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OSTEOPOROSIS and METABOLİC BONE DİSEASES. Prof. Dr. Ece Aydoğ Physical Medicine and Rehabilitation. Definition. Literally translates as “ porous bones ”

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osteoporosis and metabol c bone d seases

OSTEOPOROSIS andMETABOLİC BONE DİSEASES

Prof. Dr. Ece Aydoğ

PhysicalMedicineandRehabilitation

definition
Definition
  • Literally translates as “porous bones”
  • A progressive systematic skeletal disease characterized low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture risk.
osteoporosis
Osteoporosis
  • -most common metabolic bone disease
  • -affects both sexes and all races
  • -decline in bone mineral dansitometry
  • -disproportionate decrease in bone strength
  • -increase in fractures
  • -enormous costs for fracture treatment and disability
clinical features
Clinical features
  • Osteoporoticfractures;
  • Theclinicalpicture can be overlookedorhidden, especially in thecase of vertebralfractures, whicharethemostfrequentfractures in postmenopausalwomen.
clinical features1
Clinical features
  • Osteoporoticfractures;
  • Onlyaboutone- third of allpeoplewithradiographicvertebralfracturesarediagnosedclinically.
  • Excessmortality ( esp.hipfracture)
  • İncreased risk subsequentfractures;

(20% for a newvertebralfracturewithin 1 yearand 25% forallfractures)

slide11
Osteoporotic fractures;
  • Pain;

-Acute

-Chronic

  • Functional decline
  • Psychosocial decline
  • Reduced quality of life
physical and social outcomes
Physical and social outcomes
  • Loss of height
  • Kyphosis
  • Chronic back pain
  • Digestive problems
  • Decreased mobility
  • Loss of independence
  • Depression
wrist fractures
Wrist fractures
  • Occur after a fall
  • 1/1000 per year below age 45
  • 7/1000 per year at ages 65 and older

Most symptoms

  • Persisting hand pain
  • Weakness
  • Algodystrophy
  • İmpairment of activities of daily living (ADL)
hip fractures
Hip fractures
  • Occur after a fall
  • Spontanous insufficiency hip fractures is low (0.27%)
  • Almost all hip fractures require urgent surgical intervention

General complications:

  • Cardiovascular,
  • Pulmonary,
  • Cerebral problems
  • İnfections

Local complications:

  • Wound and prostetic problems
hip fractures1
Hip fractures
  • Mortality ranges between 1%-9%
  • 20-25% of hip fracture patients die within the first year
  • After 6 months, only 24% of patients had returned to prefracture walking competence and only 43% had returned to prefracture basic ADL.
  • Little further improvement occured after 1 year.
vertebral fractures
Vertebral fractures
  • Only one in three vertebral fractures is diagnosed.
  • Often occur after minimal trauma
  • Mortality is increased after vertebral fractures by 19% compared with the general population
  • Mortality rate highest in patients with multipl vertebral fractures and in patients who reqired hospitalization.
  • Four times greater risk for new vertebral fracture and twice the risk of hip and other non-vertebral fracture
  • Clinical message in order to prevent future fractures, vertebral fracture should be recognized and treated early with drugs.
back pain
Back pain
  • onset is sudden (73%)
  • moderate to severe
  • worsens on movement; pain is worsed by sitting, standing, staying in the same position for a long time, bending, walking, and sudden movements
  • relieved by rest
  • cause breathlessness, pallor, nausea, and vomitig
  • exacerbated by coughing or sneezing
back pain1
Back pain
  • deeply localized bone or muscle related
  • radiates laterally following the dermatomal distribution
  • accompanied by spasm of the paraspinal muscles
  • no specific circadian rhythm of pain is found
  • chronicty of the back pain is related to the number and severity of vertebral fractures
  • increased risk for chronic back pain
back pain2
Back pain

On clinical examination;

  • Tenderness over the affected vertebrae and paraspinal muscles
  • Mobility of the spine is restricted and painful
  • Kyphosis
changes in vertebral shape due to osteoporosis
Changes in vertebral shape due to osteoporosis.

Normal vertebra (1),

Wedge fracture (2),

biconcave or ‘fish’ vertebra(3),

and a compression fracture (4).

slide24
Pain and hyperkyphosis cause a spiralling decline in;
  • Mobility
  • Muscle strength
  • Function

Decline in function in turn, contrubites to pain and an increased

  • Bone loss
  • Risk of falls
  • Fractures
  • Loss of independency
kyphosis
Kyphosis
  • Heigth loss (1 cm decrease in 8 years)
  • Reduce the distance the distance between the iliac crest and ribs, resulting in problems with digestion and protruding abdomen
  • Lung function progressively decreases
  • Balance capability may be affected
  • Muscle strength significantly decreses
slide27
Dowager’s hump.

Marked thoracic

kyphosis due to

multiple osteoporotic

fractures in elderly

woman.

laboratory tests
Blood calcium

Blood vitamin D

Thyroid function

Parathyroid hormone

Estradiol levels to measure estrogen (in women)

Follicle stimulating hormone (FSH): to establish menopause status

Testosterone levels (in men)

Alkaline phosphatase (ALP)

Osteocalcin levels to measure bone formation.

Laboratory Tests
laboratory tests1
Laboratory Tests

The most common URINE tests are:

  • 24-hour urine collection to measure calcium metabolism, hidroxyproline, telopeptide
  • Tests to measure the rate at which a person is breaking down or resorbing bone.
non pharmological theraphy
Non- pharmological theraphy

Fall prevention:

  • Evaluation of fall risk
  • Modifiable risk factors should be identified, and corrected including poor vision, hearing or cognition, and myopathies.
  • Disease including alcoholism, neuromuscular disorders and dementia should be treated furthet reducing fracture risk.
  • Avoid medications like sedatives and hypnotics
  • Use of assistive devices
  • Vit D supplementation
  • Home modifications
  • Exercise; Thai Chi
dual energy x ray absorptiometry
Hip

Lumbar Spine

Distal Radius

Whole Body

Foot

T score; degree of bone loss is defined by comparison with young adult mean bone density

Z score;degree of bone loss is defined by comparison with your same sex, age, and weight.

WHO definition

T-score > -1.0 Normal

T-score < -1.0 > -2.5 ‘Osteopenia’

T-score < -2.5 ‘Osteoporosis’

Dual Energy X-ray Absorptiometry
management of osteoporosis
Management of osteoporosis
  • Evaluation for secondary osteoporosis
  • Treatment:

Non- pharmological theraphy:

  • Patient education
  • -fall risk
  • -exercise programs,
  • -dietary advice invluding adequate Ca and vit. D intake
  • -lifestyle modification
non pharmological theraphy1
Non- pharmological theraphy

Exercise:

  • Modarete, regular weigth bearing exercise is essential for skeletal health.
  • Increase BMD
  • Increase muscle strength
  • Better conditioning and balance
  • Reduce fall risk
non pharmological theraphy2
Non- pharmological theraphy

Smoking; directly toxic to bone

Alcohol; greater than 2 to drink equivalents

per day should discouraged

Caffeine; induce hypercalciuria

pharmacological nterventions
Pharmacological İnterventions

1-Hormone replacement therapy

  • Selective estrogen receptor modulators (SERMs)-Raloxifene
  • Depending on the target organ, these compounds may demonstrate estrogen antogonist or estrogen agonist effects.
  • Antiresorptive effects on bone in postmenopausal women
  • The incidence of vertebral fracture risk is decrese
  • The incidence of non-vertebral fracture including hip fracture, do not differ significantly
  • Higher risk of venous thromboembolus and hot flashes
  • 76% reduction in the risk of breast cancer
pharmacological nterventions1
Pharmacological İnterventions

3-Biphosphonates:

  • Primaryeffect is tosuppressosteoclastmediated bone resorption
    • Etidronate;oldestbiphosphonate in use
    • Alendronate
    • Risedronate
    • Ibandronate
    • Zolendronicacid
biphosphonates side effects
BiphosphonatesSide effects
  • GI side effects: Esophageal erosions and stricture
  • Impaired mineralization with etidronate
  • Bone pain
  • Impaired fracture healing in dogs with etidronate
  • Osteonecrosis of the jaw; incidence with oral biphosphonates is much less
parathyroid hormone teriparatide
Parathyroid HormoneTeriparatide

Following characteristics may be appropriate for teriparatide therapy:

  • Those who lose bone mineral density on antiresoptive theraphy.
  • Are unable to take antiresoptive agents because of side effects.
  • Fracture on antiresoptive theraphy.
  • Are treatment naive patients at high risk of fracture.
parathyroid hormone teriparatide1
Parathyroid HormoneTeriparatide

Effect of PTH on fracture reduction

  • Periosteal bone formation and a change in bone size
  • İncreases strength by increasing diameter
  • The earlier rise in markers of bone formation than in markers of resorption with PTH treatment provide a rational for the observed increases in bone density.
side effects
Side Effects
  • İnfrequent, not serious, rarerly resulting in cessation of treatment
  • Dizzines,
  • Leg cramps
  • Mild hypercalcemia (common)
  • Increase in uric acid levels, but no gout attacks
  • Osteosarcoma
should not prescribe
Should not prescribe;
  • Paget’s disease
  • Prior radiation therapy to the skeletal system
  • Pediatric population and young adult with open epiphyses
  • Patients who have bone metastases or a history of skeletal malignancies.
strontium ranelate
Strontium Ranelate
  • Strontium occurs naturally as a non-radioactive element and was first isolated in 1808.
  • Strontium competes with calcium for intestinal absorption and, once absorbed incorporation into bone and dental tissues.
  • Strontium can block the hydroxylation of 25-hydroxyvitamin D to 1,25-hydroxyvitamin D
  • Correction can be achieved either by addition of 1,25-hydroxyvitamin D supplementation or a high Ca diet.