Osteoporosis

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

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Definition/Description

Osteoporosis is a disease characterized by decrease in bone mass and damage to bone structure. Bone frailty leads to an increase risk for fractures. Bone tissue is constantly being absorbed and replaces througout ones life span. Bone mass decreases when the rate of absorbtion increases the rate or production; typically occurring with advanced age. Peak bone mass is met at the average age of 20. Those who develope less bone mass prior to this time, have a high chance of developing osteoporosis. There are two types of osteoporosis; primary and secondary. Primary osteoporosis is unrelated to other diseases or conditions, and is the more common of the two. It is most common in post menopause women or older men, but can occur at any ages. Secondary osteoporosis occurs as a side effect of medication or secondary to another condition or disease. A common precursor to osteoporosis is osteopenia, which is a condition of a mild decrease in bone mass. T-scores are 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 advanced enough to result in a 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. Hip fractures are usually not detected until a fall has occurred. 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 a general decrease in physical 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 
Bone fractures
Decrease in 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:

Inflammatory bowel or joing disease                                                                                                                                       Breast or prostat cancer                                                                                                                                                       Diabetes                                                                                                                                                                            Celiac diseases                                                                                                                                                       Moderate Renal Failure 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.

 

Antiresorptive medications, such as biphosphonates, calcitonin, denosumab, estrogen, and estrogen agonists/antagonists, work to prevent more bone loss and reduce the risk of fractures.

Anabolic drugs, such as Teriparatide (a parathyroid hormone), work to increase the rate of bone formation and reduce the risk of fractures.

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

Bone tissue is constantly being absorbed and replaces throughout ones life span. Bone mass decreases when the rate of absorption increases the rate or production; typically occurring with advanced age. Peak bone mass is met at the average age of 20. Those who develop less bone mass prior to this time, have a high chance of developing osteoporosis. *MC

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 caused by prolonged use of medications or secondary to another disease or condition which inhibits the absorption of calcium or impedes the body's ability to produce bone.

Low calcium intake or absorption can greatly increase one's risk for developing osteoporosis.*MC Life long calcium intake is crucial in building 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. Physical active individuals typically have higher bone density, then 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. *MC

 
Risk Factors
Age 50 years and older
Female gender
Caucasian and Asian *MC
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)
Thin body build *MC

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

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Medical Management (current best evidence)

    According to Kurt Kennel, M.D., an endocrinology specialist from the Mayo Clinic, the most common medications used to manage osteoporosis are biphosphonates, such as Fosamax, Boniva, Actonel, Atelvia, Reclast, and Zometa. It is also a common practice to use hormones, like estrogen, to help treat and prevent osteoporosis. Some women do not elect to use these hormones due to the increased risk of heart attacks and certain types of cancers. The choice of which drug is right for you is generally based on preference, convenience, and adhering to dosing schedule.

    The length of time that a medicine should be used is variable. Most current research shows that biphosphonate medications should be taken up to 5 years for it to be safe and effective. There haven't been enough long-term studies to prove the efficiency of the medications after 5 years of treatment. One thing is known that if you have been taking biphosphonate drugs you can still have positive effects after you stop taking the medications due to building up the medicine in your bone. Due to this effect of the medications, some doctors have patients take a break from the medications after 5 years if they believe they are at a low-risk for fractures.

    Medical management helps reduce the risk of fractures but does not eliminate it. If you experience a fracture while taking medications to help treat your osteoporosis you may need to switch to a more aggressive bone-building therapy, such Forteo which is a parathyroid hormone, or a new osteoporosis drug like Prolia or Xgeva. These drugs produce similar or better results than biphosphonates but just work in a different way.

    Medical management isn't the only way to treat osteoporosis. It is also important to include daily exercise, good nutrition (including the adequate amount of calcium and vitamin D), quit smoking, and limit your alcohol intake.

Physical Therapy Management (current best evidence)

Physical therapy intervention for individuals with osteoporosis, or even osteopenia, should include weight-bearing, flexibility, strengthening, postural, and balance exercise. Weight-bearing 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 be shown to maintain or improve bone density at the location of the targeted muscle attachments. Maintaining bone health in this population is beneficial, as this population, especially the elderly, typically has a decline in bone mass. (ZAHNACKER) Flexibility and strengthen exercises 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. (BURKE) Lastly, postural exercises 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.

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. (Liu-Ambrose).

Prevention: 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. (Martyn) Most of these studies have been performed on individuals who have NOT been diagnosed with osteoporosis. 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. (COCHRANE)

Alternative/Holistic Management (current best evidence)

    Alternative management of osteoporosis includes diet, vitamin supplementation, and herbal supplementation. Diet has a direct correlation to bone growth and as we age we may not be absorbing the adequate amount of calcium. By including a variety of calcium-rich foods, such as milk, cheese, almonds, broccoli, and cauliflower you can make sure that you are getting the amount of calcium that you need (use holistic med). It is also recommended that a person with osteoporosis should not have a high-protein diet. When the kidneys flush out excess protein they also flush out calium. Caffeine is also known to inhibit calcium absorption so you should limit your caffeine intake to the equivalent of 3 cups of coffee a day. While most leafy green vegetables are a great addition to the diet of someone with osteoporosis it has been shown that oxalate acid that is found in spinach prevents absorption of calcium in the stomach. Kale and other geen vegetables that contain calcium would be better choices.(alternative meds)

    Vitamin supplements may also be necessary when managing osteoporosis. According to the University of Maryland Medical Center (UMMC), 1,500 milligrams of calcium, taken in 3 doses of 500 milligrams per day, is an effective supplement to strengthen the bones and prevent further bone loss. Other vitamins that are recommended to retain bone strength are vitamins D and K. But be careful not to exceed 1,000 milligrams of vitamin D or 500 micrograms of vitamin K daily. Another helpful addition would be to add 4 grams of fish oils to help increase the amount of calcium that your body absorbs and decrease the amount it loses. (alternative meds)

    Herbal supplements are another form of management. The University of Maryland Medical Center reports that several herbs, such as black cohosh, oat straw, and kelp can help with management of osteoporosis. Black cohosh has many of the estrogen type characteristics that prescription hormones do without the health concerns. Oat straw appears to stimulate new cell growth, which includes bone cells. Kelp is rich in minerals and is also known to help treat disorders of the skeletal system. (alternative meds)

Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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