General data osteoporosis update lecture.ppt

Short description on osteoporosis for general public

1. OsteoporosisOsteoporosis
What What YouYou Should Know Should Know

2. 22
What is Osteoporosis?What is Osteoporosis?
A condition in which the infrastructure A condition in which the infrastructure
of bone becomes thin and weakened.of bone becomes thin and weakened.
Weakened bone is at higher risk for Weakened bone is at higher risk for
fracture to occur from minimal fracture to occur from minimal
stresses.stresses.

3. 33
Normal & Osteoporotic Bone ArchitectureNormal & Osteoporotic Bone Architecture
Normal Bone Osteoporotic Bone
Reproduced from J Bone Miner Res 1986;1:15-21 with permission of the American Society for
Bone and Mineral Research. © 1986 by Massachusetts Medical Society. All rights reserved.

4. 44
Who Gets Osteoporosis?Who Gets Osteoporosis?
ANYONE could be at risk for OsteoporosisANYONE could be at risk for Osteoporosis

Most people are identified after age 50Most people are identified after age 50

Some diseases & conditions increase riskSome diseases & conditions increase risk

Even men & children are at riskEven men & children are at risk

5. 55
Risk Factors You Risk Factors You Can’tCan’t Change Change
•
AgeAge
•
Gender (4/5 cases are female)Gender (4/5 cases are female)
•
Postmenopausal statusPostmenopausal status
•Family history, race (Caucasian or Asian), Family history, race (Caucasian or Asian),
Vit D geneticsVit D genetics
•Small frame (<127 lb = osteoporosis risk)Small frame (<127 lb = osteoporosis risk)
•
Hyperparathyroidism, RSD, cancer, organ Hyperparathyroidism, RSD, cancer, organ
replacementreplacement
•Necessary medications (steroids, Necessary medications (steroids,
antiseizure, anticoagulants, synthroid, many antiseizure, anticoagulants, synthroid, many
chemotherapies, some diuretics)chemotherapies, some diuretics)
(National Osteoporosis Foundation, 2002)

6. 66
Additional Risk FactorsAdditional Risk Factors
Diseases that Are Often Treated with
Glucocorticoid Medications*
AsthmaAsthma
BursitisBursitis
Crohn’s DiseaseCrohn’s Disease
Chronic ActiveChronic Active
HepatitisHepatitis
Dermatitis (Severe)Dermatitis (Severe)
GlaucomaGlaucoma
Lupus ErythematosusLupus Erythematosus
Multiple SclerosisMultiple Sclerosis
OsteoarthritisOsteoarthritis
PsoriasisPsoriasis
Rheumatoid ArthritisRheumatoid Arthritis
*Partial List (National Osteoporosis Foundation, 2002)

7. 77
Risk Factors You Risk Factors You CanCan Change Change
•Diet – inadequate calcium and vitamin D, Diet – inadequate calcium and vitamin D,
too much or too little proteintoo much or too little protein
•Some bone-damaging medicationsSome bone-damaging medications
•Unhealthy lifestyle choicesUnhealthy lifestyle choices
•Alcohol (more than 2 drinks/day)Alcohol (more than 2 drinks/day)
•Smoking (any!)Smoking (any!)
•Too little exerciseToo little exercise
•Under-eating (<127 lb = osteoporosis risk)Under-eating (<127 lb = osteoporosis risk)
(National Osteoporosis Foundation, 2002)

8. 88Age in Years
102030405060708090
Active
Growth
Slow
Loss
Rapid
Loss
Less Rapid
Loss

Bones build mass beginning at birth and peak by Bones build mass beginning at birth and peak by
age 20-30age 20-30
Peak bone mass is attained between 25 & 30 y/o
•50% accrued during teen years
•Declines by 1 – 1.5%/ year after peak
•Declines by 3 – 5%/ year 1
st
5 yr/ menopause
Bone Development
(National
Osteoporosis
Foundation, 2002)

9. 99
Calcium and Bone

Recommended daily calcium intakeRecommended daily calcium intake
•Children and Young AdultsChildren and Young Adults
• 1-10 years1-10 years 800 mgs 800 mgs
•11-24 years11-24 years 1,200 mgs 1,200 mgs
•AdultsAdults 1,000 mgs 1,000 mgs
•Pregnant and Lactating WomenPregnant and Lactating Women 1,200 mgs 1,200 mgs
•Postmenopausal Women Not on ERT 1,500 mgsPostmenopausal Women Not on ERT 1,500 mgs
•Men over the age of 65 Men over the age of 65 1,500 mgs 1,500 mgs
(National Osteoporosis Foundation, 2002)

Excess Excess salt displaces calciumsalt displaces calcium
–Is added to almost all Is added to almost all canned foodscanned foods!!

High High phosphates leach calciumphosphates leach calcium from bone! from bone!
–SodaSoda – the worst culprit – the worst culprit

10. 1010
Bone Nutrition - Beyond Calcium

Vitamin DVitamin D
•At least 800 units dailyAt least 800 units daily (Boonen S et al, 2006; Pfeifer M et al, 2002))
•30 minutes of sun to hands & face daily sufficient in sub-tropical 30 minutes of sun to hands & face daily sufficient in sub-tropical
latitudes but only the “sunny” 6 months in temperate latitudeslatitudes but only the “sunny” 6 months in temperate latitudes

MagnesiumMagnesium
•400-600/day400-600/day – allows calcification as a natural calcium – allows calcification as a natural calcium
chelator chelator (Barzel US, 1998)
•Depleted by stress, physical exertionDepleted by stress, physical exertion
Protein Intake and Bone - moderation is the keyoderation is the key
•Women (35-59 y/o) w/ protein intake >95g/day (5 servings red Women (35-59 y/o) w/ protein intake >95g/day (5 servings red
meat/wk) vs those <59 g/day had increased risk of forearm fracturesmeat/wk) vs those <59 g/day had increased risk of forearm fractures
(Feskanich D et al, 1996)
•High amounts of protein intake (~200 g/day) associated with High amounts of protein intake (~200 g/day) associated with
decreased bone density decreased bone density (Barzel US 1998)
•Low protein diets (<50g/day) associated with decreased bone density Low protein diets (<50g/day) associated with decreased bone density
(Chiu JF et al 1997)

11. 1111
Drug Options – FDA approved

Anti-resorptives (slow bone resorption)Anti-resorptives (slow bone resorption)
•Bisphosphonates (alendronate, risedronate, Bisphosphonates (alendronate, risedronate,
ibandronate, pamidronate) ibandronate, pamidronate) (Wasnich RD et al, 2004; (Wasnich RD et al, 2004;
Chestnut III CH et al, 2004, Chan SS et al, 2004)Chestnut III CH et al, 2004, Chan SS et al, 2004)
•Selective estrogen receptor modulators Selective estrogen receptor modulators
(raloxifene)(raloxifene)
•Calcitonin (Miacalcin)Calcitonin (Miacalcin)
•Estrogen Estrogen (Writing Group WHI, 2002; Nerhood RC 2001)(Writing Group WHI, 2002; Nerhood RC 2001)
•Risks with long-term use may outweigh benefits, Risks with long-term use may outweigh benefits,
may be safer with lower dosesmay be safer with lower doses
•Always needs to be given with progesterone when Always needs to be given with progesterone when
uterus presentuterus present

Anabolic (bone forming)Anabolic (bone forming)
•Parathyroid hormone (teraparatide) Parathyroid hormone (teraparatide) (Heaney RP, (Heaney RP,
2003)2003)

12. 1212
Why Do Bones Weaken?Why Do Bones Weaken?

Bones depend on calcium, other Bones depend on calcium, other
chemicals, and vitamins to keep them chemicals, and vitamins to keep them
strong.strong.

Bones grow as a response to physical Bones grow as a response to physical
stress being put on them.stress being put on them.

The density (hardness) of bones The density (hardness) of bones
requires a good diet, some sunlight, requires a good diet, some sunlight,
and exercise in order to stay strong and exercise in order to stay strong
and not break.and not break.

13. 1313
It’s a Big ProblemIt’s a Big Problem

Osteoporosis affects more than 10 Osteoporosis affects more than 10
million people in the USmillion people in the US
8 million women8 million women
2 million men (but they are catching up)2 million men (but they are catching up)

24 million others have low bone 24 million others have low bone
mass, called osteopeniamass, called osteopenia

Osteopenia is a precursor to Osteopenia is a precursor to
osteoporosisosteoporosis
(National Osteoporosis Foundation, 2002)

14. 1414
Why is It a Problem?Why is It a Problem?

Osteoporosis, by itself, is not a Osteoporosis, by itself, is not a
problem. It doesn’t cause pain and problem. It doesn’t cause pain and
you will not know you have ityou will not know you have it!!

The problem is that it makes bones The problem is that it makes bones
very brittle and brittle bones can very brittle and brittle bones can
break easily.break easily.

A broken bone is called a FRACTURE.A broken bone is called a FRACTURE.

15. 1515
Fracture NumbersFracture Numbers

Every year there are 1.5 million bone fractures in Every year there are 1.5 million bone fractures in
this countrythis country
300,000 hip fractures300,000 hip fractures
700,000 vertebral fractures700,000 vertebral fractures
250,000 wrist fractures250,000 wrist fractures

Women have a greater lifetime risk of sustaining Women have a greater lifetime risk of sustaining
a hip fracture than breast, ovarian , and uterine a hip fracture than breast, ovarian , and uterine
cancer combinedcancer combined

Fracture care costs Fracture care costs $3 BILLION$3 BILLION every year! every year!
(National Osteoporosis Foundation, 2002)

16. 1616
Fractures HURTFractures HURT
Fractures cause:Fractures cause:

PainPain

Limited mobilityLimited mobility
•Prolonged bedrest causes:Prolonged bedrest causes:

Loss of strengthLoss of strength

PneumoniaPneumonia

DisabilityDisability

Death Death
•20% of those with hip fractures die within one year 20% of those with hip fractures die within one year
•Increased mortality with each vertebral fractureIncreased mortality with each vertebral fracture
(National Osteoporosis Foundation, 2002)

17. 1717
DeterminantsDeterminants ofof
Osteoporotic FractureOsteoporotic Fracture

Number of Number of
osteoporosis osteoporosis
risk factorsrisk factors

Forward Forward
bending bending
(trunk flexion)(trunk flexion)

Poor balance, Poor balance,
or accidents or accidents
resulting in resulting in
fallsfalls
Vertebral Fracture Hip Fracture

18. 1818
Fracture Force Risks During
Bending and Lifting

Compression loads imposed on Compression loads imposed on
the L3 motion segment (lower the L3 motion segment (lower
back) by back) by 30º of trunk flexion30º of trunk flexion
– 1800 N with 1800 N with arms at chestarms at chest
– 2610 N with arms in front, 2610 N with arms in front, holding 2 holding 2
kg in each hand kg in each hand (Schultz et al 1982(Schultz et al 1982))

300 to 1200 N enough to fracture 300 to 1200 N enough to fracture
an osteoporotic vertebra an osteoporotic vertebra (Edmondston et (Edmondston et
al 1997)al 1997)

Practical Application - Practical Application - bend and
lift in everyday life with the trunk
in relative neutral!

19. 1919
Exercise and Vertebral FracturesExercise and Vertebral Fractures
(for women with a previous fracture)(for women with a previous fracture)
Type of ExerciseType of Exercise

Spinal Extension (Back Spinal Extension (Back
arches/lifts)arches/lifts)

Spinal Flexion Spinal Flexion
(Crunches)(Crunches)

Combined Flexion and Combined Flexion and
ExtensionExtension

No exerciseNo exercise
New FracturesNew Fractures

16%16%

89%89%

53%53%

67%67%
(Sinaki and Mikkelson, 1984)(Sinaki and Mikkelson, 1984)

20. 2020
How Do I Know if I Have It?How Do I Know if I Have It?

There are many types of screening tests There are many types of screening tests
available in the community. Many use a available in the community. Many use a
finger or a foot to estimate possible risk.finger or a foot to estimate possible risk.

The gold standard (the absolute test) for The gold standard (the absolute test) for
determining the amount of bone density determining the amount of bone density
an individual has is a an individual has is a DEXA testDEXA test. It is like . It is like
an X-ray without the radiation. an X-ray without the radiation.

You lie on a table and a scanner passes You lie on a table and a scanner passes
over you. A computer determines how over you. A computer determines how
much bone you have by the information much bone you have by the information
read by the scanner.read by the scanner.

21. 2121
What’s a T-score?What’s a T-score?

The amount of bone you have is The amount of bone you have is
determined by how much has been lost determined by how much has been lost
since childhood, assuming you had lots of since childhood, assuming you had lots of
calcium and activity at that timecalcium and activity at that time

A T-score is a statistical number which A T-score is a statistical number which
says whether you are above or below says whether you are above or below
“normal”“normal”

T-scores are such numbers as -1.4 or -3.0 T-scores are such numbers as -1.4 or -3.0
or even + 1.0 sometimes.or even + 1.0 sometimes.

22. 2222
T-scoresT-scores

Normal T-scores range from +1 to -1Normal T-scores range from +1 to -1

OsteopeniaOsteopenia T-scores T-scores
-1.0 to -2.5-1.0 to -2.5

OsteoporosisOsteoporosis T-score T-score
less than -2.5less than -2.5 (up to -6.0) (up to -6.0)

23. 2323
What Should I Do First?What Should I Do First?
There are 3 major things you can doThere are 3 major things you can do
1.1.Talk to your Talk to your doctordoctor about a Bone Density about a Bone Density
TestTest
2.2.Talk to a Talk to a physical therapistphysical therapist about your about your
activity level and an exercise program to activity level and an exercise program to
combat osteoporosiscombat osteoporosis
3.3.Talk to a Talk to a dieticiandietician to make sure your diet to make sure your diet
is providing your bones with enough is providing your bones with enough
calcium and is balanced correctlycalcium and is balanced correctly

24. 2424
What If I Already Have Osteoporosis?What If I Already Have Osteoporosis?

Talk to your physician and pharmacist Talk to your physician and pharmacist
about about medicationsmedications available to help you available to help you

Make sure your Make sure your dietdiet includes enough includes enough
calcium, not too much caffeine or alcohol, calcium, not too much caffeine or alcohol,
and adequate, but not excessive, protein.and adequate, but not excessive, protein.

Spend at least 30 minutes/day in sunlight Spend at least 30 minutes/day in sunlight
and/or eat foods which are fortified with and/or eat foods which are fortified with
Vitamin DVitamin D

and………………..and………………..

25. 2525
See a Physical TherapistSee a Physical Therapist

PTs are able to develop an exercise PTs are able to develop an exercise
program for you that will be appropriate program for you that will be appropriate
for your conditionfor your condition

PTs will evaluate your posture, your PTs will evaluate your posture, your
strength, your range of motion, your strength, your range of motion, your
balance, and your general endurance balance, and your general endurance
status status

PTs will develop a balanced program which PTs will develop a balanced program which
should help keep you fit as well as safeshould help keep you fit as well as safe

PTs can answer your questions or refer PTs can answer your questions or refer
you to others who willyou to others who will

26. 2626
Studies on ExerciseStudies on Exercise

Appropriate exercise may slow the Appropriate exercise may slow the
rate of bone lossrate of bone loss

Sedentary lifestyles and immobility Sedentary lifestyles and immobility
lower bone densitylower bone density

Effects of exercise are improved Effects of exercise are improved
when combined with proper nutrition when combined with proper nutrition
and medicationand medication

27. 2727
Exercise Effect on Bone – Exercise Effect on Bone –
Works only when “Regular”Works only when “Regular”

Postmenopausal women exercised Postmenopausal women exercised
3 times per week for 9 months3 times per week for 9 months

Stair-climbing for ~ 30 minutes Stair-climbing for ~ 30 minutes
each sessioneach session

Spinal bone density Spinal bone density  4% in 4% in
exercisersexercisers

Spinal bone density Spinal bone density  to baseline to baseline
within 9 months for those who within 9 months for those who
stopped exercisingstopped exercising
(Dalsky 1988)

28. 2828
Resistance Training
Increases Bone Density Best

Landmark study (Landmark study (Nelson & Fiaterone 1994)Nelson & Fiaterone 1994)
–Sedentary 50-70 y/o postmenopausal womenSedentary 50-70 y/o postmenopausal women
–Resistance training 2 X/wk on 5 machines for 1 Resistance training 2 X/wk on 5 machines for 1
yearyear
–Significant bone density increases in spine, hip, Significant bone density increases in spine, hip,
total bodytotal body

Many other studies validate, including:Many other studies validate, including:
–Cussler EC 2003Cussler EC 2003
–Kerr D 2001Kerr D 2001
–Kelley GA 2001Kelley GA 2001

29. 2929
Principles of Exercise for Principles of Exercise for
People with Lowered Bone MassPeople with Lowered Bone Mass

PosturePosture is critical in all activities is critical in all activities

Weight bearingWeight bearing is important is important
Walking, Dancing, Stair climbingWalking, Dancing, Stair climbing

Resistance exerciseResistance exercise is the best way is the best way
to strengthen bone & muscle groupsto strengthen bone & muscle groups

Balance exercise Balance exercise to decrease fall riskto decrease fall risk

Avoid activities or positions that Avoid activities or positions that
move the body into bent (flexed) move the body into bent (flexed)
posturespostures

30. 3030
Exercise Intervention WorksExercise Intervention Works

After Vertebral fractureAfter Vertebral fracture
–6 months of supervised exercise 6 months of supervised exercise  back strength back strength
and psychological statusand psychological status (Gold et al: (Gold et al: 2004)2004)

For kyphosis and balanceFor kyphosis and balance
–12 weeks of SAFE yoga (12 weeks of SAFE yoga (no forward bending!!!no forward bending!!!) )
improves balance & posture improves balance & posture (Greendale et al, 2002)(Greendale et al, 2002)

For osteoporosis and back painFor osteoporosis and back pain
–10 weeks of combination group and 10 weeks of combination group and
individual exercise increases height, individual exercise increases height,
improves back posture and strength improves back posture and strength (Lindsey (Lindsey
et al, 1995)et al, 1995)

31. 3131
Eclectic Treatment Focus EssentialEclectic Treatment Focus Essential

Frailty Injury Cooperative Interventions Frailty Injury Cooperative Interventions
Trial Analysis revealed that a year after Trial Analysis revealed that a year after
the intervention:the intervention:
–Fall rate decreased Fall rate decreased 10%10% in those who did in those who did
strengthstrength exercises only exercises only
–Fall rate decreased by Fall rate decreased by 17%17% in those who in those who
received received “balance” exercises“balance” exercises only only
–Fall rate decreased by Fall rate decreased by 31%31% in those who did in those who did
both plus the Tai Chi.both plus the Tai Chi.
(Wolfson L et al: Balance and strength training in older adults: (Wolfson L et al: Balance and strength training in older adults:
intervention gains and Tai Chi maintenance. 1996)intervention gains and Tai Chi maintenance. 1996)
–Those who increaseThose who increase all balance scores all balance scores
show ashow a 60% 60% reduction in fall risk.reduction in fall risk.
(Tinetti ME et al: A multifactorial intervention to reduce the risk of (Tinetti ME et al: A multifactorial intervention to reduce the risk of
falling among elderly people living in the community. 1994)falling among elderly people living in the community. 1994)

32. 3232
Prevention of Bone Loss and
Minimizing Fracture Risk

Healthy lifestyle choicesHealthy lifestyle choices
–ExerciseExercise
–NutritionNutrition

Early treatmentEarly treatment
–ScreeningScreening
–Individualized therapiesIndividualized therapies

Physical TherapyPhysical Therapy
–Resistive weight bearing exerciseResistive weight bearing exercise
–Correct body mechanicsCorrect body mechanics
–Balance interventionsBalance interventions
–Treat mechanical pain & dysfunctionTreat mechanical pain & dysfunction

33. See a Physical Therapist See a Physical Therapist
for More Details!for More Details!
http://www.apta.orghttp://www.apta.org
Click the “Find a PT” buttonClick the “Find a PT” button

34. 3434
Find Out More About OsteoporosisFind Out More About Osteoporosis
Web sites for up to date information:Web sites for up to date information:
www.geriatricspt.org/clients/resources.cfmwww.geriatricspt.org/clients/resources.cfm
www.nof.orgwww.nof.org
www.surgeongeneral/library/bonehealthwww.surgeongeneral/library/bonehealth
www.osteo.orgwww.osteo.org
www.fore.orgwww.fore.org

35. 3535
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