Osteoporosis Considerations for Physical Therapists

• Module 6 2025 will discuss osteoporosis considerations for physical therapists
• The module was developed by Tracy Spitznagle, PT, DPT, WCS and Emily Kaszyk, PT, DPT, CLT

Objectives

• Identify principles of bone turnover
• Differentiate osteoporosis (OP) from osteopenia
• Identify risk factors for OP
• Recognize standard medical management strategies for OP
• Recommend appropriate exercises and activities that optimize bone health

Key Takeaways

• Competently screen and treat patients with OP
• Classify at-risk patients as OP patients
• Consider factors outside the classic geriatric patient profile, such as SCI, transient OP in pregnancy/post-partum, and post gastric bypass surgery, etc

Makeup of Bone

• 30% organic material, primarily collagen type 1 and glycoproteins for elasticity
• 70% inorganic mineral material that is primarily calcium phosphate salts for strength

Bone and the Skeletal System.

• The skeletal system protects vital organs
• Muscles attach to it
• It transfers large loads for daily movement
• Bone is composed of collagen, calcium, and phosphate
• Organic material comprises collagen and glycoproteins
• Collagen and glycoproteins laid down in a specific pattern influence elasticity
• Inorganic materials composed of calcium phosphate salts impact bone strength
• Bone failure occurs when calcium is deficient

Types of Bone: Cortical

• Eighty percent of the structure
• Solid and more dense than cancellous bone
• Is the cortex and shaft of most bones
• Cortical bone has more mass per unit volume than cancellous bone
• The large majority of bone tissue is in the body
• Tissues are very dense due to structure like concentric lamellae that wraps around the central nutrient canal
• Eighty to ninety percent is calcified

Types of Bone: Cancellous

• Spongy
• More metabolically active than cortical bone with a higher remodeling rate
• Found at the end of long bones
• The primary composition of flat and short bones like vertebrae
• More responsive to metabolic and hormonal influences because of increased surface area
• More flexible and absorbs shock better than cortical bone

Basic Bone Cell Types

• Osteoblasts build bone
• Osteoclasts cut away bone
• Osteocytes sights, markers, and modulators for bone resorption/formation; similar lineage to osteoblasts
• Osteocytes maintain bone homeostasis and can perceive changes in mechanical forces, cell deformation, and changes in fluid shear stress, pressure gradients and electric fields

Bone Turnover

• Living bone is always metabolically active
• Turnover involves destruction by osteoclasts and formation by osteoblasts
• The phase of life impacts the rate of bone turnover
• Turnover is accelerated in infancy and adolescence
• Turnover slows during childhood and adulthood
• Peak bone mineral density occurs at age 30
• Regular bone turnover helps maintain strength and integrity of the skeleton, replacing old with new bone and providing vital minerals like calcium for homeostasis
• All bone tissue is replaced every 3 years
• Microfractures normally occur with ADLs and are repaired by osteoclasts and blasts

Important Equations to Remember

• Formation < resorption leads to decreasing BMD
• Formation = resorption leads to no change in BMD
• Formation > resorption leads to increasing BMD like in growth and development

Factors Affecting Bone Formation: Centrally

• Hormones like estrogen, testosterone, growth hormone, and thyroid hormone impact bone formation
• Calcium, Vitamin C, and Vitamin D levels affect bone formation
• Novel bone loading helps bone formation
• Hormones regulate osteoblast/clast remodeling cycles
• Hormonal factors encourage bone formation.
• Low calcium signals increased bone resorption
• Recommended calcium intake levels: 13-18 y/o: 1300mg, 18-50 y/o: 1000mg, 50+ y/o: 1200-1500mg
• Vitamins C and D helps calcium absorption
• Vitamin D deficiency is related to pelvic floor dysfunction.

Factors Affecting Bone Formation: Peripherally

• Weight bearing impacts bone formation
• Bone responds to alterations in mechanical forces and these changes are site-specific

Bone Disorders

• Osteopenia and Osteoporosis
• Osteoporosis is categorized as primary or secondary
• Osteopenia is an opportunity for change and can prevent progression to osteoporosis
• Osteoporosis requires more aggressive medical response

Bone Disorders: Osteoporosis

• Metabolic bone disease causes systemic bone loss, not a localized loss = decreased bone mass (density) + progressive microdamage + deterioration of bone tissue, leading to increased fracture risk, morbidity, and mortality related to skeletal fragility

Bone Disorders: Primary Osteoporosis

• Commonly has non-modifiable risk factors such as age and sex-hormones
• Age-related changes in people > 75 can cause decreased calcium absorption, lower vitamin D levels, sex hormone function, and osteoblast activity
• Estrogen deficiency after menopause in AFAB can lead to increased bone loss, especially in cancellous/trabecular bone of vertebral bodies and the ends of long bones
• Menopause typically occurs around age 51 in AFAB (unless ovaries surgically removed)

Osteoporosis Key Points

• Estrogen regulates osteoclast activity
• ⅓ of AFAB over 50 are estimated to have OP
• In > ⅓ people with OP, major orthopedic problems are likely to occur
• 89% of 1.2 million fractures in AFAB over 50 are hip fractures from OP
• Largely underdiagnosed and undertreated with <20% of OP pts receiving treatment
• AMAB can also get OP

T-Scores

• Dexa scores are a critical clinical value
  • Normal t score : > - 1
  • Osteopenia : -2.5 to -1
  • Osteoporosis < -2.5

Bone Disorders: Secondary Osteoporosis

• Related to lifestyle factors, diet exercise and body composition
• Lifestyle factors affect bone resorption or formation
• Bones need nutrition and physical stress to not weaken

Factors Affecting Secondary Osteoporosis

• Includes low calcium intake, high caffeine, alcohol, salt, and soda intake
• Smoking
• Low physical activity/ low BMI will decrease the ground reaction force and bone deposition as a consequence of Wolfe's law about bone change
• Lack of Pregnancy: may produce less estrogen exposure
• Race: White and Asian people may falsely appear to be the most at risk
• Secondary OP and Primary OP can exist in the same person
• An 80-year-old with decreased calcium intake could also have low vitamin D levels, or be consuming beverages that promotes bone resorption.

Secondary Osteoporosis Can Result From

• Presence of specific conditions
  • Genetic conditions such as cystic fibrosis and ehlers-danlos
  • Hypogonadal states like RED-S and premature ovarian failure
  • Hypothalamic amenorrhea associated with anorexia
• Endocrine disorders like diabetes mellitus, hyperparathyroidism, or tumors
• Gl disorders like gastric bypass, celiac disease, or inflammatory bowel disease
• Hematologic disorders such as hemophilia and leukemia
• Autoimmune disease
• Pregnancy and postpartum that causes reduced BMD

Factors Affecting Secondary Osteoporosis

• Pregnancy and lactation-associated OP is rare and may be mistaken for pelvic instability
• Premature birth has a small correlation
• Depression leads to increased cortisol which reduces physical activity and loss of BMD
• Pulmonary diseases, namely respiratory acidosis

Medications Commonly Prescribed that Affect Secondary Osteoporosis

• Anticoagulants (heparin)
• Anticonvulsants
• Aromatase (estrogen) inhibitors, used to treat hormone-sensitive cancers
• Barbiturates
• Chemotherapy drugs, can induce menopause-like states for pre-menopausal women
• Corticosteroids, most bone loss occurs during the first 6 months
• Cyclosporine A is an immunosuppressant that inhibits bone synthesis
• Contraceptives and SSRIs

Osteopenia

• Is characterized by a T-score of -1 to -2.5
• Involves abnormally low bone density with intervention focusing on patient education and treatment for BMD loss prevention
• "Penia" is the greek word for poverty
• Osteopenia happens after peak bone mass (age 25-30) where bone resorption begins to exceed bone formation after age 30
• Those with osteopenia are at risk for fractures and still needs education and treatment

Different Diagnostic Tools to Identify Osteoporosis

• QUS (quantitative ultrasound), measures estimated bone mineral density of the calcaneus, tibia, or patella, expressed as a T-score
• DEXA scan measures bone density of the hip or spine, including peripheral DEXA measures in the wrist, heel, or finger
• Quantitative CT scan assess bone density at spine
• DEXA/DXA sensitivity is higher than QUS/CT, and it predicts fracture risk in patients without previous fracture
• Diagnostic tools can't be compared within the same patient

WHO Diagnostic Criteria for Osteoporosis (Established 1993)

• BMD is assessed at the lumbar vertebral bodies, distal forearm, and hip using DEXA scans
• Data derived from 30-year-old white AFAB subjects with no known bone disease
• SD decreases corresponds with a 1.5-3x increase in fracture risk
• WHO recommends combining clinical risk factors since DEXA best predicts fracture risk for those without previous fractures
• Scoring is derived from T-scores compared to healthy, young, white AFAB controls or as a Z-score compared to matched age, BMI and sex

Key Diagnostic Considerations

• The chart will indicate what patient type the patient will fit in
• This helps determine how much load their bones can accept based on the dexascore.

Bone Density Across Lifespan in AFAB

• 90% of peak bone mass happens by age 18 in AFAB and age 20 in AMAB
• Recess and school PT class are important
• Bone turnover continues after 30 but at a slowed rate while bone healing time increases
• People lose bone mass after menopause
• It is important to intervene and address bone loss

Most Common Fracture Sites: Hips

• Hip fractures typically occur in the femoral neck
• The BMD of AFAB tends to decrease with age

Most Common Fracture Sites: Vertebral Compression

• Can occur without trauma or falls
• Symptoms include pain to palpation or radiating to abdomen/flanks, increased sitting and standing with valsalva

Less Common Fracture Sites

• Ribs
• Humerus, distal radius, from wear and tear/everyday activities
• Always consider keeping bone as the source of symptoms doing eval

Implications of Osteoporosis

• Osteoporotic fractures have significant morbidity and mortality, most especially for hip fracture
• Annual cost is estimated to increase to $95.2 billion in 2040
• Only ⅓ patients return to previous level of function after a fracture
• ½ AFAB > 50 y/o will experience fragility fracture related to OP
• 79.4 % got diagnosis at the time of fracture

Second Fracture Rates

• 6.6% at 1 year to 20.9% at 4 years

Bariatric Surgery and Osteoporosis

• Up to 35% risk of fracture 10 years post-bariatric-surgery -due to Decreased calcium uptake or deficiency due to malabsorption, low activity habits, Vitamin D deficiency, post-op hyperparathyroidism

Factors Affecting Risk Reduction with Bariatric Surgery

• Directing the patients see about to receive bariatric surgery into realistic bone-loading exercise will help to decrease the risk of fracture

AMAB and Osteoporosis

• Screening is critical for older AMAB
• 1 in 4 AMAB over 70 will experience a related fracture
• AMAB association with morbidity and mortality with fragility

Considerations that Affect Fractures in AMAB and AFAB

• Both groups can be older and have comorbidities
• Screening matters for old AMAB patients that are BMI < 20 , steroid use, low calcium, spinal injury, androgen or hormone deprivation
• Be careful of trans patients with hormone therapy
• AFAB patients can get OP

Osteoporosis and Treatment

• OP is a condition that is both underdiagnosed and undertreated
• Keep in mind the “Classic presentation” of risks but consider the possibility of diagnosis
• Screen for risks and be mindful when choosing interventions
• Keep in mind the risk of RED-S relative energy deficiency
• diagnoses which predispose them to OP like ehlers danlos.

Osteoporosis and Fractures

• First sign of OP is a fracture with acute onset of pain
• Changes in posture within the thoracic lumbar spine can also be indicative of an undiagnosed fracture

Physical therapy's role in Osteoporosis

• Look out for high-risk medications, provide patient educate, understand appropriate bone tissues

Goals of Osteoporosis Prevention

- Delay/ Prevent bone loss
- Minimize bone loss
- Minimize adverse effects through movement and activity

Pharmaceutical Management of Osteoporosis

• Medications include Calcium, Vitamin D, Bisphosphonates (atypical femur Fx), Estrogen, Calcitonin, Teriparatide (Forteo)
• Side effects blood clots, urinary incontinence, vision changes, HTN, leg cramps, etc
• Avoid giving supplements

Osteoporosis Medications: Considerations

• Taken to reduce risk = side effects include constipation and or issues with Vitamin D
• Calcium with D can decrease fractures by up to 11 % and to use with caution
• Possible association with calcium/D supplements with increased risk

Osteoporosis Treatment - Medication Considerations

• Be careful about Calcium, it can turn into a sclerotic plaque.
• Inhibilts of Action reduce osteoporosis,
• Osteoporosis side Effects are alendronate, boniva, reclast
• Action- inhibit osteoclast activity
• Good at increasing femur and spine

Osteoporosis Treatment - Recommendation

• Avoid Use
• Used to treat trial diet
• For the patient and to educate the public - achy on leg or fractures issues as high

Osteoporosis-Estrogen

• Estrogen: or selective estrogen-maintain balance bone, the body in activity (increase, the Osteoprostic, increase for home therapy
• Used for Pain and reduce body fat

Bone Health

• Calcium and exercise that can help to perform strength is better for those in calcium bone and for body
• The bone for necessary weight for improvement

Weight baring and body strength

• Exercise for calcium can help it improve the body. that some studies do not have good and better change

Physical Training with low Calcium

• Physical therapy will have you able to help with the patient and recommend the education
• Screen everyone older from AMAB to African

Kyposis and Alignment

• The patients spine is to move better but also understand how to align the kyphosis
• Severe kyphosis need to be aware that you can also have stiffness that will hinder
• To perform the movement it is important to to encourage the process

Bone health and safety

• That has to promote movement and activity that is great for the life span
• NOVEL is very important make sure that your training at all times.

Other Movement in the Body

• Make sure that you always to PROM and high intensive in the ICU
• And those patients that feel they want to be independent that is important to always have more women

Sitting Position

• We had been seeing too many of the sit up double leg with the exercise
• However its important to do the exercise

Additional Home exercise Program

• The patient has always to has spinal curves that he can never feel in the body.
• The patient does have a weight baring to increase in body but the gravity forces need to make pull the body that requires to have more loads to reach

Home Exercise Program Ideas

• Have the patient do the prone extension and also the slide of the wall

Core Exercises

• Have more cervical , strength and movement for better posture of the body

Stiff Short Exercise

• Is also making the the body of the patient to have movement with quadrapade

Aerobic exercises: Considerations

• Help the patient do the wall with the help of rocking exercise
• With the back being relax it can also have great movement and breathing that can always help

Final Movement

• Should perform what they know and what they feel it.

What you always to tell the patients

• That you had use and done the best action you had performed to make better and for them.

Surgery Options

• Vertebroplasty
• Injection of (bone cementing) into fractured Vertebral body Does not address kyphosis Reassurance kyphoplasty

Key point

• It is very good care have those care that have limited function of healing and protection to move.

Another Great Intervention 2

• Have the patients have Bracing To always Have a scapular Movement in body
• In the Body to those that you have an the movement for low BMD the the most important.

The best

• That they start to have balance with in the movement.
• With being the good
• That everyone that there has been a big and good the exercise they have great is better

This guide provides actionable advice on Physical Therapy approaches for Osteoporosis patients.