Parkinson's Disease Plays Havoc With Common Orthopaedic Conditions

Although Parkinson's disease (PD) is a neurological disorder, according to an article in the January 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons, the disease also increases a person's risk of experiencing complicated orthopaedic conditions. The author recommends that all Parkinson's treatment plans include a multidisciplinary approach in order to address additional accompanying musculoskeletal health issues.

According to the author Dr. Lee Zuckerman, M.D., chief resident of orthopaedic surgery, Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center in Brooklyn, New York, tremors, body rigidity, and problems with movement caused by PD may lead to other secondary, medical issues. One often-noted example relates to the fact that people with Parkinson's often move and walk less than non-suffers and generally stay indoors.

Decreased movement may lead to bone loss, and the reduced exposure to sunlight that generally occurs when patients spend little time outdoors is likely to generate a decrease in vitamin D, which is needed to keep bones strong. This is particularly harmful to Parkinson's patients, since the combination of decreased bone density and instability from tremors and rigidity caused by PD greatly increase a person's risk of:

Falling

Breaking bones

Osteoporosis

Ensuring family members are involved in care can have a positive impact on patient health. Dr. Zuckerman says, "I recommend patients and their families read up on Parkinson's disease so they can prepare themselves for the challenges that come with it. This type of early education is important, because it can prevent these secondary problems from occurring. For instance checking bone mineral density and getting treatment for at-risk patients can help reduce the risk of fracture."

Recommended actions to prevent orthopaedic problems in Parkinson's disease include:

Bone density

Physical therapy

Vitamin therapy

Medication to increase bone density

Optimizing therapies for gait and rigidity

The author recommends that patients with PD who are being treated by an orthopaedic surgeon should also be treated by a medical team that includes a neurologist, a neurosurgeon, a primary care physician, a physical medicine and rehabilitation physician, and a social worker. Including family members can ease the complexity of care by ensuring the patient is seeing the correct doctors while getting referrals to other members of the multidisciplinary team.

Although there are surgical treatments for orthopaedic conditions experienced by people with PD, the disease can have a negative effect on recovery. In one example, the tremors associated with PD have been shown to interfere with the repair and rehabilitation of bone injuries. Those who have had a joint replacement are often relieved of pain and initially have improvements in mobility, but these improvements only last about a year.

Dr. Zuckerman comments: "Whether this is because the disease is progressing or because the rehabilitation was insufficient is unclear. So patients now have to decide what they want to accomplish -- more mobility or decreased pain. They have to know that although their pain level should improve, their function may get worse after a year."

Treatments for PD patients have allowed them to live longer lives with improved quality of life. As these patients age, there are strong predictions that there will be an increased need for medical and surgical interventions for complicated orthopaedic issues.

Disclosure: Neither Dr. Zuckerman nor a member of his immediate family, has received anything of value from, or owns stock in, a commercial company or institution related directly or indirectly to the subject of this article.

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Estrogen Is Important For Bone Health in Men as Well as Women

Although women are four times more likely than men to develop osteoporosis, or porous bone, one in 12 men also suffer from the disease, which can lead to debilitating - or even life-threatening - fractures, mainly of the spine, hip and wrist. The underlying causes of osteoporosis are numerous, but in women, low estrogen levels after menopause have been considered an important factor.

As for men - new research at Washington University School of Medicine in St. Louis has shown that low amounts of active estrogen metabolites also can increase their osteoporosis risk.
"Most people don't think about estrogen in men, but men actually have somewhat more estrogen on average than do postmenopausal women," says Reina Armamento-Villareal, M.D., assistant professor of medicine in the Division of Bone and Mineral Diseases and a bone specialist at Barnes-Jewish Hospital. She is senior author of a new study in the journal Calcified Tissue International.

"Research by other groups had suggested that estrogen may be more important than testosterone for maintaining bone health in men," she says. "So we designed a study to look at male estrogen levels and bone density."

When estrogen circulates in the body, it passes through the liver where several enzymes convert the standard hormone to other forms - some of these forms, or estrogen metabolites, are active and some are inactive. Individuals differ in how they process estrogen, so the levels of these estrogen metabolites will vary among people. No previous studies have addressed the role of estrogen metabolism and the forms of circulating hormone in male osteoporosis.

The Washington University researchers found that the amounts of active estrogen metabolites are a strong predictor of bone mineral density in the men they studied. Testing hormone levels and bone density as measured by DXA (dual X-ray absorptiometry) scans in 61 men age 50 or older, the researchers saw that men with higher levels of active estrogen metabolites also tended to have higher bone density. Conversely, men with lower levels of these hormones tended to have lower bone density.

Testosterone levels did not affect bone density in these study subjects. Testosterone seems to be responsible for the larger size and thicker outer layers of male bones, but estrogen is possibly a key hormone for maintaining peak bone mineral mass in men, according to the authors.
The researchers also looked at whether other factors, including smoking, alcohol consumption, daily calcium intake and body mass index (BMI) affected bone density. Only BMI correlated with bone density: Men with higher BMI tended to have higher bone density, possibly because they also had higher levels of active estrogen metabolites.

Fractures due to osteoporosis are a significant health threat in the elderly. According to Villareal, 25 percent of those who suffer a hip fracture die within a year, and 40-50 percent have some degree of disability or need nursing home care. "It's a very serious problem," she says. "People of retirement age are looking forward to their leisure time, but if they fracture a hip, there are so many things they won't be able to do."

Villareal thinks the health-care system may need to reflect what research is now revealing about estrogen in men. "It would be a good idea to measure estrogen levels in older men who present with low bone mineral density or osteoporosis," Villareal says. "Not only does estrogen and its metabolism affect bone health in men, but it may also influence the risk for prostate cancer."

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