This document provides an overview of osteoporosis, including its definition, epidemiology, diagnosis, pathophysiology, clinical features, differential diagnosis, outcome measures, management, and more. Some key points: - Osteoporosis is defined as a systemic skeletal disease characterized by low bone mass and deterioration of bone tissue, leading to fragile bones and increased susceptibility to fractures. - It predominantly affects postmenopausal women, with prevalence as high as 80% in India having osteoporosis or osteopenia. - Diagnosis is based on bone mineral density T-scores measured via dual-energy x-ray absorptiometry. Medical management involves antiresorptive and an

1. OSTEOPOROSIS
Radhika Chintamani

2. Contents
• Definition
• Epidemiology
• Diagnostic and causative classification
• Physiology and pathophysiology
• Clinical features
• Postmenopausal and juvenile osteoporosis
• Differential diagnosis
• Outcome measures
• Diagnosis
• Management
• References

3. DEFINITION
• WHO has defined osteoporosis as a systemic
skeletal disease characterized by low bone
mass and micro architectural deterioration of
bone tissue, with a consequent increase in
bone fragility and susceptibility to fracture.

4. Epidemiology
• >61 million Indians have osteoporosis.
• Of these 80% are females.
• India has highest prevalence of osteoporosis and
osteopenia in the world followed by Japan.
• The mean bone mineral density (BMD) in India is about
two SDs lower than in women in the western
population. The prevalence of low bone mass is to the
extent of 40% from the age of 40 years and increases
to more than 62% by age 60 years and 80% by the age
of 65 years.

5. Diagnostic classification(definition based on T scores)
Normal (<-1 SD) A value of BMD that is below 1 SD of the
young adult reference mean.
Osteopenia (>-1 to -2.5
SD)
A value of BMD more than 1 SD below young
adult mean but less than 2.5 SD below this
value.
Osteoporosis (>-2.5 SD) A value of BMD that is 2.5 SD or more below
the adult mean.
Severe osteoporosis Value of BMD that is more than 2.5 SD below
young adult mean in presence of 1 or more
fragility fracture.

6. Fragility fractures
• Fracture occurring spontaneously or
following minor trauma such as a fall
from standing height or less.
• They exclude craniofacial, hand, ankle
and foot fractures.
• Represent 80% of fractures occurring in
post menopausal women aged 50 years
and older.
• It has a greater impact on quality of life
than COPD, diabetes or heart disease.

7. Normal physiology

8. Pathophysiology and bone fragility
• Uncoupling of remodeling
• Production of RANKL()
• Osteoclastogenesis

9. Causative Classification
• Primary-
1. age related bone loss in both men and
women.
2. Estrogen depletion in post menopausal
women.
• Secondary to any condition.

10. Conditions, diseases and medications that contribute to osteoporosis
• I. lifestyle factors:
Alcohol abuse
Smoking (A/P)
Excessive thinness
Excess vitamin A
Vitamin D insufficiency
Frequent falling
Sedentary lifestyle
Immobilization
Low calcium intake
High salt intake
• II. Genetic diseases
Cystic fibrosis
Glycogen storage diseases
Osteogenesis imperfecta
Homocystinuria
Parental history of hip
fractures
Porphyria
• III. Hypogonadal states
Androgen insensitivity
Anorexia nervosa
Athletic amenorrhea
Premature
menopause(<40 yrs)
• Endocrine disorders
Central obesity
Cushing’s syndrome
Hyperparathyroidism
Thyrotoxicosis
Diabetes mellitus
• GI disorders
IBD
Gastric bypass
Malabsorption

11. • Hematologic disorders
Hemophilia
Leukemia
Thalassemia
Myeloma
• Rheumatologic & autoimmune
diseases
AS
RA
systemic lupus
• Neurological and MSK
Epilepsy
MS
Dystrophy
PD
SCI
Stroke
• Miscellaneous
AIDS
COPD
CHF
Depression
Renal disease
Weight loss
Idiopathic scoliosis
• Medications
Antacids
Thyroid hormones
Parental nutrition
Anticoagulants
Anticonvulsants
Cancer chemo drugs
Glucocorticoids
Barbiturates
SSRIs
methotrexate

12. Generalized osteoporosis
• Senile/postmenopausal osteoporosis
• Drug induced-steroids, heparin
• Deficiency states- abnormal protein metabolism
• Neuromuscular diseases or dystrophies
• Osteogenesis imperfecta
• Ankylosing spondylitis
• Idiopathic juvenile osteoporosis
Localised osteoporosis
• Immobilized limb after trauma/fracture

13. Clinical features
• Osteoporosis has no
clinical warning signs
or symptoms.
• Opportunistic
diagnosis after a
fragility fracture.
• Silent Compression
fractures in the spine
can cause diffuse
back pain, reduced
mobility and
participation in
activities of daily
living.

14. Pathogenesis of osteoporosis related
fractures

15. Fractures
• Postmenopausal osteoporosis(type 1)-
fractures tend to involve predominantly the
vertebral bodies. Deformities range from
subtle indentations of end plates, wedging and
cod fish appearance and complete collapse of
vertebral body.
• Senile(type II)- Fractures tend to involve
peripheral skeleton. Typical sites are-femoral
neck, distal radius and ribs.

16. Vertebral fractures

17. Abnormal forces due to vertebral fractures

18. Post menopausal osteoporosis
• Onset of menopause at an
early age.
• Genetic components:
polymorphisms in estrogen
and vitamin D receptors has
been implicated in the
pathogenesis of
osteoporosis.
• Indians are known to be
deficient in vitamin B12, folic
acid, and vitamin D.
• Can be primary or secondary.

19. Post menopausal osteoporosis
There is an
accelerated
bone loss at the
rate of 2 5%‑
per year due to
declining
estrogens levels
and is seen in
the first 5 7‑
years after
menopause.

20. • A study done by keramat et al in which they have studied the
risk factors for osteoporosis in post menopausal women in
Indian and Iranian women showed that the following are
significant risk factors for Indian women:
1. Menstrual factors such as late menarche (after 14 years old),
early menopause (before 45 years old) and Postmenopausal
period more than 5 years.
2. multi-parity more than 3.
3. Bone and joint problems.
4. nil consumption of milk.
5. pure vegetarianism.
6. red meat consumption more than 4 times per week was a risk
factor among Iranian subjects.
7. no regular walking.
8. Height less than 155 cm have been shown as a risk factor of
osteoporosis in Indian subjects and in private center of Iran.
9. Cigarette smoking induces early menopause.

21. Juvenile/pediatric osteoporosis
• The WHO definition of
osteoporosis is functionally
valid for adults.
• At the first pediatric
consensus development
conference, Pediatric
Osteoporosis was defined as
bone density Z score below -2
in combination with a fracture.
• Disease is self limiting with
spontaneous clinical and
radiological improvement.

22. Differential diagnosis
• Osteomalacia
• Bone tumors
• Osteonecrosis
• Leukemia
• Lymphoma

23. Outcome measures in osteoporosis
• Qualeffo-41 questionnaire:
Contains 5 domains:
1. Pain
2. Physical function
3. Social function
4. General health perception
5. Mental function(mood)
Lower the score better is the quality of life.

24. • Osteoporosis Assessment Questionnaire-
Physical Function (OPAQ-PF)
A reliable and valid disease-targeted measure
of health-related quality of life (HRQOL) in
osteoporosis.
Also for evaluating treatment effectiveness.

25. Outcome measures used in menopausal
osteoporosis
• Greene Climacteric Scale,
• Women’s Health Questionnaire,
• Menopause Rating Scale
• Utian Quality of Life Scale.

26. Diagnosis
• Bone mineral content(BMC) and bone mineral
density(BMD) measured using
1. Dual energy x-ray absorptiometry(DXA)
2. Quantitative computed tomography(QCT)
3. Quantitative ultrasound(QUS)
4. Bone markers
5. Body composition measures
• FRAX() Tool

27. DXA scores (interpretation)
• T score-used to estimate risk of developing a
fracture.
• T score= measured BMD-mean value of young
adults / SD of young normal
• Z score= measured BMD-mean value of age &
gender matched / SD of age & gender
matched individuals.

30. FRAX
• frax tool.html
• A simple web and paper–based method of
calculating probability of fracture risk.
• FRAX is able to calculate fracture risk with or
without bone mineral density values.
• Predicts 10 year risk of hip fracture or
osteoporotic fracture.

31. Vertebral imaging
• A vertebral fracture is consistent with diagnosis of
osteoporosis even in absence of a bone density
diagnosis.
• Radiographically confirmed vertebral fractures are a
sign of impaired bone quality and strength and a
strong predictor of new vertebral and other
fractures.
• Vertebral imaging can be performed using a lateral
thoracic and lumbar spine x-ray or a lateral vertebral
fracture assessment(VFA) done on a DXA machine.

35. Biochemical markers of bone turnover
• Resorption markers-
- Serum C-telopeptide(CTX)
- Urinary N-telopeptide(NTX)
• Formation markers-
- Osteocalcin
- Serum specific alkaline phosphatase(BSAP)
- Aminoterminal propeptide of type 1
procollagen(P1 NP)

36. Singh’s index

37. Metacarpal index
• Thinning of cortex(feature of osteoporosis) is
most reliably demonstrated in 2nd
metacarpal
at the diaphysis.
• Normally cortical thickening should be
approximately 1/4th
to 1/3rd
the thickness of
metacarpal.

39. Other tests associated with osteoporosis
• Serum calcium
• Serum phosphurus
• Liver function test
• Kidney function test-GFR
• Complete blood count
• TSH
• Testosterone levels
• Serum creatinine
• Vitamin D levels

40. Medical management
Drugs
Antiresorptive
Biphosph
onates
Estrogen receptor
modulators-
raloxifene
calcitoni
n
Hormone
replacement
therapy
Anabolic
Synthetic human PTH-
teriparatide
Newer options:
Denosumab- human monoclonal antibody to RANKL.
Zolendronic acid
Strontium ranelate

41. Physiotherapy management
• Conventional
physiotherapy:
- Treatment of low back
pain.
- Basic stabilization exercises
for the spine.
- Walking, stair climbing and
weight bearing exercises

42. Exercise prescription
• Frequency: weight bearing aerobic 3-5d/wk
resistance training 2-3d/wk
• Intensity: moderate intensity 40-60% HRR for weight
bearing exs. 60-80% of 1 RM,8-12 reps for resistance exs.
• Time: 30-60 mins/day
• Type:
1. Weight bearing-stair climbing, walking with intermittent
jogging.
2. Resistance exs-weight lifting.

43. Recent advances
• Guido et al., evaluated the effects of physical
therapy on quality of life in osteoporosis patients.
44 osteoporotic patients were divided into 2
groups conventional exercises and sling exercises.
QOL was assessed using QUALEFFO-41
questionnaire.
Both groups showed significant improvement in
BMD but greater improvement in the sling
exercises group.

44. Sling exercises

45. • S.von Stengel et al., studied the effect of a
multifunctional training program and whole
body vibration on lumbar BMD in
postmenopausal women.
They found that a combination of the above
two gave significant results than whole body
vibration alone.

46. Type of exercise in middle aged adults
• High intensity progressive resistance training
is effective in improving vertebral BMD.
• High impact weight bearing exercises are
effective for femoral neck BMD.
• Premenopausal women

48. Type of exercise in older adults
• A meta-analysis has reported that mixed
impact loading programs including low-
moderate impact exercises such as jogging,
walking and stair climbing were most
effective for preserving BMD at the lumbar
spine and femoral neck when combined with
resistance training.

50. Functional electrical stimulation
• In Spinal cord injuries for extensive muscle and bone
atrophy below site of injury.
• In a study of 6 chronic and acute SCI patients, electrical
stimulation improved systolic and diastolic pressure
thereby activating the muscle pump.
• Improved circulation indirectly provides nutrition to the
bone reducing bone loss.
• Eser and collegues(2003) showed that muscle stimulation
for 30 mins/day immediately after onset of paralysis
slowed the rate of bone loss by 50% in the tibia.

51. T’ai chi chuan
• Recently emerged exercise modality
• Characterized by high demand for neuromuscular
coordination, low velocity of muscle contraction, low
impact and minimal weight bearing.
• In a case control study in postmenopausal women t’ai
chi significantly reduced trabecular bone loss in
tibia( Qin et al., 2002)
• Improves muscle strength, flexibility and
neuromuscular coordination thus reducing fall related
fracture risk in elderly.(Lane 1999)

52. T’ai chi chuan

54. Ergonomics
Outdoors:
 Use a cane or walker for added stability.
 Wear rubber-soled shoes for friction.
 Walk on grass when sidewalks are slippery.
 Be careful on highly polished floors that
become slick and dangerous when wet.

55. Indoors:
 Keep rooms free of clutter, especially on floors.
 Keep floor surfaces smooth but not slippery.
 Wear supportive, low-heeled shoes even at home.
 Avoid walking in socks, stockings, or slippers.
 Be sure carpets and area rugs have skid-proof backing or are
tacked to the floor.
 Be sure stairwells are well lit and that stairs have handrails on
both sides.
 Install grab bars on bathroom walls near tub, shower, and toilet.
 Use a rubber bath mat in shower or tub.
 Keep a flashlight with fresh batteries beside your bed.
 If using a step stool for hard-to-reach areas, use a sturdy one
with a handrail and wide steps.
 Add ceiling fixtures to rooms lit by lamps.

56. Prevention

57. References
1. Oxford textbook of orthopaedics & trauma-christopher bulstrode.
2. ACSM
3. Osteoporosis-A guide for clinicians by pauline and miller.
4. Osteoporosis-clinical guidelines for prevention, diagnosis and management-
Sarah and theresa.
5. Fundamentals of diagnostic radiology by william brant.
6. Clinical imaging: An atlas of differential diagnosis by ronald eisenberg.
7. Musculoskeletal imaging by klaus bohndorf and herwig imhof.
8. 2014 clinicians guideline to prevention and treatment of osteoporosis.
9. National osteoporosis foundation guidelines.
10.Osteoporosis: R Keith-alternative medicine review vol 12, 2007.
11.Osteoporosis:review, genetics and hormones by R Rizzoli.
12.Physical activity and bone health by karim khan.
13.Journal of molecular endocrinology, 2001-R Rizzoli.
14.2010 canada guidelines for osteoporosis.
15.Indian journal of orthopedics: heel ultradensitometer-H Rao et al., 2003.