Metabolic bone disease Flashcards
bone remodelling
bone made up of collagen, calcium/magnesium, carbonate
bone is trabecular/ cortical
regulated by hormones hormones (calcitonin, Parathroid hormone (PTH), Vit D, oestrogen, testosterone)
Continuous remodelling
6 functions of bone
- protect internal organs
- stores and release of fat
- stores and release of minerals
- facilitate movement
- supports in the body
3 bone cells
- Osteoblast - produce bone matrix and initiates bone mineralisation
- osteoclast - resorption of bone
- osteocyte - derived from osteoblasts in bone, transport Ca++ through bone
Peak bone mass
Peak bone mass occurs in late teens/early 20’s 60% during puberty Consolidation complete at 30 yrs 1% loss per year thereafter Accelerated in women after menopause Declines thereafter Influenced by Genetics Diet Physical activity Hormones
Osteoporosis
low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk
Osteoporosis risk factors
modifiable smoking low BMI sedentary lifestyle diet - low Ca/ vit D long term corticosteroid use alcohol
non modifiable age gender ethnicity early menopause family history
Osteoporosis secondary causes
AN male hypogonadism chronic liver disease renal disease Coeliac disease RA hyperparathyroidism IBD Vit d deficiency
Aetiology/ causes of osteoporosis
Bone remodelling
normally bone formation >resorption
Osteoporosis -Resorption> Formation
Osteoporosis - primary
Type 1 - females
hormone related
Post menopausal
Site - vertebrae
Type 2 Male and female Age related >70 decrease activity of osteoblasts low sunshine low Ca Low Vit D Increase parathyroid hormone increase bone resorption
Osteoporosis - Secondary
Predisposed to reduced bone density
- nutrition
- hormonal
- drugs
- Disease
- Rheumatological conditions
Investigations
DEXA X-ray - not useful (except for fractures) Ultrasound Bone scans Lab - bone tests Many markers normal USed to outrul other pathologies
DEXA
gold standard for OP
integrated measure of bone type to give measure of BMD
clinical features
Pain
E.g. Back pain
May only be present with fracture /severe deformity
Deformity e.g increased kyphosis
Fractures Mid-thoracic Low thoracic/upper lumbar Femoral neck Distal forearm/Wrist
Deformity Loss of height Kyphotic ‘long legs’ Dowager’s hump
Other
abdominal skin creases
Respiratory
Resp Tract Infection (RTI) secondary to rib fracture (#)
At risk groups
elderly fallers 1/2 women 1/8 men over 50 have osteoporosis related fracture cost implications
Progression + prognosis
cant be cured
can slow rate of bone loss
Prevention
education and awareness HRT Diet - Ca/ Vit D Medications WB exercises
MGMT
MDT education Drug therapy Physio/ OT Dietician Fracture mgmt Falls services identify those at risk
Medical mgmt
increase bone mass/ reduce rate of bone loss
Biphosphonate drugs reduce rate of bone absorption Actonel, Fosamax, Bonviva
Hormone Replacement Therapy (HRT)
Small increased risk of Breast Cancer (Ca)
Calcium + Vitamin D supplements
Physio assessment
SE - Pain - Social history - Falls history - Fracture history -DEXA results - Co-morbidities - meds PE - Posture - height - spinal mobility UL and LL mobility strenght/ endurance balance - berg balance test Function - up and go
physio mgmt
Education Self management Lifestyle risk factors Diet/Smoking/Caffeine Exercise Pain relief- options ? Postural correction WB Exercise Hydrotherapy General mobility and balance for falls prevention
Targeted WB exercise
Low impact WB activity
Characterised by always having one foot on the floor.
High impact training is not suitable for patients with osteoporosis e.g. jumping (both feet off floor)
Non-WB exercise e.g. swimming / cycling - do not stimulate bone adaptation
Resistance exercise
Weights three times / week for 30 minutes
Precautions before starting exercise
Why? Screening Questionnaires/GP sign- off
exercises for preventing and treating Osteoporosis
static WB ex dynamic low forc eWB exercise NWB force progressive Exercise NWB low force PRE combination progressive resistance strength training NWBHF for lower lim for decrease in BMD in NOF walking resistance training impact-loading activities
when is physio CI
manual therapy
manual chest clearance
Fracture mgmt
vertebral fracture
initial
bed rest and pain relief
spinal brace
later
- assessment
- Posture/ taylor brace
- exercise and HEP
other
- environmental factors
fragility fracture
Fragility fracture is a type of pathologic fracture that occurs as result of normal activities, such as a fall from standing height or less
Assessment
Advice /Education
Falls history and falls risk assessment
MDT -medical / dietician/physio/OT etc.
other metabolic diseases causes clinical features diagnosis treatment prevention mgmt
osteomalacia - rickets - soft bones - lack of vit D - inadequate mineralisation of osteoid framework cause vit d def immobility malabsorption renal disease features - bone deformity - diffuse bone and muscle pain - fatigue - proximal myopathy - hip/spine region
diagnosis - bone biopsy/ x-ray
treat with oral vit D / sun
prevent - education diet Vit D supplements
Paget's disease - increased bone turnover - excessive bone destruction - replacement of bone by fibrous tissue/ abnormal bone - sponhgy - bends later - brittle - fracture
incidence - 4% over 40 1-% over 85 fam history cause = unknown common in pelvis lumbar spine femur humerus skull tibia
investigations decrease in BD then increase --> deformity radioisotope bone scans biochemistry - blood alkaline phosphate levels
may be asymptomatic dull bone pain night pain defomrity in long bones gait changes degenerative jt changes spinal kyphosis headaces
complications pathological fractures non-union stress fracture paraplegia visual loss/ hearing loss osteogneic sarcoma
mgmt Medical / Surgical
Calcitonin & bisphosphonates
Physiotherapy
Pain Management
Improve mobility and functional restrictions
