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BSMS204 Theme 2 Musculoskeletal > Osteoperosis, nutrition and fragility > Flashcards

Osteoperosis, nutrition and fragility Flashcards

1
Q

What is a fragility (low energy) fracture?

A

A fracture which occurs without excess force
or
follows a fall from standing height or less

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2
Q

Are fractures common?

A 
They are very common! In The EU someone fractures their Hip Every 30 secs
1/3 women > 50 years
2/3 women > 80 years 
1/12 men    > 50 years
1/5 men  eventually
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3
Q

Serious consequences of hip fracture

A

20% death within one year
30% permanent disability
40% unable to walk independently
80% unable to carry out at least one independent activity of daily living

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4
Q

The aging population

A

Population > 65 years in Europe
12-17 % in 2002
20-25 % by 2025
& it will get worse!

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5
Q

Vertebral fractures

A

Clinical and silent vertebral fractures increase pain and reduce activity

Only 1/3 vertebral fractures come to clinical attention. All vertebral fractures impact on quality of life.

Lose height

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6
Q

Cost of fractures

A 
Fractures / year (UK)
 Hip     70,000
 Wrist  50,000
 Spine  120,000
COST = £ 2 billion / year 
   = > £5 million / day!
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7
Q

Fragility fractures: basics

A 
Common
Cause  significant
 Morbidity
 Mortality
Expensive
Partly preventable
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8
Q

Why do people break bones?

A 
Bone strength is reduced
Sub optimal peak bone mass
Reduced bone quality
Reduced bone Mineral ( Calcium )
Deteriorating architecture
Change in crystal size & composition
Abnormal collagen
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9
Q

Why do people break bones?

A

Bone strength is reduced

They fall

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10
Q

Fracture prevention

A

Children / Adolescents / Young Adults: optimise peak bone Mass

Adults: prevent deterioration of bone quality

Prevent falls

£ Identify the elderly at high risk £

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11
Q

Optimising peak bone mass

A

Diet
Exercise
Sex hormones

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12
Q

How to identify fracture risk in older people - history and examination

A 
Increasing Age
Previous Fracture 
Light weight ( BMI < 18 )
Family History of osteoporosis
Smoking
Alcohol
Many medical Disorders
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13
Q

Predicting fragility fracture

A

Steroids > 3 months
65 years
Use Preventative Treatment

Cushings sydrome, or more commonly treatment with pharmacological doses of glucocorticoids are potent causes of osteoporosis.

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14
Q

Effect of inflammatory conditions on fragility fracture

A

Inflammatory conditions may be associated with reduced BMD. This is seen even in those not treated with Steroids. High levels of inflammatory cytokines may stimulate osteoblast activity.

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15
Q

Androgen deprivation therapy e.g. in prostate cancer

A

Men with prostate cancer are often treated with long acting GnRH analogues – these lower the testosterone concentration to castrate levels resulting in loss of bone density in the same way as when a women goes through the menopause.

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16
Q

Other medical disorders predisposing to osteoperosis

A 
Endocrine disorders
Thyrotoxicosis
Hyperparathyroidism
Pituitary disease
Conditions causing Nutritional Deficiency
Malabsorption conditions
Eating disorders
Alcoholism
Inflammatory conditions
Many chronic general medical conditions
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17
Q

Using technology to prevent risk

A

DEXA scan
Heel ultrasound scanning devise

WHO FRAX risk calculator

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18
Q

Fracture prevention

A 
FRACTURE PREVENTION
EXERCISE – bone build 
FALLS PREVENTION
Identify risk of…
Education
Posture &amp; balance classes
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19
Q

Management of fracture

A

MANAGEMENT OF FRACTURE
(Hip, spine, shoulder, wrist, ankle)

Decrease Pain Increase Confidence

, Increase Function = Decreased risk of further fracture

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20
Q

Biggest areas of impact in osteoperosis

A

Hip

Spine

21
Q

Thoracic kyphosis effects

A

backache
extensor muscles of back overworked
front abdominal muscles become baggy

22
Q

Vertebral fractures cause pain

A 
Vertebral fractures cause pain
Bones - these heal
Muscles
Nerves
Ligaments
23
Q

Personal impact of vertebral fractures

A 
Social  - drive/washing/isolation
Family 
Depression -fragile/chronic pain
Body image
Sleep deprivation
General health – bowel, urine, swallowing, breathing, decrease activity = weight/cardiac ……….List goes on..
24
Q

What do physiotherapists do?

A

Assurance
Relaxation/mindfulness
Education – Safety (falls/high impact/forced flexion)
Empower patient, increase confidence
Pain relief (tens, acupuncture, acupressure, heat, soft tissue mobilisation, pacing, medication, heat)
Hydrotherapy
Exercises Classes – gentle, higher level, falls based, back reconditioning
Spinal supports
Referrals – orthotics, pain management team, vertebroplasty, exercise in community

25
Q

Hip fracture

A

95% caused by falls
1 in 5 dies within a year of fracture
Half of patients do not regain ability to function independently
Expensive
Recovery depends on anatomical location of fracture

Orthopaedic surgery & long rehabilitation

Problems - Muscle adaptations/permanent nerve or ligament damage/muscle wasting/leg length/decrease confidence

	= long term balance &amp; gait problems
26
Q

Personal impact of hip fractures

A

Role in society / family
Unable to drive
Carer

Decrease confidence
Isolation = depression = decrease activity levels = poor physical recovery
Effect of long hospital stay

Can age someone very quickly

27
Q

Physiotherapy for hip fractures

A

Day 1 post op → Long term management
ICT, Outpatient, Falls Services

Improve Gait & Balance
Muscle symmetry (lengthen & strengthen)
Confidence – Exercise & education
Education – Falls safety (eyes, ears, feet, house)
Exercise – classes, community, one to one
Hydrotherapy
Walking aids
Other joint/medical issues limiting exercise/balance
Referrals – pain/podiatrist/medication

28
Q

Prescribing exercise

A

Patient Specific: Goal ↓pain, ↓ falls, ↑ bone loading

ENJOYABLE, REGULAR, SUSTAINABLE

29
Q

Weight bearing exercises

A

Activity where you are supporting the weight of your own body.
Increase BMD: 30 mins, 5 x week – ideally short bursts to activate osteoblasts
E.g. Jogging, aerobics, racquet sports, tennis, dancing, brisk walking, stair climbing etc.

30
Q

Strength training

A

Muscles generate large forces in the tendons and the bones respond to this extra stress by becoming stronger.
Site specific – higher loads / smaller rep 3 x week PROGRESS SLOWLY…..
E.g. Weights or body weight, therabands, resistance exercises, back reconditioning classes, Pilates, hydro etc.

31
Q

Falls prevention

A

Posture, flexibility, co-ordination, balance .

E.g. Swimming/hydro, Tai Chi, yoga, OTAGO, balance classes, Pilates, Alexandra technique etc.

32
Q

Role of physio in osteoperosis and fractures

A

Decrease pain
Decrease fracture risk
Increase function
Exercise and education very powerful in giving a sense fo control to the patient
Fractures huge impact on patient not just their bones!

33
Q

Objectives of drug treatment

A 
Prevent bone breakdown
 Inhibit Osteoclasts
Stimulate Bone Build up
 Stimulate Osteoblasts
 Modify Osteocyte activity
34
Q

Clinical objectives of drug failure

A 
Prevent ALL types of fracture
 Vertebral
 Nonvertebral
Hip
Others
35
Q

bisphosphonates

A

inhibit osteoclast action

by inhibiting an important enyme

36
Q

Oral nitrogen containing bisphosphonates

A 
Prevent Hip &amp; Spine fracture 
 Generic Alendronate  ( weekly )
 Generic Risedronate   ( weekly )
Prevention of spine fracture only
 Ibandronate  ( monthly )
37
Q

How to take alendronate, risedronate and oral ibandronate

A 
Take 
In the morning
With a full glass of water
Standing up
Do not lie down after
No food for 30 minutes
Food inhibits absorption
38
Q

Side effect of nitrogen-containing bisphosphonates

A

Contact stomatitis if chewed

Oesophageal ulcer if not taken stood up with full glass of water

39
Q

What can impede alendonrate absorption?

A

proton pump inhibitors

40
Q

Zoledronat

A

IV - 5mg infused over 15 minutes annually
Reduced fractures: spine, hip and non-spine
reduced mortality

41
Q

Rare side effects of nitrogen containing bisphosphonates

A

Jaw osteonecrosis - 1/10,000 on long term use

Atypical femoral shaft fracture - 1/10,000 - ask about femoral shaft pain!

42
Q

Rank ligand and osteoclasts

A

Rank ligand can be used
Osteoblast makes a cytokine called a RANK ligand which binds to osteoclast and stimulates it to breakdown bone
Osteoblasts also makes another substance which blocks rank ligand
Can use monoclonal antibody against RANK to block it

43
Q

Denosumab 60 mg S/C

A 
Fully Human Monoclonal antibody
IgG2 isotype 
Binds to RANK Ligand 
Decoy Receptor
High affinity
High specificity 
No complement activation
Rapidly absorbed
Long half-life - 26 days ( 34 days with max dose )
6 monthly injection
Cleared by Reticuloendothelial system
No renal excretion
Reduces spine &amp; Hip Fractures
44
Q

Osteoporosis - AnabolicTreatment

A 
Helps build up bone
S/C  PTH 1-34
Daily s/c Injection
Pulse of PTH
Anabolic to bone
Reduces  Fractures
Vertebral
45
Q

Other therapies for treating fractures

A

HRT in 50-60 year olds
Selective oestrogen receptor modulators e.g. raloxifene
Testogel for hypogonadism in men
Tostran - testosterone 2% gel, beware contamination of partners & children
Nebido - injection testosterone uncercanoate 1000mg IM every 10-14 weeks

46
Q

Antiremodelling Drugs with evidence Prevention of HIP & Vert. FRACTURE

A 
ALENDRONATE  (weekly)
RISEDRONATE    (weekly) 
ZOLENDRONATE   IV ( annually)
DENOSUMAB  s/c ( 6 monthly )  
HRT ( Not Tibolone )
Calcium &amp; Vitamin D  (In elderly )
47
Q

Anabolic Drugs with Evidence

A 
Teriparatide  ( PTH 1-34 )
Abaloparatide
PTH / PtHRP analogue
Rososumab
Antisclerostin antibody 
Increases Wnt Signaling in bone
48
Q

Sclerostin antibody

A

Sclerostin inhibits WnT signalling which ACTIVATES osteobast, so sclerostin antibody inhibits sclerostin leading to WnT signalling and ACTIVATION of osteoblast

BSMS204 Theme 2 Musculoskeletal (22 decks)

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