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Transcript — Programme 120: Osteoporosis

How we pre­vent, man­age and diag­nose this ‘silent disease’

To lis­ten to this pro­gramme, please click here.

This edi­tion of Air­ing Pain has been sup­port­ed by a grant from The D’Oyly Carte Char­i­ta­ble Trust.

Osteo­poro­sis is a large­ly ignored con­di­tion that affects over 3 mil­lion peo­ple in the UK, with women being more at risk; a con­di­tion which, because the symp­toms are dif­fi­cult to notice by patients, is often referred to as the ‘silent dis­ease’. In this edi­tion of Air­ing Pain, we learn why pre­ven­tion, assess­ment and man­age­ment are key fac­tors to deal with this con­di­tion and devel­op a cor­rect mod­el of care in the health services.

 First-off, Paul Evans speaks to Dr Emma Clark, Con­sul­tant in Rheuma­tol­ogy & Osteo­poro­sis at North Bris­tol NHS Trust, to find out about the caus­es and char­ac­ter­is­tics of osteo­poro­sis. She dis­cuss­es how osteo­poro­sis can be ignored or mis­di­ag­nosed as osteoarthri­tis, as well as ways in which we can look after our bone health. Dr Clark also talks about how she is cur­rent­ly devel­op­ing a clin­i­cal tool for pri­ma­ry care pro­fes­sion­als to help them iden­ti­fy signs of osteo­poro­sis when they meet with their patients.

Paul also speaks to Sarah Ley­land, Nurse Con­sul­tant at the Roy­al Osteo­poro­sis Soci­ety, about the new focus on pre­ven­tion, main­ly in terms of lifestyle changes and devel­op­ing a mod­el of care designed to iden­ti­fy peo­ple who are at high­er risk of osteo­porot­ic frac­tures. She also describes the range of phys­i­cal exer­cis­es she has devel­oped to reduce the risk of frac­tures and help with pain after fractures.

Issues cov­ered in this pro­gramme include: Frac­tures, bone health, osteo­poro­sis, osteo­poro­sis pre­ven­tion, osteo­poro­sis symp­toms, risk of frac­tures, spinal frac­ture, aging, elder­ly peo­ple, ver­te­bral frac­ture, ver­ti­cal frac­ture and weak bones.

Paul Evans: This is Air­ing Pain, the pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain and for those who care for us. This edi­tion of Air­ing Pain has been sup­port­ed by a grant from the d’Oyly Carte Char­i­ta­ble Trust. I’m Paul Evans.

Emma Clark: Less than a third of peo­ple with osteo­porot­ic ver­te­bral frac­tures are being iden­ti­fied. If we can find peo­ple who have ver­te­bral frac­tures, we can give med­ica­tions to reduce the risk of future frac­tures. We can reduce the risk of a hip frac­ture by about half and that is so impor­tant because hip frac­tures for the indi­vid­ual can be a disaster.

Evans: Osteo­poro­sis is a con­di­tion where bones lose their strength and become frag­ile. It’s some­times referred to as the ‘silent dis­ease’ because, although almost 3 mil­lion peo­ple in the UK are esti­mat­ed to have it, few know that they do have it until that is they break a bone, most like­ly in their wrist, hip or spine. And accord­ing to the char­i­ty Age UK, there are more than 300,000 frac­tures every year due to osteo­poro­sis. Emma Clark is Con­sul­tant Rheuma­tol­o­gist at Bristol’s South Meade Hos­pi­tal. She’s also Read­er in Rheuma­tol­ogy at the Uni­ver­si­ty of Bris­tol where she does research into osteoporosis.

Clark: As we get old­er, like many parts of our body, our bones age and with time they become thin­ner. Both the out­side of the bone but also the struts, which make up the mesh-like struc­ture inside the bone [become thin­ner]. And this means the bones become more frag­ile and eas­i­er to break. It is this com­bi­na­tion of the thin­ner bones and the increased risk of them break­ing that we call osteo­poro­sis. Our bones devel­op obvi­ous­ly from the time we’re born, and they car­ry on [devel­op­ing] through ado­les­cence, through growth. Inter­est­ing­ly, even after we stop grow­ing around fif­teen or six­teen, our bones con­tin­ue to strength­en up prob­a­bly until [our] mid-twen­ties or late-twen­ties. At that point, that is what we call peak bone mass.

Evans: Let me go back to the begin­ning. It’s quite per­ti­nent for me because my grand­daugh­ter has just bro­ken her hand, or bro­ken her knuck­le, and she is sev­en years old. What they’ve explained is [that] it’s not actu­al­ly real bone that she’s bro­ken, it’s what might turn into a bone. So what is the devel­op­ment of a bone from ear­ly age?

Clark: So we’ve got dif­fer­ent types of bones but gen­er­al­ly our bones are laid down, actu­al­ly, when we are a foe­tus. Inside the uterus the pat­tern of our skele­ton is laid down as car­ti­lage, and then it turns into bones as we age. Our bones fin­ish grow­ing, the car­ti­lage fin­ish­es turn­ing into bone at the time of ado­les­cence (when we stop grow­ing up in height). They can still thick­en up, as I said, until our late-twenties.

It’s very inter­est­ing that your poor grand­daugh­ter has bro­ken her knuck­le, because actu­al­ly child­hood frac­tures are real­ly com­mon. They do not mean that that child is going to get osteo­poro­sis. I think that’s real­ly key. Prob­a­bly 45% of girls and 30% of boys will break a bone before they reach adult height. It’s an indi­ca­tor that they are doing activ­i­ties; it’s more of a mark­er real­ly of expo­sure to injuries. In some ways, it might be good because it means that these chil­dren are run­ning around and doing activ­i­ties. They’re being phys­i­cal, which is what we want to encourage.

Evans: Well, that is quite encour­ag­ing because two of my grand­chil­dren have just bro­ken bones. One in the leg and one in the knuck­le! So at the age of 30, you were say­ing, bones are ful­ly grown, at their peak?

Clark: Yes, absolute­ly at their peak. Then they stay like that until we devel­op the nat­ur­al age-relat­ed bone loss which is actu­al­ly the same in men and women. But women have this lit­tle accel­er­a­tion dur­ing the menopause. Of course, women are gen­er­al­ly small­er than men any­way so wom­en’s peak bone mass is low­er than men’s. Then they have this peri­od of accel­er­at­ed bone loss around the time of the menopause. But both men and women do lose bone as we get older.

Evans: Why is that?

Clark: Our bones are not actu­al­ly a rigid sta­t­ic machine that just stays there. You may not wish to know this, but every sec­ond, of every minute, of every day we have these cells liv­ing on our bones that keep them healthy. We have this real­ly big cell called an osteo­clast that wan­ders over the sur­face of the bone and takes out lit­tle bites. We don’t know nec­es­sar­i­ly why. But we won­der if it does it because it’s found a fatigued area, that’s a bit warm per­haps or has got a micro­c­rack in it. We don’t real­ly know. Then behind it, along come these oth­er cells called osteoblasts that fill it in again with new bone. Our skele­ton is con­tin­u­ous­ly bub­bling along!

We have got these cells main­tain­ing our bone health and we think that with age the osteoblasts – that build bone – just get a bit old; they don’t do what they used to do. The osteo­clasts – that take the bites out – con­tin­ue, but the osteoblasts are no longer quite so effi­cient; they don’t fill it in quite so well. The net effect of this is that our bones gen­er­al­ly become a bit thinner.

Evans: Well, the next ques­tions is ‘does osteo­poro­sis mean pain?’

Clark: I think that’s a real­ly, real­ly impor­tant ques­tion because, on its own, osteo­poro­sis is pain­less. You don’t know that you have osteo­poro­sis, because it has no symp­toms. It becomes painful only when you break a bone.

Evans: Which bones are right in the front line of risk?

Clark: We know there are a clus­ter of bro­ken bones that are more like­ly in peo­ple with osteo­poro­sis. These are the wrist, the fore­arm (you might have heard it called the Colles frac­ture), the upper arm (the humerus, the top of it, near the shoul­der), the hip and a bone in the back (the ver­te­bral body). They break in dif­fer­ent ways: the hip, fore­arm and upper arm snap. You can think of it like a twig being bro­ken. Where­as, the bone in the back does not snap in half. Instead, that is like if you imag­ine a piece of coral on the beach and you stand on it, it can crush down a lit­tle bit. That’s a process that starts grad­u­al­ly. They change shape – going from a rec­tan­gu­lar shape to more of a tri­an­gu­lar shape because the front of the bone squash­es down and that is a bro­ken bone.

Evans: Do you mean that they’re sort of crumbling?

Clark: No, I don’t think the bones are crum­bling away because that sug­gests, in my mind, frag­men­ta­tion or bits of them falling off. My impres­sion from speak­ing to patients in clin­ic is that peo­ple have used the term crum­bling bones to also mean osteoarthri­tis, which is a com­plete­ly sep­a­rate dis­ease to osteo­poro­sis. Osteoarthri­tis is the wear and tear arthri­tis where our joints become worn with age. That is com­plete­ly sep­a­rate to osteo­poro­sis, which is pure­ly about risk of fracture.

Evans: How does one frac­ture a bone in the vertebrae?

Clark: Well, actu­al­ly, we don’t real­ly know. We don’t have the full answers. We have got sto­ries from patients. A typ­i­cal sto­ry might just be some­thing sim­ple like reach­ing up into a cup­board or reach­ing up out­side to hang some wash­ing on the line. And a sud­den sort of twinge in the back. Patients describe being out­side walk­ing and step­ping off a high kerb. It’s just the jar­ring nature again of a pain in the back. But not every patient knows when they have bro­ken a bone in their back because, in some peo­ple, it’s not nec­es­sar­i­ly that painful.

Anoth­er typ­i­cal sto­ry actu­al­ly is mov­ing those great big black bins that the lor­ries pick­up. A typ­i­cal thing is that a patient describes pulling it up the dri­ve and then try­ing to twist and pull it into the lit­tle cup­board where it’s meant to go. And that twist­ing [and] pulling of a quite heavy thing caus­es sud­den pain in the back, which I think lots of patients think, ‘I’ve pulled a mus­cle! I was way sil­ly, I should­n’t have done that, I pulled a mus­cle’. I think it may be that osteo­porot­ic frac­tures can­not nec­es­sar­i­ly be that painful when they start.

Some patients def­i­nite­ly describe a very sud­den onset and severe pain when a ver­te­bral frac­ture occurs. One of my patients was on hol­i­day in New York. She’d nev­er been to the States before. She stepped off a kerb and the sud­den onset of pain in her back was so bad she thought she’d been shot. She thought it was more like­ly that she had been shot in New York then had bro­ken a bone in her back when she thought about it. Sud­den, absolute agony, the sud­den onset pain, but I think is pret­ty unusu­al. The vast major­i­ty of peo­ple do not go to their GP or go to hos­pi­tal with a ver­te­bral frac­ture because it prob­a­bly is not that painful and/or they expect back pain. I think it’s some­thing with­in our cul­ture that we expect as we get old­er [that] we’re going to get back pain. When we do some­thing sil­ly like pull a bin, or try and lift up a plant pot using a very bad pos­ture, and we devel­op sud­den onset pain in our back that’s not too bad, we think, ‘Oh, well, that’s my fault — I have pulled a mus­cle’. We just wait for it to get bet­ter, which it prob­a­bly does, that acute pain, over about six weeks.

Evans: Is that okay? If I were putting out my bins and I twist­ed and I felt some­thing in my back. Through 62 years of expe­ri­ence, I would think, ‘Ah, I’ve pulled a mus­cle, it’ll be okay’. Should we be going to the doc­tor then?

Clark: If we think about adults in gen­er­al, the vast major­i­ty of sit­u­a­tions like that will be a pulled mus­cle. But, per­haps in some­body who’s quite old and I don’t know what that means. I don’t want to put an age on it because we all age dif­fer­ent­ly. But per­haps some­one who’s frail; per­haps some­one who’s got risk fac­tors for osteo­poro­sis (per­haps those who are on steroids for oth­er dis­eases such as asth­ma, rheuma­toid arthri­tis, bow­el dis­or­ders and peo­ple who are heavy smok­ers), peo­ple who are frail. When peo­ple become quite thin, less mobile, have quite a few oth­er ill­ness­es, take many, many med­ica­tions, that whole pack­age. You know, it’s quite dif­fi­cult to describe frailty, but we all recog­nise some­one who is frail. Per­haps peo­ple who are frail who do that and devel­op sud­den onset back pain or some­one who’s on steroids, they should con­sid­er going to their GP or some­body with­in their prac­tice, it may be anoth­er allied health pro­fes­sion­al such as a nurse or phys­io­ther­a­pist, just to be assessed to make sure they haven’t had a ver­te­bral fracture.

Because hav­ing a ver­te­bral frac­ture means you are at one of the high­est risks of hav­ing anoth­er frac­ture, includ­ing a hip frac­ture, and hip frac­tures are com­plete­ly dev­as­tat­ing. If we can find peo­ple who have ver­te­bral frac­tures, we can give med­ica­tions to reduce the risk of future frac­tures. We can reduce the risk of a hip frac­ture by about half, all the evi­dence sug­gests. That is so impor­tant because hip frac­tures, for the indi­vid­ual, can be a dis­as­ter. I think 20% of peo­ple are not alive twelve months after their hip frac­ture, a third of peo­ple can­not go back to their liv­ing arrange­ments that they had before. They need addi­tion­al help; they need to change liv­ing upstairs to down­stairs; they need to go into nurs­ing homes or more shel­tered accom­mo­da­tion. And they are very expen­sive – they cost the NHS lots of mon­ey. We’ve got a very good med­ica­tion that we can use to reduce that risk but, at the moment, less than a third of peo­ple with osteo­porot­ic ver­te­bral frac­tures are being iden­ti­fied through a vari­ety of rea­sons, I have to say, but one of which I think is [that] we don’t real­ly under­stand the typ­i­cal sto­ry of some­body with an osteo­porot­ic ver­te­bral frac­ture. That’s why I’m focus­ing my research at the moment.

Evans: Well, what don’t we under­stand and what is your research?

Clark: One of the prob­lems is that back pain is very, very com­mon and peo­ple find it very, very unin­ter­est­ing. By peo­ple, I mean fam­i­ly mem­bers, I mean doc­tors…, I mean…

Evans:It’s just anoth­er ache and pain.’

Clark: Absolute­ly, absolute­ly. When some­one says, in a clin­i­cal sit­u­a­tion, ‘I have back pain’. The most com­mon reac­tion to that is, ‘Oh, and just note it down’ rather than say­ing, ‘Well, tell me about that. Where is it? What is it like? How does it start? What makes it worse? What makes it better?’

My research is real­ly try­ing to find out is there a dif­fer­ence in back pain between some­one with a ver­te­bral frac­ture, and some­one with­out. I think it’s clear that there is a dif­fer­ence. For exam­ple, peo­ple with back pain and osteo­porot­ic ver­te­bral frac­tures describe a chron­ic back­ground pain that they describe as grind­ing, gnaw­ing, a sort of a dull ache. It’s not nec­es­sar­i­ly in the cen­tre of the back, it’s often a bit more around the sides. That is prob­a­bly because when you have one or more bro­ken bones in the back, the shape of your back has changed, the height of your back is short­er, you’ve shrunk a bit. All of the tis­sues, the mus­cles, the lig­a­ments, the ribs are now in less space; your trunk has shrunk and changed. That gives sen­sa­tions around the waist area that might be described as grind­ing or a dull ache.

We also find that there is a dif­fer­ence in the pain that hap­pens with dai­ly activ­i­ties and move­ments. So patients with ver­te­bral frac­tures describe pain in their back or trunk region build­ing with activ­i­ty and reach­ing a real crescen­do or peak at which point they have to stop, and often lie down or recline back­wards – so lean back and extend the spine to relieve the pain. The typ­i­cal move­ments that con­tribute to this are stand­ing up and lean­ing for­ward slight­ly and unfor­tu­nate­ly that is sort of the posi­tion of work for humans. When we’re wash­ing up, for exam­ple, or prepar­ing food, or doing a jig­saw, or work­ing on the key­board, we’re lean­ing for­ward slight­ly, putting the weight of our upper tor­so and head on the front of our spine. For peo­ple with ver­te­bral frac­tures, I think that is what is con­tribut­ing to this crescen­do or peak in pain.

The time to reach­ing this peak varies. It seems to be much short­er in peo­ple who are old­er, pos­si­bly because they have less mus­cu­lar mass around their spine. Pain in peo­ple with ver­te­bral frac­tures tends to improve enor­mous­ly on lying down, so peo­ple with ver­te­bral frac­tures often get quite a good night’s sleep. These descrip­tions are dif­fer­ent to peo­ple who have back pain due to osteoarthri­tis, where often lying down is one of the worst times. Patients with osteoarthri­tis also tend to describe pain shoot­ing down the legs or pain worse with cold and damp weath­er. Those two things don’t seem to occur in peo­ple with pain due to ver­te­bral fractures.

Evans: That’s Con­sul­tant Rheuma­tol­o­gist Emma Clark. Sarah Ley­land is a Nurse Con­sul­tant now work­ing for the Roy­al Osteo­poro­sis Soci­ety, a char­i­ty that pro­vides infor­ma­tion and sup­port for peo­ple liv­ing with osteo­poro­sis. It has many resources, includ­ing a spe­cial­ist nurse team-lead helpline.

Sarah Ley­land: Our aims are to make sure that peo­ple get the help that they need, cer­tain­ly in terms of care. mak­ing sure peo­ple are diag­nosed appro­pri­ate­ly and get access to the appro­pri­ate med­ica­tions and treat­ment in order to pre­vent frac­tures. We’ve got a new focus more recent­ly on pre­ven­tion, mak­ing sure that peo­ple who are younger, who are not yet affect­ed by the con­di­tion are mak­ing lifestyle changes to keep their bones strong and get the best bones they can to put them in the best posi­tion before they lose bone in lat­er life.

We’re also very inter­est­ed in a mod­el of care with­in the Health Ser­vice that’s pick­ing up those peo­ple who are at the high­est risk of fur­ther frac­tures. We’re sup­port­ing a mod­el of care called Frac­ture Liai­son Ser­vices where, when some­one breaks a bone, they get a prop­er assess­ment to check out could this be relat­ed to osteo­poro­sis. Peo­ple [then] get assessed, they get treat­ed and they get fol­lowed up in spe­cial­ist teams. It’s mak­ing sure peo­ple are fed into that system.

We’re very inter­est­ed in pre­vent­ing frac­tures but we also have always had a role to play in terms of sup­port, so peo­ple either want­i­ng infor­ma­tion, local sup­port groups, peer sup­port or com­ing through to our spe­cial­ist helpline and get­ting access quite rapid­ly. We also sup­port health pro­fes­sion­als, so we run con­fer­ences, train­ing pro­grammes [to] try giv­ing them them the tools they need to help them do their job.

Evans: What do peo­ple who con­tact your helpline wor­ry about most?

Ley­land: They’re wor­ried obvi­ous­ly about the impact of osteo­poro­sis on their future life – on both their day-to-day liv­ing and qual­i­ty of life, but also that it might short­en their life. They’ve heard about peo­ple dying as a result of osteo­poro­sis, so peo­ple ring us they’re fear­ful. They may have had a diag­no­sis, some­one’s told them they’ve got osteo­poro­sis and they want to know what the future will hold. They also often ring us if they’re wor­ried about the drug treat­ments [or] the med­i­cines – they don’t want to take them unless they real­ly need to. They’ve heard about health risks asso­ci­at­ed with the med­ica­tions. We talk a lot about that. Then at the oth­er end of the con­tin­u­um, we talk to peo­ple who’ve had frac­tures, par­tic­u­lar­ly ver­te­bral spinal frac­tures, who are liv­ing day-to-day with pain and symp­toms and are strug­gling often and not get­ting the care and the help that they need.

Evans: If some­body were phon­ing you, and this might hap­pen with lots of con­di­tions, peo­ple real­ly want that help at pri­ma­ry lev­el, at GP lev­el and they feel they’re not, per­haps not being tak­en seri­ous­ly, per­haps not being lis­tened to. How would you advise some­body to go back to a health­care pro­fes­sion­al, a GP, and say, ‘Lis­ten, please will you look at this? Please, I’m wor­ried about this’?

Ley­land: I think that’s where being informed makes peo­ple feel a bit more con­fi­dent. That’s where the char­i­ty can be help­ful because if peo­ple know a lit­tle bit more about the con­di­tion and what the options are, then they’re more ready.

We also encour­age peo­ple to be, and this is the same as for any con­di­tion, to be pre­pared for their appoint­ment because there’s so lit­tle time. Go in with your ques­tions ready and stick­ing to those, per­haps writ­ing things down, maybe tak­ing some­one with you if you don’t feel very con­fi­dent. We can’t advise you what to do, but we can take you a bit fur­ther down the path­way. Help them to under­stand who might need a refer­ral to a spe­cial­ist because every­body doesn’t need to go to the hos­pi­tal, but some peo­ple may ben­e­fit from that. Par­tic­u­lar­ly younger peo­ple because the treat­ments and the care path­way is not so clear in a younger person.

Evans: Sarah Ley­land of the Roy­al Osteo­poro­sis Soci­ety. Now, ear­li­er in this edi­tion of Air­ing Pain, rheuma­tol­o­gist Emma Clark talked about her research into devel­op­ing a method where­by it would be eas­i­er for health pro­fes­sion­als in pri­ma­ry care (GPs that is) to iden­ti­fy a ver­te­bral frac­ture as opposed to osteoarthritis.

Clark: The whole point of this research is to pro­duce a very sim­ple clin­i­cal tool. So, basi­cal­ly a check­list and it is absolute­ly aimed at GP prac­tices – the first point of con­tact, whether that is a GP, a nurse or a phys­io­ther­a­pist. The goal is that in the next few years we will have this sim­ple check­list. When an old­er per­son goes to their GP prac­tice with back pain the health­care pro­fes­sion­al pro­duces this sim­ple check­list and ask, ‘Have you pre­vi­ous­ly bro­ken a bone? Is your back pain worse when you lean for­ward? Is it bet­ter at night?’

I don’t know exact­ly what it’s going to include, because we’re cur­rent­ly doing the research. Ide­al­ly, this is going to be an app so it’s just done very quick­ly on the com­put­er and the answer will come up ‘this per­son needs an X‑Ray’ or ‘this per­son does not need an X‑Ray’. It will rec­om­mend an X‑Ray if the check­list has sug­gest­ed this per­son may well have a bro­ken bone in their back due to osteo­poro­sis, so a ver­te­bral fracture.

Evans: You men­tioned ear­li­er that [whilst osteo­poro­sis] may not be reversed, per­haps the progress [could be] stalled or halted.

Clark: There are two path­ways of man­age­ment, of help, that should be giv­en to peo­ple with an osteo­porot­ic ver­te­bral frac­ture. The first are inter­ven­tions to improve their pain, their qual­i­ty of life, their fatigue and pos­ture. The sec­ond is, as you say, to reduce the risk of fur­ther frac­tures. So those large cells I talked about, those osteo­clasts – that walk along the sur­face the bone and take a lit­tle bite out – we have a med­ica­tion avail­able that inhibits them.

Evans: What can we do ear­li­er in life to man­age our lat­er life osteoporosis?

Clark: I think it’d be real­ly help­ful at this point to remind every­body that actu­al­ly our peak bone mass is quite strong­ly deter­mined by our genes, our genet­ics. Prob­a­bly 80% of our peak bone mass is deter­mined by the way we’re made. Osteo­poro­sis is not our fault in the major­i­ty of sit­u­a­tions but there are some things we can do to real­ly opti­mise our peak bone mass, such as do not smoke, do not drink excess alco­hol. It is alco­hol excess that’s also asso­ci­at­ed with poor nutri­tion that is prob­a­bly bad.

In terms of nutri­tion, dai­ly pro­tein intake and cal­ci­um intake is real­ly impor­tant. As a grow­ing per­son, we should have over one pint of milk per day or equiv­a­lent. As an adult, we should have one pint of milk per day or equiv­a­lent. Obvi­ous­ly, there are oth­er fields that you can get cal­ci­um from that it’s not just dairy prod­ucts. There are lots of real­ly use­ful resources online, such as the Roy­al Osteo­poro­sis Soci­ety, where peo­ple can go and iden­ti­fy if they’re get­ting enough cal­ci­um in their diet.

Vit­a­min D is also real­ly impor­tant. Vit­a­min D is a vit­a­min that we get through the sun and it is not pos­si­ble to get enough in a nor­mal diet – we do need to expose our skin to the sun. This can be tricky, because of the oth­er health mes­sages of ‘Don’t burn’, because of the risk of skin can­cer. There’s def­i­nite­ly a bal­ance. Plus, also if some­body is poor­ly and can’t go out­side, if some­body’s got dark skin, if some­body cov­ers up for what­ev­er rea­son, and there­fore does not expose their skin to the sun, they should prob­a­bly take vit­a­min D sup­ple­men­ta­tion to ensure that they get enough vit­a­min D.

Part of our prob­lem is also we live in the UK so it rarely gets enough sun and, occa­sion­al­ly, when the sun comes out it can be very fierce, so it’s a bit of an issue for us in the UK. So vit­a­min D sup­ple­men­ta­tion is rec­om­mend­ed to all adults prob­a­bly over the age of 65/70, but also oth­er peo­ple who don’t get enough vit­a­min D younger than that. Then [there’s] phys­i­cal activ­i­ty. Our bones are amaz­ing and if we use them as we’re grow­ing, they will grow stronger. Ten­nis play­ers, for exam­ple, the hand that they hold their rack­et in, we can show on our scans that the bones are stronger than the hand they don’t hold the rack­et in. This makes sense: if you use it, it builds up; if you don’t use it, you lose it.

Evans: Rheuma­tol­o­gist Emma Clark. Bear­ing what she said in mind, Nurse Con­sul­tant Sarah Ley­land of the Roy­al Osteo­poro­sis Soci­ety has been devel­op­ing exer­cise and phys­i­cal activ­i­ty resources for peo­ple with osteoporosis.

Ley­land: The project that I’ve been work­ing on is look­ing at what is the role of exer­cise for some­one with osteo­poro­sis. By osteo­poro­sis I mean, in the widest sense, peo­ple who’ve got reduced bone strength, with or with­out fractures.

The project focused on [the] three main areas that exer­cise con­tin­ued to be impor­tant [in]. It was impor­tant for main­tain­ing mus­cle and, there­fore, bone strength, or pro­mot­ing maybe some improve­ments (though the evi­dence isn’t very clear). Sec­ond­ly, exer­cise [is] real­ly impor­tant in terms of improv­ing bal­ance and mus­cle strength to pre­vent you falling because if you don’t fall, then some of the frac­tures that we get with osteo­poro­sis are nev­er going to occur, so not falling is impor­tant. We talked about strong, steady and the third area was about straight. How exer­cise can help you with pos­ture and help you [with] mov­ing and lift­ing. That may help to reduce fur­ther spinal frac­tures sim­ply by the sort of pres­sures you’re putting par­tic­u­lar­ly on the front part of the spine. There are ways that exer­cise might help with the pain you may get after frac­tures. So there are some sim­ple exer­cis­es we were pro­vid­ing which might help with the imme­di­ate pain prob­lems, but the oth­ers that help to build up the mus­cles around the spine. The long-term prob­lems that we get with osteo­poro­sis are [that] after you’ve had a spinal frac­ture, it’s healed but the shape of your spine does­n’t go back to what it was. It’s often the mus­cle spasm, the lig­a­ment strain, per­haps even the pinch­ing of nerves so it’s a more sort of com­plex prob­lem than long-term pain but exer­cise can help there as well.

Evans: So you said strong, steady and straight?

Ley­land: Yes, so these are just three words that we use to cap­ture the dif­fer­ent ways that exer­cise can help with osteo­poro­sis. It was just try­ing to get peo­ple to, not only think about pro­mot­ing bone strength, but think about pre­vent­ing falls. [It’s] also to help peo­ple who are very fear­ful because one of the big things is that, par­tic­u­lar­ly if you’ve had one frac­ture, you’re ter­ri­fied that if you do any­thing, if you move, if you lift, you’re going to get anoth­er frac­ture. So, the whole project was about pos­i­tiv­i­ty and help­ing peo­ple to feel con­fi­dent, to car­ry on life nor­mal­ly but with some small adap­ta­tions, or feel­ing that they could take con­trol of it.

Evans: That’s Sarah Ley­land of the Roy­al Osteo­poro­sis Soci­ety. Before we end this edi­tion of Air­ing Pain, I’ll just remind you that whilst we in Pain Con­cern believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound, based on the best judg­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well-being. He or she is the only per­son who knows you, and your cir­cum­stances, and there­fore the appro­pri­ate action to take on your behalf. You can find all the resources to sup­port the man­age­ment of chron­ic pain, includ­ing details of our helpline, videos, leaflets, all edi­tions of Air­ing Pain and the Pain Mat­ters mag­a­zine at For a wealth of infor­ma­tion on how to live well with osteo­poro­sis, go to the Roy­al Osteo­poro­sis Soci­ety’s web­site which is Here’s the society’s Sarah Ley­land to fin­ish this edi­tion of Air­ing Pain.

Ley­land: We’ve got a new range of exer­cis­es, both fact sheets and video clips. So, you can go online and have a look at how to do the exer­cis­es. For instance, in the back pain sec­tion, you can read about how the exer­cis­es may help and you can see some sim­ple dia­grams about just two or three sim­ple exer­cis­es that you can do straight away. Plus [there’s] a short video, for those who have a com­put­er, [to] see how to do it and how to adapt accord­ing to where they are. So if they’ve got mul­ti­ple frac­tures and they’re frail they can still do some­thing. One of the things we hear is peo­ple quite often, even if they’ve had painful spinal frac­tures, might see the spe­cial­ist, the rheuma­tol­o­gist who says, ‘I’ll give you a refer­ral to the physio’, [but] they don’t get the refer­ral for about six weeks [so] they sit at home. One woman told me the rheuma­tol­o­gist said, ‘Don’t do any­thing until you see the physio’ and she lit­er­al­ly sat in the chair, sort of paral­ysed with anx­i­ety. Where­as we try to give peo­ple quick access to infor­ma­tion so they can, not only get the care they need, but they can do some­thing now that might help them.


  • Dr Emma Clark, Rheuma­tol­ogy & Osteo­poro­sis Con­sul­tant at North Bris­tol NHS Trust
  • Sarah Ley­land, Osteo­poro­sis Nurse Con­sul­tant at the Roy­al Osteo­poro­sis Society.

More infor­ma­tion: