Osteoporosis (et al) Presentation 2024 PDF

Osteoporosis (et al) Troy Seely BScPT, MScPT, DPT, FCAPMT Health Conditions and Disease in Rehabilitation RS 3060A © Troy Seely, 2024  Reminders Exam for RS 3060 is Tuesday December 17th at 7 pm in 3M building,...

Osteoporosis (et al) Troy Seely BScPT, MScPT, DPT, FCAPMT Health Conditions and Disease in Rehabilitation RS 3060A © Troy Seely, 2024  Reminders Exam for RS 3060 is Tuesday December 17th at 7 pm in 3M building, room 3250. It covers the second half of the course ( MS, COPD, Asthma/CF/RLD, Arthritis, & Osteoporosis ) © Troy Seely, 2024  Outline Discuss: 1. Osteoporosis 2. Fractures with osteoporosis 3. Frailty Final comments © Troy Seely, 2024  Metabolic Bone Changes The human skeleton is a metabolically active organ than undergoes continuous remodeling throughout life. – Annual turnover of cortical and trabecular bone of about _____of 10% the adult skeleton. The remodeling is important for two reasons: 1. Maintain the structure integrity of the skeleton. 2. Serve a metabolic function as a storehouse of calcium and phosphorus. © Troy Seely, 2024  Metabolic Bone Changes The skeletal system undergoes a ‘remodeling’ process over time: – Existing bone is ‘resorbed’ – New bone is ‘formed’ This process is reliant on two cells: – Osteoclast a cell that is responsible for the break down of bone – Osteoblast a cell that secretes the matrix for bone formation. © Troy Seely, 2024  Bone Remodeling - I Bone precursor cells Differentiate into Phase 1: Activation Osteoclasts Osteoclasts form a ‘cutting cone’ which gradually resorbs bone Phase 2: Resorption leaving a ‘resorption cavity’ behind Osteoblasts lining the walls of the resorption Phase 3: Formation cavity lay down new ‘secondary’ bone © Troy Seely, 2024  Bone Remodeling-II Phase 1: Activation Phase 2: Resorption Phase 3: Formation New secondary bone From: K.L. McCance and S.E. Huether. Pathophysiology: The Biologic Basis for Disease in Adults and Children 4th edition, St. Louis, 2002 © Troy Seely, 2024  Osteoporosis Overview Osteoporosis is a chronic, progressive disease characterized by: – Low bone mass – Impaired bone quality from a deterioration of the micro- architecture of bone tissue Primary osteoporosis ( most common ): Often follows ________ in women and occurs later in life in men. menopause Secondary osteoporosis: Associated with medication, other conditions or diseases © Troy Seely, 2024  Osteoporosis: Epidemiology Osteoporosis is the most common metabolic bone disease, and with the population aging the prevalence of osteoporosis is expected to increase. It is much more common in women, especially postmenopausal women who are estrogen deficient. – Why is estrogen deficiency relevant? Estrogen promotes the activity of osteoblasts, so when estrogen levels drop during menopause, the osteoblasts aren't able to effectively produce bone. It’s suggested that approx. 20 % of people with osteoporosis are male, and a significant proportion of men that are at risk of developing the condition and have the condition are underdiagnosed and undertreated. – Risk of missing this bone disease ? Increased risk of fracture. © Troy Seely, 2024  Osteoporosis: Epidemiology ‘Silent thief’ – Osteoporosis may not be manifested until fracture, spinal deformity or loss of height – Asymptomatic until fracture 80% of all fractures in people 50+ yrs are caused by Over ____ osteoporosis – Fractures from osteoporosis are more common than heart attack, stroke, and breast cancer combined. – At least 1 in 3 women and 1 in 5 men will suffer from an osteoporotic fracture during their lifetime. – Constitutes more than 60% of in-patient rehabilitation admissions. – Overall yearly cost to the Canadian healthcare system of treating osteoporosis and related fractures was over $2.3 billion as of 2010.(4.6 billion as of 2020). © Troy Seely, 2024  Osteoporosis: Etiology Risk factors: – Age = between the ages of 25 and 35 y.o. bone mass peaks, and then bone resorption > bone formation. Significant > 65 years age. – Post-menopausal – Genetics: family history of osteoporosis – Long periods of inactivity or immobilization – Smoking – Medication with side effects that can damage bone or interfere in bone formation – Diet: calcium and vitamin D deficiency © Troy Seely, 2024  Osteoporosis: Pathogenesis It occurs because of an imbalance in the normal bone remodeling process: Bone ‘resorption’ by osteoclasts is favored over bone ‘formation’ by osteoblasts. – This results in a loss of bone mass. © Troy Seely, 2024  Osteoporosis: Pathogenesis Balance Bone formation Bone resorption by osteoblasts by osteoclasts IF decreased IF both IF increased Age-related Bone loss Post-menopausal osteoporosis (type 2) © Troy Seely, 2024 osteoporosis (type 1) Primary Osteoporosis Classification Post-menopausal women (type 1) Age-related: – Elderly men and women (type 2) © Troy Seely, 2024  Post-Menopausal Osteoporosis (Type 1 Osteoporosis) Stimulated by estrogen withdrawal. Most evident in trabecular bone (5-20% of spinal trabecular bone mineral lost yearly) – What is trabecular bone? Also known as spongy bone because it resembles a sponge or honeycomb, it has many open spaces connected by flat planes of bone Thus, often seen spinal fractures in early post- menopause. © Troy Seely, 2024  Vertebral body normal osteoporotic © Troy Seely, 2024  Age-related Osteoporosis (Type 2 Osteoporosis) Age related changes = relative deficiency of: – Dietary calcium – Vitamin D (promotes intestinal absorption of calcium) The capacity of intestine to absorb calcium decreases with age. Kidney removes calcium – Therefore, there is a need to increase calcium to prevent negative calcium balance. © Troy Seely, 2024  Age-related Osteoporosis Dietary increases in calcium or Vit D 3. 1. with supplement Vit D (diet or sunlight) Age-related decrease in kidney function limits Promotes intestinal availability of 1-alpha- 4. absorption of calcium hydroxylase in kidney Calcium & phosphate promote bone calcification 2. 1-alpha-hydroxylase Converts Vit D to its active form © Troy Seely, 2024  Secondary Osteoporosis Less common than Primary Osteoporosis. Examples: – Corticosteroids: Impairs Vitamin D-dependent intestinal absorption. Inhibits osteoblastic activity (formation). – Hyperparathyroidism: Increases parathyroid hormone secretion which increases osteoclasts (resorption). – Immobilization: Increases osteoclastic activity in various age groups, even adolescents. © Troy Seely, 2024  Clinical Presentation “Silent thief” leads to “Silent disease” Pain location? Better/worse? Observation – Dowagers Hump – Increased Kyphosis – Stooped posture with loss of height – Lower ribs settle on iliac crest – Decreased mobility of spine © Troy Seely, 2024  Clinical Presentation WebMD © Troy Seely, 2024  Diagnosis Diagnostic criteria have been established by the World Health Organization based on bone mineral density (BMD) measured by dual-energy xray absorptiometry. – This test involves lying on a table for several minutes while a small x-ray detector scans the spine, one hip, or both. – Patients may be asked to lift legs onto a support to straighten the back for the test. © Troy Seely, 2024  Dual-energy xray Osteoporosis Canada (2014) © Troy Seely, 2024  Dual-energy xray A detector measures the transmission of small amounts of x-rays (light) passing through the bones. – The amount of light that passes through the bone is measured, thus providing a radiologist with a picture that indicates how dense (thick or thin) the bones are. – “ Curtain Analogy ” © Troy Seely, 2024  Dual-energy xray Orthozane.com © Troy Seely, 2024 Diagnostic Criteria for Osteoporosis Classification Dual X-ray absorptiometry result Bone Mineral Density (BMD) Normal BMD within 1 standard deviation (SD) below the mean of young adults Osteopenia BMD between 1 and 2.5 SD below the mean of young adults Osteoporosis BMD more than 2.5 SD below the mean of young adults Severe or established osteoporosis BMD more than 2.5 SD below the mean of young adults plus one or more fragility fractures © Troy Seely, 2024 Diagnostic Criteria for Osteoporosis © Troy Seely, 2024  Osteoporosis to Fractures Fractures occur when ‘applied loads’ exceed capacity of bone. Bone capacity against forces depends upon: – The degree of bone mineralization (quality) – The architecture of bone itself (alignment) As osteoporosis progresses: – Both mineralization & internal architecture deteriorate. – This increases the risk that a given load will cause a fracture © Troy Seely, 2024  Osteoporosis and Fracture Location Typically: spine, hip or wrist (Colle’s fracture) This fracture is referred to as ‘fragility’ fracture: – It is a pathologic fracture (it should not occur). – A fracture resulting from normal activity (a fracture from a fall from standing height or less). – Spinal fracture is a significant sequela of osteoporosis. – Worst complication of osteoporosis is hip fracture. Typically in the elderly especially > 80 yrs Only 44% of people discharged from hospital for a hip fracture return home; of the rest, 10% go to another hospital, 27% go to rehabilitation care, and 17% go to long-term care facilities. © Troy Seely, 2024  Vertebral Fractures: Substantially Increase the Risk of New Fragility Fractures Women with vertebral fractures have a 5-fold increased risk of a new vertebral fracture and a 2-fold increased risk of hip fracture. Melton et al, Osteoporos Int 1999 One woman in five will suffer from another vertebral fracture within a year. Highlights the risk of progression. © Troy Seely, 2024 © Troy Seely, 2024  Hip Fracture From Cooper C and Melton LJ. Epidemiology of osteoporosis. Trends in Endocrinology & Metabolism 1992;3:224. © Troy Seely, 2024 All Hip Fractures are Associated With Morbidity Unable to carry out at least one independent activity of daily living 80% Unable to walk independently Permanent 40% disability 30% Cooper C, Am J Med, 1997;103(2A):12S-17S © Troy Seely, 2024  Intracapsular Subcapital neck fracture Transcervical neck fracture Intertrochanteric fracture Extracapsular Fracture of Fracture of © Troy Seely, 2024 Subtrochanteric fracture greater tubercle lesser tubercle  Prone to complications More potential for nonunion or malunion Intracapsular Possible for avascular necrosis of femoral head Subcapital neck fracture Transcervical neck fracture Intertrochanteric fracture Extracapsular Treatment: Usually reduction & internal fixation Treatment: Could vary from internal fixation to hemi- arthroplasty to total joint replacement © Troy Seely, 2024 Subtrochanteric fracture  Blood supply to the Hip © Troy Seely, 2024  Usual Bone Repair Hematoma formation Within hours of fracture or surgery Procallus (fibrocartilaginous Within days soft callus) formation Hard callus formation Within weeks Callus replacement Many months – up to 4 years in some cases Remodeling © Troy Seely, 2024  Speed of Bone Healing Depends on: – Aging, metabolic and nutritional factors – Comorbidity – Severity of bone disruption Type / amount of bone to be replaced Blood & oxygen supply to site – Effective treatment Promote mobilization Prevention of complications such as infection © Troy Seely, 2024  Bone Healing Complications Delayed union (i.e. bony union takes longer) – Due to ‘inadequate’ blood supply. – Examples: infection with an ‘open’ fracture; poor mobilization Malunion (i.e. bone unites with unacceptable alignment) – due to: Fracture never being reduced Fixation did not hold Non-union (i.e. bony union does not occur) – Due to: Non-treatment of delayed union. Too large a gap Avascular necrosis (i.e. bone dies: deprived of blood supply) – Example: Intracapsular fracture femoral head after surgical fixation © Troy Seely, 2024  Hip Fracture & ‘Frailty’ After a fracture of a hip in an individual with osteoporosis, there is a 6-month mortality rate: ___ 20% – This is related to the development and/or worsening of complications in immobilizing frail persons. © Troy Seely, 2024  What is meant by ‘Frailty’? Frailty in older adults is a condition characterised by a loss or reduction in physiological reserve resulting in increased clinical vulnerability. Characterized by: Weight loss Generally weary Low exercise tolerance & low activity level Slow ambulation (i.e. walking) Possibly impaired cognition or depressed © Troy Seely, 2024  “Geriatric Giants” The so-called “geriatric giants” are the major categories of impairment that appear in elderly people progressing to fraility. These include: Immobility Instability Incontinence Impaired intellect/memory When one or more present there is a large potential to initiate spiral into frailty. © Troy Seely, 2024 Chronic Disease, Age & Frailty Number of Chronic diseases increase with age regardless of gender © Troy Seely, 2024  “Polypharmacy” & Elderly “Polypharmacy” is variable: – 5 or more concurrent regular medications seems to be the most common definition (range can be 2 to 18 meds). Elderly associated with polypharmacy: more comorbidity = more meds Important because: – Initiation of new drug in prior 2 weeks, combined with variety of previously prescribed medications, is associated with increased risk of falling in elderly © Troy Seely, 2024 Osteoporotic Fractures, Frail Elderly & Fall Risk Factors An elderly person (with osteoporosis) is at risk of a fall because of: – Extrinsic factors (e.g. lighting, loose rugs or uneven floor surface, stairways, etc.) Muscle weakness, Impaired vision / balance – Chronic disease burden Comorbidity & polypharmacy and medication – Acute health care event ‘Frail’ elderly & reduced resilience © Troy Seely, 2024  Osteoporosis Summary Most common bone disease Imbalance of bone formation and resorption 2 primary types – Women: after menopause (estrogen withdrawal) – Elderly men and women: decreased Vit D & calcium Osteoporosis plays a role in spine and hip fractures Fall risk most important sequelae – High incidence of falls in elderly – Especially ‘frail’ elderly © Troy Seely, 2024  Framing the RS 3060 Course Our first major goals was to provide a foundational sense of various common rehabilitation conditions. – Anatomy to expected physiology. – Etiology to Epidemiology to Pathophysiology. Our second major goal was to appreciate clinical presentation and influence on a patient’s life. – Reported symptoms, observation, clinical testing, expected functional impacts. – Exercises in clinical reasoning in case studies. © Troy Seely, 2024  RA 20 - 50 yrs Health Conditions & Life Cycle Approach to Disability birth Stroke x2/decade after 55 CP SCI > 50% 16-30 yrs old CF widespread: adults > 65 yrs OA TBI 15-24 yrs at injury PD increases/decade after 60 80% fractures > 50 yrs Osteoporosis Multiple Sclerosis Restrictive Lung Disease 15-40 yrs adults > 55 yrs © Troy Seely, 2024 Asthma COPD  Ignorance is bliss…. Rehabilitation professionals respond to clients in categories of client need: Different needs mean Nature of Client Need different providers, sometimes in different settings (CF vs OA vs RA) Severity of Need Different severity means different settings (TBI-acute/chronic vs fracture acute/frailty rehab) Length of Time service is needed Different conditions require rehab service for differing time periods (Acute asthma attack vs COPD) © Troy Seely, 2024  Learning about In going forwardhealth conditions… Good luck on your exams! Have a good holiday break! Good luck on your journey! Finally, Thank You! © Troy Seely, 2024