OSTEOPOROSIS andMETABOLİC BONE DİSEASES Prof. Dr. Ece Aydoğ PhysicalMedicineandRehabilitation
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 • -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 • Osteoporoticfractures; • Theclinicalpicture can be overlookedorhidden, especially in thecase of vertebralfractures, whicharethemostfrequentfractures in postmenopausalwomen.
Clinical features • Osteoporoticfractures; • Onlyaboutone- third of allpeoplewithradiographicvertebralfracturesarediagnosedclinically. • Excessmortality ( esp.hipfracture) • İncreased risk subsequentfractures; (20% for a newvertebralfracturewithin 1 yearand 25% forallfractures)
Osteoporotic fractures; • Pain; -Acute -Chronic • Functional decline • Psychosocial decline • Reduced quality of life
Physical and social outcomes • Loss of height • Kyphosis • Chronic back pain • Digestive problems • Decreased mobility • Loss of independence • Depression
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 • 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 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 • 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 • 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 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 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. Normal vertebra (1), Wedge fracture (2), biconcave or ‘fish’ vertebra(3), and a compression fracture (4).
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 • 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
Dowager’s hump. Marked thoracic kyphosis due to multiple osteoporotic fractures in elderly woman.
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 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 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
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 • 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 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 theraphy Smoking; directly toxic to bone Alcohol; greater than 2 to drink equivalents per day should discouraged Caffeine; induce hypercalciuria
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 İnterventions 3-Biphosphonates: • Primaryeffect is tosuppressosteoclastmediated bone resorption • Etidronate;oldestbiphosphonate in use • Alendronate • Risedronate • Ibandronate • Zolendronicacid
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 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 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 • 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; • 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.