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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
matrix
mineral
matrix
mineral
matrix
mineral
matrix
mineral
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