Download - OSTEOPOROSIS and METABOLİC BONE DİSEASES
OSTEOPOROSIS andOSTEOPOROSIS andMETABOLİC BONE METABOLİC BONE
DİSEASESDİSEASESProf. Dr. Ece AydoğProf. Dr. Ece Aydoğ
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation
DefinitionDefinition
Literally translates as “Literally translates as “porous bonesporous bones”” A progressive systematic skeletal disease A progressive systematic skeletal disease
characterized low bone mass and micro-characterized low bone mass and micro-architectural deterioration of bone tissue, with architectural deterioration of bone tissue, with a consequent increase in bone fragility and a consequent increase in bone fragility and susceptibility to fracture risk.susceptibility to fracture risk.
OsteoporosisOsteoporosis
-most common metabolic bone disease-most common metabolic bone disease -affects both sexes and all races-affects both sexes and all races -decline in bone mineral dansitometry-decline in bone mineral dansitometry -disproportionate decrease in bone strength-disproportionate decrease in bone strength -increase in fractures-increase in fractures -enormous costs for fracture treatment and -enormous costs for fracture treatment and
disabilitydisability
Clinical featuresClinical features
Osteoporotic fracturesOsteoporotic fractures;; The clinical picture can be overlooked or The clinical picture can be overlooked or
hidden, especially in the case of vertebral hidden, especially in the case of vertebral fractures, which are the most frequent fractures, which are the most frequent fractures in postmenopausal womenfractures in postmenopausal women..
Clinical featuresClinical features
Osteoporotic fracturesOsteoporotic fractures;; Only about one- third of all people with Only about one- third of all people with
radiographic vertebral fractures are diagnosed radiographic vertebral fractures are diagnosed clinically.clinically.
Excess mortality ( esp.hip fracture)Excess mortality ( esp.hip fracture) İncreased risk subsequent fractures; İncreased risk subsequent fractures;
(20% for a new vertebral fracture within 1 (20% for a new vertebral fracture within 1 year and 25% for all fractures)year and 25% for all fractures)
Osteoporotic fracturesOsteoporotic fractures;; Pain;Pain;
-Acute-Acute
-Chronic -Chronic Functional declineFunctional decline Psychosocial declinePsychosocial decline Reduced quality of lifeReduced quality of life
Physical and social outcomesPhysical and social outcomes
Loss of heightLoss of height KyphosisKyphosis Chronic back painChronic back pain Digestive problemsDigestive problems Decreased mobilityDecreased mobility Loss of independenceLoss of independence DepressionDepression
Wrist fracturesWrist fractures
Occur after a fallOccur after a fall 1/1000 per year below age 451/1000 per year below age 45 7/1000 per year at ages 65 and older7/1000 per year at ages 65 and olderMost symptomsMost symptoms Persisting hand painPersisting hand pain WeaknessWeakness AlgodystrophyAlgodystrophy İmpairment of activities of daily living (ADL)İmpairment of activities of daily living (ADL)
Hip fracturesHip fractures Occur after a fallOccur after a fall Spontanous insufficiency hip fractures is low (0.27%)Spontanous insufficiency hip fractures is low (0.27%) Almost all hip fractures require urgent surgical interventionAlmost all hip fractures require urgent surgical intervention General complications:General complications: Cardiovascular, Cardiovascular, Pulmonary,Pulmonary, Cerebral problemsCerebral problems İnfectionsİnfections Local complications:Local complications: Wound and prostetic problemsWound and prostetic problems
Hip fracturesHip fractures
Mortality ranges between 1%-9%Mortality ranges between 1%-9% 20-25% of hip fracture patients die within the 20-25% of hip fracture patients die within the
first yearfirst year After 6 months, only 24% of patients had After 6 months, only 24% of patients had
returned to prefracture walking competence returned to prefracture walking competence and only 43% had returned to prefracture basic and only 43% had returned to prefracture basic ADL. ADL.
Little further improvement occured after 1 Little further improvement occured after 1 year.year.
Vertebral fracturesVertebral fractures Only one in three vertebral fractures is diagnosed.Only one in three vertebral fractures is diagnosed. Often occur after minimal traumaOften occur after minimal trauma Mortality is increased after vertebral fractures by 19% Mortality is increased after vertebral fractures by 19%
compared with the general populationcompared with the general population Mortality rate highest in patients with multipl vertebral Mortality rate highest in patients with multipl vertebral
fractures and in patients who reqired hospitalization.fractures and in patients who reqired hospitalization. Four times greater risk for new vertebral fracture and twice the Four times greater risk for new vertebral fracture and twice the
risk of hip and other non-vertebral fracturerisk of hip and other non-vertebral fracture Clinical messageClinical message in order to prevent future fractures, vertebral in order to prevent future fractures, vertebral
fracture should be recognized and treated early with drugs.fracture should be recognized and treated early with drugs.
Back painBack pain
onset is sudden (73%)onset is sudden (73%) moderate to severemoderate to severe worsens on movement; pworsens on movement; pain is worsed by sitting, ain is worsed by sitting,
standing, staying in the same position for a long time, standing, staying in the same position for a long time, bending, walking, and sudden movementsbending, walking, and sudden movements
relieved by restrelieved by rest cause breathlessness, pallor, nausea, and vomitigcause breathlessness, pallor, nausea, and vomitig exacerbated by coughing or sneezingexacerbated by coughing or sneezing
Back painBack pain
deeply localized bone or muscle relateddeeply localized bone or muscle related radiates laterally following the dermatomal radiates laterally following the dermatomal
distributiondistribution accompanied by spasm of the paraspinal accompanied by spasm of the paraspinal
musclesmuscles no specific circadian rhythm of pain is foundno specific circadian rhythm of pain is found chronicty of the back pain is related to the chronicty of the back pain is related to the
number and severity of vertebral fracturesnumber and severity of vertebral fractures increased risk for chronic back painincreased risk for chronic back pain
Back painBack pain
On clinical examination; On clinical examination; Tenderness over the affected vertebrae and Tenderness over the affected vertebrae and
paraspinal musclesparaspinal muscles Mobility of the spine is restricted and painfulMobility of the spine is restricted and painful KyphosisKyphosis
Changes in vertebral shape due to Changes in vertebral shape due to osteoporosis. osteoporosis.
Normal vertebra (1), Normal vertebra (1),
Wedge fracture (2), Wedge fracture (2),
biconcave or ‘fish’ vertebra(3),biconcave or ‘fish’ vertebra(3),
and a compression fracture (4).and a compression fracture (4).
Pain and hyperkyphosis cause a spiralling decline in;Pain and hyperkyphosis cause a spiralling decline in; MobilityMobility Muscle strengthMuscle strength FunctionFunction Decline in function in turn, contrubites to pain and an Decline in function in turn, contrubites to pain and an
increasedincreased Bone lossBone loss Risk of fallsRisk of falls FracturesFractures Loss of independencyLoss of independency
KyphosisKyphosis
Heigth loss (1 cm decrease in 8 years)Heigth loss (1 cm decrease in 8 years) Reduce the distance the distance between the Reduce the distance the distance between the
iliac crest and ribs, resulting in problems with iliac crest and ribs, resulting in problems with digestion and protruding abdomendigestion and protruding abdomen
Lung function progressively decreases Lung function progressively decreases Balance capability may be affectedBalance capability may be affected Muscle strength significantly decresesMuscle strength significantly decreses
Dowager’s hump.Dowager’s hump.
Marked thoracicMarked thoracic
kyphosis due tokyphosis due to
multiple osteoporoticmultiple osteoporotic
fractures in elderlyfractures in elderly
woman.woman.
Laboratory TestsLaboratory Tests
Blood calciumBlood calcium Blood vitamin D Blood vitamin D Thyroid function Thyroid function Parathyroid hormone Parathyroid hormone Estradiol levels to measure estrogen (in women) Estradiol levels to measure estrogen (in women) Follicle stimulating hormone (FSH): to establish Follicle stimulating hormone (FSH): to establish
menopause status menopause status Testosterone levels (in men) Testosterone levels (in men)
Alkaline phosphatase (ALP)Alkaline phosphatase (ALP) Osteocalcin levels to measure bone formation. Osteocalcin levels to measure bone formation.
Laboratory TestsLaboratory Tests
The most common The most common URINEURINE tests are: tests are: 24-hour urine collection to measure calcium 24-hour urine collection to measure calcium
metabolism, hidroxyproline, telopeptidemetabolism, hidroxyproline, telopeptide Tests to measure the rate at which a person is Tests to measure the rate at which a person is
breaking down or breaking down or resorbing boneresorbing bone. .
BIOCHEMICAL MARKERS OF BONE FORMATIONBIOCHEMICAL MARKERS OF BONE FORMATION
Name Name Mechanism Mechanism
Bone ALP, BAP Bone ALP, BAP Bone-specific alkaline Bone-specific alkaline phosphatase phosphatase
Secreted by Secreted by osteoblasts osteoblasts
PINP PINP Procollagen type I N Procollagen type I N terminal propeptide terminal propeptide
Collagen-based Collagen-based
OC OC Osteocalcin (bone gla-Osteocalcin (bone gla-protein )protein )
Secreted by Secreted by osteoblasts osteoblasts
ALP ALP Alkaline phosphatase Alkaline phosphatase (not very specific) (not very specific)
Secreted by Secreted by osteoblasts osteoblasts
Name Name Mechanism Mechanism
NTXNTX Aminoterminal cross-Aminoterminal cross-linking telopeptide of linking telopeptide of bone collagen bone collagen
Collagen-based Collagen-based
CTXCTX Carboxyterminal cross-Carboxyterminal cross-linking telopeptide of linking telopeptide of bone collagen bone collagen
Collagen-based Collagen-based
PYDPYD Pyridinoline Pyridinoline Collagen-based Collagen-based
DPDDPD Free Lysyl-pyridinoline Free Lysyl-pyridinoline (deoxypyridinoline (deoxypyridinoline
Collagen-based Collagen-based
TRACPTRACP Tartrate-resistant acid Tartrate-resistant acid phosphatase phosphatase
Secreted by osteoclasts Secreted by osteoclasts
HypHyp Hydroxy-proline (not Hydroxy-proline (not very specific) very specific)
Collagen-based Collagen-based
BIOCHEMICAL MARKERS OF BONE RESORPTION
Non- pharmological theraphyNon- pharmological theraphy
Fall prevention:Fall prevention: Evaluation of fall riskEvaluation of fall risk Modifiable risk factors should be identified, and corrected Modifiable risk factors should be identified, and corrected
including poor vision, hearing or cognition, and myopathies.including poor vision, hearing or cognition, and myopathies. Disease including alcoholism, neuromuscular disorders and Disease including alcoholism, neuromuscular disorders and
dementia should be treated furthet reducing fracture risk.dementia should be treated furthet reducing fracture risk. Avoid medications like sedatives and hypnoticsAvoid medications like sedatives and hypnotics Use of assistive devicesUse of assistive devices Vit D supplementationVit D supplementation Home modificationsHome modifications Exercise; Thai Chi Exercise; Thai Chi
Dual Energy X-ray AbsorptiometryDual Energy X-ray Absorptiometry
HipHip Lumbar SpineLumbar Spine Distal RadiusDistal Radius Whole BodyWhole Body FootFoot T score;T score; degree of bone loss degree of bone loss
is defined by comparison is defined by comparison with young adult mean bone with young adult mean bone densitydensity
Z score;Z score;degree of bone loss degree of bone loss is defined by comparison is defined by comparison with your same sex, age, with your same sex, age, and weight.and weight.
WHO definitionWHO definition T-score > -1.0 NormalT-score > -1.0 Normal T-score < -1.0 > -2.5 T-score < -1.0 > -2.5
‘Osteopenia’‘Osteopenia’ T-score < -2.5 T-score < -2.5
‘Osteoporosis’‘Osteoporosis’
Management of osteoporosisManagement of osteoporosis
Evaluation for secondary osteoporosisEvaluation for secondary osteoporosis Treatment:Treatment: Non- pharmological theraphy:Non- pharmological theraphy: Patient educationPatient education -fall risk-fall risk -exercise programs,-exercise programs, -dietary advice invluding adequate Ca and vit. D -dietary advice invluding adequate Ca and vit. D
intakeintake -lifestyle modification-lifestyle modification
Non- pharmological theraphyNon- pharmological theraphy
Exercise:Exercise: Modarete, regular weigth bearing exercise is essential Modarete, regular weigth bearing exercise is essential
for skeletal health.for skeletal health. Increase BMDIncrease BMD Increase muscle strength Increase muscle strength
Better conditioning and balanceBetter conditioning and balance
Reduce fall riskReduce fall risk
Non- pharmological theraphyNon- pharmological theraphy
Smoking; Smoking; directly toxic to bonedirectly toxic to bone
Alcohol; Alcohol; greater than 2 to drink equivalentsgreater than 2 to drink equivalents
per day should discouragedper day should discouraged
Caffeine; Caffeine; induce hypercalciuriainduce hypercalciuria
Non- pharmological theraphyNon- pharmological theraphy
Pharmacological İnterventionsPharmacological İnterventions
1-Hormone replacement therapy1-Hormone replacement therapy Selective estrogen receptor modulators Selective estrogen receptor modulators (SERMs)-Raloxifene(SERMs)-Raloxifene Depending on the target organ, these compounds may Depending on the target organ, these compounds may
demonstrate estrogen antogonist or estrogen agonist effects.demonstrate estrogen antogonist or estrogen agonist effects. Antiresorptive effects on bone in postmenopausal womenAntiresorptive effects on bone in postmenopausal women The incidence of vertebral fracture risk is decreseThe incidence of vertebral fracture risk is decrese The incidence of non-vertebral fracture including hip fracture, The incidence of non-vertebral fracture including hip fracture,
do not differ significantlydo not differ significantly Higher risk of venous thromboembolus and hot flashesHigher risk of venous thromboembolus and hot flashes 76% reduction in the risk of breast cancer76% reduction in the risk of breast cancer
Pharmacological İnterventionsPharmacological İnterventions
3-Biphosphonates:3-Biphosphonates: Primary effect is to suppress osteoclast Primary effect is to suppress osteoclast
mediated bone resorptionmediated bone resorption Etidronate;Etidronate; oldest biphosphonate in useoldest biphosphonate in use AlendronateAlendronate RisedronateRisedronate IbandronateIbandronate Zolendronic acidZolendronic acid
BiphosphonatesBiphosphonatesSide effectsSide effects
GI side effects: Esophageal erosions and GI side effects: Esophageal erosions and stricturestricture
Impaired mineralization with etidronateImpaired mineralization with etidronate Bone painBone pain Impaired fracture healing in dogs with Impaired fracture healing in dogs with
etidronateetidronate Osteonecrosis of the jaw; incidence with oral Osteonecrosis of the jaw; incidence with oral
biphosphonates is much less biphosphonates is much less
Parathyroid HormoneParathyroid HormoneTeriparatideTeriparatide
Following characteristics may be Following characteristics may be appropriate for teriparatide therapy:appropriate for teriparatide therapy:
Those who lose bone mineral density on Those who lose bone mineral density on antiresoptive theraphy.antiresoptive theraphy.
Are unable to take antiresoptive agents Are unable to take antiresoptive agents because of side effects.because of side effects.
Fracture on antiresoptive theraphy.Fracture on antiresoptive theraphy. Are treatment naive patients at high risk of Are treatment naive patients at high risk of
fracture.fracture.
Parathyroid HormoneParathyroid HormoneTeriparatideTeriparatide
Effect of PTH on fracture reductionEffect of PTH on fracture reduction Periosteal bone formation and a change in Periosteal bone formation and a change in
bone sizebone size İncreases strength by increasing diameterİncreases strength by increasing diameter The earlier rise in markers of bone formation The earlier rise in markers of bone formation
than in markers of resorption with PTH than in markers of resorption with PTH treatment provide a rational for the observed treatment provide a rational for the observed increases in bone density.increases in bone density.
Side EffectsSide Effects
İnfrequent, not serious, rarerly resulting in İnfrequent, not serious, rarerly resulting in cessation of treatmentcessation of treatment
Dizzines,Dizzines, Leg crampsLeg cramps Mild hypercalcemia (common)Mild hypercalcemia (common) Increase in uric acid levels, but no gout attacksIncrease in uric acid levels, but no gout attacks OsteosarcomaOsteosarcoma
Should not prescribe;Should not prescribe;
Paget’s disease Paget’s disease Prior radiation therapy to the skeletal systemPrior radiation therapy to the skeletal system Pediatric population and young adult with Pediatric population and young adult with
open epiphysesopen epiphyses Patients who have bone metastases or a Patients who have bone metastases or a
history of skeletal malignancies.history of skeletal malignancies.
Strontium RanelateStrontium Ranelate
Strontium occurs naturally as a non-radioactive Strontium occurs naturally as a non-radioactive element and was first isolated in 1808.element and was first isolated in 1808.
Strontium competes with calcium for intestinal Strontium competes with calcium for intestinal absorption and, once absorbed incorporation into absorption and, once absorbed incorporation into bone and dental tissues.bone and dental tissues.
Strontium can block the hydroxylation of 25-Strontium can block the hydroxylation of 25-hydroxyvitamin D to 1,25-hydroxyvitamin Dhydroxyvitamin D to 1,25-hydroxyvitamin D
Correction can be achieved either by addition of 1,25-Correction can be achieved either by addition of 1,25-hydroxyvitamin D supplementation or a high Ca diet.hydroxyvitamin D supplementation or a high Ca diet.