Time to Bone Up May 9, 2012

by Rick Rader, MD

While Shakespeare knew a thing or two about human nature, I recently caught him in a goof (while not necessarily an Elizabethan term I'm more comfortable with "goof" than "guffaw."). In his "Measure for Measure" (about mercy, justice and truth and their relationship to pride and humility) he offers that "Thy bones are hollow." Had he used that on a bone physiology exam he would have received his paper back with "See me after class" in bold red pen.

The bones are not hollow and lucky for us, since we rely on them for support and to provide form and structure for the sum of our parts. They are filled with lots of stuff but, unlike the storage rental units that have become so popular to store the things we don't use but can't seem to part with, the bone stores stuff that we come for on a daily basis. While the Bard would get partial credit for his "hollow" observation (since they are), we would not want anyone to be confused with "hollow" and "empty." The bones contain minerals, growth factor, fat, heavy metals, hormones and an assortment of living and dead cells. When you arrange all that stuff, there is little room left for "hollow."

It's no wonder that developmental physicians are very sensitive to the increased prevalence of low bone mineral density for people with developmental disabilities. The transition from the rigid organs that we rely on for movement, structure and protection to spongy deformation is a life changer.

Individuals with intellectual and developmental disabilities are at particular risk for conditions related to low bone density. These high risk factors include small physical frame, hypotonia, reduced mobility, neuromotor dysfunction, vitamin D deficiency, anticonvulsant medications, low estrogen levels in post menopausal women, and limited exposure to sunlight. Low bone mineral density occurs in as many as 80% of people with ID/DD with the resultant high incidence of fractures. Low bone mineral density is not a "one-size-fits-all" disorder and the astute clinician should be vigilant to ascertain "zebra" related conditions such as chronic kidney disease. Both genders are at risk for osteoporosis (low bone mass) and osteomalacia (softening of the bone).

Readers of EP appreciate that I do not typically use my editorial real estate for hard core clinical issues and this is no exception. The purpose of this article is not to provide the clinical pearls about bone disease in folks with developmental disabilities but to (once again) demonstrate the need for ongoing efforts to fortify the "process and the system."

Dr. Phil May, a noted developmental physician from New Jersey, is an exponent of that need for fortification. Dr. May is a co-founder and first president of the American Academy of Developmental Medicine and Dentistry, as well as the Medical Director of the International Foundation for Chronic Disabilities. Dr. May is what we call a "triple threat physician." In football a "triple threat player" is one who excels in running, passing and kicking; while in entertainment a "triple threat performer" is one who excels in acting, singing and dancing. In the field of developmental medicine a "triple threat" physician is one who excels as a clinician, teacher and advocate. There are far too few of them.

Dr. May has vigorously studied the physiology of bone turnover and bone integrity, has treated countless patients with ID/DD, mentored scores of medical students and neophyte physicians and, most notably, has advocated for patients and their families. It is his role as an advocate that is the impetus for this article.

Phil has never been content with treating patients in a clinical vacuum. He realizes that to truly hit the target of accessible and competent medical care for this population, in all centers of care, the physician has to promote and propagate the best practices throughout the care giving community.

As individuals are vigorously repatriated to the community (from developmental centers), there is the notion of the "dignity of risk." This is the assumption of a calculated and recognized opportunity for misadventures as people with intellectual disabilities are exposed to new ventures, new scenarios and new activities. It is the price we willingly pay (with concentrated efforts to mitigate risks) to provide "meaning" to the proverbial "meaningful day."

Dr. Maty understands and appreciates that strong bones become part of the strategy that must be incorporated into minimizing risk and vulnerability for compromised patients. He continues to coordinate and organize educational opportunities for physicians, students, nurses, policy makers and families on the recognition of the need to minimize the impact of low bone mineral density disorders.

Dr. Phil May has a simple message to the medical community, "You better bone up on your understanding of the role our skeletal system plays in fulfilling the dreams of individuals with developmental disabilities."

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