Osteoporosis is a disease characterized by low bone density and the deterioration of bone tissue.
As the bones become more porous and fragile, the risk of fractures is greatly increased. The loss the bone occurs “silently” and progressively. Often there are no symptoms until the first fracture occurs.
Osteoporosis is widespread, and as the world’s population ages, more and more people will suffer from this debilitating and sometimes fatal disease.
Thus, an efficient way of preventing osteoporotic fractures occuring in the second half of life is to build up the strongest bones possible during the juvenile periods when rapid bone growth occurs, thereby achieving maximum bone mass by the end of the teen years.
Bones are living tissue and the skeleton grows continually from birth to the end of the teen years, reaching maximum strength and size around the age of 20.
During growth the gain in bone mineral mass is mainly due to an increase in bone size with very little change in bone density. In girls, the bone tissue accumulated during the ages 11 and 13 approximately equals the amount lost during the 30 years following menapause.
From birth to the onset of the sexual maturation, the bone mineral mass at any age is the same in girls as in boys. During puberty bone mass increases more in boys than in girls. The difference appears to be mainly due to a more prolonged period of accelerated growth in males than in females, resulting in a larger increase in bone size and thickness of the cortical shell of the bones.
Osteoporosis can be characterized as either primary or secondary. Primary osteoporosis can occur in both genders at all ages but often follows menapause in women and occurs later in life in men. Secondary osteoporosis is a result of medications, other conditions or diseases.
The consequenses of osteoporosis include the financial, physical, and psychosocial which significantly affect the individual family, and the community. The incidence of fracture is high in individuals with osteoprosis and increases with age. The impact from fractures in terms of loss of mobility and independence and medical costs does not end with hospital or clinic discharge. Following a hip fracture:
10-20% of patients will die within six months
50% of sufferers will be unable to walk without assistance
25% will require long term domiciliary care
Predictors of low bone mass include:
- Female gender,
- Estrogen deficiency
- Caucasian, Asian or Native American race
- Low weight and body mass index (small thin body frame)
- Age 50 or above
- Family history of osteoporosis, or relatives who lost height with age, suffered vertebral, hip or wrist fractures or developed a hunch back
- Cigarette Smoking
- History of prior fracture
- Use of alcohol and caffeine containing beverages is consistently associated with decreased bone mass.
- Late menarche, early menopause
- Low testosterone levels in men
- Difficulty absorbing calcium
- Anorexia nervosa or bulimia
- Sedentary lifestyle
Glucocorticoid use is the most common form of drug induced osteoporosis and its long term administration for disorders such as rheumatoid arthritis and COPD is associated with a high rate of fracture. Hyperthyroidism is a well-described risk factor of osteoporosis. Some studies have suggested that women taking thyroid replacement may also be at increased risk for excess bone loss, suggesting that careful regulation of thyroid replacement is important.
Calcium is the specific nutrient most important for attaining peak bone mass and for preventing and treating osteoprosis.
National Institute of Health recommends: Optimal Calcium Intake
|Birth -1 year||
|Females, 25-49 years||
Females, post menopausal, 50-64 years
Not on HRT
|Males, 25-64 years||
|Females/Males > 65 years||
Vitamin D is required for optimal calcium absorption and thus is also important for bone health. A recommended vitamin D intake of 400 to 600 IU/day has been established for adults.
Regular physical activity has numerous health benefits for all ages. Physical activity early in life contributes to higher peak bone mass.
The influences of genetics, nutrition, exercise all play a role in the development of osteoporosis. In contrast some measures of physical function and activities have been associated with increased bone mass, including grip strength and current exercise.
Exercise during the later years, in the presence of adequate calcium and vitamin D intake, probably has a modest effect on slowing the decline in BMD. Even at advanced age exercise can increase muscle mass and strength. (see physical therapy guidelines)
Good nutrition is essential for normal growth. A balanced diet, adequate calories and appropriate nutrients are the foundation for development for all tissues, including bone.
Sex steroids secreted during puberty substantially increases BMD and peak bone mass. Gonadal steroids influence skeletal health throughout life in both women and men. In adolescents and young women, sustained production of estrogens is essential for the maintenance of bone mass. Reduction in estrogen production with menopause is the major cause of loss of BMD during later life.
Testosterone production in adolescent boys and men is similarly important in achieving and maintaining maximal bone mass. Estrogens have also been implicated in the growth and maturation of the male skeleton. Pathologic delay in the onset of puberty is a risk factor for diminished bone mass in men. Disorders that result in hypogonadism in adult men result in osteoporosis.
Growth hormone and insulin-like Growth Factor I which are maximally secreted during puberty, continue to play a role in the acquisition and maintenance of bone mass and determination of body composition into adulthood. Growth hormone defeciency is associated with a decrease in BMD.
Optimal Evaluation and treatment of osteoporosis is to establish the diagnosis, to establish the fracture risk and to make decisions regarding the need to institute therapy.
Bone Mass Density (BMD) measurement should be considered in patients receiving Glucocorticoid therapy for 2 months or more and patients with other conditions that place them at high risk for osteoporotic fracture.
BMD is not needed on a routine basis if on HRT; Consider BMD if clinical status changes, e.g. development of:
- Co-morbid condition that requires Glucocorticoid treatment or contributes to bone loss.
- Increasing risk for falls or fracture.
- Kyphosis or minimal trauma fracture
- Loss of height
- All women with no risk factors after the age of 65.
- Before the age of 65 with one or more risk factors.
If patient declines or is not a candidate for Hormone Replacement Therapy, (HRT) recommend BMD if results would influence other pharmacologic treatment decisions.
- Women discontinuing HRT should have a BMD within 1 year.
- If low, then wanting to stop therapy then they should have alternative.
- If BMD normal, then follow up with BMD in a few years.
- (If not on HRT, consider treatment for osteoporosis.)
Dual Energy X-Ray Absorptiometry (DEXA) for screening and assessing change over time; most commonly used at present. Measure bone density in the spine and hip. Spine loss is more rapid near menopause. If >60 years old, increased spine osteophytes may falsely increase spine BMD. The hip measurement may become more reliable in this situation.
If on chronic steroids, with a positive BMD test, then discuss treatment with osteoporosis medications.
Both Surgical or hormonal are treated the same.
Discuss the risks and benefits of HRT:
Risks: Stroke, Uterine Cancer, Breast Cancer
Benefits: Prevention of Osteoporosis, Colorectal cancer, possible Alzheimer’s
If not comfortable with HRT, then start on Osteoporosis prescription. After 5 years consider discontinuing HRT and changing to Osteoporosis prescription. If comfortable with benefits then start on HRT.
Calcium carbonate (2500 mg) = 40% calcium (100 mg)
Caltrate 600-1.5 gm (600 mg)Os-Cal 500-1.25 gm (500 mg)
Os-Cal 250-625 mg (250 mg)
Tums E-X-750 mg (300 mg)
Tums-500 mg (200 mg)
Titralac-420 mg (168 mg)
Titralac Suspension-1 gm (400 mg)/5 ml
Calcium Phosphate Tribasic (2667 mg) = 37.5% Calcium (1000 mg)
Posture-1.6 gm (600 mg)
Posture-800 mg (300 mg)
Calcium Phosphate Dibasic (4348 mg) = 23% calcium (1000 mg)
Calcium Citrate=21% Calcium
Calcium Lactate (7692 mg) = 13% calcium (1000 mg)
650 mg (84.5 mg)
325 mg (42.25 mg)
Calcium Gluconate (11,111 mg) = 9% calcium (1000 mg)
1 gm (90 mg)
650 mg (58.5)
500 mg (45 mg)
Calcium Glubionate (15,625 mg) = 6.4% calcium syrup (1000 mg)
One 8 oz. glass of milk = 285 mg Calcium
Vitamin D 400 IU/Day
Usually 400 IU’s in Multiple Vitamin
Exercise is important to help those with Osteoporosis in the following ways:
- To improve posture and avoid the development of a Thoracic Kyphosis (back hump) or other postural abnormalities and asymmetries.
- Weight bearing exercise will help to slow down the loss of bone mass.
- Exercise will improve balance, strength, and flexibility to help make daily living activities easier and safer; and reduce risk of fractures due to falling.
- Increased muscle pull and weight bearing activities will increase the strength of your bones.
A regular exercise routine should be performed for 20-30 minutes 3-4 times per week.
A specific exercise program will be developed for you by your physical therapist.
- General contraindications with any exercise program: increased blood pressure, abnormal heart rate, difficulty breathing, dizziness, nausea, and extreme pain.
- Avoid excessive resistive stress, especially in those who have been diagnosed with a fracture. Resistance should be applied progressively and cautiously to avoid pathological fractures.
- Avoid increased spinal flexion activities and exercises.
(Each exercise program is individualized to each person as determined by the Physical Therapist)
Signs and Symptoms:
- Single or multiplied compression fractures.
- Pain usually severe, stabbing, constant, and/or referred in name.
- Severe postural changes are evident.
Goals of Level I:
- Produce increased muscular contraction of the back extensors and scapula depressors.
- Prevent further decline of posture.
- Improve balance and endurance to decrease the chance of falls and related fractures.
- Decrease pain to a tolerable level.
Signs and Symptoms
- No fractures. Dull pain, not constant in nature.
- Moderate postural changes are evident.
Goals of Level II:
- To attain neutral spinal alignment and or spinal extension.
- To improve balance.
- To increase strength, flexability, and endurance to maintain bone strength.
- Decrease the chance of falls and related fractures.
Signs and Symptoms
- No fractures.
- No pain, complain of decreased endurance and some fatigue.
- Minimal to no postural changes are evident.
Goals of Level III:
- To maintain proper posture
- To maintain full ROM (range of motion) and flexibility.
- Prevent falls and associated fractures.
- Increase strength, endurance, and ease of ADL’s (activities of daily living).