Osteoporosis is characterized by low bone mass and deterioration of bone structure, leading to increased bone fragility and risk of fractures. It is defined by the World Health Organization (WHO) as a bone mineral density more than 2.5 standard deviations below the mean of young healthy adults. Risk factors include estrogen depletion, low body weight, prior fractures, and certain medical conditions or medications. Treatment involves lifestyle modifications like calcium, vitamin D, and weight-bearing exercise supplementation as well as pharmacologic agents like bisphosphonates, RANKL inhibitors, and anabolic drugs. Rehabilitation after fractures focuses on pain management, mobility training, bracing, and vertebroplasty or kyphoplasty if needed.

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