MAMCOTS | Backache Beyond the Spine: Metabolic, Bone, and Muscle Pain | Dr. P. S. Mamtora

Detailed case history and clinical examination pave the way for a provisional diagnosis, upon which the appropriate investigations are recommended. A thorough listening to patients' symptoms in the chronological sequence guides not only the course of the examination but also what to look for in the various tests.

Backache is not exclusive to orthopaedic diseases, but can also herald renal, abdominal, or gynaecological disorders. Orthopaedic causes of backache belong to mechanical, inflammatory, infective or other categories, such as postural, bone metabolic disorders, osteoporosis and metastasis.

A thorough history of the patient outlines the required clinical examination, points to the provisional diagnosis, recommends investigations, and sets expectations for the test reports. A laid-out working diagnosis at the first visit also aids in the next follow-up during reevaluation.

Skeleton is composed of Cancellous bone (20%) and Cortical bone (80%). Bone undergoes continuous metabolism, with key roles played by osteoclasts (resorption) and osteoblasts (new bone formation). A harmonious, balanced interplay between these 2 cell types maintains peak bone mass. Peak bone mass increases until age 30, when osteoblastic activity is dominant; thereafter, osteoclastic activity dominates, leading to gradual depletion of peak bone mass.

This video highlights the importance of calcium and vitamin D3 supplementation. Calcium is an indispensable mineral supplement required for various physiological functions and for maintaining peak bone mass. Vitamin D3 (cholecalciferol, produced when bare skin is exposed to sunlight) aids in calcium absorption and is crucial in preventing fractures. It does not matter whether calcium is ingested as a pill or through natural sources; calcium is vital for maintaining and replenishing peak bone mass.

The active metabolite of vitamin D - Calcitriol, formation involves a series of chemical process (duration 6-8 weeks)- ergocalciferol (vit D2) on exposure to sunlight gets converted to cholecalciferol which undergoes hydroxylation in liver to 25-hydroxycholecalciferol (calcidiol) which then again underdoes hydroxylation in kidney to 1,25-dihydroxycholecalciferol (calcitriol).

Metabolic Bone diseases include varied disorders pertaining to disequilibrium of the mineral composition of the bones.

Osteoporosis is a skeletal disorder characterised by increased osteoclast-mediated bone resorption, which increases fracture risk and requires appropriate, customised management, including fall prevention strategies, antiresorptive therapy, and calcium and vitamin D3 supplementation. Achieving peak bone mass through adequate calcium, protein, and vitamin D3 intake; regular exercise; and healthy lifestyle habits in early life helps ensure sufficient bone mass when physiological bone resorption (enhanced by ageing, menopause, diabetes, hyperthyroidism, and low vitamin D3 levels) begins. Primary Osteoporosis is silent and painless compared to secondary osteoporosis.

Laboratory investigations for osteoporosis include calcium, phosphorus, alkaline phosphatase, vitamin D, TSH, vitamin B12, and PTH levels. DEXA, though, is the gold standard for determining bone mineral density; other crucial factors that suggest increased fracture risk include diabetes, sarcopenia, neurological disorders, and psychological diseases, which may be associated comorbidities. DEXA measures T-scores (comparison with a healthy young adult) and Z-scores (comparison with a healthy person of an equivalent age), which are the basis for understanding bone health and estimating fracture risk.

Bone Mineral Density (BMD) is evaluated by DEXA, which is one of the determinants of osteoporotic fracture risk. T-scores (comparison with a healthy young adult) and Z-scores (comparison with a healthy person of the same age) are used to assess bone health and suggest fracture risk. DEXA is indicated in women post menopausal and in men post 60 years of age if their symptoms suggest so. Antiporotic agents should be started only with definitive criteria of T-scores lower than -2.0.

The rationale behind recommending DEXA in men should be for those aged above 65 years with an incidence of fragility fracture or a long history of oral glucocorticoid intake, which could have led to osteoporosis.

DSA is the functional analysis of the spine, it detects defects in the range of motion of the joints with regards to muscle weakness. As the test is not evaluated in static but dynamically, it isolates the group of muscles which need to be attended to through a diligent physical therapy.

The requirements for successful Osteoporosis treatment include diligent patient compliance with regular walks, weight-bearing exercises, calcium and vitamin D supplements, and specific anti-osteoporotic agents such as pro-osteoblastic therapy, anti-osteoclastic therapy, HRT, or a combination. DEXA is mandatory prior to the commencement of anti-resorptive therapy for confirmation of the diagnosis of Osteoporosis and planning a follow-up strategy.

In a patient with aches and pains who calls for calcium and vitamin D supplementation, it is prudent to also suggest vitamin B12, B3 and B5 (often homocysteine-deficient or vitamin B12). Hypervitaminosis D is defined as plasma levels above 250 ng/mL, associated with hypercalcemia, electrolyte imbalance, and mental obtundation. Anti-resorptive agents—bisphosphonates— are contraindicated in CKD with high creatinine levels. Also, in CKD patients on calcium and vitamin D supplements, monitor creatinine, urine calcium, and serum calcium, and discontinue if there are signs of hypercalciuria or hypercalcemia. In CKD patients, hydroxylation of vitamin D suffers; as a result, though serologically replete vitamin D levels (25-hydroxycholecalciferol), they will require vitamin D in the form of calcitriol

A comprehensive exercise schedule comprises weight-bearing exercises and walking, which help reduce fracture risk and prevent sarcopenia. Also crucial along with Calcium (1000-1200mg/day) and Vit D supplements (1000-2000 IU/day) is positive attitude which boosts self worth allowing one to be more physically active. Fall prevention strategies, such as proprioception exercises to improve balance, well-lit rooms, grab bars, non-skid rugs, and carpet, should be incorporated into daily living. Healthy lifestyle habits such as cessation of smoking, alcohol, carbonated drinks and restricting caffeine can prevent deterioration of bone health.

Myofascial tightness can present as soft tissue pains experienced at varied areas of the body and felt as localized areas of tenderness along the muscles. They often respond to Myofascial Release Massage which is a type of physical therapy.

Prolonged sitting in poor posture, often in front of computers or looking at screens, can cause muscle fatigue and postural pain. This type of pain often shows minimal findings on examination and responds quickly to posture correction and proper ergonomics.