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Sorting out the Osteos

By middle age, several different conditions can affect our bony skeleton, muscles and tendons, collectively known as the musculoskeletal system. Osteopaenia, osteoporosis, osteoarthritis, rheumatoid arthritis all sound similar and all have their highest incidence from age forty onwards, but each requires completely different management both pharmacologically and in terms of exercise.

The specific language of medicine allows health professionals across the disciplines accurately discuss and treat a patient presentation. Though everyone in healthcare strives to present a diagnosis to an individual in plain English, many patients come away from a consultation with poor understanding of their diagnosis. In turn this can lead to misunderstanding and less than ideal self-management of a condition.

For example osteoporosis and osteoarthritis sound quite alike, but comparing them is like comparing apples and oranges: you just cannot.

So if you want and need to know the difference between the various ‘osteos’ and arthrites, read on. To start the prefix ‘osteo’ means bone in Latin, so once ‘osteo’ is part of the diagnosis, you can assume something about the skeleton is being discussed. Arthritis refers in the main to joint surfaces and impacts the ability to move joints fully and painlessly.

Bone needs a strong internal structure to carry the weight of the body and support the weight and position of the vital organs. Bone health and strength is at issue when the words osteopaenia or osteoporosis are used. Both terms concern the density or mineral capacity of bone. Osteopaenia is an early warning sign of impending bone change. Osteoporosis is the later stage of a gradual process leading to brittle, easily broken bones. Osteoporosis affects 1 in 3 women post-menopause, and for reasons less well understood, 1 in 5 men of the same age.

Osteopaenia is a silent painless disease, often first identified on standard x-ray. Dense bone shows up as white on x-ray. In osteopaenia, the bone shows up as grey rather than white, as bone mineral content is less. The definitive test to quantify the amount of demineralisation is DEXA scanning. DEXA is an easily performed specific scan that charts the relative density of bone relative to age and sex. If DEXA shows a mild reduction compared to normal, this condition is termed osteopaenia. At a higher level of demineralisation the diagnosis changes to osteoporosis.

The importance of diagnosing osteopaenia is that if caught, it can be reversed with corrective strategies. If undiagnosed, just like raised cholesterol levels, if can become a silent stalker, worsening into osteoporosis, pain and broken bones..

Osteoarthritis (OA) is completely different problem. Joints are between the end of one bone and the next. All bone ends within a joint are covered in articular cartilage, which is a friction free surface. It is the presence of articular cartilage that allows us to move smoothly and without pain.

Articular cartilage thins with age or can be damaged by trauma. It becomes microscopically ragged, compromising movement within the affected joint. This normal wear process, now known as ‘degeneration’ or even ‘wear and tear’, happens to all of us with age. Irrespective of name, one single or several joints become painful and move less well, more often in the spine and weight-bearing lower limbs than in the arms become. Wear and tear usually comes on gradually, though on occasion it can occur almost overnight. The wear process can be kick started by trauma, like a fall. If acute, the joint may be swollen, hot to the touch and sometimes even red with the intensity of inflammation in the joint.

The wear change within a joint can usually be readily diagnosed clinically by a G.P or Chartered Physiotherapist. A simple x-ray can confirm clinical findings, but is often unnecessary. In simple wear and tear a blood test is usually clear and thus not necessary to confirm this diagnosis. However, it is sometimes ordered to rule out other types of arthritis. Standard x-rays show wear changes in 30% of 30 year olds, 40% or 40 year olds, 50% of 50 year olds, etc. Very often wear signs on x-ray are painless, explaining why the diagnosis must be made in conjunction with clinical signs.

OA is thus about wear within joints whereas osteoporosis/paenia is about the internal density of bone. A diagnosis of one does lead to the other. Thus if you have one you will not automatically have the other. However both can occur simultaneously but unrelatedly. Where both are present and active, problems emerge if a worn joint needs replacing, but the strength of the underlying bone may be insufficient to bear the new artificial joint.

Rheumatoid Arthritis (RhA) is a systemic (whole body) inflammatory arthritis. Significant irreversible joint destruction, muscle wasting and other tissue changes can be extremely painful and physically debilitating if not diagnosed and actively treated. Diagnosis is made on a combination of clinical examination, blood tests, x rays and scans. New drugs target RhA aggressively and have revolutionised the outcome of this horrible condition, which does usually burn itself out eventually. RhA and osteoporosis can occur together, making a complex presentation that also needs to be very actively managed by the medical team, especially as replacing severely damaged joints is part of the longterm management of this condition.
Mairead O’Riordan, MSc, MISCP is a senior Chartered Physiotherapist & CEO of TherapyXperts, an allied health network dedicated to clinical excellence.
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