Osteoporosis 03.04.2013

OSTEOPOROSIS

Gülseren AKYÜZ, M.D., Prof.Marmara University School of Medicine

Department of Physical Medicine and Rehabilitation

What is osteoporosis?

Description of Osteoporosis

• A progressive systemic skeletal disease characterized by compromised bone strength predisposing to an increased risk of fracture

• Bone strenght :– Bone density – Bone quality

NIH Consensus Development Panel of Osteoporosis JAMA 285 :785 95,2001

The New Concept: Osteoporomalacia

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Osteomalacia Osteoporosis / malacia

OsteoporosisNormal

Classification of OP - IGENERALIZED• OP unassosiated with other disease (Primary OP)

– Juvenile idiopathic – Postmenopausal– Senile

• OP associated with other diseases (Secondary OP) – Metabolic

• Diabetes– Endocrine

• Cushing’s syndrome/corticosteroid therapy• Hyperthyroidism• Hyperparathyroidism• Hypogonadism• Pregnancy• Anorexia nervosa

Classification of OP - II• Systemic diseases

– Chronic airways obstruction– Rheumatoid arthritis

• Environmental– Calcium deficiency– Alcoholism– Drugs– Mastocytosis

• Functional – Long term immobilization– Exercise-induced amenorrhoea

• Genetic– Osteogenesis imperfecta– Menkes’ syndrome– Ehlers-Danlos syndrome– Homocystinuria– Marfan’s syndrome

Classification of OP - III

REGIONAL

• Complex regional pain syndrome = CRPS

• Immobilization / disuse

• Transient regional osteoporosis

• Regional migratory osteoporosis

Type I (postmenopausal) OP

• Women within 15-20 years after the menopause

• Predominantly trabecular bone loss• Vertebral body and distal radius• Estrogen deficiency and other factors

Type II (senile) OP

• Both men and women over age 70• Proportionate loss of cortical and

trabecular bone• Hip and vertebral fractures• Factors related to aging

– Impaired osteoblastic function– Impairment of renal 1-alpha-hydroxylase

activity

TYPE IPostmenopaus

al

TYPE IISenile

Age (years) 50-70 >70

Sex ratio (F:M)

6:2 2:1

Types of bone loss

Mainly trabecular

Trabecular and cortical

Fracture sites

Vertebrae and/or distal

radius

Proximal femur

Main causes Menopause Aging

Pathogenesis of OP - I

• Peak bone mass• The rate of bone turnover • Menopause age (early menopause)• Microarchitectural deterioration of bone

tissue• Repair disorders of bone

Pathogenesis of OP - II

A- The factors affecting peak bone mass

• Genetic– Vitamine D receptor gene– Procollagen type I gene– The receptors of estrogen

• Hormonal and nutritional factors• Environmental factors

B- The factors affecting the rate of bone turnover• The differences between trabecular and cortical bone structure• The differences between men and women

Signs and Symptoms of OP - I

• The cardinal symptom of OP is “fracture”• Vertebral fractures present with acute back pain after

sudden bending, lifting or coughing• It is associated with progressive kyphosis• Vertebral fracture can be painless -asymptomatic- and

incidentally discovered in the X-Rays• Fractures of the distal forearm and proximal femur usually

follow falls• Rib fractures can be seen

• back pain• loss of height• increased kyphosis• immobility• increased number of bed days• loss of self-esteem• distorted body image • depression

Signs and Symptoms of OP - II

• Reduced pulmonary function• Bone tenderness• Extreme fatigue• Brittle or soft fingernails• Premature grey hair• Leg cramps at nights

Signs and Symptoms of OP - III

20 years50 years

77 years

Risk Factors for OsteoporosisWith Relative Risk ≥ 2(Major)• Age > 70• Menopause < 45• Hypogonadism• Fragility fracture• Hip fracture in parents• Glucocorticoids• Malabsorption• High bone turnover• Anorexia Nervosa• Body mass index =BMI <

18 (the weight in kilograms divided by the square of the

height in meters) • Immobilization• Chronic renal failure• Transplantation• Osteopenia in X-Ray

• Estrogen deficiency• Calcium intake < 500 mg/d• Rheumatoid arthritis• Bechterew disease• Anticonvulsivants• Hyperthyroidism• Smoking• Diabetes mellitus• Primary hyperparathyroidism• Excess alcohol and cafein intake

With Relative Risk 1 - 2(Moderate)

Brown J P,Jose RG. Clinical Practice Guidelines For The Diagnosis and Management of Osteoporosis. November 2003

Other Risk Factors

• Muscle weakness• Balance problems (Neurologic, vestibular,

ophthalmologic problems)• Visual deficiency• Slow walking• Worsened heel-finger walking

(arthrodesis, etc.)

HOW TO DIAGNOSE ?

– Serum calcium (Total and ionized Ca)– Serum phosphate– Alcaline phosphatase– 25 Hydroxia Vitamine D (Vitamine D3)– Parathormone– Calcium excretion in the urine– Bone resorption and formation markers

Laboratory Investigations

Ca PO4 ALP 25(OH) D PTH Ca PO4 HP

BLOOD URINE

Type 1 OP N N N N N N

Type 2 OP N N N N N N N N

Osteomalacia N N N N

Metastatic dise. N N N N N N N

Differential Diagnosis

Bone Markers

Blood BloodBlood

Bone Formation Bone Resorption

UrineUrine UrineUrine

Tartrate-resistant acid phosphatase

Gamma carboxy glutamic acid

Total alkalen phosphataseBone spesific alcalenephosphatase (BALP)OsteocalcineProcollagen type IProcollagen type II

Calcium/CreatinineDeoxypyridynolynPyridynolynHydroxylysine and glycosidesN-telopeptide (NTX), C-telopeptide(CTX)

None

X - Ray

• Absolutely required

• Even if bone mineral density informs us about

bone content, it does not show the fracture or it

can reveal the bone better than it is, because of

degenerative changes

Semiquantitative assessment of vertebral fractures

Genant et al. J Bone Mineral Res 1993: 8; 1137-48

SQ stage

0 normal

1 mild

2 moderate

3 severe

Genant et al. J Bone Mineral Res 1993: 8; 1137-48

BONE MINERAL DENSITY MEASUREMENT

When to do ?

From whom to request ?

World Health Organization’s Classificaiton

Kanis JA et al, J Bone Miner Res, 1994;9:1137-1141

T-ScoreNormal - 1 and above

Low Bone Density between -1 and -2.5

Osteoporosis < - 2.5

Established Osteoporosis

< - 2.5 and 1 or more fracture

• Over 65 year-old women without any risk factors

• Below 65 year-old postmenopausal women with one or more risk factors

• Postmenopausal women with fracture history

• Long term steroid use

• Primary hyperparathyroisim

• Treatment monitoring

Indications of BMD measurements

• Useful method in patient follow up• Low radiaton dose (2-4 mRem)• High precision and accuracy • Short time for assessment • Peripheral measurement is available

Advantages of DEXA

• No differentiation between cortical and trabecular bone tissues

• Degenerative changes effet the results negatively

• Obesity is a serious problem !

• Expensive

• Reference values change from country to country

• No standardization in the different devices

Disadvantages of DEXA

Bone Biopsy

Normal Bone Osteoporotic Bone

– It is usually preferrred from the iliac crest

– Invasive but definite diagnostic tool

– It must be done in certain conditions such as renal osteodystrophy and osteomalacia

Can osteoporosis be cured ?

Yes !

Management of OP - I

• The therapeutic approach to OP is a complex• It means not only taking some medicine but also

– changing a life style– leaving some harmful habituations (e.g. smoking,

alcohol), and – increasing physical activity and exercise

Management of OP- II

• Early diagnosis is the best to preserve bone mass• Medical treatment can slow bone loss and

decrease the risk of fracture• A rehabilitation program designed to reduce pain,

increase mobility, and minimize risk of falling is necessary

Antiresorptive agents

Stimulant agents

Complex agents

HRT, ERTBiphosphonates (ETD, ALN, RSD, IBN, ZLD)SERM (Raloxifen, Basedoxifen, Lasodoxifen, Arzoxifen)Calcium, Magnesium

Parathormon (PTH)Floride

Active vitamin D metabolitesAnabolic steroids

NEW AGENTS NEW AGENTS NEW AGENTS

Steroid analogs Ipryflavone TiboloneAnticytokines OsteoprotegerineDisintegrinsProton pump inhibitorsProstoglandin synthetase inhibitors

Growth hormonGrowth factorsStatinsTranscription factorsCalcium receptor sensibilizating medicines

Experimental agentsVitamin KVitaim CNitric oxideTrace elementls Cupper Manganese Zinc SiliconeThyazide diuretics

Osteoporosis Rehabilitation

• Treatment of pain• Physical restoration• Diet, medical treatment, exercises • Correcting the disability • Education of the patient and his/her family• Prevention of falls

Who falls and how?

• People at the age of 50s walk fast

and they cast forward themselves

and lean on their hands over the

floor while they are falling

• That is why it is easy for them to

have wrist fractures

• Advanced in years they walk

more slowly and they fall over

their hips

Reasons for increase in the risk of falling

• Diminished hearing and vision

• Muscle weakness• Posture and balance disorder• Excess alcohol intake• Hypertension• Diabetes mellitus• Parkinson’s disease

How to prevent falls ?

• Appropriate clothes and shoes

• Regularly ophthalmologic examination

• Use of supportive devices• Walking on a smooth way

• Moving slowly and safely

Helpers

Effects of exercises

• Execises increases bone mass

• Exercises prevent falls by increasing the muscle strength, endurance, balance, and coordination

• Exercises provide good posture

Types of Exercises

There are 5 types of exercises recommended for osteoporosis:

• Stretching exercises• Aerobic exercises performed by body mass • Strengthening exercises• Exercises with high power• Balance exercises

Stretching Exercises

Stretching Exercises

Aerobic exercises performed by body mass

Aerobic Exercises

Strengthening exercises

Strengthening exercises

Exercises with high power

Balance and Coordination Exercises

Recommended Sportive Activities

• Walking with tempo • Tennis • Golf • Skiing• Dancing• Swimming ?

Swimming is better than nothing !

Not Recommended Sportive Activities

• Horsing• Canoe• Windsurf• Soccer• Cycling ?

Thank you