Osteoperosis, nutrition and fragility Flashcards
What is a fragility (low energy) fracture?
A fracture which occurs without excess force
or
follows a fall from standing height or less
Are fractures common?
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
Serious consequences of hip fracture
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
The aging population
Population > 65 years in Europe
12-17 % in 2002
20-25 % by 2025
& it will get worse!
Vertebral fractures
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
Cost of fractures
Fractures / year (UK) Hip 70,000 Wrist 50,000 Spine 120,000 COST = £ 2 billion / year = > £5 million / day!
Fragility fractures: basics
Common Cause significant Morbidity Mortality Expensive Partly preventable
Why do people break bones?
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
Why do people break bones?
Bone strength is reduced
They fall
Fracture prevention
Children / Adolescents / Young Adults: optimise peak bone Mass
Adults: prevent deterioration of bone quality
Prevent falls
£ Identify the elderly at high risk £
Optimising peak bone mass
Diet
Exercise
Sex hormones
How to identify fracture risk in older people - history and examination
Increasing Age Previous Fracture Light weight ( BMI < 18 ) Family History of osteoporosis Smoking Alcohol Many medical Disorders
Predicting fragility fracture
Steroids > 3 months
65 years
Use Preventative Treatment
Cushings sydrome, or more commonly treatment with pharmacological doses of glucocorticoids are potent causes of osteoporosis.
Effect of inflammatory conditions on fragility fracture
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.
Androgen deprivation therapy e.g. in prostate cancer
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.
Other medical disorders predisposing to osteoperosis
Endocrine disorders Thyrotoxicosis Hyperparathyroidism Pituitary disease Conditions causing Nutritional Deficiency Malabsorption conditions Eating disorders Alcoholism Inflammatory conditions Many chronic general medical conditions
Using technology to prevent risk
DEXA scan
Heel ultrasound scanning devise
WHO FRAX risk calculator
Fracture prevention
FRACTURE PREVENTION EXERCISE – bone build FALLS PREVENTION Identify risk of… Education Posture & balance classes
Management of fracture
MANAGEMENT OF FRACTURE
(Hip, spine, shoulder, wrist, ankle)
Decrease Pain Increase Confidence
, Increase Function = Decreased risk of further fracture
Biggest areas of impact in osteoperosis
Hip
Spine
Thoracic kyphosis effects
backache
extensor muscles of back overworked
front abdominal muscles become baggy
Vertebral fractures cause pain
Vertebral fractures cause pain Bones - these heal Muscles Nerves Ligaments
Personal impact of vertebral fractures
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..
What do physiotherapists do?
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
Hip fracture
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 & gait problems
Personal impact of hip fractures
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
Physiotherapy for hip fractures
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
Prescribing exercise
Patient Specific: Goal ↓pain, ↓ falls, ↑ bone loading
ENJOYABLE, REGULAR, SUSTAINABLE
Weight bearing exercises
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.
Strength training
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.
Falls prevention
Posture, flexibility, co-ordination, balance .
E.g. Swimming/hydro, Tai Chi, yoga, OTAGO, balance classes, Pilates, Alexandra technique etc.
Role of physio in osteoperosis and fractures
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!
Objectives of drug treatment
Prevent bone breakdown Inhibit Osteoclasts Stimulate Bone Build up Stimulate Osteoblasts Modify Osteocyte activity
Clinical objectives of drug failure
Prevent ALL types of fracture Vertebral Nonvertebral Hip Others
bisphosphonates
inhibit osteoclast action
by inhibiting an important enyme
Oral nitrogen containing bisphosphonates
Prevent Hip & Spine fracture Generic Alendronate ( weekly ) Generic Risedronate ( weekly ) Prevention of spine fracture only Ibandronate ( monthly )
How to take alendronate, risedronate and oral ibandronate
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
Side effect of nitrogen-containing bisphosphonates
Contact stomatitis if chewed
Oesophageal ulcer if not taken stood up with full glass of water
What can impede alendonrate absorption?
proton pump inhibitors
Zoledronat
IV - 5mg infused over 15 minutes annually
Reduced fractures: spine, hip and non-spine
reduced mortality
Rare side effects of nitrogen containing bisphosphonates
Jaw osteonecrosis - 1/10,000 on long term use
Atypical femoral shaft fracture - 1/10,000 - ask about femoral shaft pain!
Rank ligand and osteoclasts
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
Denosumab 60 mg S/C
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 & Hip Fractures
Osteoporosis - AnabolicTreatment
Helps build up bone S/C PTH 1-34 Daily s/c Injection Pulse of PTH Anabolic to bone Reduces Fractures Vertebral
Other therapies for treating fractures
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
Antiremodelling Drugs with evidence Prevention of HIP & Vert. FRACTURE
ALENDRONATE (weekly) RISEDRONATE (weekly) ZOLENDRONATE IV ( annually) DENOSUMAB s/c ( 6 monthly ) HRT ( Not Tibolone ) Calcium & Vitamin D (In elderly )
Anabolic Drugs with Evidence
Teriparatide ( PTH 1-34 ) Abaloparatide PTH / PtHRP analogue Rososumab Antisclerostin antibody Increases Wnt Signaling in bone
Sclerostin antibody
Sclerostin inhibits WnT signalling which ACTIVATES osteobast, so sclerostin antibody inhibits sclerostin leading to WnT signalling and ACTIVATION of osteoblast
