Osteoporosis and Sarcopenia PDF

Osteoporosi s Prepared by: Marwa Eleawa Lecturer of Physical Therapy, BSU  Definition; “progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture” *Osteopo...

Osteoporosi s Prepared by: Marwa Eleawa Lecturer of Physical Therapy, BSU  Definition; “progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture” *Osteoporosis causes bones to become weak and brittle — so brittle that a fall or mild stresses such as bending over or coughing can cause a break. Osteoporosis-related breaks most commonly occur in the hip, wrist or spine. *It is a severe, chronic, progressive and clinically silent disease and the most common of the metabolic bone diseases  *Among metabolic bone diseases known to date, osteoporosis is not only the most frequent but is also a major global public health problem due to its high morbidity, which is caused by osteoporotic fractures in the older population. This process occurs in people of both sexes and the different types of osteoporosis, and it is also known to affect both pediatric and young patients, either primary or secondary to systemic diseases or medical treatments *Osteoporosis affects men and women of all races. But white and Asian women, especially older women who are past menopause, are at highest risk. *In addition, osteoporosis has been reported to occur when there is an imbalance in bone cell function. This disease has been called “the silent epidemic of the 21st century” Types of osteoporosis Within osteoporosis, several types can be classified into two large groups: primary and secondary osteoporosis. 1-Primary osteoporosis includes idiopathic osteoporosis occurring in children and young adults, with an unknown etiopathogenesis, and involutional osteoporosis affects both men and women and is more related to ageing. Likewise, involutional osteoporosis is divided into type I or postmenopausal osteoporosis, which mainly affects women between 51 and 75 years of age and is characterized by rapid bone loss. Type II or senile osteoporosis occurs in persons over 75 years of age and is characterized by a loss of trabecular and cortical bone that results from ageing. 2-Secondary osteoporosis accounts for less than 5% of all cases of osteoporosis and is a consequence of a disease or the use of medications. Among all of them, the most frequent kind of osteoporosis is postmenopausal osteoporosis, which is linked to two conditions: menopause and ageing  Symptoms There typically are no symptoms in the early stages of bone loss. But once the bones have been weakened by osteoporosis, these might have signs and symptoms that include: 1-Back pain, caused by a broken or collapsed bone in the spine. 2-Loss of height over time. 3- hyperkyphosis causes cervical pain as the patient tries to keep the head upright through cervical hyperextension 4- A bone that breaks much more easily than expected. A loss of height, as vertebral fractures and hyperkyphosis can result in a decrease in height of about 10–20 cm, approximately  Risk factors a-Unchangeable risks Some risk factors for osteoporosis are out of your control, including: -Sex. Women are much more likely to develop osteoporosis than are men. -Age. The older age, the greater the risk of osteoporosis. -Race. white or of Asian descent at great risk of osteoporosis. -Family history. Having a family history of osteoporosis increases the risk of osteoporosis, -Body frame size. Men and women who have small body frames tend to have a higher risk because they might have less bone mass to draw from as they age.  5-Medical problems The risk of osteoporosis is higher in people who have certain medical problems, including: -Diabetes mellitus (both type I and type II) is associated with an increase in the risk of hip and non-vertebral fracture. In type II diabetes, a longer duration of disease and insulin use is associated with an increased risk; (evidence level Ia), which is partly independent of BMD -Celiac disease. -Inflammatory bowel disease. -Kidney or liver disease. -Cancer. -Rheumatoid arthritis.  6-Lifestyle choices Some bad habits can increase your risk of osteoporosis. Examples include: a-Sedentary lifestyle. People who spend a lot of time sitting have a higher risk of osteoporosis than those who are more active. b-Alcohol intake shows a dose- dependent relationship with fracture risk. Where alcohol intake is on average two units or less daily, no increase in risk has been identified. Intakes of 3 or more units daily are associated with a dose-dependent increase in fracture risk c-Tobacco use. The exact role tobacco plays in osteoporosis isn't clear, but it has been shown that  Assessment: 1-Measurement of bone mineral density The risk of fracture increases progressively with decreasing bone mineral density (BMD). the reference technology for the measurement of BMD is dual-energy X-ray absorptiometry (DXA). Osteoporosis can be diagnosed based on the BMD T- score measured at the total hip, femoral neck, or lumbar spine. bone mineral density (BMD) T-Score of ≤ − 2.5. 2-Vertebral fracture assessment Most vertebral fractures do not currently come to medical attention and thus remain undiagnosed. Moderate or severe vertebral fractures, even when asymptomatic, are strong risk factors for subsequent fracture at the spine and other skeletal sites. Vertebral fracture assessment (VFA) should therefore be considered in high-risk individuals, using either lateral lumbar and thoracic spine radiographs or lateral spine.  Pharmacological treatment *Offer oral bisphosphonates (alendronate) or intravenous zoledronate as the most cost- effective interventions. Alternative options include hormone replacement therapy. * Calcitriol (1,25-dihydroxy vitamin D3) is the active form of vitamin D and is approved for the treatment of established postmenopausal osteoporosis in an oral dose of 0.25 µg twice daily. * The Scientific Advisory Committee on Nutrition (SACN) recommends a reference nutrient intake (RNI) of 400 IU daily of vitamin D for adults of all ages, in the context of osteoporosis higher levels, specifically 800 up to 2,000 IU daily may be appropriate  Non-pharmacological management of osteoporosis Recommendations Postmenopausal women, and men aged≥ 50 years, with osteoporosis or who are at risk of fragility fracture is recommended the following 1. A healthy, nutrient-rich balanced diet (strong recommendation). 2. An adequate intake of calcium (minimum 700 mg daily) is preferably achieved through dietary intake or otherwise by supplementation (strong recommendation). 3. To consume vitamin D from foods be prescribed vitamin D supplements of at least 800 IU/day if they have identified vitamin D insufficiency or risk factors for vitamin D insufficiency. Those who are either housebound or living in residential or nursing care are more likely to require calcium and vitamin D supplementation to achieve recommended levels of intake (strong recommendation).  4. A combination of regular weight- bearing and muscle-strengthening exercises, tailored according to the individual patient’s needs and ability (strong recommendation). 5. Advice about smoking cessation if an individual is a smoker (strong recommendation). 6. Advice to restrict alcohol intake to ≤ 2 units/day (strong recommendation). 7. A fall assessment should be undertaken in all patients with osteoporosis and fragility fractures; those at risk should be offered exercise programmes to improve balance and/or that contain a combined exercise protocol (strong recommendation).  Dietary modification A meta-analysis of observational studies examining different dietary patterns found a modest reduction in risk of low BMD and of hip fractures in subjects adhering to ‘healthy’ (high in fruit and vegetables, fish, poultry and whole grains) diets and a reduction in risk of low BMD in those with ‘milk/dairy’ diets. By contrast, those with a ‘meat/Western’ dietary pattern (high in processed and red meat, animal fat, refined sugar, and soft drinks) saw a modest increase in the risk of low BMD and hip fractures.  A randomized controlled trial of a ‘healthy diet’ consumed for 30 days, specifically a calcium-rich diet that emphasizes fruits, vegetables and low-fat dairy products (Dietary Approaches to Stop Hypertension (DASH)), resulted in a reduction in bone turnover. Protein is an important constituent of bone and muscle tissue, and good dietary intake is necessary to maintain the health of the musculoskeletal system. Protein intakes higher than the recommended daily allowance (RDA) of 0.75 g/kg body weight/day are associated with higher BMD at the neck of the femur and total hip in one RCT and observational studies, have been associated with a reduced risk of hip fractures.  Exercise to improve or maintain bone density Exercise has beneficial effects on BMD (evidence level Ia); however, clear evidence for a reduction in fracture risk is needed. The effect of exercise on different skeletal sites varies. Combination exercise programs, which include weight-bearing and resistance- strengthening exercises, are effective at reducing bone loss in the femoral neck and lumbar spine in post-menopausal women. Similarly, upper body resistance exercise increases forearm bone mass; (evidence level Ia). A meta-analysis of the effects of exercise interventions on BMD in men found only three studies and identified a significant but moderate improvement in BMD at the femoral neck and a trend towards increased  In people with osteoporosis, repetitive forced spinal forward flexion exercises should be undertaken with care as this specific movement may be associated with an increased risk of new vertebral fractures Combined exercise protocols may include resistance training, balance challenging, and aerobic exercise Interventions of 3 h per week or more are the most effective Home safety interventions (best delivered by an occupational therapist) have been shown to reduce the risk of falls Lifestyle measures Other measures to improve bone health include optimisation of body mass index if under or overweight, stopping smoking and reducing alcohol intake. Smoking cessation has been demonstrated to reduce the risk of vertebral and hip fractures in women  *Sarcopenia is a geriatric syndrome characterised by progressive and generalized loss of skeletal muscle mass plus muscle strength or physical performance. *Sarcopenia affects your musculoskeletal system and is a major factor in increased frailty, falls and fractures. These conditions can lead to hospitalizations and surgeries, which increase the risk of complications including death. *Sarcopenia was derived from the Greek phrase meaning poverty of the flesh and was first described by Rosenberg in 1989 *The rates of the condition range from 5% to 13% in people ages 60 and older. The estimates increase to 11% to 50% in people ages 80 and older. PATHOPHYSIOLOGY *Aging disturbs the skeletal muscle homeostasis resulting in an imbalance between anabolic and catabolic processes on the protein production pathway. Cellular changes in sarcopenic muscles are characterized by size and number declines in type II muscle fibres together with intramuscular and intermuscular fat infiltration. In addition, there is a decreased number of satellite cells. *Other factors that contribute to muscle loss include neuromuscular junction dysfunction, decreased numbers of motor units, inflammation, insulin resistance, mitochondrial dysfunctions, and oxidative stress. * Denervation of single muscle fibres is also known to cause a substantial reduction in type II fibres, which are subsequently replaced by type I fibres and fat tissue.  Diagnosis of Sarcopenia Diagnosis of sarcopenia is based on a proper definition. In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) proposed three diagnostic criteria for sarcopenia, based on muscle mass, muscle strength, and physical performance. Low muscle mass (LMM) is defined by an SMM index of less than 8.90 kg/m2, low muscle strength (LMS) by hand-grip strength below 30 kg in men and 20 kg in women, and low physical performance (LPP) by gait speeds of less than 0.8 m/s. Sarcopenia diagnosis confirmation requires the presence of LMM and LMS or LPP. -In 2018, the EWGSOP revised their tools and regarded LMS as the primary parameter for sarcopenia diagnosis and muscle strength is currently considered as the most reliable measure of muscle function. - Sarcopenia is probable when LMS is detected; a sarcopenia diagnosis is confirmed by the presence of low muscle quantity or quality. - Sarcopenia is considered severe when there is LMS, low muscle quantity or quality, and LPP. - In clinical practice, case-finding is warranted when a patient shows the symptoms or signs of sarcopenia (i.e., falling, feeling weak, walking slowly, difficulties rising from a chair, or weight loss or muscle wasting). In such cases, to confirm the diagnosis *The Short Physical Performance Battery (SPPB) is an objective measurement instrument of balance, lower extremity strength, and functional capacity in older adults (>65 years of age]. *The test includes three domains (walking, sit-to-stand and balance) to assess functional mobility. Equipment Pencil Stopwatch Instruction tool (paper or mobile app) Ruler Chair https://youtu.be/N_rJOGhQqZ4  Method of Use The test is easy to administer and takes approximately 10 mins. The SPPB includes three subtests. 1. Chair Stand Test Single chair stand: The participant is asked to perform a single sit-to-stand movement as quickly as possible. The time is recorded. Scoring: Participant stood without using arms: Go to Repeated Chair Stand Test Participant used arms to stand: End test; score as 0 points Test not completed: End test; score as 0 Repeated chair stand: The participant is asked to perform 5 sit-to-stand movement as quickly as possible. The time is recorded. Scoring: Participant unable to complete 5 chair stands or completes stands in >60 sec: 0 points If chair stand time is 16.70 sec or more: 1 point If chair stand time is 13.70 to 16.69 sec: 2 points If chair stand time is 11.20 to 13.69 sec: 3 points If chair stand time is 11.19 sec or less: 4 points 3. Gait speed test The test measures gait speed. The participant walks to the line on the floor (3 or 4 meters) at a normal pace. The time is recorded. Scoring: For 4-Meter Walk: If time is more than 8.70 sec: 1 point If time is 6.21 to 8.70 sec: 2 points If time is 4.82 to 6.20 sec: 3 points If time is less than 4.82 sec: 4 points For 3-Meter Walk: If time is more than 6.52 sec: 1 point If time is 4.66 to 6.52 sec: 2 points If time is 3.62 to 4.65 sec: 3 points If time is less than 3.62 sec: 4 points  Management of sarcopenia Non-pharmacological sarcopenia management approaches include resistance exercise and proper nutrition. Although the efficacy of nutritional intervention without exercise is sarcopenia management is unclear, some evidence shows the benefits of some dietary patterns such as adequate intake of protein, vitamin D, antioxidant nutrients, and long-chain polyunsaturated fatty acid. Resistance exercise has been demonstrated as the main no-pharmacological sarcopenia management with significant positive evidence. Exercise interventions, especially those based on resistance training, may have a role in improving muscle mass and strength, and physical performance. Moreover, resistance exercise is the most effective and affordable sarcopenia progression at least 3 months or more may be needed to obtain significant improvement in the relevant clinical parameters. Further, the impact of resistance exercise on SMM may be augmented by nutritional intervention. Leucine-enriched protein supplementation or whey protein is effective in increasing muscle mass and to a lesser extent, muscle function. While vitamin D supplementation increases muscle strength but has no effect on muscle mass, a combination of protein and vitamin D can improve functions such as stair climbing, in addition to building muscle mass. Currently, there is no specific drugs have been approved by the Food and Drug Administration for the treatment of sarcopenia.