Osteoporosis Flashcards
Whta is the difference between Z scores and T scores?
- Z scores are age matched controls
- T scores are compared to young normal adults of same sex
- There are no Z and T scores for males for bone density
a measure of disease that allows us to determine a person’s probability of being diagnosed with a disease during a given period of time; the number of newly diagnosed cases of a disease
incidence
a measure of disease that allows us to determine a person’s likelihood of having a disease; the total number of cases of disease existing in a population
prevalence
What is the mortality rate after 1 year following hip fracture?
20%
- 25% require LT care
- 50% are functionally impaired forever
What are the SD that define normal, osteopenia, osteoporosis, and severe osteoporosis?
- Normal = BMD within 1 SD of “young normal” adult (T-score at -1.0 and above)
- Osteopenia = 1-2.5 SD of “young normal” adult (t-score between -1 and -2.5)
- Osteoporosis = >2.5 SD
- Severe = >2.5 AND 1 or more fragility fractures exist
Where are the most common sights of fracture?
- distal forearm
- vertebral bodies
- hip
What are the determinants of peak bone mass?
- genotype
- mechanical stress
- endocrine factors
- nutrition
What has more demineralizing effect on bone than decrease in estrogen after menopause?
decreased physical activity
- lose the most of trabecular bone (inner network of thin calcified trabeculae)
- cortical = main fxn is structure and protection, forms external parts of long bone, dense, calcified tissue, calcium makes 80-90%
Produces bone matrix (collagen and ground substance); Bone formation
osteoblasts
orchestrator of bone remodeling through regulation of both osteoclast and osteoblast activity; compose 90% to 95% of all bone cells in adult bone
Osteocytes
- regulates the building
Responsible for bone resorption
osteoclasts
What is the hormonal regulation of: Decreased bone resorption Increased bone resorption Increased bone formation Decreased bone formation
- Decrease Bone Resorption = Calcitonin, Estrogens
- Increase Bone Resorption = PTH/PTHrP, Glucocorticoids, Thyroid Hormones, High dose vitamin D
- Increase Bone Formation = Growth Hormone, Vitamin D Metabolites, Androgens, Insulin, Low-dose PTH/PTHrP
- Decrease Bone Formation = Glucocorticoids
what gland monitors calcium levels?
parathyroid gland
What are the types of osteoporosis?
- Postmenopausal - accelerated and disproportionate loss of trabecular bone usually in decade after menopause; 6x greater women than men; Increased bone resorption, reduced production of PTH, decreased vit D activation. From age 50-80, women’s BMD decreases 30%
- Age-related - 2x greater women than men; Onset for women 1 decade earlier (70-80); Rate of loss in trabecular and cortical bone equal; Hip fractures common; Gradually resorption exceeds accretion and bone loss occurs; Loss approximately .5%/year
- Secondary – occurs in response to certain medical conditions. Women = men (Grave’s dz, hyperparathyroidism, cushing’s syndrome, chronic renal failure, malnutrition, diabetes, SCI with immobility, RA, liver dz, malignancy and malignancy-related conditions, hypercalciuria, hyperthyroidism, alcoholism, osteogenesis imperfecta, marfan’s syndrome, turners, klinefelters, glucocoritcoids, anticoagulants, thyroid hormone (excessive), anti-seizure meds, prolonged total parenteral nutrition, radiation, cyclosporin taken for organ transplant, lithium, methotrexate and prednisone
What are risk factors for osteoporotic fx?
- Low bone density
- > 65 years
- Personal hx of fracture >40 with min trauma
- Hx of fx in first-degree relative
- Low body weight (<132 lbs) post-menopause
- Caucasian or Asian race
- Female
- Poor health/frailty
- Inadequate physical activity
- Recurrent falls
- Estrogen deficiency
- Low CA+ intake (lifelong)
- ETOH and smoking
- Impaired eyesight (despite correction)
- Gluco-corticoid use
- Stroke
- Current cigarette smoking
What is the definition of a fragility fx?
fracture that results from trauma less than or equal to that from a fall from a standing height
What should your daily Ca+ and vit D intake be?
Children 1-10 = 800-1200 mg 11-24 = 1200-1500 25-64 = at least 1200 Pregnant/lactating = at least 1200 Postmenopausal with HRT = at least 1000 Postmenopausal w/o HRT = at least 1500 Men/women >65 = at least 1200 Vit D 65+ years = 600-800 IU/day
When should BMD testing be recommended?
- All postmenopausal women under 65 who have 1 or more additional risk factors
- All women 65 and older regardless of risk factors
- Postmenopausal women who present with fractures
- Women who are considering therapy for osteoporosis if BMD testing would facilitate the decision
- Women who have been on HRT for prolonged periods
- Medicare pays for testing every 2 years
What is the gold stander for measuring BMD?
DXA - only method with enough accuracy to determine change associated with drug Rx; Difficult to assess change assoc with exercise with 2 dimensional (DXA); spine/ hip
Other tests:
- pDXA use for hyperparathyroidism as loss typically greater in cortical bone; forearm, finger, heel
- SXA – single energy x-ray
- RA – radiographic absorptiometry
- QCT – quantitative computerized tomography; density of spine/hip
- QUS - speed of sound at heel, tibia, patella
What are clinical signs of osteoporosis?
- Loss of Height - normal only to lose 1” height
- Spinal changes (cervical, thoracic, lumbar)
- Pain (Rib Pain) <2 fingers
- SOB
- Hiatus Hernia
- Protuberant Stomach
What medications are used for osteoporosis?
- Bisphosphonates (Fosamax, Boniva and Actonel, Reclast) - GI problems, osteonecrosis of jaw; Must be taken on empty stomach, remain upright 30-60 min, wait 30-60 min to eat; or IV
- Calcitonin - Less effective than other therapies; intranasal; Will decrease pain from vertebral fractures
- Estrogen/Hormone Therapy - Approved for prevention of osteo and menopausal sx; Health risks = lowest effective dose recommended; ERT 5-7x incr risk endometrial CA
- Estrogen Agonist/Antagonist (aka SERM) (Raloxifene, (Evista)
Prevention and treatment in postmenopausal women; Can be associated w/increased vasomotor S/S; Is associated with decreased risk of invasive breast CA; incr risk DVT - PTH (Forteo) - Approved for Rx for high risk men/women; Daily subcutaneous injection; Used maximum 2 years
- most drugs work by decr bone resorption, but doesn’t return mass to normal (incr of 5-10%)
- medication for jaw osteonecrosis = Fosamax
What evidence exists for best practices for primary, secondary and tertiary prevention/wellness?
- Primary – stopping it before it starts; Starting in children! Proper nutrition, especially in teens in sports
- Secondary – at risk population; Women in 50s-60s; Lift weights!; Proper nutrition
- Tertiary – clients you see that are already diagnosed; Education on falls, preventing falls, screening for falls
What should education on osteoporosis include?
- Risk Factors
- Medical/Pharmaceutical Management, Bone Densitometry, HRT
- Pain Management/self-help techniques
- ADLs - fx during this; sneezing = brace hand on one thigh; hip hinge for bending
- Exercise
- Nutritional Information
- Prevention of Falls
- Team Approach
How does exercise build bone?
- Load with high peak forces (60-80% 1RM) and high strain rates
- Vary strain distributions in the bone
- Brief ex sessions 2-3x/week
- Low reps (1-3 sets of 6-8 reps)
- Progressive long term duration
What are the basic principles of exercise to benefit bone health?
- Mechanical stress is site specific and load dependent
- Exercise must by dynamic and weight-bearing/impact or resistant in nature
- Exercise load must exceed normal usage
- Exercise should provide variable or unusual loading patterns
- Short, intermittent bouts are preferable to longer, continuous bouts
- Exercise must be accompanied by adequate energy, calcium, and vit D intake.
What have sport specific BMD studies found?
- BMD highest in high strain/odd impact sports, e.g. VB, BB, gymnastics, karate compared to repetitive impact/individual sports (distance running)
- BMD higher in soccer, field hockey players, and runners compared to low impact sports
- BMD lowest in swimmers and cyclists
What should be included in PT assessment for pt with osteoporosis?
- Musculoskeletal
- Risk Factors (fall prevention)
- Current Activity Levels
- Balance/Coordination (20 sec. Stand, Tinetti, reach test)
- Current Pain Levels
- Mobility Analysis
- Cardiovascular (6 min walk)
- Gait (timed up and go)
- REEDCO - Look ahead; posture check that is specific template for examination
- Stadiometer
- Flexicurve Tracing (multiple studies, inexpensive, time efficient, patient feedback) - C7-L2; mold to spine, put onto grid for a thoracic kyphotic index divided by lumbar index
- Forward head measurement (tragus to wall)
- CROM
- Grid Photo
- Total scapular distance (sum of distance from T3 to lat. Aspect of left acromion and T3 to lat. Aspect of right acromion)
- Rib/iliac crest distance – 4 fingers normal
- lateral basal expansion – tape measure, 4-6 cm. Differential in/expiration (t-band for ex)
- Timed loaded standing – 3 min. with 2 lbs in each hand, shoulders 90 deg. Flexion
- Grip strength – assoc. with fall risk and lower BMD
- Abdominal Strength
- Trunk Extension Strength
- Osteoporosis QOL questionnaire
- Function (Functional Status Questionnaire, SF 36)
You cannot flex high risk patients. How do we test for strength?
- Isometrics
- Modified plank maintained for __s
- Trunk extension strength - We need them to get into prone
What type of exercises should be prescribed with vertebral fx?
- Spinal extension (back arches/lifts)
- Spinal flexion (crunches)
- Combined flexion and extension
- No exercise
- crunches = highest risk for fx
What are LT management goals of osteoporosis?
- Maintain/Slow loss or increase BMD in at-risk patients, dg. Patients without fracture, and those with fracture
- Reduce Pain
- Prevent spinal deformity/vertebral fractures
- Prevention of falls/maintain mobility
- Education
What are the management of vertebral fx?
- Mobility and Transfers
- Pain Management
- Bracing
- Surgery - Vertebroplasty (cement injection), kyphoplasty (ballon, then cement) ; greatly improve QOL with reduction in pain
Bone adapts positively to mechanical loading by increasing mass and strength:
- For patient and prevention care: frequent, short bouts of ______________ physical activity promote osteogenesis
- Competitive sports: encourage ____________ on bone rather than repetitive, single plan activities
- high impact/unusual strain
- cross-training for different strain
_______ exercise plays a vital role in enhancing peak BMD during childhood/adolescence, and maintaining bone mass in adults
Impact
- OA for girls in middle and HS are key
- prevent FAT in HS athletes
- Stress fractures in adolescent athletes multifactorial; Training error, menstrual dysfunction and low bone mass have most evidence
