Osteoporosis, Osteoarthritis, and Rheumatoid Arthritis

1. Osteoporosis, Osteoarthritis, and Rheumatoid Arthritis

2. Osteoporosis • “Osteo” is Latin for bone and “Porosis” means porous or full of holes • Osteoporosis occurs when the holes between bone become bigger, making it fragile and liable to break easily • Characterized by low bone mass and deterioration of bone structure • Osteopenia is low bone density, but not low enough to be considered osteoporosis • Osteoporosis is NOT a natural part of aging • All races, sexes, and ages are susceptible • Osteoporosis is preventable and treatable!

3. Osteoporosis • The bones in our skeleton are made of a thick outer shell (compact bone) and a strong inner mesh filled with collagen (protein), calcium salts and other minerals • The inside (spongy bone) looks like honeycomb, with blood vessels and bone marrow in the spaces between bone. Healthy Bone Osteoporosis Bone

4. Osteoporosis • Results from an unhealthy imbalance between two normal activities of bone: bone resorption and bone formation. • These activities rely on two major types of cells: osteoclasts for bone resorption and osteoblasts for bone formation • The combined processes of bone resorption and bone formation allow the healthy skeleton to be maintained continually by the removal of old bone and its replacement with new bone. • These combined processes are referred to as bone remodeling or bone turnover. During the first 20-25 years of life, these processes are balanced

5. Osteoporosis • Following a period of balanced bone resorption and bone formation, the destruction of bone begins to exceed the formation of bone; this imbalance leads to a net loss of bone, and the beginnings of osteoporosis. • The risk of fracture increases from 1.5 to 3-fold for every 10% decrease in bone mass • Bone mineral density (BMD), a measure of bone mass divided by bone area, increases with age until peak bone density is achieved. • Bone mineral density is correlated highly with bone strength and is therefore used to quantitatively screen and diagnose

6. Osteoporosis • Normal bone density is within 1 SD (standard deviation) of the young adult mean • Osteopenic bone density is between -1 and -2.5 SD below the young adult mean • Osteoporotic bone density is > -2.5 SD below the young adult mean

7. Osteoporosis • Diminished bone mass can result from: • Failure to reach optimal peak bone mass between ages 25 and 35 • Increased bone resorption • Decreased bone formation after peak bone mass has been achieved • All three of these factors play a role in older adults • Low bone mass, rapid bone loss, and increased fracture risk correlate with high rates of bone turnover

8. Osteoporosis • Termed a silent disease because, until a fracture occurs, symptoms are absent • Chief clinical manifestations are vertebral and hip fractures • At age 50, a woman has a 50% chance of an osteoporosis related fracture during her life • Hip fractures are associated with a high incidence of deep vein thrombosis and pulmonary embolism (20 to 50%) and 20% increased risk of death during the first year following a hip fracture

9. Men and Osteoporosis • Lifetime risk of getting osteoporosis is the same as a man’s lifetime risk for prostate cancer • Nationally, one in eight men over 50 will get osteoporosis • By age 75, one in three men will get osteoporosis

10. Osteoporosis: Risk Factors You Cannot Change • Female Gender • Women have lower peak bone mass • Men have 30% more bone mass than women, and they lose bone more slowly as they age • Women generally have lighter, thinner bones than men do • The rapid decline in estrogen at menopause is associated with an increase in bone resorption without a corresponding increase in bone formation • Women may also lose bone during the reproductive years, particularly with prolonged lactation • Another reason for female predominance is that women live longer than men

12. Osteoporosis: Risk Factors You Cannot Change • Family History • A mother, grandmother, or sister with a diagnosis of osteoporosis or its symptoms (dowager's hump) increases your risk • Dowager’s Hump: kyphosis with lordosis • The hump is caused by spine fractures • Along with the curve in the spine comes an outward curve of the stomach • The intestines have nowhere to except forward

13. Osteoporosis: Risk Factors You Cannot Change • Accelerates after menopause. Estrogen is the hormone that protects against bone loss. • Premature Menopause (<45 years) • Prolonged time (>1 year) without a menstrual period • Ethnicity • Caucasian and Asian women are at highest risk • Small Body Frame and Thin

14. Osteoporosis: Risk Factors You Can Change • Cigarette Smoking: • Women who smoke have lower levels of estrogen compared to nonsmokers and frequently go through menopause earlier. • Smokers also may absorb less calcium from their diets.    • Excessive Use of Alcohol:  • Regular consumption of 2 to 3 ounces a day of alcohol may be damaging to the skeleton, even in young women and men. • Those who drink heavily are more prone to bone loss and fractures, both because of poor nutrition as well as increased risk of falling

15. Osteoporosis: Risk Factors You Can Change • Low body weight • Sedentary lifestyle • Low muscle mass • Low estrogen level (menopause) • Estrogen replacement therapy • Low testosterone level in men    • Poor nutrition • Diet low in calcium and vitamin D • Limit caffeine and Cola 

16. Conditions Associated with Osteoporosis • Anorexia Nervosa • Malabsorption Syndromes (Irritable Bowel Syndrome) • Excessive secretion of parathyroid or thyroid hormone • Chronic renal or liver disease • Excessive secretion of cortisol (Cushing's syndrome) • Previous fracture not caused by a major accident • Cancer

17. Classifications of Osteoporosis • Type I and Type II • Type I • Menopausal osteoporosis • Occurs mainly in women aged 51 to 75 • Associated with vertebral and wrist fractures • Type II • Older adult osteoporosis • Occurs in persons > 60, is two times more common in women, and is associated with vertebral and hip fractures. • Overlap occurs between types I and II

18. Diagnosis of Osteoporosis • Without a fracture or bone density screening there is no way to diagnose the presence of osteoporosis • The most commonly used method to diagnose osteoporosis is to measure bone mineral density using dual energy X-ray absorbitometry (DEXA scans) • Density is usually measured in the spine, hip, wrist, or total body • The procedure is noninvasive • This is the most popular and accurate test to date and the test only takes about 20 to 40 minutes

19. DEXA-Bone Density Testing

20. Osteoporosis-Prevention and Treatment • Weight-bearing exercise and optimal nutrition in childhood and adolescence is the best defense • It increases the likelihood that they will attain the maximal genetically determined peak bone mass • Studies performed in postmenopausal women indicate that weight-bearing exercise prevents bone loss but does not appear to result in substantial bone gain • A large body of data indicates that optimal calcium intake and Vitamin D reduces bone loss and suppresses bone turnover

21. Osteoporosis-Prevention and Treatment • Bisphosphonates- Fosamax and Boniva are antiresorptive drugs that directly inhibit osteoclast activity • They increase bone mass and decrease the risk of fractures • Estrogen replacement therapy (ERT) may prevent menopausal bone loss in women • Calcitonin is a drug used to treat osteoporosis in postmenopausal women

22. Osteoporosis Exercise Guidelines • Weight-bearing exercise is recommended to prevent bone loss • Working against gravity • For clients with severe osteoporosis, exercises should be in water to reduce the risk of fractures; if it is not feasible, use weight supported exercise like cycling

23. Osteoporosis and Posture • Upper Cross Syndrome • Forward head and rounded shoulders • Lower Cross Syndrome • Anterior Pelvic Tilt • Low back and neck pain • Strengthen the weak muscles and stretch the tight muscles • Perform Chin Tucks

24. Osteoporosis Exercise Guidelines • Balance Training • Prevent Falls • Prevent Fractures • Easy to retrain balance • Standing on one foot with eyes open and eyes closed • Standing on a BOSU • Single-Leg Squat • 5 minutes of balance training daily can significantly reduce risk of falls

25. Osteoporosis Exercise Guidelines • Aerobic Endurance Training • Walking, Stair Climbing, Jogging • Frequency • 2-5 days per week • Intensity • 40-80% of VO2 • Duration • 30-60 minutes • Resistance Training • Squat, Step-Up’s, DB Chest Press, Cable Row… • 1-3 Sets • 8-20 Reps • Up to 85% Intensity • 2-3 days per week

26. Osteoporosis Exercise Precautions • Excessive compressive stresses must not be put on weakened bones • Avoid high-impact exercises-plyometrics • Avoid activities where there is a high risk of falling • Avoid movements with a lot of flexion & rotationof the trunk • Avoid excessive spinal loading-leg press • Progression should be slow, well monitored • Focus on exercises for the hips, thighs, back, and arms • Flexibility should be limited to static and active stretching

27. Osteoarthritis • Osteoarthritis (OA), also known as degenerative joint disease, is the most common form of arthritis • Characterized by progressive destruction of the articular cartilage • Referred to as the “wear and tear” of joints • Cartilage wears off the end of the bone and then it hurts with every step • Causes pain, stiffness, deformity and loss of function • Most commonly seen in the hips, knees, spine, and hands

29. Osteoarthritis Risk Factors • Individuals who are Overweight or Obese • Knee and hip joints are particularly vulnerable • Weight-reduction is likely to cause reduction in OA symptoms • Age • Rare in young, common in middle–aged and older adults. • 1/3 of people older than 65 years have radiographic evidence of osteoarthritis in the knee • Family History • Joint Injuries • Occupation (professional athletes)

30. Signs and Symptoms of Osteoarthritis • Swelling, pain, tenderness, and stiffness in a joint that worsens with activity and is relieved by rest • Discomfort in a joint before or during a change in weather • Bony lumps on the middle or end joints of the fingers or the base of the thumb • Loss of joint flexibility • Restricted joint movement • Creaking or cracking of joints and bones (crepitus)

31. Diagnosing Osteoarthritis • No single test can diagnose osteoarthritis • Most doctors use a combination of the following methods to diagnose the disease and rule out other conditions: • Medical History • Physical Examination • X-ray

32. Osteoarthritis Prevention and Treatment • Reducing or modifying activities that cause pain or repetitive joint trauma • Exercise • Nutrition • Weight loss • Rest and Joint Care • Drugs • Surgery

33. Dr. Andrew Weil on Diet and Osteoarthritis • Dr. Weil, is the director of the University of Arizona's Integrated Medicine program • Decrease protein toward 10 percent of daily caloric intake • Replace animal protein as much as possible with plant protein • Eliminate milk and milk products, substituting other calcium sources • Use extra-virgin olive oil as your main fat • Increase intake of omega-3 fatty acids • Eat ginger and turmeric regularly, both of which are natural anti-inflammatories

34. Glucosamine and Chondroitin • Glucosamine is found in high concentrations in joints. It is believed to stimulate the formation of cartilage that is essential for joint repair • Chondroitin sulfate found is found in cartilage. It draws fluid into the tissue, giving the cartilage resistance and elasticity. • According to the Arthritis Foundation: “Chondroitin and glucosamine supplements appear to be more effective in patients with osteoarthritis than in people with inflammatory diseases such as rheumatoid arthritis.”

35. Glucosamine and Chondroitin • A few studies show 1200 mg of chondroitin a day = same level of pain relief as ibuprofen • Currently no research shows whether greater relief occurs when both glucosamine and chondroitin are taken together • “Trials of glucosamine and chondroitin for OA symptoms demonstrate moderate to large effects, but quality issues and likely publication bias suggest that these are exaggerated. Nevertheless, some degree of efficacy appears probable for these preparations.” • McAlindon et al. JAMA 2000;283:1469-1

36. Osteoarthritis and Surgery • Helps relieve the pain and disability of OA • Surgery may be performed to: • Remove loose pieces of bone and cartilage from the joint if they are causing mechanical symptoms of buckling or locking • Resurface (smooth out) bones • Reposition bones • Replace joints

37. Osteoarthritis and Exercise • Vital to improvement of symptoms • Lubricates joints • Stimulates nerve endings other than nerve pain endings • Types of exercises • Range Of Motion Exercises to increase joint movement and flexibility

38. Osteoarthritis and Exercise • Exercises To Increase Muscle Strength and Endurance • Strong muscles maintain good bone position • Critical in carrying out everyday activities • MODERATION • Joint exercised too much->OA aggravated • Joint exercised too little->motion becomes limited, joints become stiff and more painful

39. Osteoarthritis Exercise Guidelines • Aerobic Endurance Training • Walking, Cycling, Rowing, Swimming • Frequency: 3-5 days per week • Intensity: 60-80% of maximal heart rate • Duration: 30 minutes • Resistance Training • 1-3 sets • 10-12 repetitions • Intensity as Tolerable • 2-3 days per week

40. Osteoarthritis Exercise Precautions • Closely supervise and monitor sessions • Avoid exercise during acute arthritic flare-ups (redness, pain, swelling, and tenderness) • Resistance training is recommended as tolerable • Avoid heavy lifting and high repetitions • Stay in pain free ranges of motion • Perform multi-joint exercises to distribute joint stress-closed chain exercises

41. Rheumatoid Arthritis • Rheumatoid arthritis (RA) is among the most debilitating forms of arthritis, causing joints to ache and throb and eventually become deformed • Sometimes these symptoms make even the simplest activities — such as opening a door or taking a walk — difficult to manage

43. Rheumatoid Arthritis • Autoimmune disease (body attacks itself) that causes chronic inflammation of the joints • Exact cause of is unknown, but it's believed to be the body's immune system attacking the synovial fluid • It is two to three times more common in women than in men and generally strikes between the ages of 20 and 50 • It can also affect young children and adults older than age 50 • There's no cure for rheumatoid arthritis

44. Signs and Symptoms of Rheumatoid Arthritis • Fatigue is severe • Pain, aching, swelling, stiffness and loss of function in joints • Deformity in joints • Loss of muscle strength in the affected joints • Can affect any joint but is common in the wrist, fingers-thumb, and toes • May last only a short time, or may come and go • Can cause inflammation of tear glands, salivary glands, the linings of the heart and lungs and blood vessels

45. Diagnosing Rheumatoid Arthritis • There is no single test for the disease • The symptoms can overlap other kinds of arthritis • Medical History • Physical Examination • X-ray (joint erosion) • Blood Tests

46. Rheumatoid Arthritis Treatment • Nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil helps relieve both pain and inflammation • Joint Replacement Surgery • Rest • Exercise • Aquatics or Chair Exercises (low intensity) • Physical and Occupational Therapy • Weight Control • Nutrition Therapy

47. Vegan and Vegetarian Diets and Rheumatoid Arthritis • People who follow vegan or vegetarian diets may experience significant improvement in rheumatoid arthritis symptoms • “A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens.” Rheumatology (Oxford). 2001;40:1175–1179. • Higher intakes of meat and elevated serum cholesterol concentrations are associated with increased risk of developing RA

48. American Dietetic Association Vegetarian Nutrition Practice Group • Triggers of RA Symptoms may include: • Dairy Protein • Corn • Wheat • Citrus Fruits • Eggs • Red Meat • Sugar, Fats, Salt, Caffeine • Try elimination diet, then re-introduce foods one at a time • www.andrews.edu/NUFS/arthritis.html