Have You heard of the relevance of Bemer-therapy in the treatment of severe local bone diseases?

All of us have heard of osteonecrosis, Sudeck atrophy, bone infarct or even osteochondritis dissecans. Nevertheless, few of us know, that microcirculation of the bone plays an important role in the development of these severe bone diseases.

Etiology of these local bone diseases is not completely understood. In addition to disturbances of microcirculation, metabolic and neurological factors, dominance of the sympathetic autonomous nerve system, are important in the pathomechanism. The essence of the pathology is the death of the subchondral bone and bone marrow.  In most cases damage leads to collapse of the subchondral bone, incongruity of the articular surface and to subsequent osteoarthritis. Several risk factors are know; conditions, diseases and treatments, which may have a negative impact on the circulation. Eg. glucocorticoid treatment (especially prolonged high doses), alcoholism, smoking, chemotherapy and postoperative irradiations, inflammatory bowel diseases, e.g. Crohn’s disease, ulcerative colitis, diabetes mellitus and systemic autoimmune or hematologic diseases. Clinical symptoms often present with complaints of an acute pain, restricted movement. Weight-bearing lower extremity joints, such as hips (femoral head), knees (femoral condyles, the tibial plateau) and the ankles (talus) are generally involved. Other bones, e.g. the humeral head of the shoulder and small bones around the wrist (os scaphoideum and os naviculare) are also prone to osteonecrosis.

Imaging is crucial for diagnosis; conventional x-rays and magnetic resonance (MR) imaging, the latter being far more important in the early stages of the disease. Bone marrow edema (BME) on MRI is characteristic of the disease. Nevertheless, histopathologic findings show not only edema, but bone marrow necrosis, fibrosis, sometimes bleeding and even fibrovascular regeneration and bone remodelling.

MR image of a knee with multiple osteochondritis and diffuse bone marrow edema (PD_FS, cor)  

The MR pattern of BME is in good correlation with the patient’s clinical signs and symptoms, defining severity of pain and joint limitations, and representing a negative prognostic factor for cartilage loss and predictive of arthroplasty. BME may regress or resolve completely. On the other hand, if demarcated margins develop, irreversibility of the process is no longer a question. BME determines different types of the disease. It might develop after a trauma or cartilage surgery. It is often associated with cartilage degeneration and osteoarthritis. Sudeck atrophy is a transient reversible BME syndrome and occurs after a traumatic lesion or the accompanying pain. The newly recognized stress or “insufficiency” fracture may become irreversible and progress to real osteonecrosis.

Osteonecrosis (ON) syndromes of the knee are well known; two types exist although sometimes clear differentiation is impossible. Avascular necrosis (AVN) is far more typical, usually affecting patients below 45 years and is mainly ascribable to ischemic events; disturbances of the macrocirculation to the epiphyseal bone. It can be secondary to systemic diseases (e.g. systemic lupus erythematosus), glucocorticoid use, smoking, alcohol abuse or radiation and chemotherapy of a malignancy. Bone infarcts at other locations often associate.

The so-called spontaneous osteonecrosis (SON) of the knee seems to be most common in women aged over 50 years. It is classically described as a superficial focal subchondral lesion, mainly affecting the medial femoral condyle of the knee and rarely bilateral. Patients usually complain of an acute pain, which is worse at night, without any history of trauma or risk factors for ON. A compromised microcirculation to the subchondral bone is suggested, resulting in edema and increased intra-osseous pressure, finally leading to ischemia and ON. In other cases, in overweight elderly and osteoporotic women the subchondral lesion fails to heal and repetitive micromotion of the unstable osteochondral portion can lead to infiltration of synovial fluid, detachment and fragmentation of the osteochondral fragment followed by ON changes in the disconnected area (osteochondritis dissecans).

Therapy of these severe local bone diseases is complex. Although orthopedists have been making efforts to help in the early stage of the disease (core decompression, rotation osteotomy, bone graft), surgery still remains the treatment of severe cases and those in later stages (arthroplasty, prosthesis). Treatment of the early stage is the field of complex rheumatology, pain control, different supports (sticks and canes), exercise therapy adjusted to the actual musculoskeletal state and  physicotherapy. Healthy bone has a widely extended vascular network for supplying blood, oxygen and nutrients to the large surface of on-going bone metabolism, therefore improvement of blood circulation is fundamental in the treatment of these severe local bone diseases. Beta-blockers, diosmin, pentoxifyllin and sometimes prostacyclin infusions are noteworthy. In addition, BEMER (bio-electro-magnetic-energy-regulation) vascular physicotherapy plays a crucial role in repairing microcirculation of the diseased bone.