DEFINITION, CLASSIFICATION, PREVENTION AND MANAGEMENT IN PMR

1. OSTEOPOROSIS
S.K.NAYAK
DNB PMR 2ND YR

2. • LOW BONE MASS AND DETERIORATION OF
BONE ARCHITECTURE MAINLY TRABECULAR
BONE.
• LEADS TO INCREASED BONE FRAGILITY AND
FRACTURE

3. • IN 1994, WHO ESTABLISHED THE TERM
“NORMAL BONE DENSITY” AS BONE DENSITY
WITHIN ONE STANDARD DEVIATION OF
MEAAN OF NORMAL YOUNNG ADULTS.
• OSTEOPENIA- BONE DENSITY 1.0- 2.5 SD
BELOW THE MEAN
• OSTEOPOROSIS- MORE THAN 2.5 SD BELOW
THE MEAN

4. T- SCORE AND Z- SCORE
• T SCORE COMPARES THE MEAN BONE
DENSITY AMONG THE YOUNG.
• Z SCORE COMPARES THE MEAN BONE
DENSITY AMONG THE SAME AGE, GENDER
AND ETHNICITY.

6. • IN 2008, WHO EXPANDED THE DEFINITION OF
OSTEOPOROSIS AS THE PATIENTS WITH
OSTEOPENIA AND FRAGILITY FRACTURE OF
HIP AND SPINE.

7. • NORDIN’S CLASSIFICATION-
–GENERALISED- PRIMARY AND SECONDARY
–LOCALISED
• RIGGS & MELTON CLASSIFICATION-
–PRIMARY- TYPE 1(POSTMENOPAUSAL) &
TYPE 2(SENILE)
–SECONDARY
–OSTEOGENESIS IMPERFECTA
–IDIOPATHIC JUVENILE OSTEOPOROSIS

8. Normal Bone Osteoporotic Bone

9. ETIOLOGY & RISK FACTORS

10. PATHOGENESIS
• TISSUE ABNORMALITY
• CELLULAR ABNORMALITY
• HORMONAL ABNORMALITY

11. TISSUE ABNORMALITY
• EFFECT OF REMODELING- CONSTANTLY
TURNING OVER
• STARTS WITH BONE RESORPTION BY THE
OSTEOCLASTS AND NEW BONE FORMATION
FOR 40-60 DAYS BY THE OSTEOBLASTS.
• THE FORMATION AND RESORPTION ARE
NORMALLY COUPLED.
• IN OSTEOPOROSIS THERE IS “NEGATIVELY
UNCOUPLED”.

12. CELLULAR ABNORMALITY

13. HORMONAL ABNORMALITIES
• ESTROGEN DEPLETION
• INCREASED TISSUE RESPONSIVENESS TO
PARATHYROID HORMONE(PTH)
• TRANSIENT INCREASE IN CALCIUM LEVEL
• DECREASED PTH SECRETION
• DECREASED CHOLECALCIFEROL PRODUCTION
• DECREASED CALCIUM ABSORPTION

14. SPINAL CORD INJURY
• PTH LEVEL DECREASES AFTER FIRST YEAR OF
INJURY, GRADUALLY INCREASED IN 1- 9 YEARS.
• REDUCED INTESTINAL ABSORPTION AND
INCREASED RENAL ELIMINATION OF CALCIUM,
• INHIBITION OF SEX STEROIDS, PITUITARY
SUPPRESSION OF THYROID
• STIMULATING HORMONE (TSH), AND INSULIN
RESISTANCE AND IGF

15. LAB INVESTIGATIONS
• COMPLETE BLOOD CELL COUNT
• SERUM CHEMISTRY (RENAL ELECTROLYTES, LIVER
ENZYMES, BUN,
• CREATININE, CALCIUM, TOTAL PROTEIN/ALBUMIN,
ALKALINE
• PHOSPHATASE, AND PHOSPHORUS)
• VITAMIN D-25 HYDROXY
• INTACT PTH
• SERUM PROTEIN ELECTROPHORESIS
• THYROID FUNCTION TEST
• 24-H URINE CALCIUM
• URINE MARKERS FOR BONE RESORPTION-URINE NTX

16. CLINICAL EVALUATION
• QUANTITATING BONE MASS
– PLAIN RADIOGRAPH
– DXA SCAN
– FRAX WHO
• BONE MARKERS-NTX, CTX IN URINE 24 HR CALCIUM
COLLECTION

17. PREVENTION STRATEGIES
• NUTRITIONAL ADJUNCTS-
– CALCIUM
– VITAMIN D
– PROTEIN

18. INDICATIONS FOR BONE MINERAL DENSITY (BMD) TESTING (ISCD CRITERIA)
• Women aged 65 and older
• For post-menopausal women younger than age 65 a bone density test
is indicated if they have a risk factor for low bone mass such as;
– Low body weight
– Prior fracture
– High risk medication use
– Disease or condition associated with bone loss.
• Women during the menopausal transition with clinical risk factors for
fracture, such as low body weight, prior fracture, or high-risk
medication use.
• Men aged 70 and older.
• For men < 70 years of age a bone density test is indicated if they have a
risk factor for low bone mass such as;
– Low body weight
– Prior fracture
– High risk medication use
– Disease or condition associated with bone loss.

19. CALCIUM
• DIETARY CALCIUM- DAIRY PRODUCTS, GREEN
VEGETABLES, SALMON.
• CALCIUM INTAKE OF 1200MG/DAY IN TWO OR
MORE DOSES FOR BOTH MEN AND WOMEN
MORE THAN 50 YEARS OF AGE.

20. VITAMIN D
• ACTIVE FORM- CALCITRIOL(1,25 DIIHYDROXY
VIT D)
• CHOLECALCIFEROL (VITD3) IS THE PREFERRED
FORM OF VITAMIN D SUPPLEMENT.

21. PROTEIN
• DIETARY PROTEIN SUPPLEMENTS OF 20GM
PER DAY FOR 6 MONTHS.
• THE RDA FOR PROTEIN IS
– 46GM/DAY- WOMEN
– 56GM/DAY- MEN

22. EXERCISES
• FOR OPTIMAL BONE HEALTH, EXERCISE
PROGRAM SHOULD INCLUDE WEIGHT
BEARING ACTIVITIES FOR 45 MINS THREE-
FOUR TIMES PER WEEK.
• OR WEIGHT LIFTING FOR 20- 30 MINS 2-3
TIMES PER WEEK.
• WEIGHT BEARING OR LOW IMPACT EXERCISES
ARE THE WALKING OR TREADMILL.
• HIGH IMPACT EXERCISES ARE THE JOGGING,
TENNIS AND SOCCER.

23. • MODERATE TO VIGOROUS EXERCISES ARE THE
JUMPING , WEIGHT LIFTING, RESISTIVE
EQUIPMENNTS.
• SWIMMING- MAINTAINS THE MUSCLE MASS.
• BALANCE TRAINING
• EVIDENCCE OF 20-40% REDUCTION IN HIP
FRACTURES IN OLD WITH MODERATE TO
VIGOROUS ACTIVITIES.

24. LIFE SPAN BONE PHASES
• GROWTH PHASE(PUBERTY)- 25-30% OF BONE
GROWTH
• MAINTENANCE PHASE(MIDDLE ADULTHOOD)
• MID-LIFE PHASE(50-70YRS)
• FRAILTY PHASE(AFTER 70YRS)
• AS THE BONE MINERLISATION LAGS BEHIND
GROWTH IN LENGTH, FRACTURE RATES INCRESE
DURING PERIODS OF RAPID GROWTH.

25. EXERCISE PRINCIPLES
• PRINCIPLE OF SPECIFICITY
• PRINCIPLE OF REVERSIBILITY
• PRINCIPLE OF PROGRESSION
• PRINCIPLE OF INITIAL VALUES
• PRINCIPLE OF DIMINISHING RETURNS

26. FALL REDUCTION STRATEGIES
• IMPROVED BALANCE- BY GAIT TRINING,
COORDINATION AND FUNCTIONAL EXERCISES
AND MUSCLE STRENGTHENING.
• MENTAL STATUS, VISION, EVIRONMENTAL
FACTORS, MEDICATIONS

27. FEAR OF FALL
• PHASES OF FALL-
– INSTABILITY PHASE
– DESCENT PHASE
– IMPACT PHASE
– POST IMPACT PHASE

28. PSYCHOSOCIAL
• DEPRESSION(MOST COMMON)
• ANXIETY, FEAR, LOSS OF SELF ESTEEM,
ISOLATION, VULNERABALITY AND
EMBARASSMENT TO PHYSICAL ACTIVITIES

29. PHARMACOLOGIC AGENTS
• ANTIRESORPTIVE AGENTS
– BISPHOSPHONATES
– RANKL INHIBITION
– ESTROGEN
– RALOXIFENE
– CALCITONIN
• ANABOLIC AGENTS-
– TERIPARATIDE
– TESTOSTERONE
– CYTOKINES

30. BISPHOSPHONATES
• MOA- TAKEN UP BY OSTEOCLASTS AND CAUSE
CELL DEATH BY BLOCKING THE ESSENTIAL LIPIDS
• ALENDRONATE- 70MG WEEKLY PO
• RISENDRONATE- 35MG WEEKLY PO
• IBANDRONATE- 150MG MONTHLY PO
• ZOLENDRONATE- 5MG IV OVER 15 MINS YEARLY
• SIDE EFFFECTS- GASTRIC IRRITATION, JAW
OSTEONECROSIS, ATRIAL FIBRILLATION

31. RANKL INHIBITION
• DENOSUMAB (PROLIA)-
• PREVENTS RANKL FROM INTERACTING WITH
THE RECEPTOR RANK.
• DOSAGE- 60MG SC TWICE YEARLY

32. • ESTROGEN AND PROGESTIN COMBINATION-
625MICROGM ESTROGEN,
2.5 MG PROGESTIN
• RALOXIFEN-
– SERM
– AGONISTIC EFFECT ON BONE AND LIPOPROTEIN
PRODUCTION
– ANTAGONISTIC EFFECT ON BREAST TISSUE
• CALCITONIN- 200 IU DAILY(NASAL SPRAY)

33. ANABOLIC AGENTS
• TERIPARATIDE-
– RECOMBINANT HUMAN PTH FRAGMENT
– INCREASE THE ABSORPTION OF CALCIUM AND
PHOSPHORUS
– INCREASE THE BONE TURN OVER WITH BONE
ORMATION OUTWEIGHING THE RESORPTION
– 20MICROGRAM SC DAILY
– SIDE EFFECTS- LEG CRAMPS AND DIZZINESS

34. • TESTOSTERONE
• CYTOKINES- IGF-1, TGF-BETA

35. REHABILITATION POST-FRACTURE
• VERTEBRAL FRACTURE-
– MOSTLY INVOVE ANTERIOR PORTION OF
VERTEBRAL BODY.
– THORACOLUMBAR- T8-L2
– OSTEOPOROSIS WITH COMRESSION FRACTURE
CAUSES ACUTE OR CHRONIC PAIN.
– OTHER SOURCES OF PAIN- PARASPINAL SPASM,
COSTOILIAC SYNDROME, ARTHRITIS
– SACRAL INSUFFICIENCY FRACTURE(SIF)- HONDA
SIGN “H” SIGN ON BONE SCAN

36. MANAGEMENT
• ACUTE PAIN- REST, IMMOBILISATION, ANALGESICS
• AFTER 3-4 WEEKS WEANING THE ANALGESICS,
PROGRESSIVE TRANSFER AND AMBULATION
TRAINING
• STRICT ADHERENCE TO NEUTRAL SPINE POSITIONING
DURING EXERCISE.
• IN CASE OF COSTOILIAC IMPINGEMENT- AVOIDANCE
OF LATERAL BENDING AND ROTATION.

39. BRACING AND BACK SUPPORT
• HELP IN PAIN RELIEF AND STABILISATION OF SPINE
• FLEXION AND EXTENSION OF LOWER THORACIC AND
UPPER LUMBAR SPINE ARE THE MAIN MOVEMENTS.
• TO RELIEF THE LOAD OVER THE ANTERIOR COLUMN
OF VERTEBRA BY RESTRICTING THE FLEXION.
• POSTURAL TRAINING SUPPORTS(PTS)
• THORACOLUMBAR SUPPORT-
– CASH BRACE,
– THORACO-LUMBAR CORSET,
– TLSO
• RIGID TYPE OF ORTHOSES IN ACUTE CASES

40. • CHRONIC USE OF ORTHOSIS IS DISCOURAGED.
• TLSO IS SPECIALLY USED FOR FRACTURE FROM
RETROPULSION OF FRAGMENTS INTO SPINAL CANAL
WITH NEUROLOGIC COMPROMISE.
• IF NO NEUROLOGIC COMPROMISE- SEMIRIGID TLSO-
SPINIMED OR CASH BRACE.
• LUMBOSACRAL CORSET MAY GENERATE HEAT,
PRESSURE, OR MASSAGE LIKE EFFECT.

41. VERTEBROPLASTY AND KYPHOPLASTY
• RADIO OPAQUE BONE CEMENT- PMMA
• FLUOROSCOPIC GUIDED OR CT GUIDED WITH 8-13G
BONE NEEDLE.
• CAN BE DONE AS IN-PATIENT AND OUT-PATIENT
PROCEDURE.
• SACROPLASTY FOR SIF.

43. HIP FRACTURE-
• INTERTROCHANTERIC AND FRACTURE NECK OF
FEMUR- 90%
• SUBTROCHANTERIC FRACTURE-5-10%
• REHABILITATION STARTS ON THE FIRSTDAY AFTER
SURGERY.
WRIST FRACTURE-
• MC IN POSTMENOPAUSAL WOMEN BELOW 75 YRS.
• DISTAL RADIUS FRACTURE, COLLES FRACTURE,
• INJURY TO TFCC IS ALSO COMMON.

45. REFERENCES
• INTERNATIONAL SOCIETY FOR CLINICAL
DENSITOMETRY
• DELISA- PHYSICAL MED. AND REHABILITATION