Osteoporosis/fracture

Osteoporosis is the most common metabolic disorder affecting the spine. It is defined as a syndrome associated with low bone mass and micro architectural deterioration of bone tissue which leads to an increased risk of fracture (SIGN, 2015). Bone strength has two main features: bone mass (the amount of bone) and bone quality.

Osteoporosis develops due to three main mechanisms:

• Inadequate peak bone mass (the skeleton develops insufficient mass and strength during growth)
• Excessive bone reabsorption
• Inadequate formation of new bone during remodelling (Raisz, 2005).

These mechanisms may result in fragility fractures which are defined as fractures in the absence of excessive force.

“Osteoporosis is preventable, and its prevention is a priority for all health professionals” (Turner, 2000, as cited in McKenzie and May, 2006).

Cause

The causes of osteoporosis are multifactorial and can be considered under the following categories of risk factors (SIGN, 2015):

• Non-modifiable
• Modifiable
• Co-existing diseases
• Pharmacological

With all risk factors, particularly in those aged over 50, consideration for fracture risk assessment +/- DXA scan is important.

The latter two categories of risk factors can cause secondary osteoporosis.

NON MODIFIABLE

• Age – The risk of osteoporosis rises steadily with age, and more steeply in women over 65 and men over 75
• Gender – Women are at a greater risk of fracture compared to men (i.e. vertebral, hip or distal radius)
• Ethnicity – Caucasian men and women are at more risk of fractures compared with other ethnic groups.
• Previous fracture – People over 50 with a previous fragility fracture
• Family history – Parent or sibling with a history of osteoporosis, and/or fracture, particularly hip (Raisz, 2005).
• Early menopause (age 45 years or less) – Oestrogen deficiency following menopause or oopherectomy causes a rapid reduction in bone mineral density (Sinnesael et al, 2013).

MODIFIABLE

• Bone Mineral Density (BMD) – Low BMD is a strong risk factor for fracture. BMD is influenced by genetic and environmental factors as well as co-existing diseases and various drug treatments.
• Alcohol intake – Consumption of more than 3.5 units of alcohol per day
• Low Weight – Adults with a body mass index (BMI) of less than 20 (20kg /m²).
• Smoking – Smoking increases breakdown of exogenous oestrogen lowering body weight contributing to early menopause (WHO Scientific Group, 2003).
• Physical inactivity – Bone remodelling occurs in response to physical stress (WHO, 2003). There is a high correlation between muscle strength and bone strength (Schonau, 1996).

CO-EXISTING DISEASES

• Diabetes
• Asthma
• Inflammatory rheumatic disease
• Inflammatory bowel disease or malabsorption
• Institutional patients with epilepsy
• Hydroparathyroidism or other endocrine diseases
• Chronic liver disease
• Neurological Conditions e.g. Parkinson’s disease, Alzheimer’s disease, multiple sclerosis and stroke
• Moderate to severe kidney disease

PHARMACOLOGICAL

• Long term antidepressants
• Antiepileptics
• Acromatase inhibitors (women with breast cancer)
• GnRH agonist (men with prostate cancer)
• Proton pump inhibitors (PPI) (acid suppressive drugs)
• Oral glucocorticoids
• Thiazolidinedione (TZD) (antidiabetic drugs)
• Levo-thyroxine

SIGN, 2015

Prevalence

It is estimated that 200 million people have osteoporosis worldwide IOF epidemiology). Within the European Union (in 2010) approximately 22 million women and 5.5 million men had osteoporosis (Svendborn, 2013). Globally 1 in 3 women and 1 in 5 men over the age of 50 will have an osteoporosis fracture (IOF, 2016). White and Asian people are at a greater risk, women more than men and becomes more common with increasing age (SIGN, 2015). Within the Caucasian population, 15% of those over 50 and 70% of those over 80 have osteoporosis (WHO, 2015).

Presentation

Osteoporosis is often referred to as a silent disease. There are no early clinical signs or symptoms of osteoporosis. Frequently no symptoms are present until bone loss is advanced enough that a fracture occurs. Constant mild to severe back pain may be a concern when there is no history of significant injury. Common locations for vertebral fractures are mid to low thoracic levels and higher lumbar levels.

Secondary orthopaedic problems may develop due to postural changes. Deterioration in physical condition may result in further fractures through falls (Goodman et al, 2003)

Clinical signs and symptoms of established osteoporosis:

• Acute episodic low thoracic or high lumbar back pain
• Spinal compression or other previous fracture
• Height reduction
• Increased thoracic kyphosis
• Dowager’s hump
• Reduced activity tolerance

(Goodman, 2007)

Bone density is assessed by dual energy X-ray absorptiometry commonly known as a DXA scan. This is the only test that can detect osteoporosis BEFORE a fracture occurs. DXA is important in the PREVENTION of the disease. DXA assesses the spine and hip where the loss of bone density occurs most rapidly.

Bone density results are reported using T-scores. T-scores are a comparison of bone density to that of a healthy 30 year old (peak age of bone health).

Having a bone density test, NOF 2013.

Fragility fracture assessment (FRAX) is a questionnaire utilised within the osteoporosis service.

Laboratory tests may be considered by the GP to determine the presence of co-existing diseases which could contribute to secondary osteoporosis.

First, consider supported self management (SSM) and review conservative treatment options

Link to exit/redirection and health improvement.

Long term

Treatment

Established osteoporosis is difficult to treat therefore the emphasis is on prophylaxis. Optimal management maximises bone mass in early adulthood and prevents excessive bone loss in later life.

“Osteoporosis is preventable, and its prevention is a priority for all health professionals” (Turner, 2000, as cited in McKenzie and May 2006).

Confirmed osteoporosis is best treated through:

Medication.

These are mainly anti-resorptive agents such as bisphosphonates (e.g. alendronic acid), calcitonin, denosumab, estrogen and estrogen agonists and antagonists used to prevent more bone loss and reduce the risk of fractures (NOF, 2013).

Lifestyle

• Adequate dietary calcium
• Health Improvement information especially alcohol reduction and smoking cessation and potentially weight gain

Exercise

• Combinations of exercise types promote the greatest improvements of spinal bone mass (Howe et al, 2011). These include dynamic weight bearing exercise, flexibility/stretching, strengthening exercise (i.e. weight training) (Zehnacker et al, 2007, SIGN, 2015) and endurance training (SIGN, 2015).
• Postural exercises are imperative to improve posture, reduce structural changes and through prevention of further kyphosis and help reduce falls risk through improved balance. Such exercises should include cervical and scapular retractions, thoracic and hip extensions together with strengthening of the major extensor muscle groups (Goodman et al, 2003, McKenzie, 2006).
• Flexion exercises of the spine and hips are contraindicated as anterior compression forces to the vertebra can contribute to compression fractures (Goodman et al, 2003).

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Consider general progression/escalation advice.

Goodman, C.C., Boissonnault, W.G., Fuller, K.S., 2003. Pathology: Implications for the Physical Therapist. 2nd Edition. Philadelphia, Saunders.

Goodman (2007). Snyder. Differential Diagnosis for Physical Therapists; Screening for Referral. 4th. St.Louis: Saunders.

Howe, T.E., Shea, B., Dawson, L.J., Downie, F., Murray, A., Ross, C., Harbour, R.T., Caldwell, L.M. and Creed, G. 2011. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD000333. DOI: 10.1002/14651858.CD000333.pub2. Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

McKenzie, R. and May, S., 2006. The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Spinal Publications.

National Osteoporosis Foundation. Having a Bone Density Test. Link Here (link correct as of 13/12/19).

National Osteoporosis Foundation. Making a Diagnosis. Link Here (link correct as of 13/12/19).

Raisz, L. 2005.Pathogenesis of osteoporosis: concepts, conflicts, and prospects. Journal of Clinical Invest igation, 115(12): 3318–25 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Schönau, E., Werhahn, E., Schiedermaier, U., Mokow, E., Schiessl, H., Scheidhauer, K. and Michalk, D. 1996) "Influence of muscle strength on bone strength during childhood and adolescence".Hormone Research45(Suppl. 1): 63–66. Link Here for abstract (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Shapses, S.A,, Riedt, C.S. 2006Bone, body weight, and weight reduction: what are the concerns?Journal of Nutrician136(6): 1453–6. Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

SIGN Guidelines 142 (March 2015)- Management of osteoporosis and the prevention of fragility fractures

Sinnesael, M., Claessens, F., Boonen, S., Vanderschueren, D. 2013). Novel insights in the regulation and mechanism of androgen action on bone.Current Opinion in Endocrinology & Diabetes and Obesity20(3): 240–4.

WHO Scientific Group on the Prevention and Management of Osteoporosis (2000 : Geneva, Switzerland) (2003).Prevention and management of osteoporosis : report of a WHO scientific group(PDF). p. 7, 31. Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Zehnacker, C.H. and Bemis-Dougherty, A. Effect of Weighted Exercise on bone Mineral Density in Post Menopausal Women. A Systematic Review. Journal of Geriatric Physical Therapy, 30(2):79-88 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.

Links

Osteoporosis service [StaffNet page you must be on an NHS device on the NHS network to access this page]