Lecture 5 (Osteoporosis) PDF

Prof. Dr. Mohamed Elbedewy. Associate Prof. of Physical Therapy for Cardiovascular/ Respiratory Disorder & Geriatrics  Objectives: at the end of this lesson the student will be able to: 1) Identify the basics of bone formation and what is meant by osteoporosis...

Prof. Dr. Mohamed Elbedewy. Associate Prof. of Physical Therapy for Cardiovascular/ Respiratory Disorder & Geriatrics  Objectives: at the end of this lesson the student will be able to: 1) Identify the basics of bone formation and what is meant by osteoporosis as a consequence of defect in this formation. 2) Identify the modifiable, non modifiable risk factors and secondary causes contributing to osteoporosis. 3) Recognize different radiological methods used for assessment and diagnosis of osteoporosis and identify the most accurate one as defined by WHO. 4) Recognize the importance of different physical therapy tests used for evaluation the physical performance and risk of falling in elderly with osteoporosis. 5) Describe the different physical therapy modalities which can be used for primary and secondary prevention of osteoporosis.  Definition of osteoporosis. Symptoms of osteoporosis. Risk factors for osteoporosis. Diagnosing osteoporosis. Prevention & treatment of osteoporosis.  The skeleton can be divided into appendicular and axial portions. The appendicular skeleton includes of the bones of the upper and lower limbs the axial skeleton includes the bones of the cranium, vertebral column, ribs, sternum, and pelvis.  All bones have cortical bone on the outside and trabecular bone on the inside, but the proportions differ between the axial and appendicular skeletons. Cortical bone is dense and solid and made up of lamellae, or compact plates. Approximately 80% of the mass of the skeleton is cortical bone.  Trabecular bone, also known as cancellous bone, has a honeycomb structure with horizontal and vertical bars filled with marrow and fat. Trabecular bone is responsible for about 70% of the volume of the axial skeleton, although only 35% of its weight is trabecular bone.  Bone is a dynamic living tissue that undergoes constant remodeling with coupled phases of bone resorption and formation throughout the lifespan. Bone increases in length and diameter during development, responds to mechanical stresses placed on it, and repairs itself after structural damage from trauma, fatigue, or mechanical failure. Approximately 3% of cortical and 7% of trabecular bone remodels each year. This tissue renewal helps:  Maintain the skeleton’s structural integrity and  keep blood calcium and phosphorus levels within the appropriate range.  Definition of osteoporosis: Osteoporosis: -Osteoporosis means “porous bones”, It is a metabolic bone disease usually occurring with increasing age and is defined as a skeletal disorder characterized by reduced bone mineral density and strength. (mass and quality). - It is a disorder in which bones become increasingly porous and brittle due to the loss in bone mass and bone protein leading to increased risk of fragility and fracture. - As bones become more porous and fragile, the risk of fracture is greatly increased. The loss of bone occurs silently and progressively. - Osteoporosis is characterized as a “silent disease” because is painless until the first occurrence of a fracture. - Normal healthy bone looks like a honeycomb in microscopic view, in osteoporosis it looks porous.  Osteoporosis: Is “a progressive systemic skeletal disease characterized:  By low bone mass density and micro-architectural deterioration of bone tissue,  with a consequent increase in bone fragility and susceptibility to fracture. Bone density: Is determined by peak bone mass and the amount of bone loss. Bone quality: Refers to bone remodeling rate, macr-oarchitecture, micro-damage accumulation, degree of mineralization and matrix quality. Bone strength: Is defined as a reflection of the integration of bone density and quality.  Osteoporosis is caused by an imbalance of bone resorption and bone remodeling, leading to decreased skeletal mass. As we age some of the bone cells begin to dissolve bone matrix (resorption), while new bone cells deposit osteoid (formation). This process is known as remodeling.  Bone remodeling is controlled by levels of circulating hormones, including : Estrogen, Testosterone, Calcitonin, Parathyroid Hormone (PTH), 1,25 dihydroxyvitamin D, By ongoing mechanical stresses from gravity, weight bearing, and the pull on the bones by contracting muscles.  Types of osteoporosis A) Primary osteoporosis - Primary osteoporosis occurs spontaneously, More than 95% of osteoporosis in women and probably about 80% in men is primary. Types:  Postmenopausal osteoporosis: is associated with increased bone loss due to decreased production of estrogen.  Senile osteoporosis: is an age-related bone loss that often accompanies advanced ageing.  Idiopathic juvenile osteoporosis: (of unknown cause). - It is unrelated to other diseases or conditions and is the more common of the two types. - Bone loss is even greater if calcium intake or vitamin D levels are low. Low vitamin D levels result in calcium deficiency, and increased activity of the parathyroid glands (hyperparathyroidism) which will lead to stimulation of bone breakdown. B) Secondary Osteoporosis:  The loss of bone mass is caused by:  Certain lifestyle behaviors, diseases, or medications.  The most common causes of secondary osteoporosis in men include:-  Exposure to glucocorticoid medications.  Hypogonadism (low levels of testosterone).  Alcohol abuse.  Smoking.  Gastrointestinal disease.  Hyper-calciuria and  Immobilization. Non modifiable Modifiable Risk Risk Factors  Age: the risk of osteoporosis increase.  Gender: Women are 5 times more likely to develop osteoporosis than men.  Family history of osteoporosis (broken bones/ stooped posture).  Genetic disorders.  Early menopause and depletion of estrogen level either naturally/due to surgical removal of ovaries.  Race: Caucasian and Asian women are highest risk while African & Hispanic are lower risk.  Cancer and cancer treatment.  Chronic renal failure.  Rheumatic diseases.  Chronic pulmonary disease.  Cushing’s disease.  Male hypogonadism.  Hypothyroidism.  Hyperparathyroidism.  Gastrointestinal Disease.  Hepatic disease.  Breast or prostate cancer.  Diabetes.  CHANGEABLE RISK FACTORS Sedentary life style (Lack of exercise and Physical inactivity). Vitamin D deficiency. Immobilization & bedridden people. Thin elderly with small-boned frame. Eating disordered (History of high protein). Prolonged use of some medications as glucocorticoids used as an anti-inflammatory to treat asthma/ arthritis, Prolonged overuse of thyroid Hormone , and anti-seizure medications. Smoking and excessive alcohol or caffeine consumption. Low vitamin D and calcium in diet.  - Early and correct diagnosis is essential for effective therapy. Reliable information about the state of bones is absolutely important especially if risk factors are already present. Osteoporosis is often Frequently, no referred to as a silent symptoms are present disease (silent thief) until bone loss is because there are no early advanced enough to clinical signs or result in a fracture. symptoms. A- Clinical signs and symptoms:  Medical history e.g. falling over, stumbling on steps.  The first symptom of osteoporosis is the bone fracture:  A- The first symptom of osteoporosis is the bone fracture:  Distal of radius  Proximal humerus  Vertebral collapse (Fractures). (Associated with back pain)  Femoral neck fractures.  This phase of the disease is characterized by acute pain.  Back pain: Episodic, acute low thoracic/high lumbar pain.  Acute back pain in osteoporosis is caused by sudden collapse or fracture of a vertebra. Patients often report having heard a snapping or cracking sound in the back.  In contrast, chronic back pain in vertebral fracture is due to:  Inability of the axial skeleton to withstand the demand made on it by muscles, joints, and extremities.  It is associated with:  skeletal deformity.  joint incongruity.  tension on muscles and tendons.  Pain on percussion of spinal Hip fractures, which are one of processes.  Compression fracture of the the most common broken spine. bones, can lead to permanent  Loss of height.  Bone fractures. disability, loss of  Decreased activity tolerance.  Postural deformities. independence , or even death.  Postural deformities include:-  Decrease in height loose height and get shorter (spinal compression causes a gradual decrease in height).  Kyphotic posture. (A stooped posture)  Dowager’s hump, (forward bending of the upper spine). Dowager’s hump Advanced case of Dowager’s hump kyphotic posture  B) Diagnostic investigations: Between 30 and 35 years of age osseous remodeling, (resorption and formation) are balanced which is greater in women than in men. Humans tend to lose bone mass at a rate of 0.5%-1 % per year after the age of 35. Bone density testing (DEXA). Ultrasound (QUS). Conventional X-ray to check for any bone fractures in spine. Fractures caused by osteoporosis are often called “crush” /”wedge” fractures. Laboratory investigations. 1 - DEXA scan (Dual Energy X-ray Absorptiometry): - The early diagnosis of osteoporosis, before occurrence of fractures can only be made by means of bone density measurements (bone mineral density tests, BMD). - A 10% decrease in bone density doubles the fracture risk for the vertebral body and triples it for the hip joint. - Measure bone density, quick (15 minutes), painless, safe & check effectiveness of osteoporosis treatment after 1-2 years of therapy.  Bone mineral density (BMD) provides the following information: Detects osteopenia and / or osteoporosis before occurrence of fracture. Predicts risk for later development of osteoporosis. Indicates the rate of bone loss and progression Documents the efficacy or failure of therapy. Increases compliance of both doctor and patient 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. T scores values DEXA scan  People suggested for osteoporotic tests: (Recommendations for BMD measurement) All women >65 years regardless risk factors presences or not. All women