Early warning signs of osteoporosis and determining cause before treatment; testing for the 10+ contributors
The chiropractic profession claims to treat the cause of disease. But clever marketing can make things like early warning signs of osteoporosis unrealistically simple and divert our attention, with messages such as “Take this for that!” “That” might be osteoporosis. “This” can be the most wondrous calcium from algae, coral, meteorites or the skeletal remains of jellyfish. Cunning marketers count on intellectual apathy. The unspoken message of “this for that” is “no need to think; here’s the answer.”
Patients are not generic. Thinking is a requirement.
A widespread disease such as osteoporosis has many causes. A given patient may have one or several early warning signs of osteoporosis or traits that collectively lead to premature bone loss and eventual fractures. Instead, the dairy industry tells you to simply drink more milk. From pill manufacturers, there is the latest and greatest. Or here’s a prescription for the newest pharmaceutical to prevent bone loss.
Ask your patients what steps they are taking to prevent osteoporosis. You’ll often hear “I eat yogurt and go for walks.” In order to treat the cause, you must know the cause. There are many paths to osteoporosis. Your patients may be on several of these.
- Amenorrhea
- Menopause
- low estrogen
- Low testosterone
- Anorexia
- Osteoporosis
- Hyperthyroidism
- Poor diet
- Hyperparathyroidism
- Smoking
- Cushing’s disease
- Sedentary life
- Environmental toxins
- Low vitamin D
- Excessive alcohol
- Low vitamin K
- Bone-wasting medications
Early warning signs of osteoporosis: where to begin?
Patient risk factors can give context and prompt a referral for a bone density test, the definitive test for osteoporosis. DXA (dual energy X-ray absorptiometry, aka DEXA) measures bone density, which is tightly related to bone strength and fracture risk. The DXA test of the lumbar spine and proximal femur is the current gold standard. Acquiring a baseline allows for future comparisons to evaluate change in response to prevention or treatment.
The DXA test result is expressed as a T-score, a statistical value, which quantifies and categorizes bone density:
| T-score | |
| Normal | >-1.0 |
| Osteopenia | -1.0 to -2.49 |
| Osteoporosis | <-2.5 |
| Established osteoporosis | <-2.5 with one or more fragility fractures |
Treatment(s) for someone with anorexia vs. hyperthyroidism vs. vitamin D deficiency must be different. Rather than “this for that,” the additional step of uncovering cause(s) is necessary.
Laboratory testing
If a patient’s DXA results are low or there is suspicion of metabolic conditions affecting the skeleton, then pursue laboratory tests.
First-level lab tests can point to secondary causes of decreased bone mineral density (BMD). Normal labs results rule out 90% of secondary causes of osteoporosis.1 An abnormal result or suspicion of other disease/deficiency warrants further laboratory tests and investigation.
First-level and some second-level tests are familiar and standard. The osteocalcin assay is cutting-edge and if not currently available, it will be soon.
| First level lab tests; results | Second level lab tests | |
| Complete metabolic panel | ||
| Hypercalcemia | Primary hyperparathyroidism | Serum PTH |
| Increased ALT/AST | Liver compromise | Osteocalcin assay |
| Increased BUN | Kidney compromise | 24-hour urinary calcium |
| Increase alkaline phosphatase | Osteomalacia | |
| CBC | ||
| Normocytic/normochromic anemia | Some cancers, infection, inflammatory disease | Serum electrophoresis; C-reactive protein |
| 25-OH vitamin D | ||
| Decreased 25-OH vitamin D (<30 ng/ml) | Vitamin D deficiency, osteomalacia | |
| TSH, Thyroid stimulating hormone | T3, T4 | |
| Decreased TSH | Hyperthyroidism | T3, T4 |
Laboratory tests help identify common diseases and/or deficiencies. For example, an initially asymptomatic disease such as hyperparathyroidism can profoundly demineralize bone, leading to eventual fractures. The DXA test can identify losses of bone mineral. The Complete Metabolic Panel will demonstrate hypercalcemia. PTH level is needed to confirm the diagnosis. The same need for first- and second-level tests is true for multiple myeloma, hyperthyroidism and inflammatory arthritides.
As for vitamin D, there are several sources: food, sunshine and supplements. In spite of this, studies in all nations, irrespective of latitude, show that the majority of the world’s population has inadequate vitamin D status.2-6 The lab test for the storage form, 25-OH vitamin D, is most accurate.
In addition to DXA testing, which capably measures bone quantity, and lab tests, which may identify disease/deficiency, the quality of bone must be considered. Bone quality is a composite of bone geometry, microarchitecture, microdamage, mineralization and rate of turnover.7
The most recent advances in DXA equipment and software can now include the ability to measure the proximal femur Trabecular Bone Score (TBS). TBS is a scale that quantifies the quality of bone.8-10 Bone quality is known to be compromised by smoking, obesity and decreased muscle mass.11 The composite of low BMD and a low TBS significantly increases patient fracture risk.
Every patient with, or at risk for, osteoporosis should:
- Eat a well-balanced, nutritious diet
- Exercise regularly
- Get a generous amount of vitamin D from sunshine, food and/or supplements
- Avoid bone-wasting medications
- Avoid smoking and excessive alcohol
DXA testing
The best suggestion concerning osteoporosis is to order a DXA test. If the result is poor and shows early warning signs of osteoporosis, rather than jumping to treatment, take the time to determine the cause(s).
Once the weak links and/or disease processes that are triggering an accelerated loss of skeletal health are understood, the treatment(s) can be customized to the individual’s needs. The combined use of the DXA test, plus the laboratory, plus thinking, will point the way toward better treatment choices.
Doctors of chiropractic often voice their frustration when other providers treat patients with the “this for that” method. For low back pain take NSAIDs. For headache, there’s aspirin. For high blood pressure, take (your pick of antihypertensives). And for osteoporosis, take the latest pharmaceutical.
But “this for that” is too simple. Our patients deserve to have providers who find early warning signs of osteoporosis and treat the cause of disease.
ALAN COOK, DC, has been in practice since 1989. He ran the Osteoporosis Diagnostic Center (1996-2019), participated in four clinical trials and lectured nationally. He is currently working with the Open Door Clinic system in a multi-disciplinary setting and is providing video-based continuing education with EasyWebCE.com, where he can be contacted.