OSTEOPOROSIS        Gülseren AKYÜZ, M.D., Prof.     Marmara University School of MedicineDepartment of Physical Medicine a...
What is osteoporosis?
Description of Osteoporosis• A progressive systemic skeletal disease  characterized by compromised bone  strength predispo...
The New Concept: Osteoporomalacia     matrix             matrix     mineral           mineral    Normal           Osteopor...
Classification of OP - IGENERALIZED•   OP unassosiated with other disease (Primary OP)     – Juvenile idiopathic     – Pos...
Classification of OP - II• Systemic diseases   – Chronic airways obstruction   – Rheumatoid arthritis• Environmental   –  ...
Classification of OP - IIIREGIONAL• Complex regional pain syndrome = CRPS• Immobilization / disuse• Transient regional ost...
Type I (postmenopausal) OP• Women within 15-20 years after the  menopause• Predominantly trabecular bone loss• Vertebral b...
Type II (senile) OP• Both men and women over age 70• Proportionate loss of cortical and  trabecular bone• Hip and vertebra...
TYPE I        TYPE II                  Postmenopausal    SenileAge (years)           50-70          >70Sex ratio (F:M)    ...
Pathogenesis of OP - I• Peak bone mass• The rate of bone turnover• Menopause age (early menopause)• Microarchitectural det...
Pathogenesis of OP - IIA- The factors affecting peak bone mass• Genetic     – Vitamine D receptor gene     – Procollagen t...
Signs and Symptoms of OP - I• The cardinal symptom of OP is “fracture”• Vertebral fractures present with acute back pain a...
Signs and Symptoms of OP - II•   back pain•   loss of height•   increased kyphosis•   immobility•   increased number of be...
Signs and Symptoms of OP - III•   Reduced pulmonary function•   Bone tenderness•   Extreme fatigue•   Brittle or soft fing...
20 years           50 years                      77 years
Risk Factors for OsteoporosisWith Relative Risk ≥ 2                   With Relative Risk 1 - 2(Major)                     ...
Other Risk Factors• Muscle weakness• Balance problems (Neurologic, vestibular,  ophthalmologic problems)• Visual deficienc...
HOW TO DIAGNOSE ?
Laboratory Investigations–   Serum calcium (Total and ionized Ca)–   Serum phosphate–   Alcaline phosphatase–   25 Hydroxi...
Differential Diagnosis                   Ca    PO4   ALP   25(OH) D   PTH   Ca    PO4    HP                               ...
Bone Markers Bone Formation             Bone ResorptionBlood                         BloodTotal alkalen phosphatase   Tart...
X - Ray• Absolutely required• Even if bone mineral density informs us about  bone content, it does not show the fracture o...
Semiquantitative assessment of vertebral                       fractures                                                  ...
BONE MINERAL DENSITY MEASUREMENTWhen to do ?                From whom to request ?
World Health Organization’s Classificaiton                                                 T-ScoreNormal                  ...
Indications of BMD measurements• Over 65 year-old women without any risk factors• Below 65 year-old postmenopausal women w...
Advantages of DEXA• Useful method in patient follow up• Low radiaton dose (2-4 mRem)• High precision and accuracy• Short t...
Disadvantages of DEXA• No differentiation between cortical and trabecular bone  tissues• Degenerative changes effet the re...
Bone Biopsy– It is usually preferrred from the iliac crest– Invasive but definite diagnostic tool– It must be done in cert...
Can osteoporosis be cured ?          Yes !
Management of OP - I• The therapeutic approach to OP is a complex• It means not only taking some medicine but also   – cha...
Management of OP- II• Early diagnosis is the best to preserve bone mass• Medical treatment can slow bone loss and  decreas...
Antiresorptive                   Stimulant              Complex agents        agents                        agentsHRT, ERT...
Osteoporosis Rehabilitation•   Treatment of pain•   Physical restoration•   Diet, medical treatment, exercises•   Correcti...
Who falls and how?• People at the age of 50s walk fast  and they cast forward themselves  and lean on their hands over the...
Reasons for increase in the risk of falling• Diminished hearing and vision• Muscle weakness• Posture and balance disorder•...
How to prevent falls ?• Appropriate clothes and  shoes• Regularly ophthalmologic  examination• Use of supportive devices• ...
Helpers
Effects of exercises• Execises increases bone mass• Exercises prevent falls by  increasing the muscle strength,  endurance...
Types of ExercisesThere are 5 types of exercises recommended for  osteoporosis:• Stretching exercises• Aerobic exercises p...
Stretching Exercises
Stretching Exercises
Aerobic exercises performed by body mass
Aerobic Exercises
Strengthening exercises
Strengthening exercises
Exercises with high power
Balance and Coordination Exercises
Recommended Sportive Activities•   Walking with tempo•   Tennis•   Golf•   Skiing•   Dancing•   Swimming ?
Swimming is better than nothing !
Not Recommended Sportive Activities•   Horsing•   Canoe•   Windsurf•   Soccer•   Cycling ?
Thank you
Osteoporosis 03.04.2013
Osteoporosis 03.04.2013
Osteoporosis 03.04.2013
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Osteoporosis 03.04.2013

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Osteoporosis 03.04.2013

  1. 1. OSTEOPOROSIS Gülseren AKYÜZ, M.D., Prof. Marmara University School of MedicineDepartment of Physical Medicine and Rehabilitation
  2. 2. What is osteoporosis?
  3. 3. Description of Osteoporosis• A progressive systemic skeletal disease characterized by compromised bone strength predisposing to an increased risk of fracture• Bone strenght : – Bone density – Bone qualityNIH Consensus Development Panel of Osteoporosis JAMA 285 :785 95,2001
  4. 4. The New Concept: Osteoporomalacia matrix matrix mineral mineral Normal Osteoporosis matrix matrix mineral mineral Osteomalacia Osteoporosis / malacia
  5. 5. Classification of OP - IGENERALIZED• OP unassosiated with other disease (Primary OP) – Juvenile idiopathic – Postmenopausal – Senile• OP associated with other diseases (Secondary OP) – Metabolic • Diabetes – Endocrine • Cushing’s syndrome/corticosteroid therapy • Hyperthyroidism • Hyperparathyroidism • Hypogonadism • Pregnancy • Anorexia nervosa
  6. 6. Classification of OP - II• Systemic diseases – Chronic airways obstruction – Rheumatoid arthritis• Environmental – Calcium deficiency – Alcoholism – Drugs – Mastocytosis• Functional – Long term immobilization – Exercise-induced amenorrhoea• Genetic – Osteogenesis imperfecta – Menkes’ syndrome – Ehlers-Danlos syndrome – Homocystinuria – Marfan’s syndrome
  7. 7. Classification of OP - IIIREGIONAL• Complex regional pain syndrome = CRPS• Immobilization / disuse• Transient regional osteoporosis• Regional migratory osteoporosis
  8. 8. Type I (postmenopausal) OP• Women within 15-20 years after the menopause• Predominantly trabecular bone loss• Vertebral body and distal radius• Estrogen deficiency and other factors
  9. 9. Type II (senile) OP• Both men and women over age 70• Proportionate loss of cortical and trabecular bone• Hip and vertebral fractures• Factors related to aging – Impaired osteoblastic function – Impairment of renal 1-alpha-hydroxylase activity
  10. 10. TYPE I TYPE II Postmenopausal SenileAge (years) 50-70 >70Sex ratio (F:M) 6:2 2:1Types of bone Mainly Trabecular andloss trabecular corticalFracture sites Vertebrae and/or Proximal femur distal radiusMain causes Menopause Aging
  11. 11. Pathogenesis of OP - I• Peak bone mass• The rate of bone turnover• Menopause age (early menopause)• Microarchitectural deterioration of bone tissue• Repair disorders of bone
  12. 12. Pathogenesis of OP - IIA- The factors affecting peak bone mass• Genetic – Vitamine D receptor gene – Procollagen type I gene – The receptors of estrogen• Hormonal and nutritional factors• Environmental factorsB- The factors affecting the rate of bone turnover• The differences between trabecular and cortical bone structure• The differences between men and women
  13. 13. Signs and Symptoms of OP - I• The cardinal symptom of OP is “fracture”• Vertebral fractures present with acute back pain after sudden bending, lifting or coughing• It is associated with progressive kyphosis• Vertebral fracture can be painless -asymptomatic- and incidentally discovered in the X-Rays• Fractures of the distal forearm and proximal femur usually follow falls• Rib fractures can be seen
  14. 14. Signs and Symptoms of OP - II• back pain• loss of height• increased kyphosis• immobility• increased number of bed days• loss of self-esteem• distorted body image• depression
  15. 15. Signs and Symptoms of OP - III• Reduced pulmonary function• Bone tenderness• Extreme fatigue• Brittle or soft fingernails• Premature grey hair• Leg cramps at nights
  16. 16. 20 years 50 years 77 years
  17. 17. Risk Factors for OsteoporosisWith Relative Risk ≥ 2 With Relative Risk 1 - 2(Major) (Moderate)• Age > 70 • Estrogen deficiency• Menopause < 45 • Calcium intake < 500 mg/d• Hypogonadism • Rheumatoid arthritis • Bechterew disease• Fragility fracture • Anticonvulsivants• Hip fracture in parents • Hyperthyroidism• Glucocorticoids • Smoking• Malabsorption • Diabetes mellitus• High bone turnover • Primary hyperparathyroidism• Anorexia Nervosa • Excess alcohol and cafein intake• Body mass index =BMI < 18 (the weight in kilograms divided by the square of the height in meters)• Immobilization• Brown J P,Jose RG. Clinical Practice Guidelines For Chronic renal failure The Diagnosis and Management of Osteoporosis.• Transplantation November 2003• Osteopenia in X-Ray
  18. 18. Other Risk Factors• Muscle weakness• Balance problems (Neurologic, vestibular, ophthalmologic problems)• Visual deficiency• Slow walking• Worsened heel-finger walking (arthrodesis, etc.)
  19. 19. HOW TO DIAGNOSE ?
  20. 20. Laboratory Investigations– Serum calcium (Total and ionized Ca)– Serum phosphate– Alcaline phosphatase– 25 Hydroxia Vitamine D (Vitamine D3)– Parathormone– Calcium excretion in the urine– Bone resorption and formation markers
  21. 21. Differential Diagnosis Ca PO4 ALP 25(OH) D PTH Ca PO4 HP BLOOD URINEType 1 OP N N N N N ↑ N ↑Type 2 OP N N N N↓ N↑ N N NOsteomalacia ↓N ↓ ↑ ↓ N↑ ↑↓ N↓↑ NMetastatic dise. N↑ N N↑ N N↑ N↑ N ↑
  22. 22. Bone Markers Bone Formation Bone ResorptionBlood BloodTotal alkalen phosphatase Tartrate-resistant acidBone spesific alcalene phosphatasephosphatase (BALP)Osteocalcine Gamma carboxy glutamic acidProcollagen type IProcollagen type II Urine Urine Calcium/Creatinine Deoxypyridynolyn None Pyridynolyn Hydroxylysine and glycosides N-telopeptide (NTX), C-telopeptide (CTX)
  23. 23. X - Ray• Absolutely required• Even if bone mineral density informs us about bone content, it does not show the fracture or it can reveal the bone better than it is, because of degenerative changes
  24. 24. Semiquantitative assessment of vertebral fractures SQ stage 0 normal 1 mild 2 moderate 3 severeGenant et al. J BoneGenant et al. 1993: 8;Mineral Res 1993: 8; 1137-48 Mineral Res J Bone 1137-48
  25. 25. BONE MINERAL DENSITY MEASUREMENTWhen to do ? From whom to request ?
  26. 26. World Health Organization’s Classificaiton T-ScoreNormal - 1 and aboveLow Bone Density between -1 and -2.5Osteoporosis < - 2.5Established < - 2.5 and 1 or moreOsteoporosis fracture Kanis JA et al, J Bone Miner Res, 1994;9:1137-1141
  27. 27. Indications of BMD measurements• Over 65 year-old women without any risk factors• Below 65 year-old postmenopausal women with one or more risk factors• Postmenopausal women with fracture history• Long term steroid use• Primary hyperparathyroisim• Treatment monitoring
  28. 28. Advantages of DEXA• Useful method in patient follow up• Low radiaton dose (2-4 mRem)• High precision and accuracy• Short time for assessment• Peripheral measurement is available
  29. 29. Disadvantages of DEXA• No differentiation between cortical and trabecular bone tissues• Degenerative changes effet the results negatively• Obesity is a serious problem !• Expensive• Reference values change from country to country• No standardization in the different devices
  30. 30. Bone Biopsy– It is usually preferrred from the iliac crest– Invasive but definite diagnostic tool– It must be done in certain conditions such as renal osteodystrophy and osteomalaciaNormal Bone Osteoporotic Bone
  31. 31. Can osteoporosis be cured ? Yes !
  32. 32. Management of OP - I• The therapeutic approach to OP is a complex• It means not only taking some medicine but also – changing a life style – leaving some harmful habituations (e.g. smoking, alcohol), and – increasing physical activity and exercise
  33. 33. Management of OP- II• Early diagnosis is the best to preserve bone mass• Medical treatment can slow bone loss and decrease the risk of fracture• A rehabilitation program designed to reduce pain, increase mobility, and minimize risk of falling is necessary
  34. 34. Antiresorptive Stimulant Complex agents agents agentsHRT, ERT Parathormon (PTH) Active vitamin DBiphosphonates (ETD, ALN, Floride metabolitesRSD, IBN, ZLD) Anabolic steroidsSERM (Raloxifen, Basedoxifen,Lasodoxifen, Arzoxifen)Calcium, Magnesium NEW AGENTS NEW AGENTS NEW AGENTSSteroid analogs Growth hormon Experimental agents Ipryflavone Growth factors Vitamin K Tibolone Statins Vitaim CAnticytokines Transcription factors Nitric oxide Osteoprotegerine Calcium receptor Trace elementlsDisintegrins sensibilizating medicines CupperProton pump inhibitors ManganeseProstoglandin synthetase Zincinhibitors Silicone Thyazide diuretics
  35. 35. Osteoporosis Rehabilitation• Treatment of pain• Physical restoration• Diet, medical treatment, exercises• Correcting the disability• Education of the patient and his/her family• Prevention of falls
  36. 36. Who falls and how?• People at the age of 50s walk fast and they cast forward themselves and lean on their hands over the floor while they are falling• That is why it is easy for them to have wrist fractures• Advanced in years they walk more slowly and they fall over their hips
  37. 37. Reasons for increase in the risk of falling• Diminished hearing and vision• Muscle weakness• Posture and balance disorder• Excess alcohol intake• Hypertension• Diabetes mellitus• Parkinson’s disease
  38. 38. How to prevent falls ?• Appropriate clothes and shoes• Regularly ophthalmologic examination• Use of supportive devices• Walking on a smooth way• Moving slowly and safely
  39. 39. Helpers
  40. 40. Effects of exercises• Execises increases bone mass• Exercises prevent falls by increasing the muscle strength, endurance, balance, and coordination• Exercises provide good posture
  41. 41. Types of ExercisesThere are 5 types of exercises recommended for osteoporosis:• Stretching exercises• Aerobic exercises performed by body mass• Strengthening exercises• Exercises with high power• Balance exercises
  42. 42. Stretching Exercises
  43. 43. Stretching Exercises
  44. 44. Aerobic exercises performed by body mass
  45. 45. Aerobic Exercises
  46. 46. Strengthening exercises
  47. 47. Strengthening exercises
  48. 48. Exercises with high power
  49. 49. Balance and Coordination Exercises
  50. 50. Recommended Sportive Activities• Walking with tempo• Tennis• Golf• Skiing• Dancing• Swimming ?
  51. 51. Swimming is better than nothing !
  52. 52. Not Recommended Sportive Activities• Horsing• Canoe• Windsurf• Soccer• Cycling ?
  53. 53. Thank you

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