Along the spine, women buckle at breaking points

An 80-year-old friend was lifting a corner of the mattress while making her bed when, as she put it, "I broke my back."

In fact, she suffered a vertebral fracture — a compression, or crushing, of the front of a vertebra, one of the 33 bones that form the spinal column. This injury is very common, affecting a quarter of postmenopausal women and accounting for half of the 1.5 million fractures due to bone loss that occur each year in the United States.

By age 80, two in every five women have had one or more vertebral compression fractures. They often result in chronic back pain and impair the ability to function and enjoy life. They are one reason so many people shrink in height as they age.

Multiple vertebral fractures, found in 20 percent to 30 percent of cases, often result in a hunched posture, a condition called kyphosis that impairs breathing and compresses the abdomen, leading to a protruding stomach with limited capacity.

But while vertebral fractures are a telltale sign of bone loss among women over age 50 and men over age 60, most who suffer them are unaware of the problem and receive no treatment to prevent future fractures in vertebrae, hips or wrists, the bones most likely to break under minor stress when weakened.

Yet, if a vertebral fracture is diagnosed and properly treated, the risk of future fractures, including hip fractures, is reduced by half or more, studies have shown.

"Most vertebral fractures do not come to medical attention at the time of their occurrence," Dr. Kristine E. Ensrud and Dr. John T. Schousboe wrote recently in The New England Journal of Medicine. One reason is that the pain may be minimal at first or, if more severe, attributed to a strain that subsides over a few weeks.

Indeed, patients or their physicians are made aware of these fractures in just one-fourth to one-third of the instances in which they are discovered on X-rays, according to the doctors.

"The patient may have had a chest or back X-ray for some other reason, perhaps to rule out pneumonia, but the focus is on why the test was ordered, and an incidental finding of a vertebral fracture is ignored," Ensrud said in an interview. "Doctors need to be more aware of this problem, and maybe patients should ask to see the report."

Ensrud, an internist and epidemiologist who researches osteoporosis at the University of Minnesota and the Veterans Affairs Medical Center in Minneapolis, noted that in a person with severe osteoporosis, a vertebral fracture can be caused by something as mundane as coughing, sneezing, turning over in bed or stepping out of a bathtub.

In patients whose bone loss is less advanced, a fracture may occur when lifting something heavy, tripping or falling out of a chair.

"A lot of the time, people don't recall the incident," Ensrud said. "They just report that their back has been bothering them." Patients also may mistakenly assume that their chronic discomfort is a result of arthritis or a normal consequence of age, and never mention it to their doctors.

About one-third of the postmenopausal women found to have vertebral fractures do not have osteoporosis as defined by bone mineral density testing, according to Ensrud and Schousboe. Rather, test scores indicate that these women are suffering from a lesser form of bone loss called osteopenia.

Yet the occurrence of vertebral fractures means that the situation is worse than bone density testing would suggest. "The identification of a vertebral fracture indicates a diagnosis of osteoporosis," Ensrud and Schousboe concluded in their article.

Asked if such women should receive bone-preserving medication, Ensrud said emphatically, "Yes!" One major study found that a vertebral fracture raises the risk of further vertebral fractures by five times in just one year.

A vertebral fracture can be seen on an ordinary X-ray of the spine. But there is a more practical approach involving much less radiation: a scan of the spine called a lateral DEXA, an acronym for dual energy X-ray absorptiometry, as part of a routine bone density exam.

The scan requires special computer software. Patients must ask whether a particular clinic or hospital is able to perform a lateral DEXA.

If a postmenopausal woman whose bone density measures in the osteopenic range (suggesting bone loss, but not yet full-blown osteoporosis) is found to have a vertebral fracture, her doctor may decide to prescribe medication that increases bone strength. Often the drug will be a bisphosphonate like alendronate (brand name Fosamax), which is now available in an inexpensive generic form.

Future fractures can often be prevented if a bisphosphonate is taken by someone found to have one or more vertebral fractures, even if these fractures cause no discomfort. There are many other bone-building options, too, including a once-a-year injection.

In addition, patients should consume adequate amounts of calcium and vitamin D, the critical nutrients for strong bones: a total of 1,200 milligrams of calcium daily from food and supplements, and 1,000 international units daily of vitamin D.

Initially, a painful vertebral fracture may be treated with a short period of bed rest and pain medication like a nonsteroidal anti-inflammatory drug, narcotic, pain patch or an injection or nasal spray of calcitonin. But if too much time is spent in bed, the resulting weakness can increase the risk of further fractures.

Whatever is done, or not done, to treat the injury, the pain of a vertebral fracture usually subsides over the course of several weeks.

Ensrud and Schousboe cautioned in their article against rushing into two invasive procedures that have become increasingly common in this country: vertebroplasty and kyphoplasty. During these procedures, a kind of cement is injected into the compressed vertebra to stabilize it.

The operations are performed by interventional radiologists who, naturally, endorse them enthusiastically. However, two scientifically conducted studies of vertebroplasty using sham procedures as a control found no benefit with respect to pain, disability or quality of life.

Nor are these procedures completely free of risk. Although rarely, they can sometimes injure nerves or cause pulmonary embolisms. They also may result in fractures of adjacent vertebrae by increasing the mechanical stress on them.

Exercises to improve posture, strengthen back muscles and enhance mobility are less costly and likely to be more effective in the long run, the doctors wrote.

FORGET ABOUT CRUNCHES. HERE'S HOW TO PROTECT YOUR BACK

If you have not suffered a vertebral fracture, adopting an exercise routine that improves posture and strengthens back muscles can go a long way toward preventing one. And if you are already plagued by back pain due to vertebral fractures, the exercises and protective movements described below may bring relief and prevent the problem from getting worse.

These guidelines and exercises have been adapted primarily from recommendations published in the medical journal Osteoporosis International.

First, it is critically important to know what not to do. Avoid those infamous stomach "crunches" and toe touches and any exercise or activity that involves twisting the spine or bending forward from the waist with straight legs.

Next, recall a mantra you may have heard often as a child: Stand up straight. Good posture — proper alignment of body parts when you stand, sit or walk — reduces stress on the spine. Lift your breastbone, and keep your head erect and shoulders back, all the while gently tightening abdominal muscles and maintaining a small hollow in your lower back.

More advice from the experts:

• When sitting for long periods, place a rolled towel or small pillow at the small of your back. Walk with your chin in and head upright.

• Learn to bend over safely from the hips and knees, not the waist. Start with your feet shoulder-width apart and keep your back straight. Do not twist; turn to face the object you wish to reach before you bend.

• To reach your feet (for example, to tie your shoes), sit on a chair and cross one foot at a time over the opposite knee, or stand with one foot on a stool.

• Lifting an object can be problematic. If possible, first get down on one knee and lift the object to your waist; then stand up, holding it close to your body.

• When carrying packages, use two bags with handles packed as evenly as possible, and carry one bag in each hand. If you have recently had a vertebral fracture, limit the weight you carry to 10 pounds.

Another option: Use a backpack, preferably one with straps that snap in front at the chest and waist. In fact, according to Kristine Ensrud of the University of Minnesota, one of the recommended back-strengthening exercises involves wearing a small backpacklike device containing a 2-kilogram weight.

• Avoid overreaching. Don't reach for objects on a shelf higher than one you can touch with both hands together.

• Protect your back when you cough or sneeze. Tighten your abdominal muscles, and place one hand on your back or press your back into a chair or wall for support. Alternatively, gently bend your knees and place one hand on them.

Additionally, exercise that strengthens abdominal muscles will also protect the back. Try this one: Lie on your back with knees bent, feet flat on the floor and a small pillow under your head. Tighten your abdominal muscles by pulling your pelvis and ribs together (push your rib cage toward the floor and tilt your pelvis toward it) while flattening your lower back toward the floor. Hold for five seconds, relax for five seconds, and then repeat 5 to 10 times.

Also helpful is strengthening your core. The Pilates plank exercise, which looks like the "up" part of a push-up, is excellent if you can do it. Lie face down, and raise your body into a benchlike posture, supporting it with your hands and toes and keeping your back flat. Hold the position for a count of 10, or as long as you can without undue strain. Over time, build up to a one-minute plank.

If posture is a problem, a suggested corrective exercise involves sitting or standing as tall as you can with your chin tucked in, stomach tight and chest forward. With your arms extended in a "W" position and shoulders relaxed, bring your elbows back to pinch your shoulder blades together. Hold for a slow count of three and relax for another count of three. Repeat 10 times.

— JANE E. BRODY