Osteoporosis is a systemic skeletal disease characterised by low bone mass which makes bones more fragile and brittle which results in them being able to fracture more easily than normal bones. (Even minor falls can cause serious injuries).
Demographics/Prevalence
Osteoporosis is more common in females than males (Due to smaller skeleton). 3.5% of Australians (801,800) have this disease. 5.5% of all females have osteoporosis compared to 1.4% of all males. 1 in 5 women (25.8%) aged over 75 have osteoporosis compared to 1 in 14 (7.2%) of males. Prevalence sharply increases with age (Around 6% @ 50 years, 50% after 80 years)
Risk Factors
Non-Modifiable Risk Factors
Increased age (50+), Gender (More prevalent in females), family history or genetics.
Modifiable Risk Factors
Decreased oestrogen in females particularly after menopause, decreased testosterone in males, delayed puberty or early menopause, low levels of calcium, vitamin D and C insufficiency, decreased physical activity.
How does it occur?
In normal life, bone models and remodels occur naturally and there is balance between them. With increasing age, less bone is replaced than that which is resorbed. Whne Osteoporosis occurs, bone resorption is greater than bone formation. This creates low bone density especially in trabecular bone. Ultimately resulting in bone fragility and eventually fracture. Decreased oestrogen after menopause accelerates the process of bone remodelling resulting in bone loss. Bone loss is also accelerated in males with hypogonadism due to decreased testosterone.
What are the symptoms?
Can be silent - Typically no symptoms in the early stages. Vertebral fractures (common) which also can be asymptomatic. Increased Pain due to vertebral fractures. Other fractures such as hip or wrist fractures. Back pain and height loss and rounding of the spine.
Treatment
Osteoporosis is preventable by modifying risk factors once diagnosed. Management of risk factors will slow progression of the disease. Therefore, screening for early detection is important to allow appropriate management which has a role in controlling the condition.
It is a chronic condition which is silent until fractures occur. 50% of females who experience hip fractures do not return to previous functional level. 20% of individuals who experience hip fracture require long term care. Risk of future fractures rises with each new fracture - 'cascade effect'. E.g. 2-4x increase in risk of subsequent fracture following low trauma fracture. E.g. women who have suffered a fracture in their spine are 4x more likely to have another fracture within the next year.
Thus, it is important to diagnose and treat osteoporosis to prevent further fractures!
Diagnosis
Bone Mass Density (BMD) is a predictor for fracture rate. Also, used to monitor fracture rate during treatment. Assessed via bone densitometry.
Assessment of Risk Factors – Smoking, alcohol exposure, corticosteroids, low BMI, family history and previous fragility fractures.
Clinical Diagnosis – History of minimal trauma fracture, loss of height in middle aged to elderly, pain e.g. thoracic spine etc.
X-Ray to show bone density reduction
Blood Tests for people with low bone mass and rule out other forms.
Bone Biopsy’s are rare but provide the best results.
Physiotherapy Management
1 - Screening risk factors thoroughly and manage where appropriate through continuum
2 - Screen risk factors for falls and manage where appropriate
3 - Referral for screening and management (BMD, pharmacology, vision correction, drug review etc.)
4 - Strategies for falls prevention (exercise, environmental modification). The consequences of fractures are serious therefore physiotherapists can help prevent falls to a degree. Exercises might include (Walking, Resistance training and Aerobics).
5 - Provision of gait aids and prescription of hip protectors
Weight bearing and strengthening exercises are the main priority. Strong back muscles are significantly correlated with decrease risk of vertebral fractures.
Other Management
Liaison with GP regarding bone density (for assessment)
Include foods high in calcium
Possible Vitamin D supplement
Balance exercises (to reduce risk of falls)
Medication such as bisphosphonates, vitamin D and calcium to inhibit osteoclastic activity, reduce bone remodelling and improve BMD,
Stop smoking and reduce alcohol intake as this may reduce risk of falls.
Reduce risk of falls through specific exercise programmes (ROM, strength, balance, visual acuity) and the provision of hip protectors
Risk factor screening and management (smoking, eyesight, nutrition, multi medication, tripping hazards in environment)