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Growing older is a natural part of life. In Singapore, we have a rapidly ageing population, where 17.3% of our population are over 65 years old and there is a decline in the old-age support ratio to 3.7 as of 2023. Taken together, this simply means that as Singapore continues to have a larger greying population, we also have fewer younger people to rely on for support in our golden years. Thus, it is important for us to remain l healthy and age gracefully.
Many physical changes occur when we progress to middle and old age. This is due to the accumulation of loading and stress on our joints, ligaments and muscles. In our joints, there is a gradual loss of the smooth cartilaginous surface, while the ligaments start to lose elasticity, and our muscles gradually lose strength and volume. With these degenerative changes, one starts to experience stiffness, clicking in joints, a gradual loss of flexibility, and a decrease in muscular strength. We may experience fatigue and pain, with a loss of endurance strength and an inability to partake in prolonged activities.
LUMBAR SPONDYLOSIS
Lower back pain is one of the common complaints in the older population, often due to lumbar spondylosis. Other causes can include abnormal spinal alignment or poor sagittal balance. However, there are certain types of back pain that require greater attention. They include:
- Persistent pain with increasing frequency or intensity.
- Pain that disturbs sleep and or is accompanied by other symptoms like loss of appetite, loss of weight or fever.
- Associated history of injury trauma.
- Neurological symptoms like numbness, weakness, pins and needles, or electric/burning sensations.
- Any bladder and bowel disturbances.
So, what exactly is lumbar spondylosis? Simply put, it is a degeneration or ageing of the lumbar spine. Let us now go into some details on the physiology of this condition. The ageing process occurs in all components of the spine: vertebrae, discs, ligaments and paraspinal muscles. However, disc degeneration and reduction in bone mass of the vertebra are two independent processes.
Disc degeneration occurs from the first decade and is a result of the loss of nutrient supply from chronic inflammation, leading to the degradation of the disc matrix and loss of its ability to provide cushioning. This change in loading biomechanics causes more stress on the end plates and joints as the loading forces shift backward.
Hence, we start to see joint wear and tear as well as bony changes along the end plates of the vertebrae. This then becomes a vicious cycle where the shift of loading forces backwards results in more changes at the posterior part of the disc. This can lead to tears of the annulus and a prolapsed disc.
In the ligaments, these tissues lose elasticity, and undergo remodeling and thickening, resulting in abnormal translation of the vertebra (spondylolisthesis) and narrowing of the spinal canal. The facet joints will initially be inflamed, become unstable, and then finally increase in size in response to the increased shear forces from the disc degeneration. As for degenerative changes in the bone and muscles, they generally take place much later, from the 40s to 50s onwards. Gradual thinning of the bony trabeculae and loss of muscle volume/mass occur. In severe cases, osteoporosis or sarcopenia occurs.
Osteoporosis can be primary or secondary, where secondary osteoporosis is due to other underlying causes like chronic renal disease or renal failure, long term steroid usage, or other metabolic disorders. Primary osteoporosis can be either post-menopausal (in women) or senile (in men). Treatment of osteoporosis is recommended to reduce risk of fragility fractures and the associated complications of an osteoporotic fracture. Treatment consists of dietary measures (adequate calcium and vitamin D intake), weight-bearing exercise for stimulation of bone growth, and medications.
OSTEOPOROSIS
Osteoporosis is a condition where there is a loss of bone mineral density with a subsequent increased risk of fragility fractures, defined by a BMD T-score<-2.5. Patients with osteoporosis may experience gradual hunching, back pain and fractures with minimal injury.
Osteoporosis can be primary or secondary, where secondary osteoporosis is due to other underlying causes like chronic renal disease or renal failure, long term steroid usage, or other metabolic disorders. Primary osteoporosis can be either post-menopausal (in women) or senile (in men). Treatment of osteoporosis is recommended to reduce risk of fragility fractures and the associated complications of an osteoporotic fracture. Treatment consists of dietary measures (adequate calcium and vitamin D intake), weight-bearing exercise for stimulation of bone growth, and medications.
SARCOPENIA
On the other hand, sarcopenia is the loss of muscle mass and strength, with a subsequent loss in function. Sarcopenia is derived from the Greek words sarx meaning flesh and “penia” meaning poverty. It is fast becoming a global phenomenon as the world’s population ages. The consequence is increased mortality, morbidity and disability, thereby translating to a significant financial healthcare burden.
What is more alarming are the local numbers. In a study published in 2021 titled the Yishun Study, 32.4% of the cohort between 21-59 years of age have low muscle mass, and 14.1% have probable sarcopenia. There are also studies suggesting that the presence of sarcopenia correlates with poor spinal balance and back pain, with an increased risk of poor surgical outcomes for spine surgery in these patients.
However, all is not lost. There are mitigating measures for sarcopenic patients. More importantly, there is a need to identify these patients in the pre-sarcopenic phase. Management of sarcopenia depends on two important factors: nutrition and exercise. For nutrition, it is important to have adequate long-chain proteins and vitamin D for muscle building. As for exercise, it is recommended to do resistance training of moderate intensity for at least two days per week.
CONCLUSION
All in all, it is important to keep healthy and recognise signs of severe degeneration, such as osteoporosis and sarcopenia, so that treatment can be started early to prevent further complications.
