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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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osteoporosis

Osteoporosis

Stephanie Wetmore, PT

PED 596: Adv. Cardiac Rehab

Wayne State College

osteoporosis1
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.
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
slide7
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.
homeostasis
Homeostasis
  • 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
slide11
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.
pathophysiology
Pathophysiology
  • 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
Glucocorticoids

Corticosteroids

Excessive thyroid hormones

Anticonvulsants

Gonadotropin releasing hormones

Methotrexate

Cyclophosamide

Dexamethasone

Lithium

Cyclosporine A

Heparin or Coumadin

Cholestyramine

No ERT or HRT

Low testosterone levels

Chemotherapeutics

Antacids

Isoniazid

Immunosuppressants

Diuretics

Risk Factors…Medications
risk factors chronic diseases
Arthritis

Glycocorticoid excess

Lung disease (COPD)

Organ transplants

SCI

Hyperthyroidism

Hyperparathyroidism

Chronic kidney/liver disease

RA

RSD

Malabsorption problems

Turner syndrome

CVA

MS

Lupus

IDDM

Chronic inflammation

Chron’s disease

CA

Burns

Asthma

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
pharmacology
Pharmacology
  • 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
biphosphonates
Biphosphonates
  • 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
resources
Resources
  • 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)