Guide to Osteoporosis

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Introduction

Osteoporosis & Rehabilitation Options

 

Among the more common disorders that affect the skeletal system, osteoporosis is one of the most prevalent in modern society. Among individuals living in Europe, Japan, and the United States, approximately 75 million people are afflicted with this disease.

With osteoporosis, bones suffer mineral loss, leading to a less supportive skeletal structure. Because of the now added stress on the bones, the bones themselves become brittle and are more likely to fracture.

While not seeming serious, fractures suffered from osteoporosis have serious consequences. These types of fractures account for almost half of all total bone fractures. To showcase the seriousness, an individual with a fractured hip has a 20% chance of succumbing to their fracture, via secondary issues caused by the fracture. To be safe, patients who suffer an osteoporosis-related hip fracture spend a large amount of time in hospitals and physical therapy. More often than not, these individuals will enter a nursing home for some length of time.

Our guide will enable you to understand the following:

  • What occurs to your skeletal system as a result of osteoporosis.
  • The process of diagnosing osteoporosis by a medical professional.
  • The various methods to either slow down or stop the loss of bone.
  • Our approach to rehabilitation here at Hicksville Physical Therapy.

Anatomy

What occurs to bones that have become afflicted with osteoporosis?

The fact is that, regardless of osteoporosis, bones are consistently changing, never remaining the same. This change is often a result of the way that people’s bodies are used. As a particular muscle, or group of muscles, become stronger, the bones underneath that muscle or group respond in kind and become stronger. Vice versa, if a muscle becomes weaker, the bone will do the same. Further changes in both the immune system and individual hormone levels can also affect how weak, or strong, a bone is.

For children, this is never truer as bones are constantly evolving in both size and density. This rapid bone growth ceases around age 25 when average peak bone mass is reached. Once adulthood is reached, this aforementioned peak bone mass can be maintained by living an active lifestyle and ensuring that a balanced diet with enough calories, vitamin D, and calcium is eaten each and every day. Like most things, however, maintaining this peak bone mass becomes increasingly more difficult as individuals age. Age, this single factor, makes building, or even keeping bone mass difficult. For women, lower estrogen levels during menopause and afterwards have the ability to cause bone mass loss at a rapid rate.

Osteoblasts are the particular cells responsible for the creation of new bone material. Stimulating the creation of these cells is one of the key ways to assist an individual’s body in building bone material and improving the overall density of the bone.

In what is known as high-turnover osteoporosis, cells known as osteoclast take in bone cells at a very quick rate. This absorption means that osteoblasts cannot produce bone cells faster than what they are being absorbed. The end result is an overall depletion of bone mass, often in the trabecular bone. This trabecular bone is better known as the spongy bone both inside vertebrae and as well at the end of long bones. Women who are postmenopausal frequently have high-turnover osteoporosis (primary type one osteoporosis) due to the aforementioned decrease in estrogen that occurs during menopause. Spinal and wrist fractures are more likely to occur due to this type of osteoporosis.

With what is known as low-turnover osteoporosis, the cells known as osteoclasts work at a normal rate, but osteoblasts do not produce bone cells quickly enough. Older individuals tend to have this form of osteoporosis (primary type two osteoporosis). In this form, injuries such as hip fractures are common.

Secondary osteoporosis occurs when bone loss is the cause of another medical issue. These other medical issues have the potential to interfere with osteoblasts and osteoclasts, causing some sort of imbalance. Among the numerous medical issues that can cause secondary osteoporosis, maladies include hormone imbalances, cancers, bone diseases, and other conditions that can cause a decrease in movement. Certain medications such as corticosteroids, used over a lengthy period of time, can also cause secondary osteoporosis.

In essence, osteoporosis leads to weak bones. When the bones have weakened, fractures are likely to occur as a result of an injury. Common fractures include the hip, vertebrae, wrist, ankle, knee, and upper arm.

Causes

What is the cause of osteoporosis?

Out of all factors, age is by far the most important risk factor when dealing with osteoporosis and accompanying fractures. This is especially true in women where the loss of estrogen during and after menopause can lead to an average of 2% each year in lost bone mass. Women of Caucasian ethnicity who are over 50 years of age tend to have an approximately 50% chance of fractures during the remainder of their life. As these individuals age, this number only increases.

Apart from age, gender, and certain medications, these factors can also put you at risk for osteoporosis:

  • Below average body weight
  • Individuals with a slender build
  • Weight loss that is recent
  • Usage of tobacco
  • Personal and family history of fractures
  • Abuse of alcohol
  • No exercise
  • Anorexia or bulimia
  • Individuals who are Caucasian or Asian

 The aforementioned risk factors, along with a bone mass measurement, can be very helpful in seeing if you are likely to experience a fracture due to osteoporosis. Individuals who have a lower overall bone mass, but very few additional risk factors, are not likely to experience a fracture. Vice versa, individuals who have a lower overall bone mass and multiple risk factors are increasingly more likely to experience a fracture.

Symptoms

Can I feel osteoporosis?

When bones fracture due to osteoporosis, there is quite a bit of pain. However, the disease itself has no pain and no list of symptoms. For this reason, osteoporosis is known as the “silent disease” because individuals never know they have it until some sort of fracture happens. Because of this, it is important that post-menopausal women, people with multiple risk factors, women over the age of 65, individuals with other bone diseases, and people who take a potentially damaging medication be tested frequently for osteoporosis.

Diagnosis

In what way will my health care professional diagnose my osteoporosis?

At many pharmacies, healthcare professionals will provide free osteoporosis screenings. These screenings are done to determine an individual’s bone density measure. More often than not, these free screenings will involve a machine that looks at the bone in the heel of your foot. While this is a quick and easy way to learn about your bone density, it is not the most effective. Due to this particular bone bearing the weight of your body, it may be denser than bones found elsewhere in your body. If the scan shows a low bone density in this area, a meeting with your doctor should be scheduled immediately. Even if this type of scan reads that your bone density is normal, but you have concerns, you should still speak with a medical professional.

When visiting a medical professional, that professional will take an elaborate medical history to determine any risk factors that may put an individual at a higher risk for osteoporosis. For those that this disease is suspected or those that may be suspectable to it, further testing may be done. Often, a bone density test, or a dual-energy X-ray absorptiometry (DEXA) test, will be used to measure bone mass. DEXA tests are done utilizing special x-rays of an individual to determine the bone mass of the hips and spine. These x-rays are compared to that of a healthy 30-year-old with the result being a T score. For those individuals that are within one standard deviation (SD) when it comes to bone density, they are considered to have a normal bone mass. Individuals lying between 1 and 2.5 SDs are considered to be osteopenic or are considered to have a mild form of osteoporosis. Individuals who are 2.5 SDs and lower are considered to have osteoporosis.

Despite the detail of a DEXA test, this test alone cannot show medical professionals whether your bone mass is stable or not. Certain medications can be prescribed to create various markers in the blood or urine that will allow medical professionals to track bone mass. These medications will help medical professionals determine if someone is afflicted with either high-turnover osteoporosis or low-turnover osteoporosis.

Furthermore, DEXA tests are by no means perfect. Depending on both different equipment and medical professionals, DEXA tests can provide different readings. If an individual is in need of more precise readings, tests such as an ultrasound, a CT scan, or a single-photon absorptiometry may be used in addition to, or instead of, a DEXA scan to determine if someone is afflicted with osteoporosis.

If any of these tests come back reading that the individual has a low bone mass, a medical professional will then rule out other causes besides osteoporosis. Issues with the marrow inside bones, and even hormone levels, can be attributed to bone loss. For these issues, a blood test can be used to determine if these are indeed the culprit. Apart from this, a condition called osteomalacia may also be to blame for a loss in bone density.

Osteomalacia is caused by a lack of vitamin D. When lacking this nutrient, bones tend to soften. A general lack of sunlight and improper diet are contributing causes of osteomalacia. In the northern most parts of the planet, where sunlight is less common, almost 10% of individuals who suffer a hip fracture have osteomalacia as opposed to osteoporosis. Tests such as a urine sample and blood draw can rule out this disease.

Depending on the circumstances, your general practitioner may refer you to a specialist for further care. Such circumstances can include if a medicine utilized to prevent bone loss is not working or if fractures are becoming common occurrences. This specialist of osteoporosis can help you understand your situation.

Treatment Options

What are the treatment options for osteoporosis?

Ultimately, the goal of any treatment is to stop fractures from occurring. This is even more true if you have already sustained a fracture due to osteoporosis. The primary way to achieve this goal is to increase bone mass and retain it.

Here are some steps that can be taken to increase bone mass:

  • Stop smoking
  • Reduce alcohol consumption
  • Increase both calcium and vitamin D intake.
  • Increase, or decrease, caloric intake to ensure a healthy weight is maintained.
  • Exercise on a regular basis, regardless of how strenuous or relaxed the activity is.

Physical Therapy

For those individuals that suffer from osteoporosis or are at risk for developing it, working with a Nassau County physical therapist here at Hicksville Physical Therapy will help provide tremendous benefits.

Here at Hicksville Physical Therapy, our primary goals are to educate patients on correct posture, teach proper movement and lifting techniques, and to provide patients with a variety of exercises that can be done at home to help prevent a loss in bone mass and, ultimately, prevent fractures. The aforementioned exercises will not only focus on strengthening a patient’s bones but will focus on improving balance. Patients who have optimum balance are at much less of a risk for fractures due to a fall. Additional exercises can include a focus on flexibility to help decrease stress places on osteoporotic bones. For those patients that have had the misfortune to experience a fracture due to osteoporosis, physical therapy with us can help regulate pain levels and, gradually, return that patient back to their normal life.

The important thing to remember with osteoporosis is that posture is key. Kyphosis, a posture in which the upper spine is stooped, is frequently seen in patients with osteoporosis. Kyphosis is caused when a wedge-like fracture of the thoracic spine occurs. A loss of height is common with this type of fracture. This singular reason is why we measure a patient’s body height as a part of our evaluation during physical therapy. Height measurements allow us to see how osteoporosis is affecting a patient and if treatment is working, or if the condition is worsening.

In order to correct this, posture exercises are commonly recommended. These exercises allow us to align patients’ bodies so that weight is distributed evenly through the body and hips. When healthy spinal posture is present, the head is aligned at the top of the spine rather than positioned forward. This forward positioning is common in patients with osteoporosis. In patients with advanced osteoporosis, the body is also bent forward at the hips. This bend puts stress on the hip bones, making them weaker and more prone to fractures as a result. This is why correct posture and posture exercises are pertinent to not only prevent a further loss of height, but to help regain any lost height.

Our physical therapists here at Hicksville Physical Therapy will demonstrate the variety of ways that correct posture can be practiced and will help you improve your overall body mechanics. This process will involve showing you how to keep your body properly aligned at all times, including bending over, for instance. Many people tend to round the shoulders when they bend, when a healthier position involves keeping the back in its proper alignment and bending at the hip. This technique can help reduce the risk of a spine fracture since it reduces pinching on your vertebrae. Keeping your posture in mind is especially important when you’re holding something that could add extra weight, such as a shopping bag or purse. Proper posture in combination with lightly tightening your core muscles can help you protect your spine; your physical therapist will go into detail about this process with you and teach you proper execution. Your physical therapist will also show you how to extend your spine (as opposed to flexing) in rapid bending situations like coughing or sneezing, when one sudden movement could result in a fracture.

Twisting motions can also be extremely stressful for an osteoporotic spine. Even when healthy, this bone is not designed to twist at an extensive rate. When the spine suffers from osteoporosis, twisting can cause a fracture. While twisting is indeed a normal occurrence, patients suffering from osteoporosis should limit this when possible and avoid activities such as golf, tennis, and bowling.

Another form of exercise recommended by our physical therapists is strengthening exercises. As previously mentioned, bones will grow stronger if the muscles around them grow stronger. This is why gentle weight exercises are prescribed to help combat osteoporosis. These exercises can be achieved via elastics or weights. Our physical therapists will educate patients on not only the appropriate amount of weight but the appropriate amount of resistance as well. In addition to these recommendations, our staff will instruct patients on proper lifting and techniques, and overall proper movement, to avoid potential injuries to the spine while performing strengthening exercises. While our physical therapists will recommend exercises for the upper back to counteract bad posture caused by osteoporosis, any exercises which require flexing the spine should be completely avoided.

Activities such as walking, gentle dance, and stair climbing are all recommended as forms of weight bearing cardiovascular exercises. These exercises not only encourage an upright posture but put weight throughout the skeletal system, allowing for strengthening of bones. More aggressive forms of these exercises such as running, aggressive dancing, cycling, and even pool exercises are not recommended, as these exercises either put too much stress on bones suffering from osteoporosis or not enough stress to allow for building bone mass.

As treatment progresses in physical therapy, overall focus will be shifted to balance. Poor balance can lead to falls which has the potential to cause fractures. Depending on the severity, these fractures can be life-threatening. Simple exercises such as standing on one foot or standing with one foot in front of the other can help improve balance tremendously. Simple improvements in balance can help decrease the overall likelihood of a fall. Our physical therapists provide patients with balancing exercises that are comfortable, but challenging, to their skill set. As balance improves, patients will often progress to exercise forms such as tai chi to continue balance improvement.

The last component of physical therapy is to undergo flexibility exercises. Increasing overall flexibility is a great way to not only reduce the stress on bones, but it will also lead to better posture and overall body mechanics. Mobility will also see a leap in improvement which will further improve balance and decrease any likelihood of a fall. These stretches can include the upper back, chest, hips, calves, and neck depending on the severity of the osteoporosis.

Throughout physical therapy, your physical therapist will consistently look at test results ranging from height to posture and balance. These evaluations will be done to see how you are progressing and if alternative routes need to be taken for treatment. Once you’ve established a safe routine that can be done at home, regular visits to Hicksville Physical Therapy will no longer be required. However, we encourage all our patients to come to us with any questions they may have or issues they may encounter.

To sum it up, our wonderful team of physical therapists will help you progress into physical therapy if you’ve recently sustained a fracture due to osteoporosis. Treatment will initially start with a reduction in pain utilizing techniques such as ice, heat, or electrical currents. Once a reduction in pain has been achieved, our team will partner with your doctor to calculate the best path for you to not only begin more advanced exercises such as strengthening, balance, and flexibility, but for you to ultimately return to your normal activities.

Medication

Based upon the unique situation of each patient, a medical professional may prescribe medications that will slow the body’s reabsorption rate of bone to help prevent worsening osteoporosis.

Apart from this, many other medications are available that will help prevent and/or treat osteoporosis. The correct medication for each patient can be different depending on medical history and risk factors. A licensed medical professional will determine which medication will provide the best results for a specific patient.

For postmenopausal women, hormone replacement therapy can be beneficial to reverse osteoporosis. A variety of studies have shown that over 80% of women who undergo hormone replace therapy see up to a 2% increase in bone mass each year. The presence of estrogen has demonstrated an overall decrease in fractures of the spine by 50% and fractures of the hip by 25%. Apart from these benefits, hormone replacement therapy can also help to lower the risk of coronary artery disease, ease menopause, and potentially delay or prevent Alzheimer’s.

Many women, however, worry about the long-term risks of hormone replacement therapy. Various studies have linked an increased risk of breast cancer to this therapy. For patients who have any family history of breast cancer or those that have suffered from medical conditions such as a stroke or a blood clot, this type of therapy is not often recommended. Women that do not find themselves in the aforementioned group should seriously consider hormone replacement therapy as medical professionals estimate that, if this therapy were widely used, fractures caused by osteoporosis could decrease by as much as 50% to 75%.

This type of therapy requires continued practice. If a woman stops taking estrogen as part of her hormone replacement therapy, bone loss will occur at a quick rate again. Within a period of seven years, a woman who stopped taking estrogen will have the same bone density as that of a woman who never started.

Alternative therapies include the usage of calcitonin. Calcitonin is a non-steroidal hormone that binds to osteoclasts, decreases their numbers, and lowers their activity levels. This process helps to lower the reabsorption of bone and, in turn, slow osteoporosis. Methods of treatment include an injection, nasal spray, and a rectal suppository. The nasal method is most often provided to women who are at least five years post-menopause and cannot be treated by other methods. In addition to slowing bone reabsorption, calcitonin also has a penchant to help ease pain.

For those patients that take calcitonin, the medication will need to be monitored closely by a medical professional. As this is a newer medication, the long-term effects are not well known. What is known is that approximately 20% of calcitonin users eventually develop a resistance to the medication meaning that an alternative treatment will be needed to treat osteoporosis.

Another group of medications useful in the fight against osteoporosis are bisphosphonates. These drugs also slow the bone reabsorption rate by affecting osteoclasts, much like calcitonin. Common medications in this group include Ibandronate, Alendronate, and Risedronate.

These medications, depending on which one is chosen, can be taken as a daily pill, a weekly or monthly dose, or an annual injection. Zoledronate can be provided as a yearly annual injection while Ibandronate can be taken via pill or by injection every three months. The injectable versions of these medications are most commonly used with postmenopausal women.

A variety of research has shown that this group of medication increases overall bone mass but does not result in a reversal of bone mass growth if the medication is stopped like in hormone replacement therapy. Regardless, close monitoring by a professional will need to be done as the long-term effects of bisphosphonates are not well known as well as the fact that side effects can appear suddenly.

Medication research for osteoporosis is ever evolving and is constantly being researched. Medications such as sodium fluoride have shown positive results in individuals with low-turnover osteoporosis by increasing the bone mass production of osteoblasts. While this medication is not yet available, another potential treatment drug is known as Raloxifene.

Raloxifene is an anti-estrogen medication also referred to as selective estrogen-receptor modifiers (SERMs). SERMs been shown to have similar results to normal estrogen but does not increase the long-term risk for breast cancer. As such, it is mainly prescribed to postmenopausal woman less than 65 years old. These women cannot have a history of, or be at risk for, blood clots or a form of cardiovascular disease.

For men, the anabolic medication known as Teriparatide can be prescribed for the management of osteoporosis. This medication is a kind of parathyroid hormone that is used for high-risk patients as it helps to build muscle and bone mass. Another medication with antiresorptive properties, like a bisphosphonate, often accompanies it.

Overall, changes in lifestyle, a sold exercise regimen, hormone replacement therapy, and continued advances in modern medicine can help patients control their osteoporosis. Between a patient, their doctors, and our team of physical therapists, the best course of treatment to help prevent fractures will be found.

Hicksville Physical Therapy provides a variety of physical therapy services in Hicksville, New York, and the surrounding area.

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