What is Osteoporosis?

Osteoporosis, a disorder characterized by low bone mass, and associated with pathologic fractures is the most common metabolic bone diseases in the developed countries. It effects more than 25 million Americans and leads to more than 1.5 million fractures each year. Osteoporotic fractures may affect any part of the skeleton except the skull. Most commonly fractures occur in the distal forearm, thoracic and lumbar vertebrae, and proximal femur.

Symptoms of Osteoporosis

Back pain: Episodic, acute low thoracic/high lumbar pain

·         Compression fracture of the spine 

·         Bone fractures

·         Decrease in height 

·         Kyphosis

·         Dowager’s hump

·         Decreased activity tolerance

·         Early satiety

Causes of Osteoporosis

 Primary osteoporosis has no known definite cause, but there are many contributing factors associated with the disorder. These include prolonged negative calcium balance, impaired gonadal and adrenal function, estrogen deficiency, or sedentary lifestyle.

 Postmenopausal osteoporosis is associated with increased bone loss due to decreased production of estrogen. Women commonly lose 1% per year after peak bone density has been met, for up to 8 years post-menopause. Senile osteoporosis is an age-related bone loss that often accompanies advanced aging

 Secondary osteoporosis is caused by prolonged use of medications or secondary to another disease or condition which inhibits the absorption of calcium or impedes the body's ability to produce bone.

Low calcium intake or absorption can greatly increase one's risk of developing osteoporosis. Life long calcium intake is crucial in building up bone stock prior to peak levels of bone mass, as well as maintain bone mass after the age of 20. Excessive alcohol consumption can decrease the body's ability to absorb calcium.

Hormone levels, either too little or too much, can impede on the body's ability to produce and maintain adequate bone mass. Dysfunction with sex glands, thyroid, parathyroid, or adrenal glands is often associated with osteoporosis.

Diagnosis of Osteoporosis

Patients with a diagnosis of osteoporosis should have   

·         Laboratory assessment of their renal and thyroid function, a 25-hydroxyvitamin D and calcium level.      

·         DEXA scan. The World Health Organization (WHO) established dual x-ray absorptiometry tests scans (DEXA) of the central skeleton is the best test for assessing bone mineral density.  

Bone density test results are reported using T-scores. T-scores are relative to how much higher or lower your bone density is compared to that of a healthy 30 year old adult

A t-score reflects the difference between the measured bone mineral density and the mean value of bone mineral density in young adults.

It is measured in standard deviations.

The WHO has defined normal bone mineral density for women as a t-score within one standard deviation of the young adult mean.

Scores between negative 1 and negative 2.5 reflect a diagnosis of osteopenia.

Scores below negative 2.5 reflect a diagnosis of osteoporosis.

The Fracture Risk Assessment Tool, FRAX, has become a more accurate way to measure 10years fracture probability. The FRAX questionnaire takes into account elements that influence an individual's bone quality as well as their bone density.

Treatment of Osteoporosis

Medical management:   Osteoporosis medicines can increase bone density and while the increases may appear small this can have a very positive effect on reducing fracture rates.

Osteoporosis medicines are grouped into different 'classes' depending on their 'active ingredient'

1.Bisphosphonates - Tablets (daily, weekly or monthly)

2. Denosumab - 6 monthly injection: Denosumab (brand name: Prolia)

3. Selective oestrogen receptor modulators (SERMS)

Daily tablet: Raloxifene (brand name: Evista)

4. Hormone replacement therapy (HRT) - The active ingredient is the hormone oestrogen. Some HRT treatments also contain progestogen (combined HRT)

5. Teriparatide - Daily injection for 18 months (self-administered): Teriparatide (Brand name: Forteo).

Physical therapy management: Physical therapy intervention for individuals with osteoporosis, or even osteopenia, should include:

·         weight-bearing

·         flexibility exercise

·         strengthening exercise

·         postural exercise

·         balance exercise

1.      Weight-bearing exercises

·         Exercises such as walking or hopping, has been shown to maintain or improve bone density in this population.

·         Strengthening exercises, using weights or resistance bands, has also been shown to maintain or improve bone density at the location of the targeted muscle attachments.

·         Maintaining bone health in this population is extremely important, especially in the elderly as there is typically has a decline in bone mass with age.

2. Flexibility and strengthening exercises

·         These can help improve the individual's overall physical function and postural control. eg yoga

·         Improving postural control is important to reduce the risk of falls

·         Falls often result in fractures in frail individuals.

·         Balance exercises are also important to incorporate to further reduce the risk of falls. eg Otago Progra

2. Postural exercises

·         These are crucial to prevent structural changes that often accompany osteoporosis, such as thoracic kyphosis.

·         Every osteoporosis program should include extension exercises; chin tucks, scapular retractions, thoracic extensions, and hip extensions.

·         Strengthening the extensor muscles will promote improved posture and improved balance.

·         Flexion exercises are CONTRAINDICATED. Anterior compressive forces to the vertebra can contribute to compression fractures.

3. Back pain

Physical therapist may treat patients with osteoporosis for back pain.

Agility training, resistance training, and stretching have all been shown to decrease back pain and its related disabilities in this population.

4. High intensity training - Research highly supports high intensity training in the prevention of bone loss for women in menopausal years and early stage post menopausal.

·         High intensity training would include body-weight and resistive exercises at a high intensity, similar to circuit training. This type of training is often contraindicated for individuals with low bone mass.

Dietary Management

The most important nutrients for people with osteoporosis are calcium and vitamin D.

·         Calcium is a key building block for bones. Vitamin D helps the body to absorb calcium.

·         Calcium and vitamin D can be from diet, supplements, or both. (It’s best to get these nutrients from food, rather than supplements).

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