Osteoporosis

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Alli Castagno & Christy Kaiser  from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Definition/Description

Osteoporosis, literally meaning porous bones, is a decrease in bone mass and damage to the bone structure. The combination of the two causes bones to be more susceptible to fracture. There are two types; primary and secondary osteoporosis. Primary osteoporosis is unrelated to other disease or condition, and is the more common of the two. It is most common in women post menopause or older men, but can occur to either gender at all ages. Some types of primary osteoporosis are idiopathic osteoporosis, postmenopausal osteoporosis, and senile or involutional osteoporosis. Secondary osteoporosis occurs as a side effect of medication or secondary to another condition or disease. Osteopenia is the condition of low bone mass. This is often a precursor to osteoporosis. Low bone density, frequently reported as T-scores, is often used to classify individuals as osteoporotic. According to the World Health Organization, 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.

Prevalence

Osteoporosis is the most prevalent bone disease in the world. According to the National Osteoporosis Foundation, about 10 million Americans currently have osteoporosis, while about 34 million are at risk for the disease. It is estimated that one in two women over the age of 50 and one in four men will break a bone because of osteoporosis. It is projected that by 2020, half of Americans over the age of 50 will have osteoporosis or low bone density.

Characteristics/Clinical Presentation

Osteoporosis is often referred to as a silent disease because there are no early clinical signs or symptoms. Frequently no symptoms are present until bone loss is sufficient enough to result in fracture. Common locations of fracture include; proximal femur, vertebrae, hip, pelvis, proximal humerus, distal radius, and tibia. Proximal femur and vertebrae are the two most common sites. Therefore, a constant mild to severe back pain may be a concern, when there is no history of injury or falls. Because of the lack of early symptoms, those at risk are highly suggested to get routine bone scans. Many individuals will develop secondary orthopedic problems related to associated postural changes, fractures and general decrease conditioning. A common presentation of an individual with osteoporosis may be a Caucasian female, 65 years or older, with a thin body type.

Clinical Signs and Symptoms
Back pain: Episodic, acute low thoracic/high lumbar pain
Compression fracture of the spine (post-menopausal osteoporosis)
Bone fractures (age-related osteoporosis)
Decrease in height (more than 1 inch shorter than maximum adult height)
Kyphosis
Dowager’s hump
Decreased activity tolerance
Early satiety

Associated Co-morbidities

As many diseases increase an individuals risk of osteoporosis, they also may be seen as comorbidities.

Eating disorders
Cancer and cancer treatment
Chronic renal failure
Osteogenesis imperfect
Rheumatic diseases
Chronic pulmonary disease
Cushing’s Disease
Male hypogonadism
Hypothyroidism
Hyperparathyroidism
Type 2 Diabetes Mellitus
Gastrointestinal disease                                                                                                                                                                    Hepatic disease

The following comorbidities should may increase the risk of fracture or subsequent fractures; inflammatory bowel and joint diseases, breast cancer and prostate cancer, diabetes (mainly type 1), celiac disease, moderate renal failure and depression.

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.

 

Diagnostic Tests/Lab Tests/Lab Values

In order to make a diagnosis of osteoporosis there are series of diagnostic tests and lab tests that your doctor may perform after taking a thorough patient history and performing an examination.

Bone Density Test

The most common test used is a bone density test, which is the only test that can detect osteoporosis before a fracture occurs. There are two types of bone density tests: Central DXA and Screening Tests. Central DXA uses a dual energy absorptiometry machine to test the bone density of the hip and spine. If testing can’t be done to the hip and spine then it is recommended to test the radius of the forearm. Central DXA is the preferred method because it measures bone density at the hip and spine where bone loss occurs most rapidly.

Screening Tests, also called peripheral tests, measure bone density in the lower arm, wrist, finger, or heel. These are useful when Central DXA testing is not possible. Screening tests cannot accurately diagnose osteoporosis or measure how well medication is working.

Bone density test results are reported using T-scores. T-scores are relative to how much higher or lower your bone density is compared to that of a healthy 30 year old adult.

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

Laboratory Tests

- Blood Calcium levels
- 24-hour urine calcium measurement
- Thyroid function tests
- Parathyroid hormone levels
- Testosterone levels in men
- 25-hydroxyvitamin D test to determine whether the body has enough vitamin D
- Biochemical marker tests, such as NTX and CTX

Some of these tests can help to identify if you have any other medical conditions that could contribute to osteoporosis, which would be called secondary osteoporosis. Biochemical marker tests can help estimate how fast you are losing or making bone.

Etiology/Causes

Primary osteoporosis has no known definite cause, but there are many contributing factors associated with the disorder. These include prolonged negative calcium balance, impaired gonadal and adrenal function, estrogen deficiency, or sedentary lifestyle. Postmenopausal osteoporosis is associated with increased bone loss due to decrease production of estrogen. Women commonly lose 1% per year after peak bone density has been met, for up to 8 years post menopause. Senile osteoporosis is an age-related bone loss that often accompanies advanced aging. Secondary osteoporosis is often caused by prolonged use of medications, lack of proper nutrition, or secondary to another disease or condition.

 
Risk Factors
Age 50 years and older
Female gender
Caucasian
Menopause (especially early or surgically induced)
Family history of osteoporosis or fragility fractures
Northern European ancestry
Long periods of inactivity or immobilization
Depression
Alcohol (>3 drinks/day)
Tobacco
Caffeine (>4 cups/ day)
Amenorrhea (abnormal absence of menses)
Low body weight and body mass index

Associated Diseases & Disorders:
Endocrine Disorders:
Hypothyroidism
Hyperparathyroidism
Type 2 Diabetes Mellitus
Cushing’s Disease
Male hypogonadism (testosterone deficiency) Malabsorption syndrome:
Gastrointestinal disease; gastric surgery
Hepatic disease

Medication-related:Organ transplant
Chronic pulmonary disease
Rheumatic diseases, including juvenile rheumatoid arthritis

Other:
Chronic renal failure
Osteogenesis imperfect
Cancer and cancer treatment; skeletal metastases
Eating disorders
Spinal cord injury
Cerebrovascular accident or stroke
Acid-balance imbalance (metabolic acidosis)
Depression (men > women)

Medication (>6 months)
Corticosteroids/steroids
Immunosuppressants
Heparin; Coumadin
Nonthiazide diuretics
Methotrexate
Chemotherapy
Antacids (containing aluminum)
Laxatives
Anticonvulsants
Some antibiotics
Buffered aspirin
Thyroid hormone
Lithium
Depo-provera (contraceptive)

Diet & Nutrition
Calcium and magnesium deficiency
Vitamin D deficiency
Vitamin C deficiency (helps with calcium absorption)
High ratio of animal to vegetable protein intake
High-fat diet (reduces calcium absorption in the gut)
Excess sugar (depletes phosphorus)
Eating disorders or repeated crash dieting

Systemic Involvement

add text here

Medical Management (current best evidence)

add text here

Physical Therapy Management (current best evidence)

add text here

Alternative/Holistic Management (current best evidence)

add text here

Differential Diagnosis

add text here

Case Reports/ Case Studies

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1NGmwZeh8JwVIzrKgHG1LrDm0izTr7ViJiDkSYAY2BW5hiXsx0|charset=UTF-8|short|max=10: Error parsing XML for RSS

References

see adding references tutorial.