Osteoporosis: Causes, Risk factors

Osteoporosis

• Osteoporosis involves changes in bone microarchitecture due to reduced bone mineral density (BMD).
• Bones weaken, leading to increased fracture susceptibility.
• Osteoporosis is often first diagnosed upon fracture occurrence.
• Common fracture sites include the wrist, spine, shoulder, and hip.
• Osteopenia is a less severe form of osteoporosis.

Osteoporosis: Risk Factors

• Age is a risk factor; women over 60 and men over 70.
• Roughly 1 in 3 women and 1 in 5 men over 50 will experience an osteoporotic fracture.
• Being female increases the risk.
• Estrogen deficiency and premature menopause in women are risk factors.
• Family history is a risk factor.
• A history of fractures in adulthood increases risk.
• Low body weight and physical inactivity are contributing factors.
• Dementia increases the risk.
• Other suggested risk factors include Vitamin D deficiency, smoking, certain medications, underlying diseases, low or high protein intake, low calcium intake, excessive coffee consumption, low or excessive phosphorus intake, insufficient sun exposure, alcohol consumption, and a sedentary lifestyle.

Burden of Osteoporosis

• Global prevalence is approximately 18.3%.
• Prevalence in women is about 23.15% and in men about 11.7%.
• A single hip fracture can cost over $45,000 USD per patient.
• Direct annual treatment costs for osteoporotic fractures are about $5,000–6,500 billion USD in Canada, the USA, and Europe alone.
• Indirect costs like disability and loss of productivity are not included in those estimates.

Burden in Canada

• Approximately 2.3 million Canadians are living with osteoporosis.
• 1 in 3 hip fracture patients will experience another fracture within a year.
• Bone loss starts in the mid-30s for both women and men.
• 22% of women and 33% of men who experience a hip fracture will die within one year, potentially due to secondary causes like pneumonia from inactivity.
• The annual cost related to osteoporosis is over $4.6 billion.

Diagnosing Osteoporosis

• Diagnosis involves medical history and physical exams.
• Bone Mineral Density (BMD) assessment through Dual Energy X-ray Absorptiometry (DEXA/DXA) Scan.
• T-score > 2.5 standard deviations below average is classified as osteoporosis.
• Osteopenia is with a T-Score between 1 and 2.5 below average.
• Ultrasound imaging and CT scans are further testing examples.

Physiological & Psychological Impact

• Osteoporosis is known as the "silent thief" due to bone loss occurring without symptoms until a fracture happens.
• Fractures, particularly vertebral fractures, lead to height loss, protruding abdomen, hyperkyphosis, and postural changes.
• Chronic pain, loss of height and weight, changes in posture, loss of strength, depression, gastrointestinal disorders, sleep disorders, difficulty in daily activities, and reduced quality of life are further impacts to quality of life.

Treatments

• Treatment options include medication and lifestyle changes.
• Facilitators and barriers to physical activity/exercise should be considered.
• Benefits must be carefully evaluated against potential risks.

Exercise Benefits & Training Focus

• Exercise can achieve pain reduction and prevention of falls and fractures.
• Benefits of improved mobility and posture are more likely in earlier stages.
• Therapeutic exercise goals are to prevent falls, reduce bone loss, and promote spine-sparing strategies.
• Exercise can help improve quality of life.
• Posture education and training, breathing exercises, balance and functional strength training, water training, and joint mobility are further benefits.
• Osteogenic exercise should be load-bearing with few repetitions, have variable strain distributions on bone, and be site-specific.
• In order to optimize results, exercise should be long-term, progressive, and spread throughout the day, which is often the most conservative management method.

Exercise Testing

• Avoid high-impact skeletal loading in testing.
• Bicycle protocol are lowest impact options.
• A bicycle protocol helps to maintain neutral spine and are recommended for severe vertebral cases.
• Treadmill protocol should involve walking only and put trip/fall preventative measures in place.

Exercise Prescription

• Aim for 30-60 minutes of moderate aerobic activity daily or 150-300 minutes weekly, per ACSM recommendations.
• Balance training and flexibility should be incorporated.
• Progressive resistance training should follow ACSM guidelines similar to older adults.
• Spine-sparing strategies are important due to the difficulty of quantifying exercise intensity in terms of bone loading forces.

Special Considerations

• Explosive movements, high-impact loading, twisting, bending, and spinal compression should be avoided.
• No specific guidelines exist regarding contraindications for exercise in individuals with osteoporosis, and moderate-intensity exercise is best.
• Activities that improve balance should be included for older adults.

Low Back Pain

• Low back pain reflects many disorders and causes.
• Low back pain is discomfort between the 12th ribs and gluteal folds, with or without leg pain.

Low Back Pain & Risk Factors

• Risk factors include age, decreased hamstring, back extensor muscle flexibility, lower trunk muscle strength, obesity, smoking, and lifting with twisting.

Burden of Low Back Pain

• 619 million individuals had low back pain in 2020, and projections estimate 843 million by 2050.
• Low back pain is a leading cause of disability worldwide.
• Affects up to 80% of adults at least once in their lifetime.

Diagnosis of Low Back Pain

• Diagnosis involves screening procedures to “rule in” or “rule out” more severe pathology.
• ROM and flexibility testing, scan of posture and neurologic screening are further testing.
• Diagnostic tests involve X-rays, MRIs, CT scans, and nerve conduction assessments to assess any nerve damage/cause.

Treating Low Back Pain

• Treatments may include pharmacologic interventions for acute and chronic pain, as well as psychological and physical or rehabilitation approaches.
• Surgery may be necessary.

Benefits of Exercise

• Exercise increases physical activity tolerance, pain tolerance, range of motion, health-related quality of life, physical fitness & strength, functional capacity, and overall physical activity participation levels.

Exercise Testing & Prescription

• In prescribing exercise note safety equipment use, address any risks of modifiable lifestyle factors, limit twisting/prolonged positioning, encourage breaking up work stations, modifying exercise to a person's needs.

SCI Facts

• Primary SCI results from force applied to the spinal column, with secondary SCI due to hemorrhage and local edema.
• Spinal Cord Injuries (SCI) impact neural signal conduction across injury sites.
• Complete or incomplete loss of sensory and function is associated with spinal injuries.
• Cervical lesions mean tetraplegia with impaired arm/trunk/leg function and a 4x higher risk in men.
• Thoracic lumbar lesions are linked to paraplegia through impaired trunk function.

SCI Statistics

• Over ~2 million people are affected by SCI.
• ~40% die before even reaching the hospital, with the result being long-standing/profound personal/social and financial impacts.
• A SCI costs $1.5-$3 million in lifetime expenses vs 30,000+ who are living with it.
• The SCI rate has increased ~37%, with roughly 1200 new injuries per year.

Complete SCI Lesions

• Cervical injuries often need breathing support above C4 but may retain shoulder, elbow, and wrist control with hand function depending on the injury site.
• Thoracic SCI between T1-T6 experiences poor thermoregulation, orthostatic hypotension, and autonomic dysfunction with bradycardia, and limited breathing capacity.
• Thoracic SCI from L2 to S2 relates to deficits in bowel, bladder, and sexual function.

In general

• Depending on the lesion area, low BP, stroke volume, impaired thermoregulation, glucose intolerance, venous stasis related thrombosis, autonomic dysreflexia as well as muscular atrophy and a loss of bowel control can occur.

Physiological & Psychological Impact of SCI

• Those with Spinal Cord Injuries are high risk due to secondary complications, and are subject to chronic pain, Osteopenia, Cardiovascular Disease, urinary tract infections depression, spasticity, obesity, skin ulcers and type II diabetes.

Treatments for SCI

• Autonomic/circulatory dysfunction, catheter and chronic pain treatment is key.
• Medications/SCI research focuses on neuroprotection, cell and nerve regeneration treatment.

SCI Rehabilitation

• Rehab focuses on returning independent function and improving quality of life, where clinicians work to tailor interventions to those affected by traumatic injury.

Activity-Dependent Neuroplasticity

• SCI rehab has shifted to focus on nervous structural changes and re-enforcing movement, where limb-specific training can be used to build movement/function.

Exercise Benefits

• SCI induces changes in cardiovascular, nervous, and muscular systems, which are further reduced by low levels of physical exertion.
• Exercise training is essential to improve mental and physical outcomes for those affected.

Special exercise-related considerations

• It is important to screen for autonomic dysreflexia, orthostatic hypotension for certain interventions and determine any ROM needed.
• Function should be assessed to ascertain the proper protocol and safety precautions to be taken.

Exercise Precriptions for Sci

• Exercise perscriptions depend on the goal for that level
• They all require at least adapted equipement, and a weight supported treadmill.
• Exercise must take into account impairment of body structure, and medication use.

Parkinson's Disease (PD)

• Parkinson's disease affects neuromotor ability
• It stems from the loss of neurons in the substantia nigra of the brain.
• The risk can span across genetics-to-poor living enviroments-to-age.
• It involves alpha-synuclein accumulation, and affects cognitive and emotional behaviour as well as movement.
• There is no cure, but exercise along with medication is key.
• Physical training can improve QOL, motor control, and slow effects.
• The use of prescriptions are key, as are safety preparations.

Common symptoms

• May involve a Resting trmor, and can vary in severity and nonmotor related symptoms (fatigue, depression, cognitive impairement)

General risks

• Patients may experience orthostatic hypotension, and cardio- or muscular symptoms.

General Considerations for Exercise

• Exercise training requires a dose-dependent approach for cardio with the goal of improving walking economy, gait, and transfer.

Training approaches

• Strength routines involve weights, and balance work, tai chi and yoga can improve motor control.

Depression and Anxiety causes and factors

• Genetic predisposition, biological differences, and environmental considerations from long-term stress play a factor.
• Increased rates were recorded in people affected during 2019-2023.

Tests and treatment

• Primary care providers and mental helth practioners are best to test/advise.
• Accumulation of a cardiovascular system is often linked.
• Behavioural and mental therapy includes exercise, acknowledging mental health, talking to support and medication.

Exercise plans

• Include patient centered care, social support and attainable goals.