Osteoporosis

I. Description

Osteoporosis is defined as decreased bone mass and micro-damage to the bone structure that results in a susceptibility to fracture.¹ The term osteoporosis means porous bones. In osteoporosis the bones to become weak and brittle. They can become so brittle that a minor stress or a fall can cause fractures.² Fractures are often common in patients with osteoporosis, usually in the spine, hip, or wrist. Osteoporosis is characterized by low bone mineral density and changes of the microarchitecture of the bone.³ Osteoporosis can be classified as primary or secondary. Primary Osteoporosis is more common, and can occur in both men and women. It often occurs later in life in both genders. Primary osteoporosis has two subtypes: postmenopausal/estrogen-deficient and age related/senile. Secondary Osteoporosis is associated with medications or other conditions.¹

II. Anatomy

Bone is a combination of collagen and minerals. The collagen gives bone flexibility while the minerals add stiffness. There are two types of bone: cortical bone and trabecular bone. Cortical bone is dense and comprises the shaft of long bones. It also works as a protective cover around the trabecular bone. Trabecular bone is found around flat bones, the end of long bones, and in cuboidal bones. Trabecular bone is more porous and flexible. Modeling and remodeling are important factors that determine the characteristic of bone. Modeling is the action of osteoclasts and osteoblasts on the surface of bones, where in some spots there is adding of the bone and in others there is removal of the bone. Remodeling involves the coupled action of osteoclasts and osteoblasts. Osteoclasts will resorb older bone and osteoblasts with recruit to the site to form new bone. When patients reach about the age of 20, this process begins to slow down. Breaking down of bone starts to exceed the building up of bone.^4,5

III. Indications

During the early stages of Osteoporosis there is usually no pain or any symptoms. As bones become progressively more weakened, patients may have the following symptoms:

• Back Pain
• Bone Pain or Tenderness on the Bone
• Loss of Height
• Stooped Posture or kyphosis, including Dowger’s Hump
• Fracture of Vertebra, Wrist, Hip or Other Bones
• Fracture with Little or no Trauma^1-3

IV. Incidence/Prevalence

Osteoporosis is the most common metabolic bone disease and it affects approximately 10 million people living in the United States. There are another 34 million people at risk for osteoporosis.⁶ The age increase in America is expected to increase the prevalence of this pathology. Osteoporosis is much more common in postmenopausal women because they are estrogen deficient. However, osteoporosis is becoming an increasing problem in men, with approximately 2 million men being affected. One in two women over the age of 50 and one in four men will experience as osteoporosis related fracture during their lifetime.^1,2

V. Clinical Presentation

The most common presenting factors for a patient with osteoporosis are loss of height, postural changes, back pain, and fracture. Patients may present with forward head, kyphosis, dowager’s hump, loss of lumbar lordosis, posterior pelvic tilt, knee hyperextension, shoulder internal rotation, scapular forward rotation, and other postural deviations. The most postural common findings include thoracic kyphosis and loss of overall body height.^2,3

Fractures are another common symptom in patients with osteoporosis, most commonly in the vertebral bodies, hip, ribs, radius, and femur. These fractures are more often than not compression fractures. Vertebral compression fractures are the most common osteoporosis. Patients will present with back pain, postural changes, loss of height, functional impairment, disability, and diminished quality of life. Pain with vertebral compression fractures are usually severe and localized to the site of the fracture.^1-3

VI. Potential Etiologies

The cause of primary osteoporosis is currently unknown but there are many factors that contribute to this pathology such as:

• Low Calcium Intake
• Impaired Calcium Absorption
• High Protein Intake
• Petite Body Frame
• White or Asian Ancestry
• Tobacco Use
• High Caffeine Intake
• High Carbonated Soda Intake
• Eating Disorders
• Sedentary Lifestyle or Immobilization
• Nulliparity
• Excessive Alcohol Consumption
• Females
• Age
• Race
• Family History
• Frame Size
• Thyroid Hormone^2-4

Secondary osteoporosis may be caused by prolonged therapy with corticosteroids, heparin, anticonvulsants, and other medications. Other conditions that can contribute to secondary osteoporosis are alcoholism, malnutrition, malabsorption, or lactose intolerance. Associated diseases for secondary osteoporosis include: hyperthyroidism, type two diabetes mellitus, Cushing’s disease, Celiac disease, GI disease, and Hepatic disease.^1,3

VII. Diagnostic Tests

Bone densitometry is used to determine bone mineral content. This is used to diagnose osteoporosis as early as possible. The earlier osteoporosis is diagnosed, the more effective the treatment. The longer the wait, the less likely treatment will be successful. An x-ray can sometimes be used to identify fractures or if the patient has had height loss or postural changes. If an x-ray is used, it can miss early osteoporosis because x-rays only show when there is more than a 30% depletion.^3,4,7 Bone densitometry can provide early and accurate measurements of bone strength and content to identify osteoporosis in the early stage.
The most often tested areas include: lumbar spine, radius, and proximal hip.
Dual energy densitometry is most commonly used to identify osteoporosis. Two different methods are used; these methods are called dual-photon absorptiometry(DPA) and dual energy x-ray absorptiometry(DEXA). Because these methods use photons, the soft tissue can be penetrated more easily. A t score of -2.5 or below is indicative of osteoporosis.⁷

VIII. Evaluation/Special Orthopedic Tests

There are no specific special orthopedic tests to determine if a patient has osteoporosis but an examination can be done to see if a patient is at risk. This exam might include:

• An Initial Physical Exam
• X-rays
• Laboratory tests
• Bone density test⁴

IX. Conservative Treatment

Although osteoporosis is not curable, interventions can be used to stop the prevention of bone loss. Secondary osteoporosis intervention begins with treatment of the underlying cause. Management of primary and secondary osteoporosis would be to prevent falling and increase calcium intake. Daily calcium intake for women is 1000 mg for premenopausal women and 1500 mg for postmenopausal women.^1-3

Bisphosphonate are a helpful drug that inhibit bone resorption and reverse bone loss. Bisphosponates are the primary drug used to both prevent and treat osteoporosis. These drugs are used to inhibit bone breakdown and preserve bone mass. Bisphosphonates include such drugs as:

• Alendronate(Fosamax)
• Ibandronate(Boniva)
• Risedronate(Actonel)
• Zoledronic Acid(Reclast)

Calcitonin is another drug used for patients with osteoporosis. It is used to slow the rate of bone loss and relieve bone pain. This hormone is used to prevent spinal fractures. This is normally used on patients who can’t take bisphosponates.³
Goals in treating osteoporosis include:

• Controlling Pain
• Slowing Down or Stopping bone Loss
• Prevent Bone Fractures with Bone Strengthening Medication
• Minimize the Risk of Falls

Exercise is an important aspect of treating osteoporosis as well as eliminating certain factors such as smoking cigarettes or drinking alcohol. Exercise has a positive effect on bone mass levels by doing the following: building bone mass, slowing the decline of bone mineral density, preventing fracture, and maintaining muscle mass and strength. Aerobic and resistance training are both good options for patients with osteoporosis although research shows that resistance training works best for these patients. Exercises can also be done to prevent falls. These exercises include: flexibility, balance, and strength.

• Weight bearing exercises include: Walking, Jogging, Playing Tennis, Dancing
• Resistance exercises include: Free Weights, Weight Machines, Theraband
• Balance training includes: Tai Chi, Yoga^1-3

For patients with risk factors for osteoporosis weight bearing aerobic activities should be done 3-5 times a week and resistance exercises should be done 2-3 times a week. Patients can work at a moderate to high intensity for 30-60 minutes per session. Patients that have been diagnosed with osteoporosis should be advised to stay at a moderate intensity.⁶
Some considerations to be aware of when treating patients with spinal fractures include using cycle ergometry instead of a treadmill. Walking may be painful in these patients. Compression fractures in these patients may also shift the patient's center of gravity. This will also effect the patient's balance on a treadmill. High impact loading should be avoided as well as twisting, bending or compression of the spine.⁶

X. Surgery & Post-op Treatment

There are no surgeries specifically for osteoporosis. Surgical treatment depends on the site of the fracture as in the case of spinal fracture. In the case of spinal fractures a vertebraoplasty can be used. This procedure is used by injecting a glue into the areas where the fracture has occurred.²

There is also a procedure called a kyphoplasty, that uses a balloon instead of the glue.³

XI. Modalities

Thermotherapy has been shown to be effective in the treatment of chronic pain. Increase in tissue temperature can increase the availability for oxygen which can increase tissue repair and decreasing ischemia. Heat increases vasodilation in vessels, which helps clear the region from prostaglandins. Contraindications to thermotherapy include acute inflammation, hemorrhagic areas, malignancy, impaired sensation, and thrombophlebitis.^8,9

Cryotherapy can be used to control pain, edema and inflammation. It can also be used to decrease spasticity. Cryotherapy has been shown to be effective in the treatment of acute pain but can also be effective in chronic pain.^8,9

There have been many studies put out about the effects of ultrasound, both continuous and pulsed. Ultrasound is said to be effective in treating acute and chronic inflammation and tissue healing. Although this has been stated to be effective in some studies, these studies are controversial. One of the contraindications for ultrasound is recent fractures, which is important to note because one of the main problems with osteoporotic patients is fractures.⁸

TENS is also said to be used with patients that are suffering from chronic pain. Although this has been stated in a few studies, the evidence to support this is lacking. There have been a few case studies that stated that patients had decreases in pain secondary to treatment with TENS while other studies have demonstrated that TENS was ineffective in treatment of pain.^8,9

XII. Additional Web Based Resources

http://www.mayoclinic.com/health/osteoporosis/DS00128
http://www.nlm.nih.gov/medlineplus/ency/article/000360.htm
http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/
http://www.nof.org

XIII.References

1. Goodman CC, Fuller K. Pathology Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders Elsevier; 2009.
2. Mayo Clinic staff. Osteoporosis. http://www.mayoclinic.com/health/osteoporosis/DS00128. Updated November 20, 2010. Accessed November 24, 2010.
3. Medline Plus. Osteopororis. http://www.nlm.nih.gov/medlineplus/ency/article/000360.htm. Updated November 15, 2010. Accessed November 16, 2010.
4. American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th edition. Philadelphia: 2010. Lippincott Williams & Wilkins.
5. NIH Osteoprosis and Related Bone Diseases. Osteoporosis. http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis. Updated July 2010. Accessed November 16,2010.
6. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th edition. Philadelphia: 2010. Lippincott Williams & Wilkins.
7. Pagana KD, Pagana, TJ. Mosby's Diagnostic and Laboratory Test Reference. 8th ed. St. Louis, MO: Mosby Inc; 2008.
8.Allen RJ. Physical Agents Used in the Managment of Chronic Pain by Physical Therapists. Physical Medicine and Rehabilitation Clinics of North America. 2006; 17:315-345.
9.Hurley MV, Bearne LM. Non-exercise Physical Therapies for Musculoskeletal Conditions. Best Practice and Research Clinical Rheumatology. 2008; (22)3: 419-433.