Osteoporosis is a systemic skeletal disease, which is characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and an increased risk of fractures.
The risk of fractures is best captured by BMD (bone mineral density). The World Health Organization (WHO) defines the BMD:
- Normal: T>-1
- Osteopenia: T between -1 and -2.5
- Osteoporosis: T<-2.5
(Measures of BMD are often cited with T-score or Z-score)
Fractures can occur in any site, however the most common are those involving the thoracic and lumbar spine, distal radius and proximal femur. Females more affected than males.There are different types of osteoporosis:
- Type I: postmenopausal osteoporosis is thought to result from gonadal (estrogen, testosterone) deficiency.
- Type II: senile osteoporosis occurs in women % men due to decreased formation of bone and decreased renal production of 1.25 (OH)2 D3 occurring later in life.
- Type III: secondary osteoporosis due to medications (glucocorticoids) or other condition causing bone loss.
Causes Exact etiology is poorly understood (unless is Type I, II or III). However there are many risk factors such as:
- Long-term use of medications associated with low bone mass or bone loss such as corticosteroids, some anti-seizure medications, Depo-Provera, thyroid hormone, or aromatase inhibitors. Long-term use of corticosteroids (more than 5 mg/day for more than 3 months) is a specific risk factor.
- History of medical conditions such as diabetes, thyroid imbalances, estrogen or testosterone deficiencies, early menopause, anorexia nervosa, rheumatoid arthritis, chronic liver disease, renal disease.
- Significant loss of height
- Weight loss or low BMI (body mass index)
- Smoking
- Sedentary lifestyle (individuals with a sedentary adolescent lifestyle should be considered at higher risk of osteoporosis. Those who currently have a sedentary lifestyle may also be at higher risk).
- Age: the BMD decreases, and consequently the risk of osteoporosis increases with age.
- Sex: women are at greater risk.
- Family History.
- Ethnicity:white women have a greater risk of getting osteoporosis.
- Menopause: early menopause should be considered at higher risk of osteoporosis than others at a similar age.
- Inflammatory bowel disease or malabsorption.
Diagnosis Usually osteoporosis is asymptomatic until a fracture occurs. Patient may experience loss of height, increased kyphosis (dowager hump) and may complain of severe back pain.
Diagnostic imaging:
The standard technique for determining bone density is the Dual-energy X-ray Absorptiometry (DEXA or DXA) preferably anteroposterior spine and hip. Other tests may be used, but they are not usually as accurate as DXA.
They include ultrasound techniques, DXA of the wrist, heels, fingers, or leg (peripheral DXA) and quantitative computed tomography (QCT) scan. X-Ray conventional radiographs should not be used for the diagnosis or exclusion of osteoporosis, therefore when plain films are interpreted as severe osteopaenia, it is appropriate to suggest referral for DXA.
Treatment
Prevention: fundamental as most patients are asymptomatic until fracture occurs, calcium and vitamin D intake are recommended.Reduce tripping hazards at home (see hints).
Medication:
- Alendronate (Fosamax) increases bone density and decreases risk of fractures.
- Bisphosphonates are useful in decreasing the risk of future fractures in those who have already sustained a fracture due to osteoporosis (ex. Alendronate-Fosamax-).
- Denosumab is also effective for preventing osteoporotic fractures.
- HRT (hormone replacement therapy) maintain estrogen levels however it seems increases the risk of breast cancer, stroke and heart disease, thus the long term risks are greater than benefits.
Lifestyle changes:
- Smoking cessation.
- Decrease or eliminate alcohol consumption.
- Exercise more especially between the 20’s and 30’s to help increase the bone mass and continue through life.
Physiotherapy: gentle mobilization and massage therapy to relieve musculoskeletal issues. Extension mobilization of the thoracic spine may offer benefit.
Hints
Calcium supplements 500-1000 mg/d + vitamin D 400-800 IU (An average daily intake of 1000 mg of calcium can most easily be obtained from 600 ml (1 pint) of milk with either 50 g (2 oz) hard cheese (eg Cheddar or Edam), one pot of yoghurt, or 50 g (2 oz) sardine). Prevention at home to avoid falls and hip fracture among elderly:
- Lighting should not be too dim or too direct, and light switches should be accessible.
- Carpets and rugs should be tacked down.
- Bathrooms should have a chair for bathing or skid-resistant mats, grab bars should be placed where needed and the toilet seat needs to be tall enough for easy transferring.
- Chairs need to be stable (without wheels) and have arm rests.
- Kitchen items that are frequently used should be at waist level or on low shelves, a rubber mat should be placed in front of the sink and non-slip wax should be used on the floor.
- Stairways need handrails and steps should not be slippery.
Exercising and osteoporosis
Resistance training refers to training where an overload resistance is applied. The resistance can be low, usually referred to as muscular endurance training, or moderate to high, called strength training. Strength training needs to be of a high intensity to produce gains in strength and BMD. Any form of strength training should be site specific i.e. targeting areas such as the muscle groups around the hip, the quadriceps, dorsi/plantar flexors, rhomboids, wrist extensors and back extensors. Weight-bearing activity is carried out when standing. Low impact weight bearing activity is characterised by always having one foot on the floor. Jumping (both feet off floor) is termed high impact training. High impact training is not suitable for patients with osteoporosis. Weight bearing exercises should be targeted to loading bone sites predominantly affected by osteoporotic change such as hip and spine. To be effective all exercise programmes need to be progressive in terms of impact and intensity as fitness and strength levels improve. Programmes should begin at a low level that is comfortable for the patient. An initial assessment by a suitably trained individual such as a physiotherapist will give the patient a reference point from which to start the exercise programme
Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232http://www.osteopathy.org.uk/home/)
"Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome
