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204-theme 2 -anatomy > SYMPOSIUM Osteoporosis, Nutrition and Fragility Fractures > Flashcards

SYMPOSIUM Osteoporosis, Nutrition and Fragility Fractures Flashcards

1
Q

what is a fragility fracture

A

-A Fracture which occurs
without excessive trauma

or

follows a fall
from standing height or less

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2
Q

describe the facts about fracture -epidemiology

A

They are very common

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

what factors cause an increase in the incidence of the osteoporosis

A

-the aging population >65 years in Europe

  • 12-17 % in 2002
  • 20-25 % by 2025
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4
Q

what are some of the consequences of a hip fracture

A
  • 20% die within one year
  • 30% have a permanent disability
  • 40% unable to walk independently
  • 80% unable to carry at least 1 independent activity of daily living
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5
Q

what’s interesting about the clinical signs of vertebral fractures

A
  • they can be very silent -(only 1/3 come to clinical attention)
  • increasing pain and reduce activity

-

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6
Q

what’s the differences and similarities observed between the vertebral fractures observed in:

1- No Incident Fracture

2-Radiographic Fracture

3-Clinical Fracture

A
  • Although they all expressed moderate and severe back pain levels:
  • they were increased limited activity and bed rest from 1-3
  • but in patients who have suffered either a morphometric or a clinical new vertebral fracture there was increased back pain, limited activity and increased bed rest.
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7
Q

what does incident fractures relate too

A
  • a physical sign/recorded sign
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8
Q

describe the cost of fractures in the UK

A

Fractures / year (UK)

  • Hip 70,000
  • Wrist 50,000
  • Spine 120,000

COST = £ 2 billion / year
= > £5 million / day!

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9
Q

aetiology of osteoporosis

A

Bone strength is reduced:

1- Sub optimal peak bone mass

2- Reduced bone quality:

  • Reduced bone Mineral ( Calcium )
  • Deteriorating architecture
  • Change in crystal size & composition
  • Abnormal collagen
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10
Q

what Is the trauma that causes people to break their bones-how?

A

Bone strength is reduced

They fall

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11
Q

overview: how can fractures be prevented

A

1-Children / Adolescents / Young Adults-
Optimize Peak bone Mass

2-Adults :
-Prevent deterioration of bone quality

-Prevent falls

3-Identify the elderly at high risk £

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12
Q

expand on prevention via optimising peak bone mass

A

Diet
Exercise
Sex Hormones

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13
Q

describe osteogenesis imperfecta

A
  • genetic disease
  • Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of genetic disorders that mainly affect the bones. It results in bones that break easily.
  • The severity may be mild to severe.
  • minimal impact
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14
Q

how can fracture risk be identified in older people

A

History & Examination :

  • Increasing Age
  • Previous Fracture
  • Light weight ( BMI < 18 )
  • Family History of osteoporosis
  • Smoking
  • Alcohol
  • Many medical Disorders
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15
Q

what is a consequence of treating diseases like Cushings syndrome with steroid like glucocorticoids

A
  • potent causes of osteoporosis.

- especially if being put on them for greater than 3 months & being over the age of 65

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16
Q

what is a rheumatoid nodule

A

Rheumatoid nodules are firm lumps under the skin. They do not change color or bleed and do not resemble other bumps on the skin, such as pimples. Instead, they look like firm, round lumps.

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17
Q

what is the association between Rheumatoid nodules and Inflammatory conditions

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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18
Q

what is another factor to do with hormones that can cause osteoporosis and evidence

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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19
Q

what are other medical disorders that predisposes people to osteoporosis

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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20
Q

what technology can be used to predict risk of osteoporosis

A

-Heel Ultrasound scanning device

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21
Q

what is the FRAXTM based risk calculator

A

FRAXTM is a computer-based algorithm (http://www.shef.ac.uk/FRAX) that provides models for the assessment of fracture probability in men and women (1-3). The approach uses easily obtained clinical risk factors to estimate 10-year fracture probability. The estimate can be used alone or with BMD to enhance fracture risk prediction

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22
Q

what are the 2 main objectives of drug treatment

A

1) Prevent bone breakdown
- Inhibit Osteoclasts

2) Stimulate Bone Build up
- Stimulate Osteoblasts
- Modify Osteocyte activity

23
Q

what types of fractures do we aim to prevent

A

Prevent ALL types of fracture:

  • Vertebral
  • Nonvertebral
  • HIP
  • Others
24
Q

what is the main drug for osteoporosis in both men and women

A
  • Bisphosphonates :

work by inhibiting osteoclasts by inhibiting enzyme

25
Q

what is the use of oral containing bisphosphonates

A
  1. Prevent Hip & Spine fracture
    - Generic Alendronate ( weekly )
    - Generic Risedronate ( weekly )

2) Prevention of spine fracture only
- Ibandronate ( monthly )

26
Q

how do you take alendronate, risedronate & 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

27
Q

what are the side effects of taking alendronate the wrong way

A

Short term:
- contact stomatitis

-oesophageal ulcer

28
Q

what can be given to combat side effects of alendronate treatment

A
  • Proton pumps inhibitors

- ie - ranitidine- showed no reduction in effect of alendronate

29
Q

what is an alternate to alendronate

A

Zoledronate:

  • 5 mg IV infused over15 mins annually
30
Q

what is a long term side effect of the use of bisphosphonates- (rare-1/10,000)

A
  • Jaw osteonecrosis

- Atypical femoral shaft fracture

31
Q

how do osteoblasts and osteoclasts work to remodel bones

A
  • stromal osteoblast cells express a rank ligand that binds to the rank receptors of the osteoclast precursor
  • this causes maturation into an osteoclast which can go on to resorb bone

(also Osteoprotegerin (OPG) is secreted by osteoblasts and osteogenic stromal stem cells and protects the skeleton from excessive bone resorption by binding to RANKL and preventing it from interacting with RANK. )

  • in RA results in secondary osteoporosis.
32
Q

what is the function of denosumab 60mg S

/C

A
  • its an OPG
  • Fully Human Monoclonal antibody
-IgG2 isotype 
Binds to RANK Ligand 
-Decoy Receptor
-High affinity
-High specificity 
-No complement activation
33
Q

what are the advantages of denosumab use

A

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

34
Q

what is the anabolic treatment of osteoporosis

A

Daily s/c Injection

Pulse of PTH

-Anabolic to bone

Reduces Fractures

  • Vertebral
  • Non-vertebral
35
Q

what hormone causes an increase in fractures

A
  • Oestrogen

-

36
Q

how can oestrogen be medicated

A
  • HRT
  • raloxifene
  • Selective Estrogen Receptor Modulators
37
Q

what hormonal conditions can cause osteoporosis in men and women

A
  • hypogonadism

- menopause

38
Q

what can be given to help hypogonadism

A
  • tostran 2% gel
  • Nebido tablets 1000 mg (4 mls ) IM every 10 – 14 weeks
  • cold
39
Q

summarise drugs used for osteoporosis and their directed usage

A

ALENDRONATE (weekly)

RISEDRONATE (weekly)

ZOLENDRONATE IV ( annually)

DENOSUMAB s/c ( 6 monthly )

HRT ( Not Tibolone )

Calcium & Vitamin D (In elderly )

40
Q

give a name of an anabolic drug PTH mediated and antibody mediated

A

-Teriparatide ( PTH 1-34 )

  • Rososumab
  • -Antisclerostin antibody
  • -Increases Wnt Signaling in bone
41
Q

describe the SOST gene and what can be used to inactivate it

A

The SOST gene provides instructions for making the protein sclerostin.

Sclerostin is produced in osteocytes, which are a type of bone cell. The main function of sclerostin is to stop (inhibit) bone formation.

The maintenance of bone over time requires a balance between the formation of new bone tissue and the breakdown and removal (resorption) of old bone tissue. Inhibition of bone formation is necessary to ensure that bones are of the correct shape, size, and density. Research suggests that sclerostin exerts its effects by interfering with a process called Wnt signaling, which plays a key role in the regulation of bone formation. Sclerostin may also promote the self-destruction (apoptosis) of bone cells, further inhibiting bone growth.

  • therefore activating osteoblasts
  • admin of sclerostin antibodies
42
Q

describe an indicator of a hip fracture and physiotherapy for it

A
  • wedge fracture in the thoracic kyphosis
  • puts pressure on intrinsic muscles
  • prescribing exercise and multidirectional loading - different high low and medum impact
  • can also prescribe alendronic acid when on high dose steroids
43
Q

what can physiotherapy target

A

impact on the hip and spine

44
Q

where can vertebral fractures cause pain to

A
  • bones
  • muscles
  • ligaments
  • nerves
45
Q

what is the personal impact of osteoporosis

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..

46
Q

name some physiotherapy methods

A

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

47
Q

epidemiology of 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
48
Q

what in specific would a physio do in day1 of a hip fracture

A

Long term management

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
49
Q

what type of exercises are prescribed

A

1)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.

2)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.

3)Falls prevention
Posture, flexibility, co-ordination, balance .
E.g. Swimming/hydro, Tai Chi, yoga, OTAGO, balance classes, Pilates, Alexandra technique etc.

50
Q

Nutrition and bone health: maximising bone health - what is the peak bone mass

A

Peak bone mass, which can be defined as the amount of bony tissue present at the end of the skeletal maturation- until 25 years of age

51
Q

Nutrition and bone health: what in diet affects peak bone mass

A

increase intake of :
- cows milk- source of vit D fat protein and magnesium

  • vitamin D- first hydroxylation in liver- d to 25(oh)vit d, calcidiol, second in kidney forming physiologically active 1,25(oh)2D, known as calcitriol
  • plant based milk- reinforced with phosphatase and oxylates that impact bioavailability

Decrease intake of:

  • PUFA: N6:N3 ratio important as N6 (PGE2) is pro-inflame but N3 is anti and is PGE2 which increase metabolic acidosis- needed for bone deposition
  • Gluten intolerance- gliadin and phytate (creates insoluble complexes with calcium ) linked to reduced calcium absorption
  • oxalate: inhibits bioavailability of calcium…
  • protein- reduce calcium (but can eat fish with soft bones)
  • (vitamin A)

Note in uk due to low sun exposure, there are fortified fat spreads.
fortified breakfast cereals, flour (bread) and soya (contain more vitamin D.

52
Q

Nutrition and bone health: what are the current concerns and what should be avoided

A
  • average blood vitamin measures of 25-OHD were lowest from jan-march due to sun, with 29% adults having below threshold levels of 25nmol/L 25-OHD, and 37%-19% children 11-18 and 4-10, indicating deficiency.
  • avoid fizzy drinks
53
Q

Nutrition and bone health: how in adults can we manage osteoporosis to reduce bone loss and encourage new growth

A

Increase:
-supplement vitamin D-with calcium for max effect with +ve result (ESP for post menopausal women)

  • calcium- decreased bone loss in post menopausal women
  • vit K - effects osteocalcin, involved in bone mineralisation enhances ability to bind calcium
  • phytoestrogens

-strontium- stable in low does increases bone formation and decrease resorption
Reduce:

  • sodium: increases urinary loss of calcium with high intake
  • reduce omega 6 intake and increase omega 3

-

204-theme 2 -anatomy (15 decks)

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