The Bone Matrix

05/30/2023

For those of you who attended the Kripalu event and had REMS testing done or anyone else who is curious:

Better Bones - REMS Report Explanation
We commend your interest in Bone Health and your interest in Echolight – REMS. The accuracy of REMS in determining BMD and the ability of REMS to measure Bone Quality called the Fragility Score are important parts of your Bone Health assessment. And remember that since we all have a skeleton made up of bones, we need to pay attention to and take care of our bones because………...
If you ignore your bones, they will go away!
What is REMS?
REMS is a method of bone assessment the utilizes pulsed echographic ultrasonography – REMS is a technology developed by Echolight. REMS is utilized by the EchoS, an ultrasound unit that generates a sound wave that bounces off your bones creating echoes. REMS will then listen to the echoes to determine properties of your bones. REMS can do that because an echo from a strong bone will be different than an echo from a weak bone. The measurements obtained by REMS comply with the standards established by the World Health Organization for bone assessment. REMS assess your spine and left and right hips to generate two values that are critical to your bone health: These numbers are:
(1) Fragility Score - FS
(2) Bone Mineral Density - BMD

Historically, Bone Mineral Density (BMD) has been the number that was used to determine if you were at risk of sustaining a fragility fracture. However, it is now recognized that BMD is not the only important number because there are individuals with low BMD that never fracture and there are other individuals who sustain fragility fractures and have good BMD. Research is showing that there are other properties of bone that need to be measured. The important bone equation is:

Strength = Bone Quality & BMD

Fragility Score (FS) is a measure of bone quality that can help you have a better understanding of your risk of a fragility fracture. Also, there is a third bit of information that the REMS assessment will provide. This is:
(3) Body Composition and Estimated Activity Metabolism

The information provided by the Body Composition Analysis may provide useful information for a comprehensive weight loss program. The results obtained by REMS examinations are clinically valid and can be used in your bone health care.

How will I know what my REMS results mean?
A written generalized explanation of REMS reports will be made available. For a more detailed explanation of the information presented in a REMS report or for additional information concerning your bone health, please contact Central Carolina Orthopedic Associates:
• Office – 919-774-1355 – ask for Cindy
• Cindy – cmcauley@centralcarolinaortho.com
• Web address – www.centralcarolinaortho.com
What is included on a REMS report?
SPINE PAGE 1 of the report will have a graph with your T-score and an anatomical diagram of the spine Region of Interest (ROI) that are color-coded based on the BMD and T-score results.
• To the left of the anatomical diagram is a color-coded graph (green, yellow, red) plots age vs. T-score.
• T-score results will appear on the graph as a target providing a quick and easy way to visualize T-score values.
• The blue-gray table located immediately below the graph has the BMD, T-score, Z-score, and Diagnosis.
• The presence of two colors on the spine diagram is acceptable if the color combinations are either green-yellow or yellow-red. A green-red combination will need further assessment by your examiner.
• If any of the vertebral bodies are resulted as gray color, then that is an indication that REMS did not have enough information at that particular bone for analysis and it was excluded from the final report. If that were to happen, ND (Not Diagnostic) will be listed in the accessory blue-gray table underneath the diagram next to the level (L1-L4) that was excluded.
• Up to two levels can be excluded by REMS and the results will still be clinically valid.
• The blue-gray table below the diagram of the spine provides the BMD values and T-scores for each individual vertebral body evaluated and should be qualitatively assessed but has no quantitative clinical application.
• It is important to look at all the BMD values on the table – the BMD values should be getting larger as the numbers go from L1 to L4. Unfortunately, that does not happen all the time - L3 is sometimes larger than L4. Also, in general, if the numbers are close in value, they are acceptable.
• If any single BMD value and T-score is way out of line with the other vales (i.e., green, and red on the same diagram) the out-of-range number needs to be assessed by your provider but disregarded in the final test scores. This situation is rare in REMS assessments.
• The REMS spine exam will report the statistically-weighted averaged total of the areal BMD values (g/cm2) of the individual vertebral bodies that were successfully examined.
• The TOTAL (statistically-weighted average of L1-L4) BMD then is converted to a T-score and Z-score. A Diagnosis is determined from the T-score.
• The TOTAL BMD is also used for quantitative comparisons year-to-year.
• In addition, on the bottom of SPINE PAGE 1 you will find very important clinical information in the Fracture Risk Assessment Box. The Fragility Score will be presented as a number from1 to 100. This will be explained in greater detail on SPINE PAGE 2.
• The next line of information, the 5 Year Risk of a Major Osteoporotic Fracture, will be presented as a number out of 1000!!! Presenting the data as a per thousand is a scientific method of data presentation and reflects the ability of the REMS to measure to the BMD to the thousandth.
• To convert that number to a percent, just divide by ten – that will yield the fracture risk as a percent.

SPINE PAGE 2 depicts the position of the obtained FS value on a colored graph. The graph represents a database of individuals who were determined to be either fragile (had a history of one or more fragility fractures) or non-fragile (no history of a fragility fracture).
• The FS has been determined to be currently most reliable number in determining fracture risk.
• The FS value is presented as a unitless number that is plotted on the Age vs. FS graph.
• FS values that are present in the green area of the graph indicate low fracture risk.
• FS values in the red area of the graph indicate very high fracture risk.
• The yellow zone is a zone of some uncertainty – if the FS is close to the green zone, then that would indicate that the fracture risk is still relatively low. If the FS value is plotted in the yellow zone near the red zone, then the fracture risk would be high.
• Therefore, fracture risk increases as the FS rises and the position on the graph gets closer to or into the red zone.
• It is important to remember that the FS is independent from the BMD – FS was determined by a unique soundwave.
• Academic studies have determined the validity of FS as a predictive value for fracture risk and in those studies, FS was found to be both the most sensitive (true-positive for fracture) and the most specific (true-negative for no fracture) test when compared to either DXA-derived or REMS-derived BMD.
• The SPINE FS database includes individuals who sustained major fragility-type fractures.
• The FS value was derived from the mathematical analysis of the backscatter radiofrequency wave (echo) that was produced by the interaction of the sound wave with the micro structural elements of your bone. The FS is compared to a database of individuals who were identified as either fragile (had sustained a fragility fracture) or non-fragile (had not sustained a fragility fracture). Fracture risk is determined by that comparison.
SPINE PAGE 3 is currently under development and has no practical clinical application.
SPINE PAGE 4 is also still under development but it does provide some clinical value in the form of basic body composition information.
• Since the ultrasound waves pass through body tissue to reach the bones, some of the echoes received and analyzed contain information on % adipose (fat) composition.
• Estimates for kilocalorie requirements is listed.
• This information is available on the spine examination only.
SPINE PAGE 5 is the page with the B-mode doppler images used during the REMS examination for determining correct depth and focal settings.

HIP PAGE 1 of the report will have a graph of your T-score and an anatomical diagram of the hip (Right or Left Femur) Region of Interest (ROI) that are color-coded based on the BMD and T-score results.
• The REMS hip exam is similar in format to the spine report but has slightly different information that is relevant to the hip.
• To the left of the anatomical diagram of the hip is a color-coded graph (green, yellow, red) plots age vs. T-score.
• T-score results will appear on the graph as a target providing a quick and easy way to visualize T-score values.
• The blue-gray table located immediately below the graph reports the BMD, T-score, Z-score, and Diagnosis for the hip (NECK).
• There are two important values on the REMS hip report: NECK and TOTAL HIP. The TROCHANTER is reported but it is not important.
• NECK is the femoral neck (or hip) and is the ROI being evaluated for fracture risk.
• The NECK is the colored region on the diagram of the femur (hip bone).
• The blue-gray table below the diagram of the hip provides the BMD values and T-scores for two other structures – the TOTAL HIP and the TROCHANTER.
• The TROCHANTER is the darker shaded pointed knuckle of bone neck to the colored NECK on the diagram.
• The TROCHANTER has no quantitative clinical application but it is included in the bone that is assessed to generate the TOTAL HIP values.
• The TOTAL HIP is the part of the hip that includes the NECK, TROCHANTER, and the bone in-between the NECK and TROCHANTER.
• The TOTAL HIP is important for 2 reasons – (1) it should be larger than the NECK BMD value to indicate appropriate positioning (especially on the DXA report) and (2) the TOTAL HIP BMD is also used for quantitative comparisons year-to-year.
• The NECK BMD is converted to a T-score and Z-score. A Diagnosis is determined from the T-score.
• In addition, on the bottom of HIP PAGE 1 you will find very important clinical information in the Fracture Risk Assessment Box. The Fragility Score will be presented as a number from 1 to 100. This will be explained in greater detail on HIP PAGE 2.
• The next line of information, the 5 Year Risk of a Major Osteoporotic Fracture, will be presented as a number out of 1000!!! Presenting the data as a per thousand is a scientific method of data presentation and reflects the ability of the REMS to measure to the BMD to the thousandth.
• To convert that number to a percent, just divide by ten – that will yield the fracture risk as a percent.
HIP PAGE 2 depicts the position of the obtained FS value on a colored graph. The graph represents a database of individuals who were determined to be either fragile (had a history of one or more fragility fractures) or non-fragile (no history of a fragility fracture).
• The FS has been determined to be currently most reliable number in determining fracture risk.
• The FS value is presented as a unitless number that is plotted on the Age vs. FS graph.
• FS values that are present in the green area of the graph indicate low fracture risk.
• FS values in the red area of the graph indicate very high fracture risk.
• The yellow zone is a zone of some uncertainty – if the FS is close to the green zone, then that would indicate that the fracture risk is still relatively low. If the FS value is plotted in the yellow zone near the red zone, then the fracture risk would be high.
• Therefore, fracture risk increases as the FS rises and the position on the graph gets closer to or into the red zone.
• It is important to remember that the FS is independent from the BMD – FS was determined by a unique soundwave.
• Academic studies have determined the validity of FS as a predictive value for fracture risk and in those studies, FS was found to be both the most sensitive (true-positive for fracture) and the most specific (true-negative for no fracture) test when compared to either DXA-derived or REMS-derived BMD.
• The HIP FS database includes individuals who sustained fragility-type hip fractures.
• The FS value was derived from the mathematical analysis of the backscatter radiofrequency wave (echo) that was produced by the interaction of the sound wave with the micro structural elements of your bone. The FS is compared to a database of individuals who were identified as either fragile (had sustained a fragility fracture) or non-fragile (had not sustained a fragility fracture). Fracture risk is determined by that comparison.
HIP PAGE 3 is currently under development and has no practical clinical application.
HIP PAGE 4 is not relevant to Body Composition determination.
HIP PAGE 5 is the page with the B-mode doppler images used during the REMS examination for determining correct depth and focal settings.
References:
(1) Section 510(k) premarket notification of intent to market - FDA REMS approval
(2) Delia Ciardo, Paola Pisani, Francesco Conversano, Sergio Casciaro, Pulse-Echo Measurements of Bone tissue; Techniches and Clinical results at the Spine and Femur, Bone Quantitative Ultrasound, Advances in Experimental Medicine and Biology, 2022, 1364, https://doi.org/10.1007/978-3-030-91979-5_7
(3) M. Di Paola, D. Gatti, L. Cianferotti, L. Cavalli, C. Caffarelli, F. Conversano, E. Quarta, P. Pisani, G. Girasole, A. Giusti, M. Manfredini, G. Arioli, M. Matucci-Cerinic, G. Bianchi, R. Nuti, S. Gonnelli, M. L. Brandi, M. Muratore, M. Rossini, Radiofrequency echographic multispectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck Osteoporosis International (2019) 30:391–402 https://doi.org/10.1007/s00198-018-4686-3
(4) Paola Pisani, Francesco Conversano, Maurizio Muratore, Giovanni Adami, Maria Luisa Brandi, Carla Cafarelli, Ernesto Casciaro, Marco Di Paola, Roberto Franchini, Davide Gatti, Stefano Gonnelli, Giuseppe Guglielmi, Fiorella Anna Lombardi, Alessandra Natale, Valentina Testini, Sergio Casciaro, Fragility Score: a REMS based indicator for the prediction of incident fragility fractures at 5 years Aging Clinical and Experimental Research https://doi.org/10.1007/s40520-023-02358-2.
(5) Paola Pisani, Antonio Greco, Francesco Conversano, Maria Daniela Renna, Ernesto Casciaro, Laura Quarta, Daniela Costanza, Maurizio Muratore, Sergio Casciaro, A quantitative ultrasound approach to estimate bone fragility: A first comparison with dual X-ray absorptiometry Measurement 101 (2017) 243–249 http://dx.doi.org/10.1016/j.measurement.2016.07.033 0263-2241/ 2016 Elsevier Ltd. All rights reserved.

All rights reserved and property of Andrew Bush MD, FAAOS and Kimberly Zambito MD, FAOA, FAAOS
May 2023

05/03/2023

Join Dr Bush and Dr Susan Brown Thursday, May 4th at 7:30 for a free, live presentation about Echolight and how it can help you. Click on link for details and to register:

Better Bones, Better Body

04/25/2023

Core strength is a term that gets thrown around.

What does core strength mean to you? Do you visualize wash-board abs? Do you think of crunches or push-ups? Core muscles stabilize and control the spine and pelvis. The activation and strengthening of these muscles are critical to posture and movement…unless you are a jellyfish.

The core muscles include the transverse abdominis, multifidus, internal and external obliques, erector spinae, diaphragm, pelvic floor muscles, and the re**us abdominis (your six-pack abs). Your minor core muscles include your lats, traps, and the glutes. Please refer to an earlier post when we paid respect to the glutes…an unsung hero of the core. Another unsung hero…the pelvic floor…it keeps the p*e off the floor. Seriously…the pelvic floor deserves its own post.

Some of the best exercises for strengthening the core are planks and side planks. The key is performing planks properly. If you have yet to be introduced to planks, there are ways to build up to doing planks and side planks through modifications. Breathing techniques are important, as is understanding how to activate your pelvic floor. We recommend the book, “Strengthen Your Core”, by Margaret Martin, PT, CSCS. Consider a visit with a physical therapist or an experienced trainer who can provide you with instructions on proper plank position.

04/18/2023

Have you added some plyometrics to your routines yet?

If so, please share in the comments section. If not, why are you waiting? Hop to it! Pun intended.

If you are concerned about adding plyometrics, check out the video series on YouTube by Alyssa Kuhn, a physical therapist who is connecting with people with osteoarthritis and osteoporosis. She explains and demonstrates exercises that can stimulate bone building. Some of the exercises are plyometric and some are modifications to plyometric exercises that can be done if you are concerned about your feet leaving the ground.

https://youtube.com/playlist?list=PLT1BsCAFHo-n1P1R-PU2Frd2_CguPjwm

04/12/2023

Spring has sprung!
Spring-time flowers are blooming. Birds are singing. Squirrels are stealing seed from bird feeders. Bunnies are hopping around. Hopping around…gets us thinking about PLYOMETRICS.

Plymetrics is defined in Merriam-Webster dictionary as exercise involving repeated rapid stretching and contracting of muscles to increase muscle power. Plyometrics exercises can include jumping and rebounding. What does this have to do with bone health? Plyometrics exercises can be added to an exercise routine to increase muscle power, stimulate our bones, and can be incorporated into exercises that work on balance. Some people visualize plyometrics as box jumping. Plyometric exercises are so much more. And…you don’t have to catch extreme air when doing plyometrics. One of my favorite plyometric exercises is the sp*ed skater. When doing sp*ed skater, I ease into it. I start with a few repetitions of simply stepping into sp*ed skater. After feeling warmed up, I’ll add a leap…nothing too crazy. Once I’m good with the leap, then I’ll keep the back leg suspended (toes do not touch the ground). This works my single leg balance, then I leap to the other side. Some days I’m a sp*ed skating fool. Some days sp*ed stepping with a little leap is just fine.

Plyometric exercises can be added during a walk. Pick an interval (time or distance) when you stop during the walk and add some hops or air squats with a jump or sp*ed skaters or reverse lunges with a knee drive and a hop.

There is a work out video on youtube that nicely demonstrates modifications/variations for different plyometric exercises. It is described as a 30-Minute Standing Cardio Workout. It is https://youtu.be/-YJXparbrX4k

Here are some exercises that you may not have considered plyometric exercises: jumping jacks, jumping rope, squat jumps, side lunges with a leap or hop, broad jumps, hopping over small obstacles, and burp*e variations. I must confess…I do not use a jump rope when jumping rope…I use a ghost rope. This means I move my arms and legs as if I were holding a jump rope. Double Dutch is not an option for me, but if you can do it- go for it!

For those of you who would like some light reading:
Vetrovsky T, Steffl M, Stastny P, Tufano JJ. The Efficacy and Safety of Lower-Limb Plyometric Training in Older Adults: A Systematic Review. Sports Med. 2019 Jan;49(1):113-131. doi: 10.1007/s40279-018-1018-x. PMID: 30387072; PMCID: PMC6349785.
Hinton PS, Nigh P, Thyfault J. Effectiveness of resistance training or jumping-exercise to increase bone mineral density in men with low bone mass: A 12-month randomized, clinical trial. Bone. 2015 Oct;79:203-12. doi: 10.1016/j.bone.2015.06.008. Epub 2015 Jun 16. PMID: 26092649; PMCID: PMC4503233.
Witzke KA, Snow CM. Effects of plyometric jump training on bone mass in adolescent girls. Med Sci Sports Exerc. 2000 Jun;32(6):1051-7. doi: 10.1097/00005768-200006000-00003. PMID: 10862529.

Please share your favorite plyometric exercise in the comments below.

03/15/2023

Here is a link to the latest American Bone Health newsletter:
http://go.pardot.com/webmail/991202/196159590/184a7a059d1c7650f55028bd0ab8eba313f90b1288ba46b82a029ab7f84ebf8e

Lots of good information!

March is Women’s History Month.  What a great opportunity for American Bone Health to recognize one of the many women who have a long history of helping people improve their bone health.  Read on to meet Dr. Risa Kagan, founding member of the American Bone Health Medical and Scientific Advisory ...

03/07/2023

Vibration plate technology is a topic of interest for many bone babes.

It can be a great option for individuals who are not able to participate in active exercise. Rubin, et al (2001) showed that small amplitude microstrains from muscular contractions may increase bone density.

Some enthusiasts integrate use of vibration plates with regular exercise routines. If you have been considering the use of vibration plate technology, do your research. Not all vibration platforms are safe. Not everyone should use this technology. For example, if you have a history of retinal detachment, this is not a good option for you.

If after doing some research, you decide to try this technology. Look for Vertical oscillation, 0.3 g in magnitude and 30Hz in frequency.

For our literature seeking followers, here a couple of resources for you, in addition to the reference above:
Bogaerts, A., et al. Age and Ageing, July 2009, 38(4): 448-454
Verschueren, S., et al. J Bone Miner Res, March 2004, 19(3): 352-359

03/01/2023

Let’s discuss some questions about doing the hustle for the muscle.

How often should I do exercises to build muscle? In general, we recommend exercise 3-5 days per week. Everyone has different abilities and commitments that can affect frequency of exercise. Some of us need more time to recover. Some weeks you may be able to work out 5 days of the week. During another week, you may be happy to get in 3 days out of the week.

How long should workouts last? In general, 30 minutes of activity or exercise.

How much weight should I use? You want to challenge your muscles to work. If something is a little too easy, then make it a little more challenging. A physical therapist or a personal trainer can give you some guidance if you are new to lifting weights. It is important to learn proper ex*****on of an exercise, challenge your muscle, and avoid injury.

What if I don’t have weights or don’t like using weights? There are many options for resistance training- bodyweight, resistance bands (which can easily go anywhere), dumb bells, machines, TRX, isometric exercises. When my son was a toddler, he was my weight when I did squats and lunges. Soup cans, water bottles, medicine balls. Get creative.

What if I cannot exercise for 30 minutes? Worry not. Break it up into smaller segments, then each week, add a little more time to a segment or change the number and time of segments. Smaller segments can be six 5 minutes segments throughout a day; three 10 minutes segments throughout a day; two 15 minutes segments throughout a day…so on and so forth…This can make getting activity and exercise in easier if there is a time crunch or if you have not built up to doing 30 minutes at one time.

How do you plan to hustle for your muscle this week? Please share in the comments.

02/21/2023

The glutes, especially the gluteus medius - another unsung hero in bone health.The gluteus medius helps with balance throughout gait. The gluteus medius stabilizes the pelvis and maintains the trunk upright when standing on one leg, running, and walking when one leg is off the ground. Gluteus medius weakness can force you overcompensate by using the muscles in your back to stabilize your body, causing low back pain.

Most people think of working out the gluteus maximus (the baby got back muscle). The gluteus medius is deeper in form and function and does not contribute too much to the aesthetics of our back sides. Sometimes it does not get the attention it deserves.

What exercises are good for the glutes- both maximus and medius?
Glute bridges, single leg glute bridges, clamshells, side planks with hip abduction, banded side walking…the list can go on and on. The point is to make sure you work those glutes. If you do not care for dedicated work outs, that’s fine. Consider performing a single leg stance while you brush your teeth as a daily activity. Seriously. Are you able to balance on one leg? If not, maybe your gluteus medius is weak. Keeping our “balance” muscles active and strong is important in fall prevention. Prevention of a fall, prevents a potential fracture.

Let’s work those glutes!

02/20/2023

Radio silence from the masses…no one had questions related to the last post. Does it mean we are great educators or does this mean no one is interested in the last few posts? We welcome feedback in comments or a thumbs up.

In the last post we mentioned showing some appreciation to the unsung muscle heroes important to bone health- back muscles and the glutes. Strengthening the muscles of our backs is important for increasing strength of the bones of our spine. For strengthening the back muscles, we suggest starting with proper posture. Focus on your posture while seated, standing, and during activity. Good posture should be the starting point for any activity. A physical therapist may be a good resource for a postural assessment and to start you on a program to strengthen your postural muscles. A program may include stretching the “front” side of your body and strengthening the “back” side. More advanced exercises may include “I’s”, “Y’s”, and “T’s”, superman/woman, starfish, and bird dog.

Stronger back muscles reduced the incidence of vertebral fractures: A prospective 10 year follow-up in postmenopausal women. Sinaki, M. et al. June 2002. Bone, 30 (6): 836-841

Margaret Martin, PT, CSCS, wrote a series of books- Exercise for Better Bones, Yoga for Better Bones, and Strengthen Your Core for Better Bones.

Next week we will focus on the gluteus medius.

02/08/2023

Our own Dr Bush has been included in the "10 Orthopedic Surgeons to Know" list on BeckersSpine recently. View it here:

Below is a list of 10 orthopedic surgeons who have made a positive impact on their organizations and the profession.

02/07/2023

Have you heard of Wolff’s Law?
Wolff’s Law states that bones will adapt based on the stress or demands placed upon bone. It is also referred to as functional adaptation of bone. In general, the more force applied to a bone, the stronger the bone becomes. Conversely, the less force applied to bone, the weaker bone becomes. Think about someone who has fractured a bone and has limited use of the affected limb. The muscles atrophy. Bone does too. Think about someone who has been bedridden. Muscles atrophy. Bone does too. Muscle and bone are related. As goes muscle, so goes bone. The below website is a nice summary of this.

webmd.com/osteoporosis/what-is-wolffs-law

For something more scholarly, about this topic, we recommend the following which highlights Wolff’s Law and various applications from a clinical standpoint:
Frost, HF. From Wolff’s Law to the Utah Paradigm: Insights About Bone Physiology and Its Clinical Applications. The Anatomical Record (2001); 262: 398-419

As we age, we lose muscle mass and bone mass. Perhaps this occurs as a result of inactivity, oxidative stress, changes in nutrition, medical conditions, or various other reasons. The good news is we can work on bone strength by maintaining, if not building, muscle strength through resistance training and adequate protein intake.
Strength training can be done with body weight exercises, dumbbells, resistance bands, machines, and isometric exercises. Body weight exercises can be done anywhere you take your body…and your body goes with you everywhere, right? Resistance bands are easy to pack in a backpack, briefcase, or suitcase. Isometric exercises do not require fancy equipment. These three options are “no excuses” options. You can do these while watching the news or watching your favorite show. You can do these in the kitchen while cooking dinner. If you are like Dr. Z and your “free time” is spent at kid sporting events for hours on end…do them while your kid is at practice. Someone may look at you…they are not being judgmental. They are thinking, “I wish I wasn’t too chicken to do that.” No one will hustle for your muscle the way you will!

If you are not familiar with strength training or do not know how to begin, consider working with a physical therapist or a personal trainer who is knowledgeable about osteoporosis. We listed a few resources in an earlier post a few weeks ago.

Next up will be a post about muscles that are unsung heroes in bone health conversations…and exercise suggestions to show some appreciation to those unsung muscle heroes.

We would love to get questions or comments about this week’s post!