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Osteoporosis. Stephanie Wetmore, PT PED 596: Adv. Cardiac Rehab Wayne State College. Osteoporosis. A disease characterized by irregularities in the quantity and architectural arrangement of bone tissue that lead to decreased skeletal strength and increased vulnerability to fractures .

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Stephanie Wetmore, PT

PED 596: Adv. Cardiac Rehab

Wayne State College

  • A disease characterized by irregularities in the quantity and architectural arrangement of bone tissue that lead to decreased skeletal strength and increased vulnerability to fractures.
normal physiology
Normal Physiology
  • Functions
    • Provides support to body
    • Protects vital organs
    • Assists in movement via leverage
    • Hematopoiesis (blood cell production)
    • Storage area for Ca++
cell types
Cell Types
  • Osteoblasts
    • Synthesize bone
    • Remodeling and repair
  • Osteoclasts
    • Responsible for bone resorption
    • Remodeling and repair
  • Osteocytes
    • Primary cells of mature bone
    • Osteoblasts surrounded by matrix during bone formation
    • Maintenance and resorption
bone formation growth
Bone Formation & Growth
  • Intermembranous ossification
    • Bone forms directly in the embryonic connective tissue
  • Endochondral ossification
    • A “scale model” of hyaline cartilage is replaced by bone
    • Process of formation for most bones
a closer look at endochondral ossification and growth
A Closer Look at Endochondral Ossification and Growth
  • 1. Formation of cartilage skeleton in embryo (6-12 wks gestation)
  • 2. Ossification and growth occur in subsequent months
  • 3. When ossification completed, growth in length occurs at epiphyseal plates
4. Widen by multiplication of cartilage cells and cancellous bone replaces the dying cartilage
  • 5. Growth in width occurs by depositing of compact bone beneath the periosteum (outer surface) and enlargement of the marrow cavity by bone resorption
  • 6. Growth ceases when epiphyseal plate is replaced by bone.
  • Balance between bone formation & resorption
  • Remodeling process
    • Old bone destroyed by osteoclasts
    • New bone constructed by osteoblasts
  • Dependent upon Ca++, P, and vitamins (esp. vit. D)
  • Controlled by hormones
regulation of bone formation growth
Regulation of Bone Formation & Growth
  • Vitamin D
    • Increases rate of Ca++ absorption from intestine
  • Growth Hormone
    • Needed to stimulate proliferation of cartilage cells at growth plate
  • Vitamin C
    • Important in synthesis of collagen
  • Thyroxin
    • Increases rate of replacement of bone at growth plate and needed for synthesis of GH
Vitamin A
    • Stimulates resorption of bone
  • Estrogens & androgens
    • Promote ossification and maintenance of matrix
  • Parathyroid hormone & Calcitonin
    • Regulate release of Ca++ from bone
parathyroid hormone calcitonin
Parathyroid hormone & calcitonin
  • When blood Ca++ levels are low, PTH is released.
  • Release of PTH increases rate of bone resorption, which increases the concentration of Ca++ in the blood.
  • When blood Ca++ levels are high, calcitonin is released, which inhibits resorption.
  • Osteoporosis can be either hormonally induced or mechanically induced.
  • Mechanical
    • Electrical changes created with weight bearing stimulate activity of osteoblasts, which lead to a build up of Ca++.
    • This does not occur without weight bearing (when someone is on bed rest)
as we age normally
As we age normally
  • Birth to age 20-30
    • GH influences deposition of bone, which exceeds resorption rate
  • Age ~50 to age 80
    • Resorption exceeds deposition due to decreased osteoblast activity and changes in Ca++ metabolism
rates of bone loss with normal aging
Rates of Bone Loss with Normal Aging
  • Female >30-35
    • Lose .5-1% of bone mass/year
  • Postmenopausal Females
    • Lose 2-3% bone mass/year until ~age 70
  • Women will lose ~45-50% in lifetime
  • Men will lose ~20-30% in lifetime
epidemiology of primary involutional osteoporosis
Epidemiology of Primary Involutional Osteoporosis
  • Most common fracture sites
    • Wrist, vertebrae and hip
risk of fracture
Caucasian Women

Vertebral 15.6%

Hip 17.5%

Wrist 16%

Overall 39.7%

Caucasian Men

Vertebral 5%

Hip 6%

Wrist 2.5%

Overall 13.1%

Risk of Fracture
fracture risk cont
Fracture Risk (cont.)
  • Wrist & hip fractures are most commonly the result of a combination of bone loss and moderate trauma such as a fall
  • Of all NH admissions, 21% are made following a hip fracture.
  • Vertebral compression fractures can occur simply by coughing, bending forward or hugging.
risk factors
Risk Factors
  • Advancing age – 1.4 to 1.8 fold increase with each decade
  • Gender – women > men
  • Family or personal hx of fx as an adult
  • Repeated fx’s, severe stooped posture
risk factors cont
Risk factors (cont.)
  • Race – Caucasian & Asian > African American or Hispanic
  • Bone Structure and Body Weight – small-boned and thin women (<127#) are at greater risk
  • Menopause/Menstrual history
    • Normal, premature (<45 y/o) or surgical
    • Late onset menarche (>15 y/o) or prolonged amenorrhea – anorexia nervosa, bulimia, excessively low body fat
risk factors cont1
Risk Factors (cont.)
  • Lifestyle/Nutrition
    • Cigarette smoking – inhibits estrogen
    • Alcoholism
    • Inadequate intake of Ca++
    • Sedentary lifestyle
    • High caffeine consumption and phosphoric acid intake (cola drinks)
    • Eating disorders
what is adequate ca intake
What is adequate Ca++ intake?
  • Age 1-3 years 500 mg/day
  • Age 4-8 years 800 mg/day
  • Age 9-18 years 1300 mg/day
  • Age 19-50 years 1000 mg/day
  • Age >50 years 1200 mg/day
risk factors medications


Excessive thyroid hormones


Gonadotropin releasing hormones





Cyclosporine A

Heparin or Coumadin



Low testosterone levels






Risk Factors…Medications
risk factors chronic diseases

Glycocorticoid excess

Lung disease (COPD)

Organ transplants




Chronic kidney/liver disease



Malabsorption problems

Turner syndrome





Chronic inflammation

Chron’s disease




Mental illness (depression)

Risk Factors…Chronic Diseases
bone mineral density testing
Bone Mineral Density Testing
  • Painless, non-invasive test, which identifies osteoporosis, determines fx risk and monitors response to treatment.
who definitions
WHO Definitions
  • Normal
    • +/- 1 SD of the young adult mean
  • Low Bone Mass (osteopenia)
    • -1 to –2.5 SD of the young adult mean
  • Osteoporosis
    • >-2.5 SD of the young adult mean
  • Severe (established) osteoporosis
    • >-2.5 SD of the young adult mean & one or more osteoporotic fractures
  • Estrogen Replacement Therapy/Hormone Replacement Therapy
    • Reduces bone loss, increases bone density, reduces risk of fx in postmenopausal women
    • Increase risk of uterine and breast CA, increased risk of thromboembolism
  • Alendronate Sodium (Fosamax)
    • Reduces bone loss, increases bone density, reduces risk of spine and hip fractures
    • Side effects include bone, muscle and/or joint pain and headache
  • Risedronate Sodium (Actonel)
    • Slows bone loss, increases bone density and decreases spine and hip fractures
    • Also approved for men & women to prevent and/or treat steroid-induced osteoporosis
serms family
SERMs family
  • Selective estrogen receptor modulators
  • Raloxifene (Evista)
    • Prevent bone loss, increase bone mass and decrease risk of vertebrae fracture
    • Side effects: DVT, leg cramps, syncope, arthralgia, tendon disorder and vertigo – chest pain, myalgia and arthritis possibly (<placebo).
calcitonin miacalcin
Calcitonin (Miacalcin)
  • Naturally occurring hormone involved in Ca++ regulation and bone metabolism
  • Slows bone loss, increases bone density and relieves pain associated with vertebral fractures
exercise testing modification exercise limitations capacity
Exercise Testing Modification/Exercise Limitations/Capacity
  • Weight-bearing exercise and resistance training recommended with precautions
weight bearing exercise
Weight-bearing Exercise
  • Brisk walking is ideal
  • Alternatives: hiking, stair climbing, dancing and racquet sports
  • Contraindicated = stair steppers, bicycling (including stationary), rowing machines, running and high-impact aerobics
    • Stair steppers – combination of unilateral WB and force to depress step
    • Bicycle – increased flexion
    • Rowing machines – deep forward bending (flexion)
testing contraindications
Testing Contraindications
  • Sub maximal cycle ergometer
  • Step-tests
resistance training
Resistance Training
  • Light weights recommended
  • Major muscle groups emphasized
  • Slow progression over several months
    • Fatigue after 10-15 reps
    • Increases do not exceed 10% per week
    • Proper technique
    • Every third day
    • If joint swelling, limping or pain after, decrease weight by 25-50%.
resistance training contraindications
Resistance TrainingContraindications
  • Weight carrying tests
  • Repetitive lifting tests
flexibility exercises
Flexibility Exercises
  • Flexion exercises contraindicated if vertebral bone density decreased or risk of compression fx
    • Avoid knee to chest
    • Forward bending
    • Touching the toes
    • Partial sit-up
      • Okay if thoracic spine stabilized and do not lift head and chest above T-6 level.
flexibility exercises contraindications
Flexibility ExercisesContraindications
  • Sit-and-reach test
  • Curl-up muscular endurance test
other exercise
Other exercise
  • HR, BP, ECG, ventilation frequency, tidal volume, oxygen saturation and expired oxygen and carbon dioxide should not be affected by osteoporosis medications.
  • Increasing kyphosis of the thoracic spine will make it more difficult to expand the lungs fully during inspiration
sample exercise prescription
Sample Exercise Prescription
  • Brisk walking 15-20 minutes 3-4x/wk
    • Begin with 5-minute walks and increase by one minute every other session
  • Flexibility program – body extender, shoulder pinches, chin tucks, elbow backs, arm reaches and back arches daily
  • Sinaki & Mikkelsen study
    • Flexion programs – 86% fx rate
    • Extension programs – 16% fx rate
    • Control group – 67% fx rate
    • Flex/Ext programs – 57% fx rate
sample exercise cont
Sample Exercise (cont.)
  • Resistance Training
    • Every third day
    • Major muscle groups especially those integral to fall prevention
      • Hip extensors, flexors, adductors, abductors, quadriceps, ankle dorsiflexors & plantar flexors and trunk extensors & stabilizers
    • One set 10-15 reps
    • Increase no greater than 10% per week for amount of weight
  • National Osteoporosis Foundation
    • http://www.nof.org
  • American Academy of Orthopedic Surgeons
    • http://www.aaos.org
  • Lewis, C.B. (1990), Aging: The Healthcare Challenge (2nd ed.)
  • Sinaki & Mikkelsen (1988)
  • Katz & Sherman (1998)