Osteoporosis is an increasingly prevalent problem for which several traditional, effective pharmacologic therapies exist. Despite the availability of these agents, many patients prefer to augment or substitute traditional therapies with nontraditional alternative substances and practices. Patients who choose alternative therapies may be concerned about adverse effects, economic cost, fear, mistrust of the pharmaceutical industry, or a general reluctance to take prescription medications. Nurses need to be aware of nontraditional options to provide comprehensive information to the growing number of people at risk for or diagnosed with osteopenia or osteoporosis.

Bone formation and bone mass maintenance is a complex process that occurs throughout life. The action of osteoclasts that resorb bone and osteoblasts that form new bone maintains bone mass. In people with normal bone mass, these cells work collaboratively. In osteopenia, bone mass is low because the cycle of bone resorption and formation becomes unbalanced — that is, resorption exceeds formation. Osteoporosis occurs when the cycle becomes so unbalanced that bone mass is low enough to make bones susceptible to fracture. Bone mass maintenance by osteoclasts and osteoblasts is dictated by the endocrine system. Serum levels of estrogens, testosterone, parathyroid hormone, vitamin D, calcium, and other biochemical substances are responsible for maintaining adequate bone mass. Bone mass development typically peaks around age 30, gradually declining as men and women age. The risk of vertebral and hip fractures increases proportionally to the amount of critically low bone mass in people with osteoporosis.

Osteoporosis is chronic, debilitating, and insidious. It is usually not discovered until a bone density test is performed, or even worse, until after an osteoporotic fracture occurs. Its incidence and morbidity are increasing as the population ages. In the U.S. more than 10 million people have osteoporosis, and 34 million more are estimated to have osteopenia.¹ Historically, these problems were thought to only affect elderly women. Although the majority of osteoporosis sufferers are aging women, we now know that the disease can occur much earlier in life, and that men are also at risk.²

The rising incidence of osteoporosis has provided the scientific community with an incentive to develop and investigate new pharmacologic therapies. In the past 10 years, the Food and Drug Administration has approved six drugs for the prevention and/or treatment of this disease. These drugs — alendronate (Fosamax), raloxifene (Evista), nasal calcitonin (Miacalcin), risedronate (Actonel), ibandronate (Boniva), and teriparatide (Forteo) — have expanded options for countering osteoporosis. Advances in drug therapy options have additionally included once a week oral dosing for alendronate and risedronate, once a month oral dosing for ibandronate , daily subcutaneous injections for teriaparatide, nasal sprays for calcitonin, and every three-month IV dosing for inbandroate. Additionally, many different hormone replacement therapies have been found to increase bone mineral density and presumably prevent osteoporotic fractures. Further information about these therapies can be obtained in a previous Nursing Spectrum module, CE 204, “Osteoporosis Update,” online at http://www.nurse.com/ce/syllabus.html? CCID=3139.

Despite available options, many people at risk for osteoporotic fractures are reluctant to use traditional therapies prescribed by their health care providers. Hormone replacement therapy (HRT) is something many men and women will not even consider due to potential risks of cancer and, for some, unpleasant adverse effects. Some patients believe that HRT is unnatural and that gradual withdrawal of hormones is an inevitable consequence of aging that should not be corrected. The release of data from the Women’s Health Initiative (WHI) study has made hormone replacement therapy an even more controversial issue and less accepted by many patients and providers. Other traditional therapies may not be tolerated because of cost, gastrointestinal (GI) upset, allergic reactions, or other intolerance to the medications. Those at risk for osteoporosis and osteoporotic fractures may seek assistance from alternative substances or therapies. Nurses need to understand these alternative modalities and be able to help patients make informed decisions about usage.

Soy isoflavones

Although soy supplements have recently gained popularity in the U.S., they are not new. In other parts of the world, soy products have been a mainstay of diets for centuries. The use of soy as a food has been documented in China as early as the 11th century. Recent interest in soy proteins has increased around the world because of their potential estrogen-mimicking effects.

In animal research studies, soy isoflavones have produced effects similar to estrogen. Because isoflavones are structurally similar to that hormone, they may protect against bone loss that occurs as a result of estrogen deficiency. Adequate amounts of circulating estrogens are necessary to regulate the activity of osteoclasts and maintain normal bone mass. So far, studies in human populations have been short-term with relatively small sample sizes. Two researchers have demonstrated increases in bone mineral density at the end of six months of supplementation with soy proteins.^3,4 Preliminary data from a study of isoflavones derived from clover seeds have also shown significant suppression of bone loss in the lumbar spine.⁵ While these early results of clinical studies are encouraging, long-term fracture prevention studies are needed to verify the efficacy of soy isoflavones in prevention and treatment of osteoporosis.

Isoflavones are a class of phytoestrogens found in legumes and beans. Phytoestrogens are plant substances that mimic the actions of estrogens. Soybeans are a rich source of isoflavones. Other sources of isoflavones are lentils, kidney beans, lima beans, and chickpeas. Soy supplements are also available commercially. Two products — New Phase® and Remifemin® — have recently gained national recognition through advertisements in consumer magazines. Health food stores sell soy powders that can be mixed with milk, ice cream, or cereals. Soy isoflavones are nonsteroidal molecules with a chemical structure similar to estradiol and the selective estrogen-receptor modulators (SERMs),⁶ potentially producing the same positive effects on bone as prescription agents, such as HRT and raloxifene (Evista).

Progesterone cream

Scientists have believed that estrogens were the primary hormones responsible for postmenopausal bone loss. However, although they are important, recent research suggests that progesterones and their withdrawal during menopause also contribute to bone loss. Progesterones down regulate estrogen receptors and make the withdrawal of estrogen during menopause more tolerable. They temper adverse effects of estrogen withdrawal, such as hot flashes, irritability, and insomnia. Several studies also suggest that progesterones may promote bone protection and guard against osteoporosis by increasing osteoblastic activity.^7,8,9

Progesterones are available as part of traditional hormone replacement supplements, either alone or in combination with estrogens. Natural or bioidentical progesterones can also be administered via transdermal creams prepared with a penetrating base, typically to the thighs, although they can be applied anywhere. Natural progesterones are free of adverse effects and have been successfully used in Europe for decades. However, they should not be confused with wild yam creams currently marketed in health food stores. Yam creams contain precursors of progesterone — diosgenin and sarsasapongenin. Humans lack the necessary enzymes to produce progesterone from these substances; yam cream preparations without added progesterone are useless. To obtain pure progesterone cream that may help to maintain bone density, consumers should obtain preparations from reputable wholesale pharmaceutical sources or a local compounding pharmacist. While the use of such a pharmacist may be costly and not covered by prescription insurance plans, it is the only way to guarantee amount and quality of the progesterone cream.

Electromagnetic therapy

Magnet therapy has existed on the fringes of health care for many years. Therapeutic magnets are readily available in health food stores, through sports magazine advertisements, and from many other venues. The theory of magnets as healing agents dates back to Franz Mesmer, who used them to hypnotize people in the 18th century.¹⁰ Today, advances in electromagnetic wave technology has provided such common conveniences as the microwave oven and cellular telephones. The diagnostic effectiveness of magnetic resonance imaging (MRIs) is also due to magnet technology.

Pulsed electromagnetic fields (PEMFs) have been available as bone-growth stimulators for 20 years, although they have just recently become the standard of care for posttraumatic-delayed union bone fractures.¹¹ PEMF therapy is noninvasive, cost-effective, and free of complications. Bone healing is thought to occur in response to the electromagnetic energy. In animal models, PEMF therapy produced favorable results in bone healing and surgical repair.¹²

The promising results of PEMF in fracture healing have led many scientists to speculate about alternative uses of electromagnetic therapy. Although no current research data supports its use in osteoporosis-induced fractures, magnet therapy may be a helpful alternative. Large, independent clinical trials at several major osteoporosis centers throughout the U.S. may provide the clinical evidence to recommend magnet therapy in the treatment of osteoporotic fractures in the future.

Dynamic motion therapy

Dynamic motion therapy is a drug-free way to halt bone loss and grow new bone, which would ultimately reduce fracture incidence. It is delivered via a platform that transmits high-frequency, low-intensity mechanical forces through the patient’s feet and up through the skeleton. Patients are instructed to stand on the platform at least five days per week for 20 minutes each day. Several countries throughout the world approve dynamic motion therapy for building bone mass. Currently, this therapy is approved in the U.S. where it is marketed as a way of maintaining muscle mass. Ongoing studies seek approval for using it to enhance bone mineral density and prevent osteoporosis fractures. The underlying theory of dynamic motion therapy is that bone is very sensitive to mechanical stimulus and can adapt its structure to become denser and stronger when functional demands are placed on it. Recent research studies have demonstrated increases in bone mineral density in young women and in postmenopausal women.^13,14

Tai Chi and other exercise

Tai Chi is a form of Chinese exercise that has been practiced for more than three centuries. Its origins are firmly rooted in ancient Chinese medicine and philosophy.¹⁵ Tai Chi is recommended for exercise, relaxation, and meditation in people of all ages and has been extensively researched as a method of enhancing flexibility and preventing falls in the elderly. Fall prevention is critical in patients with osteoporosis, especially with those of low bone mass of the hip. Strong evidence suggests that elders who practice Tai Chi improve their balance and agility, reducing the risk of falls.¹⁶ Although practicing Tai Chi does not directly build new bone, it may help to avoid the consequences of falls and fractures. The soothing and meditative aspects of the exercise may give elders other benefits, such as better coronary circulation, respiratory function, GI flow, and neurological functioning.

Weight-bearing exercises, such as walking, jogging, dancing, or running, may also be helpful in osteoporosis. Additional exercise options are listed in the sidebar. The mechanical and electrochemical forces during exercise may help to stimulate bone growth. Peak bone mass is achieved during adolescence; it is probably then that exercise is most helpful in building sufficient bone for the future. Adolescent boys and girls who engage in regular physical exercise may reduce the future risk of osteoporosis in aging and delay the physiologic decrease of bone mineral density.¹⁷ Regular exercise has an important and early role in osteoporosis and fracture prevention. Some studies have suggested that continued, regular weight-bearing exercise may help preserve bone mass and prevent osteoporotic fractures in postmenopausal women.^18,19

As a treatment modality, exercise only modestly increases bone mass.²⁰ However, the benefits of muscle strengthening and flexibility that come with regular exercise may protect elders who do fall from injury and bone fractures. Recently, a group of scientists at a consensus development conference at the National Institutes of Health postulated that regular exercisers might fall differently, thereby reducing the risk of fractures.²¹

Vertebroplasty

The most devastating consequences of osteoporosis are fractures. Unlike healthy bone fractures, osteoporotic fractures result in delayed healing and permanent damage. The most painful and debilitating of those are vertebral, which depending on the degree and number, are associated with kyphotic deformities and chronic pain.

Percutaneous vertebroplasty is a therapeutic, interventional radiologic procedure where bone cement is injected into a cervical, thoracic, or lumbar vertebral body to relieve pain and to strengthen existing bone. Vertebroplasty is typically reserved for patients who have failed to achieve pain control and stabilization with more traditional therapies. Research surrounding vertebroplasty has been positive; the procedure can alleviate pain and prevent further vertebral collapse.²² A newer variation of this technique is called kyphoplasty. In this procedure, a balloon catheter is inserted into the collapsed vertebrae and inflated. Then, cement is injected via the balloon catheter. Vertebroplasty and kyhoplasty are useful therapies to relieve the acute pain of osteoporotic vertebral fractures. Patients must be identified and treated soon after a fracture has occurred for maximum benefit. Vertebroplasty and kyphoplasty are done commonly in many parts of the country by qualified surgeons and interventional radiologists. However, these procedures are not without risks, such as lack of pain reduction, infection, increased pain, paralysis, allergic reactions, and extravasation of the cement. Since the procedures are still relatively new, no data has been collected from controlled clinical trials with long-term follow-up.

Hip protectors

Hip fractures, a common and debilitating result of osteoporosis, result in costly hospital stays and for many elders, require nursing home recuperation. Osteoporotic hip fractures cost millions of health care dollars each year in ED visits, hospitalizations, and nursing home stays. Although pharmacologic treatments for osteoporosis may help to prevent hip fractures, many elders cannot or will not take osteoporosis medicines necessary to prevent them. In these cases, fall prevention is a key aspect of patient care. Beyond usual recommendations of home assessment, proper footwear, and vision and hearing evaluations, nurses can offer an interesting alternative — hip protectors.

Hip protectors disperse the weight of a blow from the neck of the femur during a fall or impact to the hip. Acting like the crash helmets of racecar drivers, they are hard, flexible shell protectors sewn into the hip areas of cotton and Lycra undergarments. Flexible shells cover and protect the neck of the femur by dispersing and absorbing the shock of a fall. Several studies have shown that hip fractures are preventable in institutionalized elders who wear hip protectors.^23,24 While hip protectors are effective, they are sometimes difficult for frail elders to apply and therefore compliance, particularly in community settings, has not been ideal. Future models that are less costly and easier to use may result in increased use of this option. Hip protectors can be purchased from medical supply companies or through the Internet at Safehip®, found at www.safehip.com.

Nurses’ role in alternative therapies

Nurses have learned to educate patients about medical options that are scientifically proven or at least traditionally accepted. Extensive, placebo-controlled clinical research trials and long-term follow-up studies are the best evidence for recommending treatment options to their patients. Additionally, many medical therapies are recommended on the basis of years of experience and anecdotal evidence. However, some of the therapeutic options noted here are not yet supported by any of this evidence. Some alternative therapies are still too new for the science and clinical experience to have generated complete supporting data. Options such as soy supplements, progesterone creams, and electromagnetic therapy may prove to be helpful agents or products without real efficacy. Whatever happens, many patients are interested in these therapies. In the U.S., surveys consistently show that 30% to 40% of people go to alternative providers, often spending more money on complementary therapies than on traditional primary care.²⁵

Despite their personal biases, nurses need to become knowledgeable about alternative therapies. For patients with osteoporosis, effective pharmacological options are sometimes limited in choice and tolerability. As with complementary modalities, the safety and lifelong efficacy of traditional, yet relatively new therapies may not be established. Alternative or traditional treatments may be useful as adjunctive or even primary therapies. They may simply produce a placebo effect to alleviate the chronic pain of osteoporotic fractures.

Patients should be encouraged to be open about all therapies, but at the same time, discuss them with their health care providers. As providers, we must be aware of the availability, quality, prices, and potential adverse effects of alternative therapies. Holistic care of patients mandates that we explore both traditional and nontraditional approaches to disease prevention and management. Patients with chronic, debilitating diseases, such as osteoporosis, seek health care advice from many different venues — consumer magazines, Internet sources, and friends and neighbors. Nurses caring for the increasing numbers of people at risk for osteoporosis and osteoporotic fractures must be able to discuss alternative therapies and products knowledgeably from solid clinical evidence and experience and with an honest and nonjudgmental attitude.