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Saturday, 23 July 2011

Sprains and bruises

What are sprains and bruises?

For a sprain, you can also wrap bandages around the damaged area to prevent movement.

A sprain causes pain, swelling and loss of movement of the affected part. There may also be bruising, or a blue discolouration.

This happens because the small blood vessels and fibres in the flesh burst, causing blood to enter the surrounding tissue. This results in swelling and the blue colouring.

A sprain is due to damage to a ligament, which is usually due to a stretching or awkward movement to a joint, eg a twisted ankle.

A bruise happens when the skin is exposed to such a hard blow that the blood vessels break.

What should I do about a sprain?

If you have a sprain, you will also suffer pain. The injured area must be kept still or the bleeding in the tissue will continue more intensely.

The most important treatment for a sprain is: protection, rest, ice, compression, elevation (PRICE).

Protection

Protect the injured part from further injury, eg foot support or insole.

Rest

Rest is important to ensure that healing occurs as quickly as possible. You should rest the injured area for at least one or two days, because the bleeding can continue for up to 24 hours.

If possible, the sprained area should be kept straight – an arm, for example, can be supported in a sling. Try to keep the injured area in the same position while you are sleeping, perhaps by placing a couple of pillows under your sprain.

Ice

Since blood enters the tissues when you have a sprain, the main thing is to limit the bleeding. This can be done by cooling.

Try the following techniques.

Put ice cubes in a plastic bag, then place over the sprained area.
In an emergency, use frozen vegetables in a bag.
Use custom-made cooling-packets, which are bags containing a special jelly that can be chilled in your freezer.

In each case, wrap the cold bag in a towel before placing it on the sprain. Always put a piece of fabric between your skin and the coolant, otherwise your skin may get cold damage.

Stop the cooling long before your skin turns white or hard. Contact a doctor if your skin does not regain its usual colour after the process has stopped.

It's a good idea to cool the skin for 15 minutes, stop for 15 minutes, then cool again, and so on.

Usually, the cooling is felt in different ways. This can range from cold to painful, burning and finally numbing.

Be careful if you are diabetic. To prevent damage to your blood circulation, do not cool an area without consulting your doctor.

Compression

You can also wrap bandages around the damaged area to prevent movement.

Most people use a pressure bandage at first, followed by tape when the swelling has disappeared.

If you are wearing bandages, it's important to monitor the area surrounding them. If this becomes blue-coloured and the surrounding tissue seems cold, you should remove the bandages and contact a doctor.

Elevation

The injured area shouldn't point downwards, otherwise fluid build-up may occur. This prolongs the healing process and causes more pain.

How can I relieve the pain?

The most important treatment for a sprain is protection, rest, ice, compression and elevation, as described above.

However, the pain experienced following a sprain can also be relieved with over-the-counter painkillers, such as paracetamol (eg Panadol) or paracetamol and codeine (eg Panadol ultra).

Good advice

Ask a pharmacist for advice on which painkillers are suitable for you.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (eg Nurofen, Advil), used to be frequently recommended following a sprain, because they reduce the inflammation and swelling as well as relieving pain.

However, inflammation is a necessary part of the healing process. It limits movement to prevent further damage to the joint and also initially helps to repair the damaged tissue.

There is now some suggestion that reducing inflammation with this type of painkiller can actually slow down the healing process in the long-term. It's considered best to avoid these types of painkillers in the first 24 to 48 hours after the injury.

When to consult a doctor

If the sprain is accompanied by severe pain and severe swelling.
If one of your joints gives way and is unable to carry your weight.
If the pain is still present and getting worse after two days.
If the sprain has not improved after four days of self-treatment.

What should I do to prevent sprains?

Ask yourself what caused your accident and focus on the cause. Note that the following information is a rough guide: if in doubt, consult a doctor.

Running too quickly?
Exercising without any warm-up or stretching exercises?
Running, working out or playing sport without the proper shoes?
Running on hard or uneven surfaces?
Are any of your muscles overcompensating for weakness in another – for instance, due to a bad knee?

Recovering from sprains

When the pain and the swelling have gone, start exercising the injured part of the body gently. After one or two days' rest, it is important to start moving again to reduce the amount of scarring formed in the damaged tissue.

As with any activity, warm up slowly and use stretching exercises to begin with.

If it's possible to stay physically active without further injuring the sprained area, do so.

Keep your other muscles functioning and maintain physical fitness. It may take up to three months after an ankle sprain to return to full sporting activity.

How to treat bruises

Bruises and swellings are caused by bleeding under the skin.

Again, bruises are best treated with cooling. To do this, follow the instructions given above for cooling treatment of sprains.

If you seem to be bruising easily or without any reason, see your GP who can advise you further.

Osteoporosis: preventing falls

Why prevent falls at home?

About 1 in 20 falls at home results in a bone fracture and of these, one in five is a hip fracture. Hip fractures have a high mortality rate; some 10 per cent of patients are dead within a month. In addition many older people lose their indepen

dence due to falls. While osteoporosis is a major factor in hip fractures, falls from other causes are at least equally significant. It is therefore important to do everything possible to prevent them happening in the first place.

What can be done to make the home safer?

Wear appropriate, flat shoes.
Wear glasses with the correct prescription and have this checked regularly.
Avoid having loose rugs and carpets or trailing electrical flexes. Repair any torn floor coverings.
Make sure the home is well lit.
Be extra careful when taking medicines - especially sleeping pills and sedatives that may leave you drowsy and more likely to trip or stumble.
Many elderly people need antihypertensive and diuretic medicines, which may increase the risk of a fall when given in high doses. Consult a GP to confirm that the dose is correct.
Anyone who experiences dizziness or is at risk of falling should talk to their doctor about how their medication might affect this.
Anyone who needs to get up during the night to visit the toilet should consider using a chamber pot to avoid the risk of falling in the dark. Otherwise, leave some lights on where possible and make sure the route from the bed to the toilet is safe and clear of items that could cause a fall.

Can hip protectors help?

Yes. The risk of an elderly person fracturing a hip can be reduced by 50 per cent using a hip protector. It is worn under the clothes, and cushions the hip should a fall occur.

Prevention and treatment of osteoporosis

Ideally, osteoporosis is a condition that should be prevented from occurring. But this is unrealistic given our present state of knowledge and ability to influence it.

What steps can I take to prevent osteoporosis?

These general measures can be used by everyone, whether or not you ultimately go on to

develop osteoporosis.

Exercise and lifestyle

Advice for runners

Excessive running may cause increased bone loss.

Because some runners are very thin, they should take advice on the best way to avoid bone problems later in life.

The majority of us who are not in the elite athlete category need not be so concerned.

Healthy bones at least partially reflect healthy living: taking regular exercise is the single most important action anyone can take to improve the strength of their bones.

Exercise also greatly reduces the risk of heart disease, high blood pressure and diabetes, and it has positive effects on mental wellbeing, too.

The sort of exercise that's beneficial in preventing osteoporosis is weight-bearing, such as walking or aerobics.

Stopping smoking should be a priority for anyone interested in enjoying a longer life and keeping away from orthopaedic wards.

Alcohol consumption should also be kept within safe limits.

Diet

Non-dairy food sources of calcium

Nuts and pulses: almonds, Brazil nuts, hazelnuts, sesame seeds.
Green leafy vegetables: broccoli, spinach, watercress, curly kale.
Dried fruits: apricots, dates, figs.
Fish: mackerel, pilchards, salmon, sardines.
Tofu and various calcium-fortified foods.

A good calcium intake is essential throughout life for healthy bones.

There is good evidence that the adequacy of a child’s diet at least partially determines their osteoporosis risk in adulthood.

The recommended daily intake of calcium for an adult is around 800mg.

On average, 250ml (half a pint) cows' milk or 150g (5oz) yoghurt contains 300mg of calcium. Low-fat dairy products contain the same amount of calcium as higher fat varieties.

What about taking supplements?

Calcium supplements can be bought. There are several types available on prescription if someone’s dietary intake is low or marginal.

Frail elderly people with poor mobility may be helped by taking a calcium supplement along with vitamin D.

This type of supplement is safe, but it's best discussed with a doctor first.

Treatment

More detailed intervention depends on individual circumstances, and so only an overview can be presented here.

There are several types of treatment available, and often a combination will be more appropriate than just one.

Hormone replacement therapy (HRT)

Oestrogen seems to protect bone strength. The drop in oestrogen, which occurs following menopause, is mirrored by an increased loss of bone for a few years thereafter. The loss continues, but less steeply, in older women.

Hormone replacement therapy replaces oestrogen and so reduces the rate of bone loss.

The pros and cons of HRT are many, and they are the subject of much debate.

HRT is thought to be of most benefit for preventing osteoporosis if it is started early in menopause and is taken for at least five years. However long-term use increases the risk of side-effects.

Any woman considering HRT should therefore discuss the risks and benefits for her individual circumstances with her doctor before making a decision about treatment.

Briefly, HRT is known to be associated with an increased risk of breast cancer, cancer of the lining of the womb (endometrial cancer), blood clots in the veins (thrombosis), stroke and heart disease.

However, as well as preventing osteoporosis, HRT reduces the symptoms of the menopause, which can be distressing for some women. It's also associated with a reduced risk of bowel cancer.

The length of time that treatment should be continued is also an issue of contention.

Whether or not to use HRT to prevent osteoporosis and how long for will depend on a woman’s individual risk of developing the condition, her personal and family medical history and her individual views on the potential risks and benefits, all of which should be discussed with her doctor.

HRT is not now recommended as a first choice of therapy for long-term prevention of osteoporosis in women who are over 50 years of age because there are other medicines available that do not carry the risks associated with HRT.

There's more information about these medicines below.

HRT remains an option for women over 50 at risk of fractures for whom these other medicines are not suitable.

HRT is also still a suitable option for women who have had an early menopause.

However in this case HRT should only be used for treating menopausal symptoms and preventing osteoporosis until the age of 50, after which time other medicines may be more suitable.

Bisphosphonates

This is a group of medicines that slows the rate at which bone is dissolved, thus favouring a build-up in bone strength over time. Two types are in common use: alendronic acid (Fosamax) and disodium etidronate (Didronel PMO).

Alendronic acid and disodium etidronate can be used in men and women who have, or are at risk of developing, osteoporosis, including where this is secondary to the use of steroid drugs.

Risedronate sodium (Actonel) and ibandronic acid (Bonviva) are other bisphosphonates used only in women after the menopause, but are otherwise similar to the others.

There are slight differences between the bisphosphonates in the available preparations and how frequently they are taken, but they act in the same way.

Alendronic acid and risendronate sodium reduce the occurrence of fractures of the hip and spine, whereas etidronate and ibandronic acid have only been shown to reduce fractures of the spine.

The most common side-effects associated with bisphosphonates are digestive in nature, for example indigestion, diarrhoea, constipation and abdominal pain.

Alendronic acid and ibandronic acid have strict instructions for how they should be taken because they can cause irritation and ulceration of the foodpipe (oesophagus).

Strontium ranelate

Strontium ranelate (Protelos) is used for the treatment of osteoporosis in postmenopausal women. It is usually reserved for women who cannot take bisphosphonates.

It has a dual action of increasing bone formation, as well as decreasing bone breakdown, and it has been shown to reduce the risk of spinal and hip fractures.

Strontium seems to be asociated with an increased risk of blood clots in the veins, but not to the same extent as HRT or raloxifene (see below).

Raloxifene

Raloxifene (Evista) is a type of medicine called a selective oestrogen receptor modulator (SERM). It can be used to both prevent and treat osteoporosis in postmenopausal women.

Raloxifene stimulates bone growth just as oestrogens do, but it has an anti-oestrogen effect on the uterus (womb) and on breast tissue.

The latter effect is seen as desirable because it may reduce the tendency for long-term oestrogen-based HRT to increase the risk of developing breast cancer.

However, raloxifene may increase the risk of developing blood clots in the veins and can't be used by a woman with a past history of deep vein thrombosis (DVT). The risk of thrombosis with raloxifene is similar to the risk with HRT.

It is preferably used only in women who are five years past their menopause. It would be an option for a woman between 55 and 70 years.

It has been shown to reduce the occurrence of spinal fractures, but not hip fractures.

What other treatments are used in osteoporosis?

These treatments are quite specialised and not commonly used.

Calcitonin

Calcitonin (Miacalcic) is a hormone involved in the regulation of bone turnover. It is given by injection or nasal spray and is used for postmenopausal osteoporosis when treatment with bisphosphonates, strontium or raloxifene is unsuitable.

It can relieve pain when used following a collapsed vertebrae. But it has a number of potential side-effects, including allergic reactions.

Calcitriol

Calcitriol (Rocaltrol) is a vitamin D-like compound that can be used in osteoporosis following the menopause or in situations where osteoporosis has been caused by steroid drugs.

Studies of the effect of calcitriol on bone loss and fractures have produced conflicting results, however it has been shown to reduce the risk of spinal fractures but not hip fractures.

Teriparatide

Teriparatide (Forsteo) is used for the treatment of osteoporosis in postmenopausal women and in men with an increased risk of fracture.

It works by increasing the formation of bone and is given by daily injection under the skin, using an injection pen similar to those used by people with diabetes for injecting insulin. It has been shown to reduce the incidence of spinal but not hip fractures.

Hip protectors

Hip protectors are shock-absorbing pads that can be worn to cushion the impact over the hip bone, should a person fall down. They spread the load across a wider area of the upper leg and are useful as an extra measure in an elderly person prone to falls.

Hip protectors come as a sort of girdle with padding at the sides. However, it can be difficult for people to remember to put one on, or even wish to wear one.

Sticking to treatment

Compliance is the business of sticking to the prescribed treatment, whether it be tablets or protective clothing.

Because osteoporosis treatment and prevention needs to be taken for years, poor compliance can be a major issue in treating the condition.

Elderly people are the most at risk of falls. They are also the most likely to become muddled about pills and suffer more severe side effects from them.

Those in sheltered or supervised environments can be given help to remember their medication.

Where this is not possible, and someone is forgetful, using a weekly or monthly dose form of bisphosphonate, supervised by a carer or nurse, might be more reliable than a daily dose.

Osteoporosis and men

Women tend to get more coverage in osteoporosis than men because they:

live longer
have generally weaker bones
experience more osteoporotic fractures.

However, men do develop osteoporosis. Men show an increase in osteoporotic hip fractures after the age of about 70, similar to that shown by women 5 to 10 years younger.

Men may not experience the recognisable hormone shift represented by the menopause in women, but they do experience a steady drop in output of testosterone (the ‘male hormone’) by the testes as they get older.

Like oestrogen in women, testosterone has a protective effect on bone.

Low testosterone and the male menopause

A low level of testosterone can be suspected if there are obvious physical signs, such as an absence of beard growth in a man.

Other, more subtle, symptoms are also thought to be due to a lack of testosterone.

These include:

depression
nervousness
fatigue
poor concentration and memory
flushes and sweats
decreased libido
difficulty obtaining a satisfactory erection.

This is a controversial area and experts remain uncertain about the phenomenon of the 'male menopause'. The situation is not helped by the fact that no easy test for this condition exists.

Low blood levels of testosterone are insufficient to diagnose menopause in men because there is widespread disagreement over:

what is the normal range for testosterone levels
exactly what form of testosterone should be measured in the blood.

The timing of the blood sample also matters because testosterone is released into the bloodstream in pulses, and levels vary throughout the day.

Diagnosing osteoporosis in men

These difficulties need to be tolerated, but a doctor can make allowances for the difficulty in being sure of the diagnosis.

Perhaps more important is being aware of the possibility of osteoporosis in a man:

who has had a fracture at a relatively young age or after relatively little trauma
who shows signs of height loss
whose spine X-rays are suggestive of some bone loss.

Treating osteoporosis in men

Very often the penny simply does not fall, yet men can benefit from all of the treatments that apply to women, other than HRT and raloxifene.

Testosterone treatment is controversial, and uncertain in value in the majority of men who do not have very low testosterone levels.

Osteoporosis management should be along the lines of encouraging exercise, diet supplements and taking the lifestyle measures mentioned above. Bisphosphonate drugs should be used when more active treatment is required.

Osteoporosis

Osteoporosis is where the amount of bone tissue in the body is below what is normal for a person, taking into account their sex and age.

Put simply, osteoporosis causes weaker bones, increasing the likelihood of a fracture.

Osteoporosis on its own does not cause symptoms. Unless it's caused a bone fracture, it’s not a painful condition, nor is it a type of arthritis.

Understanding bone structure

Bone has a complex structure that achieves the maximum amount of strength for the least amount of weight.

It can increase its thickness in areas subjected to repeated heavy loads, repair itself when broken and is the site of manufacture of most of the components of blood (the bone marrow).

If you take a typical bone, such as the femur (upper leg bone), and cut it across – you will see there's an outer shell of hard bone. In the middle space it has a honeycomb structure, through which is mingled the bone marrow.

Bone is made up mostly of collagen fibres, upon which are laid down crystals made from calcium and phosphate that give bone its ability to withstand compression and bending forces.

Cells that repair and dissolve bone

If you looked at bone under a microscope, you'd see two types of specialised cells scattered throughout:

cells that continually make new bone, called osteoblasts
cells that continuously dissolve bone into its component materials, calledosteoclasts.

Bone is therefore not a static tissue, but is always on the go. The actions of bone manufacture and disassembly are usually exactly balanced.

How bone repairs itself

When increased loads are repeatedly put upon a bone, the osteoblasts become more active, laying down more bone and increasing the strength of the region.

When a bone fractures, osteoblasts go into overdrive around the fracture site, laying down more collagen fibres and minerals on top to strengthen them.

How does osteoporosis affect bone?

In osteoporosis, the osteoclasts – usually over years – dissolve a bit more bone than is replaced, resulting in weaker bones.

Fractures in bone affected by osteoporosis are most likely in areas where there is a greater percentage of the honeycomb type of bone, which is less able to take the shock of a fall:

in the wrist
in the femur close to the hip joint (called the ‘neck’ of the femur)
in the vertebrae of the lower spine.

Hip and wrist fractures usually result from falls, whereas fractures of the spine tend to occur spontaneously when a weakened vertebra eventually crumples under the stress of supporting the body's weight.

The scale of the problem

One in three women and 1 in 12 men over the age of 50 will suffer a fracture of the hip, wrist or spine as a result of osteoporosis.

In total, osteoporosis causes 310,000 fractures in the UK every year. The estimated cost of treating these fractures is an enormous £1.7 billion each year.

But the cost to the individual can be higher.

Bone fractures can cause considerable pain and disability.
Fifty per cent of people who suffer a fractured hip lose the ability to live independently.
Around 20 per cent of people who fracture a hip die within a year, as a result of their fracture.

Detecting osteoporosis

The majority of people who suffer a fracture from osteoporosis are not known to have the condition prior to breaking their bone.

Osteoporosis is an under-recognised condition, which is partly because an organised approach to detecting it has not yet been developed in the UK. As a result, people at high risk of getting a fracture are not offered appropriate advice or treatment to reduce their risk.

Many people who have had a fracture due to osteoporosis do not receive follow-up treatment that helps reduce the chance of their getting another one.

There are wide variations throughout the UK in the quality and quantity of effort put into detecting and treating osteoporosis.

There are further divisions in the quality of care delivered to people from different social groups. In a recent study in Glasgow, people from the most deprived areas were eight times less likely to be referred for tests to detect osteoporosis than those from affluent areas.

The government has recognised the deficiencies that exist in osteoporosis management nationally. More funding is slowly coming through to expand the services, to be used for bone scanning machines to help diagnosis as well as specialists in osteoporosis.

What's classified as 'abnormally weak'?

It is normal for bone to get a bit weaker each year after the age of about 30, when our bones are at their maximum strength. Men tend to have greater bone mass than women of the same age.

For a few years after the menopause, women experience an increased rate of bone loss. This is secondary to the drop in oestrogen that is part of the hormone change of menopause – oestrogen has a protective effect upon bone strength.

Defining when bones are abnormally weak has to take account of what is normal for the two sexes and the different age groups.

Modern bone scanning devices can measure the density of bones and have allowed doctors to set a range for normal bone strength. Osteoporosis can therefore be diagnosed if a person’s bone density measurement is significantly low compared to these standards.

Low impact fractures

A person is also deemed to have osteoporosis if they have suffered a fracture too easily, ie a ‘low impact’ or ‘osteoporotic’ fracture.

A low trauma fracture is:

one that occurs from a fall from standing height or less
a fracture of the hip, wrist or forearm.

It's more difficult to categorise spinal fractures because they occur out of the blue and are not related to falls – sometimes they are not even accompanied by much pain.

However, the sudden onset of back pain should suggest there has been a collapsed vertebra, possibly due to osteoporosis.

Identifying people who have osteoporosis after they have suffered a fracture allows efforts at prevention to be concentrated on them. This can reduce the chance of them suffering another fracture later.

Causes of osteoporosis

Various factors are known to increase the rate at which bone loss occurs.

These can be divided into three groups:

factors you can do nothing about
things you can change
causes related to other medical conditions or drug therapy.

Listed below are the main conditions that can lead to osteoporosis.

Unchangeable causes of increased bone loss

Increasing age.
Family history of osteoporosis.
Being female.
Following menopause.
Being thin (see below).

Changeable causes of increased bone loss

Inactivity.
Poor diet (low in calcium).
Smoking.
Increased alcohol intake.

Medically related causes of increased bone loss

Steroid drug treatment, particularly if prolonged more than a few weeks.
Early menopause or the removal of the ovaries at a young age (under 45 years).
Hormone abnormalities, such as over-activity of the thyroid gland or the glands that produce the body's natural steroids, or under-production of testosterone in men.
Chronic liver or kidney disease.
Vitamin D deficiency.

Diagnosing osteoporosis

The best test to diagnose osteoporosis is a scan to determine the density of the bones.

Usually the same reference point in the skeleton is chosen, which allows better comparison between different people. The hip, forearm, heel bone or spine are all used, but exactly which varies according to local procedure.

DEXA scan

There are several ways in which a bone scan can be done, but the best is the‘DEXA’ scan. DEXA is short for dual-energy X-ray absorptiometry.

As the name implies, a DEXA scan uses X-rays to determine the density of bone.

Ultrasound

Ultrasound of the heel bone is another common technique for determining bone density. It uses cheaper equipment, but it's not yet clear if it is as accurate or reliable as DEXA scanning.

X-rays

Ordinary X-rays are not reliable as a tool for diagnosing osteoporosis. It can be possible to suspect from a standard X-ray that the person has less bone mass than normal, because the bone outline on the film might appear fainter.

However, the same appearance will show if the exposure of the film is slightly too high. Conversely, if the film is slightly underexposed, the bones will look normally dense.

As much as 30 per cent of bone mass needs to be lost before it shows up on ordinary X-rays.

Who can have a DEXA scan?

There are not enough DEXA scanners in the UK to make the test freely available, so some form of vetting procedure is used to ensure that those most at need are being scanned.

The details of these criteria vary across the UK, but could look like the list below, in which the presence of any one factor would justify a DEXA scan.

A woman over 50 who has had a low trauma fracture.
Anyone taking an oral steroid, eg prednisolone 5mg daily, or greater, for three months or more.
A woman under 45 who has had an early menopause or removal of the ovaries.
A man with a high alcohol consumption of more than 50 units of alcohol weekly.
A woman who is around the menopause with any two of the following:
- a body mass index (BMI) less than 21
- a history in her mother of a hip fracture below 80 years of age
- who smokes
- who drinks more than 35 units of alcohol weekly (see below).

Thinness

People who are unusually thin are more likely to develop osteoporosis, and the way to define ‘thinness’ is to measure your body mass index (BMI).

People with a BMI of 21 or less have a higher rate of bone loss than those who are heavier, and obese people have lower rates of bone loss than those who are ideal weight.

It is not known if a thin person who deliberately puts on a lot of weight will reduce their subsequent fracture risk.

Obesity, of course, carries with it many other health hazards.

Alcohol

Historically, the recommended maximum consumption of alcohol per week has been 21 units for women and 28 units for men.

High levels of alcohol intake (over 50 units per week in men or 35 units in women) are associated with osteoporosis, as well as the other serious health risks that accompany alcoholism.

It is possible that lower levels of alcohol consumption than this could still damage bone and be associated with problems such as raised blood pressure or diabetes.

Many experts therefore now recommend lower safe limits of alcohol consumption of 21 units weekly for men and 14 units weekly for women.

Prevention and treatment

There are some general measures that people can take to prevent and treat osteoporosis including changing their diet and modifying their lifestyle and attitude to exercise, as well as taking supplements or treatment prescribed by a doctor.