indicator of OA.
» Arthroscopy: TO visualize the joint internally.
» CT scan or MRI of the affected joint

» Controlling body weight
» Taking medication regularly as advised by the doctor.
» Eat healthy: Take high intake of antioxidants specially vitamin C that reduces the progression of osteoarthritis. Calcium and vitamin D intake should be adequate.
» Taking adequate rest
» Avoiding joint overuse or repetitive injury
» Exercise : Isometric (physical exercises in which muscles are made to act against a fixed object) strengthening of supporting muscles around joints may be helpful. Swimming is the best form of aeobic exercise for those with osteoathritis of hip or knees. Running should be avoided.
» Yoga and other alternative therapies have been scientifically documented to complement the use of drugs. ( To see the proper scientific and validated yogic protocol for Arthritis, log on to www.bestonhealth.com )

Non Medicinal Management

A. Effective Exercise Programme:
B.Heat Therapy
» Moist heat is better than dry heat.
» Application of deep heat before starting exercises.
» Therapies like short wave, microwave & ultrasound are most commonly used.
C. Hydrotherapy:
Hubbard tank hydrotherapy.
D. Patellar tapping:
Patello femoral joint pain is relieved by patellar tapping to pull it medially, followed by quadriceps exercise to strengthen the vastus medialis portion particularly.
E. Wedging the heel & sole:
Lateral wedging.

Semi Invasive Techniques:
» Intra articular steroids like cortisone
» Intracuticular Hyaluronic acid
» Arthroscopic knee washouts

Medicinal:
» NSAIDS ( Non Steroidal Anti-inflammatory drugs)
» Glucosamine
» Chondroitin
» Antioxidant Vitamins

Surgery:
For patients where the comprehensive medicinal & non-medicinal management has been ineffective, surgical intervention like:
» Soft tissue release.
» Osteotomy of bones.
» Arthoplasty – THR(Total Hip Replacement),TKR(Total Knee Replacement), etc.

Surgical options available are:
» Arthroscopy & Arthroscopic debridement
» Osteotomy (Alteration of joint biomechanics by joint realignment)
» Joint replacement (Total Joint replacement, hemiarthroplasty, unicompartmental arthroplasty)
» Arthrodesis (Surgical fusion of the joint)

Aims of artificial joints are:
» Patient should be able to perform all activities of daily living.
» Joint replacement should last more than the life of the patient.
» The patient should be able to play sports.
» The total joint should be a cost saving surgery.

Hip:Ball & Socket joint.
» Ball : attached to the top of the femur
» Socket : Part of the pelvis

It is estimated that 1kg of extra body weight increases 10kg of extra vertical load on the knee joints. Hence, losing weight can help you to reduce this excess load on your joints and lessen the symptoms.

High-impact and weight-bearing exercises such as jogging, skipping, basketball, running, weight lifting should be avoided by osteoarthritis patients.

Warm bath, Jacuzzi or hot shower, hot water bottle and cold packs do reduce pain, swelling and stiffness in Osteoarthritis.

Physiotherapy is a broad term used commonly for exercises, muscle strengthening and gadgets used for pain relief. Muscle strengthening and mobility of joints is very important. For pain relief Short Wave Diathermy (SWD), Interferential Therapy (IFT), Ultra Sonic Therapy, Lazer and Paraffin Wax Therapy are commonly used.

Rheumatoid arthritis (RA) is an inflammatory disease that causes pain, swelling, stiffness, loss of function an deformity in the joints.

As it is a systemic disease, areas outside the joints may also get involved for example membranes surrounding internal organs, such as the heart, lungs or eyes. RA tends to run in families, Moreover Women are three times more prone to develop rheumatoid arthritis. But with advanceing age the ratio of women to men becomes almost equal.

Rheumatoid arthritis is an autoimmune disorder. Normally, a healthy immune system is programmed to protect the body from harmful foreign bodies like bacteria and viruses but in rheumatoid arthritis the immune system (defense system) of the body, for unknown reasons, starts attacking the body's healthy tissue. The reaction results in inflammation of joints causing reduction in joint space and loss of normal joint shape and alignment. Important features of Rheumatoid arthritis:

» It may begin by age 25 and usually before 50 years of age but some times seen in children too.
» May develop suddenly within a period of weeks/ months but is usually gradual (slow onset)
» Involves the joints symmetrically i.e. joints on both sides of the body are involved
» Usually affects the small joints of the hand, foot, wrist, elbow, shoulder or ankle.
» Causes inflammation resulting in pain and swelling of joints where the joint is warm and tender.
» Early morning stiffness lasting for more than one hour
» Causes symptoms in other organs of body besides the joints such as lungs, heart & eyes.
» May cause overall tiredness, weight loss and occasional fever
» Finger deformities (‘swan neck' deformity and ‘boutonniere' deformity) are characteristics of RA.

Apart form a detailed medical history and physical examination the doctor will recommend various tests to evaluate and diagnose the condition.

These includes: Blood test for ESR (increase in RA) and blood cell count (shows increase in white blood cells and platelets because of inflammation) · Serology test for Rheumatoid factor (an abnormal antibody), which is present in 70-80% of RA cases. X-ray is usually done to find out the degree of damage that the joint has suffered and later to monitor the progress of the disease. Synovial fluid examination to rule out infection.

Becoming aware about the disease · Taking the medications regularly · Take a diet low in fat, moderate in sugar, rich in Gamma linolenic acid (found in nuts and fish, promrose oil) and omega 3 fatty acids like nuts and fishes like salmon, mackerel, and herring. · Controlling body weight · Taking adequate rest. Acutely involved joints must be given rest or splint to reduce inflammation. · Regular exercise to strengthen muscles (as advised by the doctor) surrounding the involved joints.

Yoga and other alternative therapies have been scientifically documented to complement the use of drugs.

NSAIDs These drugs are mainly used for Pain relief and Anti-inflammatory action.

DMARDs: Methotrexate (Oral & I/V), Salzopyrine, Hydroxychloroquine, Leflunomide. Earlier medicines in this group included Gold salts, D-Penicillamine are less used now.

Advanced treatment of Rheumatoid arthritis.
The Biological: The biologicals are injectible drugs – Tumor necrosis factor Alfa (TNF Alfa) blocking agents and interleukin – 1 receptor antagonist (IL-1ra) are new drugs for RA treatment. They are expensive but have been found to benefit otherwise inadequate response patients.

The anti TNF Alfa agents – Infliximab, Etanercept and adalimumab have set new standards for RA therapy.

Stem Cell implantation: is another new, promising area for the hopeless patients. It is embryonic and adult type – principle is once implanted stem cell has potential to replicate and grow more healthy cells and hence cure the disease.

Smoking tends to increase the Rheumatoid factor (RF) concentration in blood and high concentration of RF is usually associated with severe rheumatoid disease. Besides smokers are more at risk of lung disease. Hence, it is best to quit smoking.  

Although Rheumatoid arthritis may affect you daily in long run, early detection of disease and judicious management (with medications, exercise dietary modifications) can easily prevent the progress of your disease, preserve joint movement and prevent deformities.

Frequent Blood tests are required to assess the progress of disease or side effects of medication on vital organs such as liver, kidneys and bone marrow. Your doctor may advise ESR, Hemoglobin, Complete blood count, Liver function test (kidney function test (KFT) at frequent intervals.  

Response to treatment may be observed as a general sense of well-being through the course of treatment with adequate treatment there may be decrease in the duration of morning stiffness, decrease in the number of swollen and painful joints. You will be able to perform your daily activities with less discomfort. Monitoring of laboratory parameters such as ESR (Erythrocyte Sedimentation Rate), Rheumatoid factor, C-reactive protein also helps in assessing the disease activity and response to treatment.

Rheumatoid factor is present in blood of approximately 75% of rheumatoid arthritis patients. Those patients having RF in blood are called “Seropositive” whereas remaining 25% who do not have RF in blood are called “Seronegative”. Seronegative rheumatoid arthritis patients have a better prognosis than seropositive patients. 

High levels of Rheumatoid factor is commonly associated with more severe rheumatoid disease and non-joint manifestation of rheumatoid arthritis such as rheumatoid nodules, rheumatoid lung disease etc.

Gout(Presents as a Swelling in one joint, most commonly Great Toe)It is a metabolic disorder characterized by recurrent attacks of acute inflammatory arthritis—a red, tender, hot, swollen joint.

Colchicine is very effective for pain relief in acute gout but not used frequently due to its side effects. These drugs decrease in blood uric acid levels by increasing excretion of uric acid in urine (Probenecid and Sulfinpyrazone) or reducing production of uric acid (Allopurinol) inside the body. It is important to remember that while taking Probenecid or Sulfinpyrazone one should take plenty of water.

 Cervical Spondylosis is a degenerative disease characterized by abnormal growth of bones (osteophytes) of the spine in the neck region (cervical vertebrae), herniation (protrusion) and deposition of calcium in the cushions (interverterbral disc) present between the cervical vertebrae. This phenomenon may cause compression of nerves in the neck region resulting in symptoms of Cervical Spondylosis. The nerve roots commonly involved are C5 and C6, C6 andC7.

» With advanced age some degree of bone degeneration (deterioration) is normal. Hence Cervical Spondylosis is commonly seen in the middle aged and elderly people.
» Any kind of trauma to the neck region may also result in early degeneration of the bones.
» People suffering from degenerative diseases like Osteoarthritis are more prone to develop Cervical Spondylosis.

Usually a person may have no symptoms, unless there is compression or stretching of cervical nerves or spinal cord. Symptoms may include:

» Pain and stiffness in the neck, reducing the range of movement especially rotation and lateral (sideways) movement of the head.
» Neck pain may also radiate to the shoulder and to the arms and usually gets worse with movements of neck, coughing sneezing or straining effort.
» Headache especially at the back of head.
» Tingling, burning sensation or loss of sensation at shoulder, arms or forearm.
» Nausea, giddiness and vertigo, tinnitus (ringing in ear).
» Muscle weakness or wasting of muscles of the shoulder, arms, or hands.
» Weakness in lower limbs and loss of control of the bladder and bowel movements (if spinal cord is compressed).

It can be judiciously controlled in the following ways:

» Neck exercise (with doctor consultation) to strengthen the muscles and increse the range of the movement. Exercises may be learned from a physiotherapist and practiced at home regularly.
» Restriction of neck movements by means of cervical collar may relieve pain.
» Painkillers and muscle relaxants (with doctor consultation) can also help in relieving pain Avoid any unnecessary strain in the neck area:
» Avoid driving car but if driving, wear a cervical collar and avoid any jerky movements as it may trigger pain.
» Avoid bending neck for long hours, after every two hour take a 5 minutes break and carry out neck exercise prescribed by the physiotherapist.
» Neck traction (a process of pulling) with the help of a special device may also be recommended by the doctor to relieve pain.
» Short wave diathermy or Transcutaneous Electrical Nerve Stimulation (TENS) may provide pain relief. Surgery may be required only in severe cases where there is significant loss of muscle strength or sensation or if the symptoms do not respond to the above measures.

There are more than hundred forms of arthritis and in most common of them some dietary modifications are advised to patients. This not only eases the pain but also reduces the chance of other associated complications. Some forms of arthritis like Gout has a close relationship with dietary practices.

Maintain your ideal weight – Obese people are more prone to these disorders because, excess weight puts an added burden on weight-bearing joints, which can worsen the situation. So, try to avoid excess calories and make your meals light (low-fat) and healthy. If you are obese, try to reduce the weight gradually. Do not practice fasting or crash diet as these practices do more harm than good.

» Eat a well-balanced diet – your diet should compromise of all the major food groups (cereals, pulses, milk, flesh, foods, vegetables, fruits, fats and sugars). However, the form of meat consumed can be altered. It has been observed that fish and fish based oils have some anti-inflammatory properties (due to the presence of omega-3 fatty acids) and are therefore, beneficial in arthritis.
» Fluid intake-Liberal fluid intake (up to 2-2.5 L/day) is advised.
» Vitamins and minerals – Sometimes different dietary supplements are used to correct the imbalance of vitamins and minerals. Vitamin D, C and Calcium are of utmost importance in arthritis. Some rich sources of them are milk and milk based products, leafy green vegetables, mackerel and other oily fishes.
» Regular physical exercises – Regular exercise schedule not only takes care of obesity but also provides some movement to joints. Proper exercises can be selected with the consultation of some good physical trainer.

» Avoid high calorie, deep-fried fatty foods and use combination of various oils as the cooking medium (rice bran, sesame, groundnut, sunflower, safflower, cottonseed, corn, mustard, soybean oils can be used).
» In gout you have to avoid purine rich food products like glandular meat (brain, kidney, liver, heart etc), meat extracts, sea foods, sardines, beans, peas, lentils, spinach, oatmeal, yeast and yeast based products. ·
» Avoid alcohol completely.

Yes, some studies have indicated that omega 3 fatty acids (a type of polyunsaturated fatty acids) have some anti-inflammatory qualities. Due to this they can help in reducing joint tenderness and morning stiffness in the arthritis patients.Some rich sources of omega-3 fatty acids are fishes (salmon, mackerel, herring etc.), mustard soyabean., flaxseed and evening primrose oil. There are various supplements available in market for Arthritis patients. Are they effective? Supplements that contains Glucosamine and Chondroitin sulphate can provide some relief in Arthritis symptoms. Glucosamine not only helps in protecting joint structure but also provides pain relief and increased mobility. Similarly, Chondroitin sulphate helps in repairing the damaged articular cartilage.

It has been observed that high intake of antioxidants specially vitamin C reduces the progression of osteoarthritis. However, antioxidants cannot prevent the onset of diseases. Other antioxidants, which can be useful in Arthritis, are vitamin A and E.Some rich sources of these vitamins are wheat, papaya, pineapple, mango, citrus fruits, carrots, pumpkin, dark green leafy vegetables and tomatoes.

Yes, exercising forms an integral part of the arthritis control plan and helps in lifting the sprits. It helps to maintain: Normal muscle strength, Joint structure and Function of joint and The type and pattern of exercises have to be individualized depending on the type of arthritis, the joints involved, the range of mobility and extent of joint damage.

» Before starting an exercise programme always consult your doctor and get an individualized exercise plan made for yourself.
» Identify the type of exercise you feel more comfortable.
» Massage or apply heat/cold application to the sore joint before starting the exercise.
» Warm up before exercising by starting exercise at a slower pace.
» Know your limit and don't over do the exercise ·
» Do exercise at a comfortable pace and allow the muscles to relax in between.
» Doing exercise exactly as per the instruction is more important than doing it number of times.
» Wear comfortable clothes and shoes while exercising.
» While exercising avoid jerky movements.
» Cool down for 5-10 minutes after the exercise. To cool down, simply do exercise activity at a slower pace, such as walking slowly.
» Avoid exercising during flare ups i.e. when you are having symptoms.
» Stop exercising immediately if you have:
» Severe pain in chest.
» Severe breathlessness.
» Dizzy feeling or sick feeling in the stomach Note :
» In osteoarthritis of knees or hip, all exercises need to be done in non- weight bearing position (i.e. not in standing position).

Over 85% of the population in the industrial world will experience low back pain sometimes in their lives. In fact back pain is the most frequent cause of activity limitation in people younger than 45 years.It generally remains a benign condition. Some 60% of patients recover in a week and about 90% in 6 weeks.

» Faulty posture habit especially seen in people who tend to sit around for long time at one place (e.g. those working with computers).
» Osteoarthritis (especially in old people).
» Osteoporosis (especially in post-menopusal women).
» Tuberculosis.
» Injury to spine.
» Cancer prostate (especially in old age).
» Stress also plays an important in causing low back pain.

Usually low back pain resolves within a few days to 1-2 months. Following symptoms may be suggestive of serious low back pain:
» Weight loss, fever and chill (indicative of infection & sometimes malignancy)
» Intolerable pain, patient tosses about in bed and is unable to lie still due to pain (indicative of kidney stone or ruptured organ)
» Evolving nerve problems such as bladder/bowel problems (e.g. repeated urination without adequate control)
» Early morning stiffness (for more than 30 minutes) in a person less than 45 years of age (indicative of rheumatoid arthritis).
» Unresponsive pain (lasting for more than 2 months).

X-ray of spine, MRI (for tumor), CT (for tumor), Bone densitometry (for thinning of spine), Radionuclide scanning (for tumor and osteomyelitis – infection of the inner part of bone i. e. till bone marrow) may be advised.

Key elements of the conservative treatment for low back pain includes:
» Taking medication for pain regularly as advised.
» Maintaining proper body weight- Education and activity alteration.Certain precautions need to be taken in low back pain:
» Avoid lifting heavy objects .
» Use the legs rather than the back lifting
» Maintain proper posture while sitting and standing, do not slouch .
» Use a chair with arm rests.
» Rise from the bed by first rolling to one side and then using the arms to push to an upright position.