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Osteoporosis 03.04.2013
- 1. OSTEOPOROSIS Gülseren AKYÜZ, M.D., Prof. Marmara University School of Medicine Department of Physical Medicine and Rehabilitation
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- 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 quality NIH Consensus Development Panel of Osteoporosis JAMA 285 :785 95,2001
- 4. The New Concept:Osteoporomalacia matrix matrix mineral mineral Normal Osteoporosis matrix matrix mineral mineral Osteomalacia Osteoporosis / malacia
- 5. Classification of OP- I GENERALIZED • 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. 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. Classification of OP- III REGIONAL • Complex regional pain syndrome = CRPS • Immobilization / disuse • Transient regional osteoporosis • Regional migratory osteoporosis
- 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. 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. TYPE I TYPE II Postmenopausal Senile Age (years) 50-70 >70 Sex ratio (F:M) 6:2 2:1 Types of bone Mainly Trabecular and loss trabecular cortical Fracture sites Vertebrae and/or Proximal femur distal radius Main causes Menopause Aging
- 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. Pathogenesis of OP- II A- The factors affecting peak bone mass • Genetic – Vitamine D receptor gene – Procollagen type I gene – The receptors of estrogen • Hormonal and nutritional factors • Environmental factors B- The factors affecting the rate of bone turnover • The differences between trabecular and cortical bone structure • The differences between men and women
- 13. Signs and Symptomsof 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. Signs and Symptomsof OP - II • back pain • loss of height • increased kyphosis • immobility • increased number of bed days • loss of self-esteem • distorted body image • depression
- 15. Signs and Symptomsof OP - III • Reduced pulmonary function • Bone tenderness • Extreme fatigue • Brittle or soft fingernails • Premature grey hair • Leg cramps at nights
- 16. 20 years 50 years 77 years
- 17. Risk Factors forOsteoporosis With 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. Other Risk Factors •Muscle weakness • Balance problems (Neurologic, vestibular, ophthalmologic problems) • Visual deficiency • Slow walking • Worsened heel-finger walking (arthrodesis, etc.)
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- 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. Differential Diagnosis Ca PO4 ALP 25(OH) D PTH Ca PO4 HP BLOOD URINE Type 1 OP N N N N N ↑ N ↑ Type 2 OP N N N N↓ N↑ N N N Osteomalacia ↓N ↓ ↑ ↓ N↑ ↑↓ N↓↑ N Metastatic dise. N↑ N N↑ N N↑ N↑ N ↑
- 22. Bone Markers BoneFormation Bone Resorption Blood Blood Total alkalen phosphatase Tartrate-resistant acid Bone spesific alcalene phosphatase phosphatase (BALP) Osteocalcine Gamma carboxy glutamic acid Procollagen type I Procollagen type II Urine Urine Calcium/Creatinine Deoxypyridynolyn None Pyridynolyn Hydroxylysine and glycosides N-telopeptide (NTX), C-telopeptide (CTX)
- 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. Semiquantitative assessment ofvertebral fractures SQ stage 0 normal 1 mild 2 moderate 3 severe Genant et al. J BoneGenant et al. 1993: 8;Mineral Res 1993: 8; 1137-48 Mineral Res J Bone 1137-48
- 26. BONE MINERAL DENSITYMEASUREMENT When to do ? From whom to request ?
- 27. World Health Organization’sClassificaiton T-Score Normal - 1 and above Low Bone Density between -1 and -2.5 Osteoporosis < - 2.5 Established < - 2.5 and 1 or more Osteoporosis fracture Kanis JA et al, J Bone Miner Res, 1994;9:1137-1141
- 28. Indications of BMDmeasurements • 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
- 29. 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
- 30. 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
- 31. Bone Biopsy – Itis usually preferrred from the iliac crest – Invasive but definite diagnostic tool – It must be done in certain conditions such as renal osteodystrophy and osteomalacia Normal Bone Osteoporotic Bone
- 32. Can osteoporosis becured ? Yes !
- 33. 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
- 34. 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
- 35. Antiresorptive Stimulant Complex agents agents agents HRT, ERT Parathormon (PTH) Active vitamin D Biphosphonates (ETD, ALN, Floride metabolites RSD, IBN, ZLD) Anabolic steroids SERM (Raloxifen, Basedoxifen, Lasodoxifen, Arzoxifen) Calcium, Magnesium NEW AGENTS NEW AGENTS NEW AGENTS Steroid analogs Growth hormon Experimental agents Ipryflavone Growth factors Vitamin K Tibolone Statins Vitaim C Anticytokines Transcription factors Nitric oxide Osteoprotegerine Calcium receptor Trace elementls Disintegrins sensibilizating medicines Cupper Proton pump inhibitors Manganese Prostoglandin synthetase Zinc inhibitors Silicone Thyazide diuretics
- 36. 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
- 37. Who falls andhow? • 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
- 38. Reasons for increasein the risk of falling • Diminished hearing and vision • Muscle weakness • Posture and balance disorder • Excess alcohol intake • Hypertension • Diabetes mellitus • Parkinson’s disease
- 41. How to preventfalls ? • Appropriate clothes and shoes • Regularly ophthalmologic examination • Use of supportive devices • Walking on a smooth way • Moving slowly and safely
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- 43. Effects of exercises •Execises increases bone mass • Exercises prevent falls by increasing the muscle strength, endurance, balance, and coordination • Exercises provide good posture
- 44. Types of Exercises Thereare 5 types of exercises recommended for osteoporosis: • Stretching exercises • Aerobic exercises performed by body mass • Strengthening exercises • Exercises with high power • Balance exercises
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- 47. Aerobic exercises performedby body mass
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- 51. Exercises with highpower
- 52. Balance and CoordinationExercises
- 53. Recommended Sportive Activities • Walking with tempo • Tennis • Golf • Skiing • Dancing • Swimming ?
- 54. Swimming is betterthan nothing !
- 55. Not Recommended SportiveActivities • Horsing • Canoe • Windsurf • Soccer • Cycling ?
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