The management of osteoporosis

As we get older we tend to lose bone mass and this can lead to fractures and osteoporosis. According to WHO  a normal bone mineral density score is -1.0 or higher, -1.0 to -2.5 for osteopenia, and -2.5 or lower for osteoporosis and it is detected by the most common test DXA (https://www.youtube.com/watch?v=68odYBQfKgQ) 

Category	T-score
Normal	-1.0 or above
Osteopenia (low bone mass)	-1.0 to -2.5
Osteoporosis	-2.5 or less
Severe Osteoporosis	-2.5 or less with one or more fragility fractures

Osteoporosis causes more than 8.9 million fractures annually worldwide, of which more than 4.5 million occur in the Americas and Europe. The lifetime risk for a wrist, hip or vertebral fracture has been estimated to be in the order of 30% to 40% in developed countries. Osteoporosis is not only a major cause of fractures, it also ranks high among diseases that cause people to become bedridden with serious complications. These complications may be life-threatening in elderly people.

Why osteoporosis occurs?
Bone tissue is constantly being absorbed and replaced throughout life span. When bone mass absorption increases over its production then it leads to osteoporosis.  

If someone has low calcium intake or absorption then he or she is at risk for developing osteoporosis. That is why it is important to take calcium throughout your life to build up bone stock prior to peak levels of bone mass, as well as maintain bone mass after the age of 20.

Excessive alcohol consumption can decrease the body's ability to absorb calcium.

Bone produces in response to the load applied to it. Physically active individuals typically have higher bone density, than those who have a sedentary lifestyle.

Hormone levels, either too little or too much, can impede on the body's ability to produce and maintain adequate bone mass. Dysfunction with sex glands, thyroid, parathyroid, or adrenal glands is often associated with osteoporosis.

There are two types of osteoporosis: primary and secondary.

Primary osteoporosis is idiopathic- there is not know reason, but there are number of factors associated with the disorder:
-  prolonged negative calcium balance,
- impaired gonadal and adrenal function,
- estrogen deficiency,
-  sedentary lifestyle.

Due to prolonged use of medication or comorbidites secondary osteoporosis can occur.

Risk Factors

• Age 50 years and older
• Female gender
• Caucasian and Asian
• Menopause (especially early or surgically induced)
• Family history of osteoporosis or fragility fractures
• Long periods of inactivity or immobilization
• Depression
• Alcohol (>3 drinks/day)
• Tobacco
• Caffeine (>4 cups/ day)
• Amenorrhea (abnormal absence of menses)
• Thin body build

Clinical Signs and Symptoms

• Back pain: Episodic, acute low thoracic/high lumbar pain
• Compression fracture of the spine 
• Bone fractures
• Decrease in height 
• Kyphosis
• Dowager’s hump
• Decreased activity tolerance
• Early satiety

Management of osteoporosis

Recently updated NICE guidance about the management of osteoporosis in adults and risk assessment says that:

-  all options should be consider to prevent and treat fractures in people who suffer from osteoporosis;

- people with osteoarthritis at high risk of fragility fractures should be offered drug treatment to improve bone density and reduce chance of future fractures;

- advice on the selection and use of risk assessment tools for those at risk of fragility fractures;

Medications

Class and Drug	Brand Name	Form	Frequency	Side Effects
Biphosphonates
Alendronate	Generic Alendronate and Fosamax	Oral (tablet)	Daily/Weekly	Side effects for all biphosphonates may include bone, joint, or muscle pain. Side effects of the oral tablets may include nausea, difficulty swallowing, heartburn, irritation of the esophagus, and gastric ulcer. Side effects that can occur shortly after receiving an IV biphosphonate include flu-like symptoms, fever, headache, and pain in muscles or joints.
Alendronate	Fosamax Plus D (with 2,800 IU or 5,600 IU of Vitamin D3)	Oral (tablet)	Weekly
Ibandronate	Boniva	Oral (tablet)	Monthly
Ibandronate	Boniva	Intravenous (IV) injection	Four times per year
Risedronate	Actonel	Oral (tablet)	Daily/Weekly/Twice Monthly/Monthly
Risedronate	Actonel with Calcium	Oral (tablet)	Weekly
Zoledronic Acid	Reclast	Intravenous (IV) infusion	One time per year/Once every two years
Calcitonin
Calcitonin	Fortical	Nasal spray	Daily	Runny nose, headache, back pain, and nosebleed (epistaxis)
Calcitonin	Miacalcin	Nasal spray	Daily
Calcitonin	Miacalcin	Injection	Varies	May cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea, and a skin rash.
Estrogen
Estrogen	Multiple brands	Oral (tablet)	Daily	Increased risk of endometrial and breast cancer, vaginal bleeding, breast tenderness, gallbladder disease, stroke, venous blood clot, cognitive decline.
Estrogen	Multiple brands	Transdermal (skin patch)	Twice Weekly/Weekly
Estrogen Agonists/Antagonists also called Selective Estrogen Receptor Modulators (SERMs)
Raloxifene	Evista	Oral (tablet)	Daily	Hot flashes, leg cramps, and deep vein thrombosis (blood clots)
Parathyroid Hormone
Teriparatide	Forteo	Injection	Daily	Leg cramps and dizziness
RANK Ligand (RANKL) Inhibitor
Denosumab	Prolia	Injection	Every 6 Months	May lower calcium levels in the blood. May also increase the risk of injection and skin rashes.

Physiotherapy

Physical therapy intervention for individuals with osteoporosis, or even osteopenia, should include:

• weight-bearing
• flexibility exercise
• strengthening exercise
• postural exercise
• balance exercise

Weight-bearing exercises

Exercises such as walking or hopping, has been shown to maintain or improve bone density in this population. Strengthening exercises, using weights or resistance bands, has also been shown to maintain or improve bone density at the location of the targeted muscle attachments. Maintaining bone health in this population is extremely important, especially in the elderly as there is typically has a decline in bone mass with age.

Flexibility and strengthening exercises

These can help improve the individuals overall physical function and postural control. Improving postural control is important to reduce the risk for falls. Falls often result in fractures in frail individuals. Balance exercises are also important to incorporate to further reduce the risk of falls.

Postural exercises

These are crucial to prevent structural changes that often accompany osteoporosis, such as thoracic kyphosis. Every osteoporosis program should include extension exercises; chin tucks, scapular retractions, thoracic extensions, and hip extensions. Strengthening the extensor muscles will promote improved posture and improved balance. Flexion exercises are CONTRAINDICATED. Anterior compressive forces to the vertebra can contribute to compression fractures.

Back Pain

Physical therapist may treat patients with osteoporosis for back pain. Agility training, resistance training, and stretching have all been shown to decrease back pain and its related disabilities in this population.

High intensity

Research highly supports high intensity training in the prevention of bone lost for women in menopausal years and early stage post menopausal. High intensity training would include body-weight and resistive exercises at a high intensity, similar to circuit training. This type of training is often contraindicated for individuals with low bone mass.

A Cochrane review has been completed to determine the best exercise for prevention and treatment of osteoporosis. The population was healthy post menopausal females, age 45- 70. Duration of the intervention was at the least ten months, several lasting over a year. The majority of the studies has a frequency of 2- 3 days per week. The results were that combination of exercise promotes greatest improvements in bone mass at the spine, wards triangle, and the femoral trochanter. Dynamic weight-bearing, high force exercise results with greatest improvements at the femoral neck and moderate results at the femoral trochanter. Dynamic weight-bearing, low force exercise had moderate positive effects at the spine. Non-weight-bearing, high force exercise were shown to have moderate effects at the femoral neck

Resources:

 https://www.nice.org.uk/guidance/qs149/resources/osteoporosis-pdf-75545487906757

https://www.nof.org/

Goodman. Fuller. Boissonnault. Pathology; Implications for the Physical Therapist. 2nd. Philadelphia: Saunders, 2003.

National Osteoporosis Foundation. What is osteoporosis? http://www.nof.org/articles/7

 

National Osteoporosis Foundation. Treatment with Osteoporosis Medication. http://www.nof.org/articles/21

National Osteoporosis Foundation. Having a Bone Density Test. http://www.nof.org/articles/743

National Osteoporosis Foundation. Making a Diagnosis. http://www.nof.org/articles/8

Zehnacker CH, Bemis‐Dougherty A. Effect of Weighted Exercises on Bone Mineral Density in Post Menopausal Women A Systematic Review. Journal of Geriatric Physical Therapy. 2007; 30(2):79-88. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0025196/

Burke TN, Franca FJR, Ferreira de Meneses SR, Pereira RMR, Marques AP. Postural control in elderly women with osteoporosis: comparison of balance, strengthening and stretching exercises. A randomized controlled trial. Clinical Rehabilitation; 26 (11): 1021-1031. https://www.researchgate.net/profile/Thomaz_Burke/publication/224005205_Postural_control_in_elderly_women_with_osteoporosis_comparison_of_balance_strengthening_and_stretching_exercises_A_randomized_controlled_trial/links/0deec5163f3d5f3d55000000/Postural-control-in-elderly-women-with-osteoporosis-comparison-of-balance-strengthening-and-stretching-exercises-A-randomized-controlled-trial.pdf 

Liu-Ambrose TYL, Khan KM, Eng JJ, Lord SR, Lentle B, McKay HA. Both resistance and agility training reduce back pain and improve health-related quality of life in older women with low bone mass. Osteoporosis International; 16: 1321- 1329. http://www.scielo.br/pdf/rbr/v54n6/en_0482-5004-rbr-54-06-0467.pdf

Martyn-St James M, Carroll S. High Intensity resistance training and postmenopausal bone loss: a meta-analysis. Osteoporosis International; 17: 1225-1240. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0023563/

Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women (Review). The Cochrane Collaboration. 2011;(2) https://www.ncbi.nlm.nih.gov/pubmed/21735380

Sran MM, Khan KM. Physiotherapy and osteoporosis: practice behaviors and clinicians' perceptions--a survey. Manual Therapy. 2005 Feb;10(1):21-7. http://www.zf.uni-lj.si/data/datoteke/acam21/polonap/NBG%C5%A1tudijskogradivo0708/PRESNOVNEBOLEZNI/Osteoporoza/Physiotherapy_and_osteoporosis.pdf

Medscape. Osteoporosis Differential Diagnoses. http://emedicine.medscape.com/article/330598-differential

http://www.who.int/chp/topics/Osteoporosis.pdf