Boporosis and H

What Does Calcium Have to Do With it?

By Ruth

122 MASSAGE & BODYWORK OCTOBER/NOVEMBER 2006

T
o complement this issue's theme on posture, let's
discuss a common postural problem among many
older Americans: the hyperkyphosis that often
accompanies osteoporosis.
We in the United States have grown up under the
paradigm that dairy products are an important source
of calcium. Indeed, according to many resources, it
would appear that dairy products are the only source of
calcium American adults need (to wit: "Got milk?").
Those of us in alternative healthcare may have learned
that many options to milk exist, but debate still rages
over the best ones, how useful they are, and whether
calcium in any form actually provides protection
against osteoporosis.
I can't give definitive answers on this topic in this
limited space, but I can perhaps shed light on some
organizing principles so that massage therapists (and
the clients who may ask them for advice) can make
informed decisions about how to prevent, slow, or man-
age this common and painful disorder.
It is estimated that
ten million people have
osteoporosis (eight million
women and two million
men), and an additional
thirty-four million
have osteopenia.
What is Osteoporosis?
O steoporosis is a condition in wbich the
calcium deposits in bone tissue become danger-
ously tbin. Literally, it means porous bones. It is pre-
ceded by osteopenia: thinning bones. Botb osteoporosis
and osteopenia are extremely common in this country.
It is estimated that ten million people have osteoporosis
(eigbt million women and two million men), and an
additional tbirty-four million have osteopenia. One out
of every two women, and one out of every eight men
over age fifty, will have an osteoporosis-related
fracture.' Osteoporosis contributes to one and a half
million fractures each year, and less than one-third of
those patients return to pre-fracture levels of activity.''
Bone Construction
T o understand tbe process of osteoporosis and bow it
leads to hyperkypbosis, we need to take a brief look
at bow bealtby bones grow and maintain their mass.
Perhaps tbe most important principle in understanding
OCTOBER/NOVEMBER 2006 MASSAGE & BODYWORK
bone physiology is Wolffs Law, which essentially says
that every change in the form and/or function of a
bone is followed by changes in internal and external
architecture. In other words, bone is a use-it-or-lose-it
proposition: weight-bearing stress sends the signal that
maintaining bone density is a high priority. Lack of
weigbt-bearing stress sends tbe signal that bone density
is a low priority, and calcium can be spared for otber
purposes.
Osteoclasts and osteoblasts work under hormonal
control on bone that is either dense or spongy. Dense
bone, formed of concentric rings of mineral deposits, is
found in tbe sbafts of tbe long bones, while spongy or
trabecular bone is found in the epiphyses and vertebral
bodies. Trabecular bone is metabolically much more
active than dense bone. It is bere tbat new blood cells
are formed and where the majority of remodeling
occurs in adulthood. It is in these areas, then, that cal-
cium deficiency bas the greatest impact (see Figure l).
Figure I. i_ompare normal bone density (left) to osteoporatic
bone (right). Copyright 2005 Lippincott Williams SWilkins. From A
MossogeTTierapist's Guide to Pomology by Ruth Werner.
Loss of key struts of trabecular bone can cause the
wbole structure to collapse in a spontaneous fracture.
Tbe most common locations for tbese injuries are the
head and neck of the femur (this is the dreaded broken
hip of old age), tbe distal forearm, and the vertebral bod-
ies. When these crumble, tbis is called a compression frac-
ture (see Figure 2, page 124). The upper and mid-thoracic
vertebrae are tbe most likely to collapse, leading to the
exaggerated kyphotic curve we often see in elderly people,
especially women. The layperson's term for tbis condi-
tion is dowager's hump (see Figure 3, page 124).
The Calcium Question
S o far tbe process of developing osteoporosis isn't
hard to understand: calcium is pulled off tbe bones
123
 p a t h o l o g y
Figure 2. Compression fracture. Medico/ Illustration Copyright
2006. Nucleus Medical Art All right reserved, www.nucleusinc.com.
Dowager's
Hump
Normal
Figure 3. Dowager's Hump. Medical Illustration Copyright 2006.
Nucleus Medical Art All rights reserved www.nudeusinc.com.
faster than it is replaced, and the result is spontaneous
fractures. We use calcium for many processes besides
maintaining dense bones: muscle contraction, nerve
transmission, blood clotting, and pH buffering, to name
a few. Questions arise, bowever, with regard to how
much calcium is the rigbt amount, what are the best
sources, and does having high bone density actually
protect us from osteoporosis and spontaneous fracture?
The answers are not always clearprobably because
the truth lies in a combination of factors not always
studied together.
How Can We Get Calcium?
T he human skeleton increases in mineral density
between conception and about age thirty, but close
124 MASSAGE & BODYWORK OCTOBER/NOVEMBER
p e r s p e c t i v e s
to 98 percent of bone mass has been acquired by about
age twenty. Clearly, tbe time to build up deposits in our
calcium bank is during childhood and early adulthood.
From that time forward, we either maintain our bal-
ance or we make withdrawals to use calcium for any of
its many other purposes.
We get calcium from dietary sources. Dairy products
are rich in calcium, so these appear to be an efficient
resource for this important mineral. Children tend to be
extremely good at extracting calcium from dairy prod-
ucts, but adults may have a harder time for a number of
reasons. Calcium requires an acidic environment for
absorption; milk interferes with stomach acidity and
acidity decreases with age. Many people (especially
those who are not of Northern European descent) are
lactose intolerant: they are missing the digestive
enzyme that breaks down lactose, and so dairy products
make them feel ill. Ultimately, some sources suggest
that about 32 percent of the calcium in dairy products
is absorbed into the bloodstream.^
Proponents of a dairy-free diet suggest that "beans
and greens" are a good way to supplement calcium,
with absorption rates tbat vary between 40 and 64 per-
cent.' Many leafy vegetables are high in calcium but
some (notably Swiss chard and spinach) also have sub-
stances that interfere with calcium uptake, so they are
not recommended as good sources for this mineral.
Other sources for calcium include dried fruits (figs
especially), some nuts (including almonds), canned fish
with the bones (salmon or sardines), and calcium-sup-
plemented foods (tofu, soy, and orange juice).
If food sources are not sufficient, calcium supple-
ments may be considered. Here again there is contro-
versy on the best forms. One common suggestion is to
avoid calcium in the form of dolomite: tbis has been
associated with a risk of lead poisoning. Beyond that,
calcium carbonate, calcium phosphate, and calcium cit-
rate head the list for being easily absorbed. It is impor-
tant to bear in mind, however, tbat calcium must be
ingested with other substances (specifically vitamins D
and K and magnesium) for best use.'* Some people rec-
ommend using antacids for calcium supplementation,
but those that are formulated with aluminum or high
levels of magnesium may have the opposite effect.
How Do We Lose Calcium?
G etting calcium in the mouth is only the first part of
the equation. It turns out that several factors lead
to the loss of calcium through sweat or urine. Some of
these have to do with eating and drinking habits, but
calcium loss can also be due to underlying disorders or
medications.
A diet heavy in meat-based proteins and low in fruits
and vegetables turns out to be a significant factor in
calcium metabolism, because calcium operates as a
chemical buffer to neutralize tbe acid by-products of
protein metabolism," Caffeine is another risk factor: -
2006
 p a t h o l o g y
drinking more than four caffeine-enhanced heverages
per day has been seen to interfere with retention.'
Smoking and alcohol have also been associated with
poor calcium absorption.
Many disorders and diseases lead to calcium loss.
Chronic stress and depression have been seen to
increase cortisol and decrease hone mass." Any
endocrine disorder tbat upsets hormonal secretions
(diabetes, hyperthyroidism, or Cushing disease), or
digestive disorders that make it difficult to absorb nutri-
ents (Crohn disease, ulcerative colitis, cehac disease,
etc.), can be contributing factors. A history of eating
disorders can change estrogen and progesterone secre-
tion, which has impact on calcium uptake. And any
cancer that influences bone marrow (leukemia, myelo-
ma) can lead to bone thinning.
Additionally, a whole plethora of medications interfere
with calcium absorption or retention. Chemotherapeutic
drugs, some birth control drugs, diuretics, cortico-
steroids, anticonvulsants, and blood clotting drugs all
influence hone density.
Finally, the hormonal changes that occur in women at
menopause may be the single biggest factor in developing
In the treatment
of clients who have
osteoporosis, the
appropriateness
of massage is determined
by the fragility
of the individual client
osteoporosis later in life. A sudden drop in secretions
of estrogen and progesterone can lead to a loss of 1-5
percent of bone mass per year, for several years.^
How Does Calcium Relate to Osteoporosis?
T he answers to this question are not always clear.
While many studies support the relationship of higb
calcium diets to a reduced risk of osteoporosis, some
inconsistencies continue to demand attention. Why, for
instance, do some countries with much lower average cal-
cium consumption tban the United States also have lower
rates of spontaneousfracture?'"'"Why do women with
low calcium diets have the same bone density as women
with high calcium diets?'' And why does increased calci-
um consumption in postmenopausal women not protect
them from spontaneous fracture, while it does make them
more vulnerable to kidney stones?'^
126 MASSAGE & BODYWORK OCTOBER/NOVEMBER
p e r s p e c t i v e s
Again, the answers probably lie in combinations of
factors that include not just how much calcium a person
consumes, but what other issues (like diet and medica-
tions) influence calcium uptake. Although we have been
studying osteoporosis for decades, the subtleties of this
disease are just now beginning to be explored.
Will Massage Make a Difference?
M assage will probably not change calcium uptake or
bone density. In the treatment of clients who bave
osteoporosis, the appropriateness of massage is deter-
mined by the fragility of the individual client: some will
be able to take more pressure than others, obviously.
The only way massage could make the situation worse
would be to exert enough force to cause a fracture.
On the otber hand, consider the condition of the
muscles of someone with osteoporosis. The anterior
muscles (anterior deltoid, pectoralis minor, scalenes,
sternocleitomastoid) are tight and hard, while the pos-
terior muscles (rhomboids, trapezius, paraspinals) are
stretched and irritated. Massage can offer symptomatic
relief, even if it can't reverse the degeneration of the
bone tissue. In any case, caution is the key with this
condition. Don't look for miracles; taking someone out
of her pain for a few hours is miracle enough.
Riilh Wnncr is a writn and educator for massage therapists. She teach-
es several couraes at the M^otherapy College of Utah and is approved hy the
NCTMB as a provider of continuing education. She wrote A Massage
Therapist's Guide to Pathology (Lippimvtt, Williams & Wilkin.s, 2005),
now in its third edition, which is med in massage schools worldwide. Werner
is available at www.ruthwemer.com or wernerworkshops@ruthwenier.com.
Notes
I Nacional Institutes of Health Osceoporosis and Related Bone Disease!Nacional Resource
Cencer'Osceoporosis Overview" www,osteoorg/newfile.aspMoc=rl06iAdoccype=HTML+
Facc+Sheec&doctitle=OsteoporQSistOverview+%2D+HTML+Ver5ron (accessed summer 2006)
2. Coburn Hobar,"Osteoporosis." WebMD. v/ww.emedicine.com/med/topicl693.htm (accesied
summer 2006).
3 Physicians Committee for Responsible Medicine. "Preventing and Reversing Osteoporosis,"
w w w, pcrm,org/healch/p rev med/osteoporosis, hem I (accessed summer 2006),
4. Ibid.
5. Harvard School of Public Heaich, "Calcium and Milk: What's Best For Your Bones!" 1006
www. h sp li. ha rvardedu/nuiricion source/calcium, htm I (accessed summer 2006).
6. Charles C. McCormick. "Calcium & OsceoporosisA Weak Link." Cornell Cooperative
Eicension. vaww.tce.cornell.edu/food/expflles/copics/mccormick/mccormickoverview.htnil (accessed
summer 2006).
7. The John Hancock Center for Physical Activity and Nutdcion.'"More About Soda and Your
Bones." Tufts University, http://nutrition.lufcs.edu/research/Jhc pan/cor sumers/soda_and_bones. hem I
(accessed summer 2006).
8. National Institute of Mental Health."Depression. Bone Mass, and Osceoporosis,"
www.nImh.nih.gov/events/prosteo.dni (accessed summer 2006).
?. Co burn Hobar. "Osceoporosis."
10, Physicians Committee for Responsible Medicine, "Preventing and fteversrng Osceoporosis "
11, B. J. Abelow."Cross-culcural association between dietary animal protein and hip fracture: a
hypothesis." Co'cfTissue Inc. SO.no. I (January 1992) l4-8,AbstracC available at
wvvw.ncbi.nlm.nih,gov/entrei/query.fcj;i?cmd-RetneveAdb-pubmed&dopC=Abstract&iis[_iiids= 1739
a648ritool-iconabscrAquery_hl=IShtool=pubmed_DocSum (accessed summer 2006).
12, Charles C. McCormick, "Calcium i OsteoporosisA Weak Link." Cornell Cooperative
Extension, www,cce. cornel I edu/food/expfiles/copics/mccormick/mccormickoverview.hcml (accessed
summer 2006)
I 3. Laurie Barclay, "Calcium Plus Vitamin D May N o l Reduce Hip Fracture or Colorectal
Cancer Risk," Medscape. February IS, 2006. www, med scape, com/vie warticle/52 3 698 (accessed
summer 2006).
Resource
Beck, Belinda R. and M, Rebecca Shoemaker Osteoporosis: Underscanding Key Risk Factors and
Therapeutic Options. The Phyziaan and Sportsmediane 28. no. 2 (February 2000),
www,physsportsmed.COm/issues/2000/02_0O/beck,him (accessed summer 2006)
2006