The Harvard Medical School Family Health Guide
Bones, Joints, and Muscles
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Back, Hips, Legs, and Feet

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Movement Disorders in Sleep

Sleepers typically shift position every 15–30 minutes, and it’s normal for muscles to jerk at the onset of sleep. For some people, however, uncontrollable movements make it impossible to obtain a restful night’s sleep.

Restless Leg Syndrome (RLS)

An estimated 1%–5% of adults have restless legs syndrome (RLS), a neurological disorder characterized by strange aching, crawling, or painful sensations in the lower legs that can be temporarily relieved by moving the legs.

Sleep deprivation is a major problem for people with RLS, as the symptoms are most prominent at night. People develop a variety of coping strategies, such as pacing, doing knee bends, rocking, or stretching the leg muscles. Symptoms are worse when sitting still, and the irresistible urge to move can make it difficult for people with RLS to take car or plane trips, enjoy a movie, or even hold a desk job. At night, RLS symptoms may compel the person to get in and out of bed many times.

Daytime symptoms sometimes abate for a few hours, days, or even years. Some people get temporary relief by rubbing or squeezing their leg muscles, wrapping their legs in bandages, or applying cold or warm compresses.

Because the symptoms sound bizarre or vague, and the need to be constantly mobile seems like nervousness, people with RLS are frequently thought to have psychiatric problems. In the past, they were often misdiagnosed as having hypochondria, manic-depressive illness, or a stress-related disorder. Children who have RLS are often diagnosed as having attention-deficit disorder. In adolescents, RLS may be mistaken for growing pains or back trouble. RLS usually worsens with age. Women may find that symptoms flare up during menstruation, pregnancy, or menopause. At least 1 in 4 pregnant women experiences restless legs.

As many as half of people with RLS note that other members of their family have similar symptoms. In at least a third of cases, genetic studies indicate that the disorder results from a single aberrant gene, with each child of an affected person having a 50% chance of inheriting the condition.

Restless legs can be a complication of alcoholism, iron deficiency anemia, diabetes, heart failure, or kidney failure. In some people, caffeine, stress, nicotine, fatigue, or prolonged exposure to a cold or very warm environment can worsen the symptoms. Certain medications — including antihistamines, antidepressants, or lithium — can exacerbate RLS.

Periodic Limb Movement Disorder (PLMD)

This neurological condition is similar to RLS, except that it occurs during sleep. During the night, the leg muscles involuntarily contract every 15–45 seconds, which causes jerking movements that at least partially rouse the person from sleep. The same movement (involving the hip, knee, or ankle) may be repeated hundreds of times a night. Unless a bed partner complains, the affected person will likely remain oblivious to the movements and baffled at feeling tired after what he or she believes was a full night’s rest. Up to 50% of the elderly may experience such leg movements during sleep. Nearly everyone with RLS will also have PLMD.

Treatments for Movement Disorders

Drugs that ease the tremors of Parkinson’s disease also reduce the number of leg movements and thus improve quality of life for people with RLS and PLMD. Levodopa-carbidopa (Sinemet), pergolide (Permax), and pramipexole (Mirapex) are first-line treatments for these disorders.

People with mild movement disorders may be prescribed diazepam (Valium), clonazepam (Klonopin), or temazepam (Restoril), which may improve sleep by reducing the number of awakenings due to leg movements. Most people who take these medications for insomnia develop a tolerance to them after a few weeks, but this doesn’t seem to happen when such drugs are taken for RLS.

Because of the potential for addiction, most physicians are reluctant to treat sleep disturbances with opiates (opium-containing drugs) such as propoxyphene and oxycodone. However, these drugs often help people with severe RLS symptoms that resist other treatments. The opiates decrease the discomfort of RLS and, for some patients, dramatically reduce leg movements at night. When properly used, they may provide long-term benefit with little risk of addiction.

February 2003 Update

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Medications for postmenopausal osteoporosis prevention

Risk of osteoporosis increases after menopause, when levels of estrogen — which helps preserve bone density — drop. Until recently, most doctors recommended long-term hormone replacement therapy (HRT) to treat postmenopausal women who need medication to prevent bone loss. But things changed after results from a large trial on a common HRT drug showed that estrogen plus progestin (as the medication Prempro) did more harm than good. An increased risk for breast cancer and cardiovascular events outweighed the benefits of less colorectal cancer and fewer fractures. (See the Update from July 2002 for more information on the trial.)

Health experts now encourage most women who have been taking long-term HRT for osteoporosis prevention to consider an alternative. Fortunately there are several options. Each of the FDA-approved treatments (see chart) has potential benefits and risks that women and their doctors should weigh before making a decision. Even with HRT’s proven risks, it may still be a good choice for certain women — especially in lower doses, which recent data have shown to have bone benefits comparable to higher, standard doses.

Approved medications for osteoporosis prevention

Medication

How to take it

Bone benefits

Side effects

Comments

Alendronate (Fosamax)

Orally, once daily in the morning or as a larger dose once a week; take with 6–8 ounces of water and stay upright for 30 minutes.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Heartburn, nausea, inflammation of the esophagus, muscle pain.

Interferes with cells that break down bone. Well-tolerated when taken properly.

Risedronate (Actonel)

Orally, once daily in the morning or as a larger dose once a week; take with 6–8 ounces of water and stay upright for 30 minutes.

Increases bone density at the spine and hip; reduces spinal and hip fracture risk. Side effects uncommon.

Abdominal pain, nausea, constipation, joint pain.

Interferes with cells that break down bone. Well-tolerated when taken properly.

Raloxifene (Evista)

Orally, once daily, any time.

Increases bone density (but less so than alendronate or risedronate); reduces spinal fracture risk. Side effects uncommon.

Hot flashes, leg cramps, deep-vein blood clots.

Acts like estrogen in bone but is an anti-estrogen in breast tissue; may reduce breast cancer risk.

Estrogen (Premarin, Estrace, other brands)

Orally, once daily, any time; or weekly by skin patch.

Increases bone density; some evidence for fracture reduction.

Increases the risk for breast cancer (after 4–5 years) and cardiovascular events when combined with a progestin (as Prempro) and taken orally.

May be recommended if other medications are not tolerable or menopausal symptoms persist.

Sources: Boosting Bone Strength: A Guide to Preventing and Treating Osteoporosis, Harvard Health Publications, Boston, 2000; Managing Osteoporosis, Part 3: Prevention and Treatment of Postmenopausal Osteoporosis, American Medical Association, 2000; Osteoporosis: Guide to Prevention, Diagnosis, and Treatment, Brigham and Women’s Hospital, Boston, 2002

December 2002 Update

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Drinking Tea Benefits Heart and Bones

The health benefits of drinking tea have been well publicized lately, and recent studies point to two newly discovered advantages to consuming this beverage. One shows that drinking tea can help prevent death after a heart attack. The other reports that tea may increase bone mineral density, which helps prevent fractures and osteoporosis.

In the first study, published in Circulation, researchers questioned 1,900 patients hospitalized for heart attacks about the amount of caffeinated tea they drank in the past year. After adjusting for age, gender, and other variables, researchers found that those who drank 14 or more cups of tea per week were 39% less likely to die of cardiovascular disease in the 3.8 years following their heart attack than non-tea drinkers. Patients who consumed 1–14 cups of tea per week were 31% less likely to die from cardiovascular causes during that period than non-tea drinkers.

When researchers further looked into subjects' caffeine intake, they found that caffeine from sources other than tea did not affect death rates.

In the second study, published in the Archives of Internal Medicine, researchers surveyed 1,037 men and women age 30 and older about their tea consumption. Subjects who drank tea at least once a week for the preceding six months were labeled "habitual tea drinkers." This group was asked about their tea-drinking history, the kind of tea they drank, how often they drank it, and how much they drank in each sitting.

Researchers then measured the bone mineral density (BMD) of the lumbar spine, hip, neck, and total body of both the habitual tea drinkers and the non-drinkers.

The researchers found that people who consumed tea regularly for more than 10 years had the highest BMD scores compared to the other groups, after they adjusted for sex, age, weight, and lifestyle variables that may affect BMD. Those who drank tea regularly for the past 6–10 years also had significantly higher lumbar spine BMDs than the nonhabitual tea drinkers. People who consistently drank tea for the past 1–5 years did not have any significant differences in BMD score compared to the nonhabitual drinkers.

It didn't seem to matter what type of tea the person drank, and neither did the amount of tea consumed each time. Only duration of habitual tea consumption was an independent predictor of BMD score. Tea contains several components, including fluoride and flavonoids, which may work separately or in concert to maintain or restore bone density.

Although BMD score is often a good gauge of the risk of fracture from osteoporosis, this study did not actually test the link between tea consumption and bone fracture.

July 2002 Update

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Inhalers Lead to Hip Bone Loss

Medications commonly used for the long-term treatment of asthma may lead to hipbone loss in premenopausal women.

Researchers at Brigham and Women's Hospital in Boston found bone mass in the hip and trochanter decreased in women taking inhaled glucocorticoids, a type of steroid used for treating asthma. The rate of bone loss also increased with the rate of dosage. The three-year prospective study involved 109 women aged 18 to 45. Bone density was measured at the beginning of the study, after six months of treatment and at one, two, and three years.

Bone density was found to decline 0.00044 grams per square centimeter per puff of medicine per year of treatment. Although that's a small amount, it can be significant in the long run. If a woman with asthma is treated with six puffs of triamcinolone acetonide (the glucocorticoid studied) twice a day for 20 years, she could expect to have 0.106 grams per square centimeter less bone in her hip than she would have had without the treatment, according to this study. That degree of bone loss has been associated with a risk of hip fractures more than double that of normal women 65 and older.

Besides the hip, measurements were also taken at the spine and femoral neck, but no changes were found there. The rate of decline also varied between patients in the same dosage group and no reason for that could be found.

Though osteoporosis is a major health problem for women, the study's authors admit that inhaled glucocorticoids are among the most effective and safest medicines for asthma. They suggest doctors prescribe the lowest effective dose and patients using high doses should ask their doctors to periodically assess their bone density.
The results of previous, less extensive studies on inhaled steroids and bone density have been mixed.
October 2001 Update

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Physical Therapy and Exercise Helpful for People with Arthritis of the Knee

Osteoarthritis of the knee, a condition that can make it difficult to walk, climb stairs, or rise from a chair, affects one out of every three people between the ages of 63 and 94. It is commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Aleve) or ibuprofen (Motrin), physical therapy and exercise, cortisone injections, or joint replacement surgery. A recent study in the journal Annals of Internal Medicine confirms the effectiveness of physical therapy and exercise in relieving the discomfort of osteoarthritis of the knee, and suggests that a combination of these two treatments may delay or prevent the need for knee replacement surgery.

At the beginning of the study, patients with osteoarthritis of the knee described the level of pain and discomfort they experienced. Researchers then measured the distance that the patients were able to walk in six minutes. About half of the patients were then assigned to receive manual physical therapy and to participate in an exercise program that included stretching, strengthening, and range-of-motion exercises. The treatment lasted four weeks. The other patients, assigned to a placebo group, did not receive manual physical therapy or perform any exercises.

At the end of four weeks and eight weeks, patients in the treatment group reported significantly less pain and stiffness than before they started treatment. Patients in the placebo group did not show notable improvement. Patients who had undergone treatment were also able to walk a greater distance in six minutes than they could before the start of the study, unlike patients in the placebo group.

At the end of one year, patients who had received treatment continued to feel better and perform better than the placebo group, reflecting the long-term benefits of physical therapy and exercise. Treatment also reduced the likelihood of needing joint replacement surgery. At the end of one year, only 5% of patients in the treatment group had undergone knee replacement surgery, compared to 20% of patients in the placebo group.

For more information about osteoarthritis, see page 604 of the Harvard Medical School Family Health Guide.

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