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The nuts and bolts of bones and joints

The increased weight on musculoskeletal health

By CARMEN MARTI

Do you know that you're living in the Bone and Joint Decade? Do you even have a clue what the Bone and Joint Decade is? You will by 2012 if the American Academy of Orthopaedic Surgeons has anything to do with it. That organization and a worldwide consortium of health care professionals, patient organizations and medical institutions have given themselves 10 years, from 2002 to 2011, to make a dent in the wildly accelerating prevalence of bone and joint disorders.

With the first wave of baby boomers turning 60-years-old, it's no wonder bone and joint issues are increasing. But the cost, both monetarily and socially, may be more surprising. According to a 2003 report issued by the World Health Organization and the Bone and Joint Decade organization, "Total costs of musculoskeletal disease in the United States in 2000 were calculated at $254 billion. In developing countries, the costs for injuries care is estimated at $100 billion, a figure nearly twice that of total foreign aid for these nations."

That's not to mention the prevalence of people affected. Musculoskeletal conditions, as bone and joint problems are technically known, are common in all regions of the world and encompass approximately 150 diseases and syndromes affecting children and adults. They can develop throughout the body, in the neck, shoulder, spine, arm, elbow, hand, hip, knee, leg or foot. Conditions include ligament damage, arthritis, osteoporosis, fractures, sprains and back pain. The number one cause of reported chronic pain or disability, these kinds of impairments also rank as the number one in reason for visits to physicians' offices.

Treatments can involve joint replacement, spinal disk fusion and traction, none of which are painless. These procedures are on the rise nonetheless.

According to the WHO report, there's an urgent need to address the impact of musculoskeletal conditions across the globe. "Longer life expectancy with an increasing number of elderly in all population groups have led to an escalating prevalence of musculoskeletal diseases worldwide," said lead investigator Anthony Woolf when the report was issued. "This will continue

to increase." Woolf went on to say that musculoskeletal conditions are among the most costly illnesses, consuming on average 3 percent of the total Gross Domestic Product in developed countries. "With an increasing prevalence in both developed and developing nations, the financial and health care burdens are set to escalate dramatically," Woolf said.

To address this problem, the people behind the Bone and Joint Decade have set out to promote research and to educate the public about prevention and treatment. One in three Americans is treated for chronic musculoskeletal impairment or a musculoskeletal injury in any given year.

Back pain, one of the most common musculoskeletal conditions, is something Christine Warner has lived with for 20 years.

The fit, 51-year-old human resources executive first jammed her back while sledding. She thought she had broken her tailbone, but as it turned out, Warner had a herniated disk, one that had ruptured and protruded, potentially pressing on spinal nerves. Warner had lower back spasms and shooting leg pain. Her herniated disk was pressing on the roots of her sciatic nerve, which runs the length of the lower spine to the foot. She had sciatica, a common and painful condition.

After a round of physical therapy and steroids to reduce inflammation, Warner tried to let the condition heal itself. Many people feel better seven days after back pain begins, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases at the National Institutes of Health. The problem is usually completely gone after another four to six weeks. Most often self- care, including ice packs, heating pads, analgesic medications, such as Advil, and a slowed pace can heal an orthopedic problem (bed rest isn't usually recommended- movement is better).

After five years of chronic pain, Warner decided she wasn't getting better. The next step was surgery.

"Let's go," Warner told her doctor, prepared to try anything to relieve her discomfort. Finally, after a laminectomy to remove part of her protruding vertebra, Warner's back pain improved. She felt so good she over-exerted herself, causing a new round of spasms. But with post-surgical physical therapy, Warner learned to manage her condition and control pain with over-the-counter painkillers.

At least for a while. After about a decade, Warner started experiencing pain in her upper back. The doctors first thought it was carpal tunnel syndrome, and they fit her with wrist braces. She hoped for the best and continued with plans for a vacation in Paris with her husband, but Warner was miserable. Her only relief came when walking. "Sitting was uncomfortable," she remembers. "Lying down nearly unbearable."

When the couple returned to the United States, Warner was diagnosed with a herniated disk in her upper back. She was, as she describes it, put on "the rack," a traction system that stretches the body from head to toe in 30-second increments. She went to the hospital three times a week for a three-week stretch of 30-minute treatments. "It was amazing for the disk," Warner says. "If I ever feel that kind of pain again, I'll go for the rack." Since then, Warner has been "very functional," she says. "But I am aware now. I know the difference between normal and neural [discomfort]."

Warner takes precautions. To help prevent pain, she first turned to swimming because of its low impact on bones and joints. Now she includes time on the treadmill and light weight lifting. "I definitely find that the more exercise I get, the better."

The same is true for all musculoskeletal patients and those who have yet to experience bone or joint discomfort. Injuries can take time to manifest and can occur from the simplest movements. Warner's doctor told her she could just as easily have herniated a disk stepping off a curb as she did snow sledding. That's not to mention all the conditions that tend to onset with age such as arthritis and osteoporosis. These days, osteoporosis is the most prevalent bone

condition among Americans, with nearly one in two women and one in four men, likely to suffer from it in their lifetime.

So get moving, says Dr. Sherwin Ho, associate professor of orthopedic surgery at the University of Chicago and spokesman for the American Academy of Orthopaedic Surgeons. "Our biggest push is to get people to be more active and to appreciate the value of exercise. It prevents childhood obesity in the young and osteoporosis in the elderly."

Ho says one of the television spots sponsored by his organization portrays the classic couch potato kid, watching TV with a remote control, walking the dog on a treadmill while he sits beside it, playing video games. It's kind of funny, but also very serious. The message: "Be active in everyday life," Ho says.

"We encourage physical activity in young people, period," he says. "In adults we encourage activity, but safe activities and proper exercise. Now is the time when stretching and a good warm-up before exercise become important."

And if you've had specific problems, there are low-impact exercises that target various parts of the body. For example, Ho says core body strengthening for back pain, which builds the abdomen and back muscles, is critical to prevention and recovery. And he cites the

McKenzie Method of physical therapy and exercise, which extends the spine to help relieve back or neck pain, as being proven effective.

"At 18, 22, the body can handle injury and bounce back," Ho says. "But once you hit your 30s, 40s [and] 50s, that doesn't always happen. This is the age that needs common sense pointers."

One pointer: don't over do it. Ho says the problem doctors tend to see most is overuse, often causing knee injuries. "One thing we're pushing for is managing and preventing knee wear and tear."

And keep down weight, Ho adds. "Obesity is a bad thing for bones and joints. Take care of your body. Be aware of how important it is to take care of your bones and joints now, and they will take care of you in the future."

Stand up Straight

Little things can make a big difference when it comes to back pain. To help

prevent problems with bones and joints, particularly those associated with the back, MayoClinic.com recommends proper body mechanics:

* Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back.

* Sit smart. Choose a seat with good lower back support, armrests and a swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level.

* Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward.

* Sleep smart. People with back pain have commonly been told to use a firm mattress, but recent studies indicate that a medium-firm mattress might be better. Use pillows for support, but don't use a pillow that forces your neck up at a severe angle.

Orthopedic Progress

Cutting edge musculoskeletal treatments

Orthopedists have seen big breakthroughs both in operative and non-operative treatment of musculoskeletal disorders, according to Dr. Sherwin Ho, Associate Professor of Orthopedic Surgery at the University of Chicago and spokesman for the American Academy of Orthopaedic Surgeons.

Ho cites advances in physical therapy and exercise, beginning with the development of the McKenzie Method in the 1960s. "These things are becoming more widely used," he says. "There's been a lot of progress treating back injuries non-operationally."

In addition, Ho says four developments over recent years have made a huge impact on surgical treatment:

* Arthroscopic surgery

Arthroscopy, a minimally invasive surgery, is performed while looking into the joint with a tiny camera. It enables surgeons to operate through small incisions, reducing trauma and minimizing recovery.

"Arthroscopic surgery is becoming successful in treating injuries we couldn't treat before," says Ho. "Hip arthroscopy has become a big new field. Now hip surgery is an outpatient procedure with three small incisions and a cure within weeks."

* Computer-assisted surgery

Computers, now common in the operating room, enable surgeons to work with more visual resources and thus more precisely. As a result, existing surgeries such as knee replacements or ligament reconstructions are being fine-tuned. "With fine-tuning, we improve outcomes," Ho says.

* Biologics

New drugs now support surgeries such as cartilage transplants that use a patient's own cells, or a donor's, to replace damaged cartilage.

* Genetics

"We can now replace tissue through gene therapy," Ho says. The identification of bone morphogenic protein 2, which induces the formation of bone and cartilage, enables surgeons to stimulate tissues that previously wouldn't heal to grow.

In other news:

* Osteoporosis not only affects women--it's also prevalent in aging men. In fact, it's estimated that more than two million men in the United States have the condition. Osteoporosis is often considered a woman's disease because it's linked to the loss of estrogen that occurs during aging. Because women have higher levels of estrogen, most of the research on osteoporosis has been focused on them. However, men also undergo a loss of estrogen and other hormones that affect bone density, albeit more gradually than women. Men who have the greatest risk of osteoporosis are those who are over the age of 75, have a low body-mass index, have lost more than five percent of their body weight in the previous four years, currently smoke and are physically inactive. Men are more likely than women to have osteoporosis secondary to an underlying disease or metabolic problem.

* People who take just dietary calcium, or a combination of dietary calcium with supplements, have better bone density than those who take supplements alone, according to a new study from Washington University School of Medicine.

* Nutrition researchers are recommending a big increase in the recommended daily dose of vitamin D, the sunshine vitamin. Dozens of recent studies suggest that deficiencies of the vitamin make people more vulnerable to everything from fractures to certain cancers and diabetes.

* Mushrooms may be a significant source of vitamin D. New research, while preliminary, suggests that brief exposure to ultraviolet light can initiate production of vitamin D in all mushrooms.

* Controlled clinical trials on the treatment of low back pain with chiropractic therapy and exercise are now being conducted by

the National Institutes of Health. NIH is recruiting patients for studies on the combination of integrative and conventional treatments for back pain. Visit nccam.nih.gov/health/chiropractic.

--Carmen Marti

Published: August 01, 2006
Issue: Fall 2006