Osteoporosis and the Bone Health Program with Stacey Rothwell, P.A.-C

Osteoporosis is often called a silent disease because it often has no symptoms. You cannot feel your own bones weakening, and many people are not diagnosed until they have broken a weakened bone. Stacy Rothwell, a certified physician assistant at MUSC Health, joins the show to discuss the importance of talking to your doctor about your risk of osteoporosis, the process of getting screened and possible treatments for those who do have the disease.

“We did a study that showed the benefits of how we're running our program … and it's shown a reduction in secondary fracture occurrence, which is really the main goal. That's been really rewarding.”
—Stacey Rothwell, P.A.-C

Topics Covered In This Show

• Osteoporosis is a very common disease that causes low bone mass and weakened bones. Extremely underdiagnosed in the United States, osteoporosis and low bone mass affects about 54 million Americans.
• Osteoporosis is more common in women. About one in two women and up to one in four men, age 50 and older, will end up breaking a bone due to osteoporosis. Women who are postmenopausal are at greater risk. Anyone over the age of 50 should speak with his or her doctor about the risks of osteoporosis.
• Family history as well as other health conditions can put you at greater risk for osteoporosis: those who have had gastric bypass surgery, for example, and have had nutritional deficiencies as a result; patients who have had cancer and chemotherapy treatments; those who have had a stroke or other issues that have caused mobility trouble; those who are heavy drinkers and suffer from malnutrition as a result; and those with diabetes or kidney disease.
• A fragility fracture is when a bone breaks after falling from a ground level height. Patients of osteoporosis who have never had a fragility fracture are often resistant to care and prevention because it is not immediately evident that they have the disease.
• There are three ways you can be diagnosed: a very quick test called a DEXA scan which measures bone density, the presence of a fragility fracture or osteopenia, which is low bone density not yet considered to be osteoporosis.
• It is possible to support osteoporosis prevention through a calcium-rich diet, sufficient vitamin D intake and regular weight-bearing exercise.
• MUSC Health’s unique Bone Health Program, which has over 1000 patients now, offers screening, primary prevention and treatment options for osteoporosis. In fact, the program has shown a substantial decrease in secondary fragility fracture occurrence in patients since it began in 2018. 

Read the Show Transcript

Erin Spain, M.S. [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Osteoporosis is called a silent disease because it often has no symptoms. You cannot feel your own bones weakening. And many people are not diagnosed until they have broken a weakened bone. Stacy Rothwell, a certified physician assistant at MUSC Health, is here to discuss the importance of talking to your doctor about your risk of osteoporosis, the process of getting screened and possible treatments for those who do have the disease. Welcome to the show, Stacey. 

Stacey L. Rothwell, P.A.-C [00:00:49] Thank you so much for having me. 

Erin Spain, M.S. [00:00:51] So tell me about osteoporosis. Define it for me. What is it and what causes it? 

Stacey L. Rothwell, P.A.-C [00:00:56] Osteoporosis is a disease that as most people get older, their bones weaken for various reasons. It's very common. It's actually extremely underdiagnosed in the U.S. And about 54 million Americans have osteoporosis and low bone mass. Typically, it's more common in women. About one in two women and up to one in four men, age 50 and older, will end up breaking a bone due to osteoporosis, which is the biggest reason why we are trying to be proactive at diagnosing it. 

Erin Spain, M.S. [00:01:26] Tell me a little bit about you. You work very closely with patients who have osteoporosis. Is that right? 

Stacey L. Rothwell, P.A.-C [00:01:31] Yes. We have developed a bone health program here at MUSC that initially started off with treating our patients who have already fallen and had what's called a fragility fracture, which is when you break a bone from a ground level height. And typically, if your bone is a normal strength, it wouldn't break in that situation. So we've been trying to bring those patients into the clinic and do a bone health evaluation along with their fracture care. And since we've been doing it, we've also started doing primary fracture prevention on patients who actually even haven't had a fracture yet to hopefully prevent them from having to go through it. 

Erin Spain, M.S. [00:02:04] So tell me, you work one-on-one with these patients. When they come in and they get a diagnosis of osteoporosis, are a lot of them surprised? 

Stacey L. Rothwell, P.A.-C [00:02:12] Well, it's actually a lot easier to get their attention once they've had a fracture, because going through the rehab and being dependent on a walker or cane makes them a lot more amenable to listening to what you have to say and believing actually the fact that they are getting older and they might have weak bone. It's a little bit more difficult to talk to people about it who haven't had a fracture unless they've had a family member go through it because it is silent and they don't have any pain from it. And so they don't quite understand why they need medication for something that they don't feel like they have. 

Erin Spain, M.S. [00:02:41] You mentioned a medication. So let's walk through a little bit. First of all, who's at risk for osteoporosis? You said as people get older, it becomes more common. 

Stacey L. Rothwell, P.A.-C [00:02:49] The typical patient that you would see is a thin Caucasian female, because especially as females go through hormone changes, post-menopausal, that puts them at risk. But it actually is a lot more common. And other people, such as people who have been on long-term prednisone for various diseases, people who've had gastric bypass surgery and have had nutritional deficiencies as a result, patients who have had cancer and chemotherapy treatments, anybody who's had like a stroke or other issue that has caused them mobility trouble where they're not weight bearing much, they end up getting weak bone, diabetes, kidney disease. There's a lot of other comorbidities that actually puts you at risk. A lot of the men that I see, they have low testosterone or a lot of them are heavier drinkers. And so they also have the malnutrition standpoint from that. So there's actually a wide variety of people that we see in clinic. 

Erin Spain, M.S. [00:03:43] And you said most folks, you get their attention when they have one of these fragility fractures. These can be really serious. Tell me about these fractures and why making the prevention of fragility fractures really important for vulnerable patients? 

Stacey L. Rothwell, P.A.-C [00:03:59] It's extremely important because a lot of these fractures can actually take the patient's independence away, where we have previously older folks who've been able to live on their own are all of a sudden having to either move in with family members or go to a nursing home because they can't stay on their own anymore because they're weaker and they have to use a walker or a cane to get around. So that's the primary way we kind of get through to people as far as trying to prevent this, because it's not just, okay, the surgery and then you recover and you go home, because as they get older, it's harder to come back from these things and you lose your independence. They had done a study that from 2015 showed that more people were hospitalized due to fragility fractures than breast cancer, stroke and heart attack combined. So it's a much bigger issue than people realize. And patients who have had one fracture have an 86% increase in their risk for another fracture. So it's extremely important to diagnose and treat. The other thing is that overall, 24 to 35% of hip fracture patients 50 years or older will die within one year following their fracture. So it's a huge reason to obviously prevent it. But also when they get in the hospital, we need to treat them quickly to get them up and moving. 

Erin Spain, M.S. [00:05:11] So screening is pretty critical and you can be screened for osteoporosis. Tell me about that process. 

Stacey L. Rothwell, P.A.-C [00:05:18] A lot of people don't know there are actually three ways that you can get diagnosed with osteoporosis. One is by having a DEXA scan that shows your T score is less than -2.5. DEXA is the gold standard on how you get it diagnosed, but you can also just by having a fragility fracture, puts you in the osteoporosis range kind of regardless of what the DEXA shows. And then the third way is by having osteopenia, which doesn't look as bad on DEXA. So it's between negative one and -2.4, which a lot of people say, okay, that's no big deal. But if you have a lot of risk factors such as family history or other comorbidities that put you at higher risk, frequent falls, things like that, that can also put you in the osteoporosis category of needing medications. 

Erin Spain, M.S. [00:06:00] Explain the scan to me. What's it like from the patient point of view? What happens? 

Stacey L. Rothwell, P.A.-C [00:06:05] DEXA is the gold standard on how you get a diagnosed primary care, or there are some other bone health specialists, endocrinologists, rheumatologists also specialize in osteoporosis and can do that DEXA screening for you. The nice thing is it's very easy. They just have to be able to lie flat, which has been an issue with just a couple of people, if they have a bad back or things like that, but typically you just have to lie still for a few minutes. And I believe it just kind of scans over the top of you. There's no contrast. It's low radiation, but it's a very quick test, which is nice. So a lot of times I try to set up my post-op patients with a DEXA scan before they see me the same day, and then we can go over the results and everything all at once. 

Erin Spain, M.S. [00:06:43] What age would you say you should start having osteoporosis on the radar and bringing it up to your primary care physician if they haven't brought it up to you? 

Stacey L. Rothwell, P.A.-C [00:06:52] I would say at any time over 50, but especially if you're, you know, 65, 70, post-menopausal, some people don't go through menopause until mid-50s, but that's really the main time to do it as a female, but especially if you have a family history. That tends to be a really strong risk factor for having osteoporosis yourself. 

Erin Spain, M.S. [00:07:10] And are there ways to prevent getting the disease? Are there things that you can do with your diet or medications, supplements, things like that? 

Stacey L. Rothwell, P.A.-C [00:07:17] Absolutely. So we try to make sure everyone maximizes their conservative things, such as regular weight bearing exercises. Even walking on a regular basis is better than not. But even like light weight bearing 3 to 5 times a week with some weights or pilates or anything like that, that can help with balance as well. Dietary, you want to get about 1200 milligrams of calcium a day between diet and supplement. So I typically tell my patients if you're at least getting five or 600 milligrams in a supplement, usually you can get the other half through diet. And then my typical dose recommendation for vitamin D is 2000 units a day. But I do screen my patients and most people actually are vitamin D deficient unless they're already on supplementation. So sometimes I have to give them a boost for the first few months and then get back on that maintenance dose. But trying to get different foods in your diet, such as, you know, dairy products, milk, yogurt, cheese, that kind of thing. Fish such as salmon and tuna have a lot of vitamin D and calcium. Green vegetables like spinach, kale, broccoli have a lot of calcium. So we just try to go through the different things in their diet that they can also make sure they try to get as well as good lean proteins. And that's also important when they're trying to heal from our fracture as well. 

Erin Spain, M.S. [00:08:26] So if you do end up having osteoporosis, let's talk through some of the treatment options and how things have changed in recent years. 

Stacey L. Rothwell, P.A.-C [00:08:33] So for a while they only had Fosamax or Actonel, which is the medication most people are familiar with, and that's a pill either once a month or once a week. They also had an infusion that was once a year, but it had some flu-like symptoms that people would often get afterwards. So they didn't really like that. And since people were on those for so long, they started having more side effects because they had a really long half life and people started having atypical femur fractures and other issues from it. So they got really scared about taking those medicines. Now there are multiple other injection medications that you can use. Some of them do have black box warnings which scare people. But if you do a good thorough history, you can make sure that there's no contraindications keeping them from being able to take these medications. They actually do a good bit of improving bone health, not just keeping them where they're at and they actually get improvement on their scores, on their DEXA scan as well. There's a few different categories. There are some that stimulate the bone building cells in your body, and then there's some that decrease the action of the osteoclasts. Those are the cells that are resorbing the old bone. So it slows those down, allowing the bone building cells to catch up. So there's a couple of different mechanisms of action of these medicines. 

Erin Spain, M.S. [00:09:38] MUSC Health has a bone health program, which you are part of. Tell me about your role in the program and about MUSC Health's approach to bone health. 

Stacey L. Rothwell, P.A.-C [00:09:48] It's a really neat program. It's unique compared to other programs around the nation because I've gone to multiple meetings and people have various approaches depending on what their resources are within their institution. But the way ours kind of came about was back in 2016, Dr. Hull, who's an endocrinologist, approached Dr. Reed, one of my attendings, and wanted to start a bone health program where we would refer our patients who were in the hospital with the fragility fracture to their practice, and then they would treat them for their bone health. But after a couple of years of doing that, we looked back and realized most of these people weren't coming to their endocrinology appointment because either they forgot or they weren't sure why they were going, because they have so much else going on or they were in rehab. So the follow up was pretty abysmal. I decided that I was going to take it over in 2018 because I saw what a need there was and that there was a good benefit we could provide these folks. So in 2018, I took it over with just a half day clinic, just seeing some post-op patients and doing their bone health at the same time. It just has grown since then. So in October of 2021, they allowed me to hire another APP. So my friend Rebecca and I are now running the program together. We kind of have mirroring schedules, so at least every day, somewhere, either in West Ashley, Mount Pleasant or downtown, we're able to see bone health patients and our practice has just started to really grow now that we have more opportunity to see people. We've provided outreach. We're doing primary prevention now too. So we've outreached to a lot of our primary cares who find it difficult to go through all this because our patient visits for a new patient are about 45 minutes, because we do such an extensive history and education. They go online and look at these medications. They sound very scary, but you need to be able to talk to them about it, about the risks and benefits. And the primary care just doesn't have time for that with everything else that they're treating with the patients. So they've been giving us a lot of patients. When they screen them and see they have osteoporosis, they'll send our way so we can talk with them, which has been great. 

Erin Spain, M.S. [00:11:41] Tell me about some of the success stories that have come out of the Bone Health program. What are you seeing in some of the patients being sent your way after you're able to kind of go through all of this and give them some really dedicated time and pay attention to their diagnosis? 

Stacey L. Rothwell, P.A.-C [00:11:57] Well, it's definitely been rewarding. We've done a study that showed the benefit of how we're running our program versus how it was run when we were trying to refer to endocrinology and the patients, their compliance with the medications, it's shown that it's reduced their secondary fracture occurrence, which is really the main goal, is to prevent them from having to go through this again. So we've actually shown in a study that it's been beneficial and that was just from more of the beginning part. So now we're doing an even better job at follow up and whatnot. So that's been really rewarding. And then just to see them coming back and you can see just the numeric improvements on their bone density. So you can see that it's actually doing good. 

Erin Spain, M.S. [00:12:33] Give me an idea of the number of people that you're able to help. 

Stacey L. Rothwell, P.A.-C [00:12:36] On a typical day, we see probably between nine and, well yesterday I had 18 people. That's a big day because I think eight or nine of them are new patients. So that's a long time to take with each one. But we've now we keep a Excel spreadsheet of all the patients that we've seen, and we're over 1000 now, and especially since we've just been doing the full board clinics on a daily basis just for a little over a year, I think that's pretty impressive. So it's definitely grown a lot. 

Erin Spain, M.S. [00:13:03] You see a lot of these patients when they're in a pretty delicate situation. Maybe they're just coming out of a hospital stay or they've gotten a new diagnosis. And like you said, maybe they're worried. Just tell me what it's like working with this particular population. And what do you like about working with them? 

Stacey L. Rothwell, P.A.-C [00:13:18] It's nice to be able to get to know them because I work in trauma. And so typically you don't get to know your patients as well because, you know, you fix their fractures and they're gone. But these guys, we continue to follow up. We'll see them once a year to check in, do any medication changes we do in every other year, DEXA scan. So I get to know them really well and to see how we're helping them and to know that they're still able to be as active as they want to be is really exciting. 

Erin Spain, M.S. [00:13:41] So for folks listening today, maybe they're thinking of their loved one, their parent or grandparent, or maybe for themselves. This is something that they should be thinking about. What advice would you give when it comes to just keeping osteoporosis at top of the mind? 

Stacey L. Rothwell, P.A.-C [00:13:54] Well, I would definitely recommend anybody getting screened, especially if they're, you know, over the age of 50 or 60. You've never had a bone density screening, if you have any family history of it or any kind of concern or any previous fractures too, because we've diagnosed this in patients who are even younger than that for other reasons. So definitely to get that screening DEXA scan, just talk to your primary care about it because they can give you the resources that you need to get checked. 

Erin Spain, M.S. [00:14:18] What do you do to optimize your health and live well? 

Stacey L. Rothwell, P.A.-C [00:14:21] Well, I try to stay very active. I have two children that we always are very busy with and I work out doing some weight bearing CrossFit things four days a week. And I try to just maintain a very healthy diet because I don't like telling people what to do if I'm not doing it myself. 

Erin Spain, M.S. [00:14:36] Well, Stacey Rothwell, thank you so much for coming on the show and talking about this topic that I know is near and dear to your heart, which is osteoporosis. And best of luck on the work you're doing with the clinic. 

Stacey L. Rothwell, P.A.-C [00:14:47] Thank you so much. I really appreciate it. 

Erin Spain, M.S. [00:14:48] If you are interested in making an appointment with MUSC's Bone Health Program, you can call 843-876-0111 or schedule online at MUSC.edu. And you can make an appointment with either Stacey Rothwell, P.A.-C or Rebecca Henson, P.A.-C. For more information on this podcast, check out Advance.MUSCHealth.org.