Osteoporosis and

Osteoarthritis
Sgd # 9
Osteoporosis
• Osteoporosis means 'porous bones',
causes bone to become brittle - so
brittle that even mild stresses like
bending over or coughing can cause
fracture.
• In most cases bone weakens due to
low level of calcium , phosphorous and
other minerals in the bones and results
in low bone density.
• Common result of osteoporosis is
fractures of the spine, hip or wrist.
• Although it is most often thought as a
women's disease, osteoporosis also
affects many men.

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Normal bone has the appearance of honeycomb matrix whereas,
osteoporotic bone looks more porous.
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Epidemiology

• Osteoporosis is the second most

common bone disorder in elderly
persons.
• Affects 1 to 3 million people in US.
• Prevalence increases with age
 very rare in individuals age < 25
 1-3% of individuals age > 40
 >10% of individuals age > 80

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Prevalence

• The overall prevalence of osteoporosis in adult Filipinos

60 to 69 years of age is 0.8% while those beyond 70
years old is 2.5%.

• The overall prevalence of fracture is 11.3% in females

and 9% in males.

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Symptoms

• Back pain, which can be severe if fractured or collapsed

vertebra.

• Loss of height over time, with an accompanying stooped

posture.

• Fracture of the vertebrae, wrists, hips or other bones.

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Causes

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Classification
Primary osteoporosis Secondary osteoporosis
• Congenital
• Juvenile osteoporosis
• Diet
• Idiopathic osteoporosis • Drugs
• Postmenopausal • Endocrine disorder
osteoporosis • Other systemic disorder
• Age related or senile
osteoporosis

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Pathogenesis

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Pathogenesis

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Risk factors

• Sex
Unchangeable • Age
Risks • Race
• Family History
• Body Frame Size

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Hormone Levels

• Sex Hormones
• Thyroid Problems
• Other Glands

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Dietary Factors

• Low Calcium intake

• Eating Disorders
• Gastrointestinal surgery

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Steroids & other medications

• Corticosteroid medications
• Anti-Epileptic drugs
• PPI's
• Chemotherapeutic Drugs
• Immunosuppressive medications

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Medical Conditions

• Celiac Disease
• IBD
• Kidney or Liver Disease
• Cancer
• SLE
• Multiple Myeloma
• Rheumatoid Arthritis

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Lifestyle Choices

• Sedentary Lifestyle
• Excessive Alcohol consumption
• Tobacco Use

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Diagnostic tests

Bone Mineral Density (BMD) Test

• Most common type is a Dual-Energy X-ray

Absorptionometry (DEXA) scan.

• The NOF recmmends BMD Tests for

-Women 65 and older and Men 70 and older
-Anyone who has broken a bone after age 50
-Women of menopausal or Postmenopausal age with risk factors
-Men age 50-69 with Risk Factors

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Diagnostic Criteria

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Other Diagnostic Imaging tests:

• CT scans
• X-rays
• Ultrasounds
• Bone Scan

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Laboratory tests
Blood tests that may be ordered include:
• Blood calcium levels
- This test is usually normal in osteoporosis but may be
elevated with other bone diseases.
• Vitamin D
- deficiencies can lead to decreased calcium absorption
• Thyroid tests
- such as T4 and TSH to screen for thyroid disease
• Parathyroid hormone
- to check for hyperparathyroidism.
• Follicle-stimulating hormone (FSH)
- to check for menopause
• Testosterone
- to check for deficiency in men
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Laboratory tests

Tests measuring bone

Tests measuring bone loss
formation
(Bone resorption markers)
(Bone formation markers)
 Bone resorption tests tell  Bone formation tests tell
about the rate of bone loss. about the rate of bone
 C-telopeptide (C-terminal production.
telopeptide of type 1 collagen  Bone-specific alkaline
(CTx)) phosphatase (ALP)
 Urinary collagen type 1  Osteocalcin (bone gla
cross-linked N-telopeptide protein)
(NTX)
 Deoxypyridinoline (DPD)
 Urinary hydroxyproline

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Treatment
Pharmacologic therapies
 Biphosphonates e.g. Alendronate & Zoledronic acid
 Hormonal Replacement Therapy
 Selective estrogen receptor modulators (SERM) e.g.
Tamoxifen & Raloxifene
 Strontium Ranelate
 Calcitonin
 Tibolone
 RANKL inhibitor (Denosumab)
 Vitamin D or its analogue, in combination with
calcium, is used as mandatory adjunct

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Treatment
Non-pharmacologic management

INTERVENTION REMARKS
 Daily calcium intake of 1000-1200 mg (supplement
NUTRITION doses should be taken ≤600 mg at a time)

 Supervised high-intensity resistance exercise (8-12

EXERCISE reps at least 2-3 days/wk)
 Moderate levels of walking

 Smoking cessation and limiting alcohol

consumption
LIFESTYLE  Hip protectors for individuals with a high risk of
falling
 Environmental risk reduction
Kyphoplasty and vertebroplasty may be used for
SURGERY painful vertebral fractures 31
 Primary prevention

Aims at reaching at adolescent age a peak bone mass as

high as possible. Should begin in childhood and continue
throughout the lifespan to maximize bone mass.
 Ensure a nutritious diet and adequate calcium intake
 Maintain an adequate supply of vitamin D
 Participate in regular weight bearing activity
 Avoid smoking and second-hand smoking
 Avoid heavy drinking

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Secondary prevention
Directed at high risk groups: Aim is to reduce prevalence of
osteoporosis through early diagnosis (BMD and/or fracture
risk algorithms) and prompt treatment.

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Tertiary prevention

All remedies to retard the process of bone loss, reduce

complications of osteoporosis and prevent fracture
reoccurrence.

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Prognosis
• The prognosis for osteoporosis is good if bone loss is
detected in the early phases and proper intervention is
undertaken.
• Patients can increase bone mineral density (BMD)
and decrease fracture risk with the appropriate anti-
osteoporotic medication.
• In addition, patients can decrease their risk of falls by
participating in a multifaceted approach that includes
rehabilitation and environmental modifications.
• Worsening of medical status can be prevented by
providing appropriate pain management and, if
indicated, orthotic devices.

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Osteoarthritis
Definition

Osteoarthritis (OA) is a disorder characterized by

progressive joint failure in which all structures of the
joint have undergone pathologic change. The
pathologic sine qua non of OA is hyaline articular
cartilage loss accompanied by increasing thickness
and sclerosis of the subchondral bone plate, outgrowth
of osteophytes at the joint margin, stretching of the
articular capsule, and weakness of the muscles
bridging the joint.

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Epidemiology

OA is the most common type of arthritis. The

prevalence of OA correlates strikingly with age, and it
is much more common in women than in men.
Joint vulnerability and joint loading are the two major
risk factors contributing to OA. These are
influenced by factors that include age, female sex,
race, genetic factors, nutritional factors, joint trauma,
previous damage, malalignment, proprioceptive
deficiencies, and obesity.

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Prevalence

• In the Philippines, 0.5% in individuals aged 20 years and

above and increases to 11% in the population aged 60
years and above.
• 10 million Filipinos with the disease. This number is
expected to double in the next 25 years.

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Pathogenesis
The earliest changes of OA
may begin in cartilage. The
two major components of
cartilage are type 2 collagen,
which provides tensile
strength, and aggrecan, a
proteoglycan. OA cartilage is
characterized by gradual
depletion of aggrecan,
unfurling of the collagen
matrix, and loss of type 2
collagen, which leads to
increased vulnerability.
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Clinical
Manifestations
OA can affect almost any joint but usually occurs in weight-
bearing and frequently used joints such as the knee, hip,
spine, and hands. The hand joints that are typically
affected are the distal interphalangeal (DIP), proximal
interphalangeal (PIP), or first carpometacarpal (thumb
base); metacarpophalangeal joint involvement is rare.

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Symptoms

• Use-related pain affecting one or a few joints (rest and

nocturnal pain less common)
• Stiffness after rest or in morning may occur but is usually
brief (<30 min)
• Loss of joint movement or functional limitation
• Joint instability
• Joint deformity
• Joint crepitation (“crackling”)

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Physical Examination

• Chronic monarthritis or asymmetric oligo/polyarthritis

• Firm or “bony” swellings of the joint margins, e.g., Heberden’s nodes
or Bouchard’s nodes
• Mild synovitis with a cool effusion can occur but is uncommon
• Crepitance—audible creaking or crackling of joint on passive or
active movement
• Deformity, e.g., OA of knee may involve medial, lateral, or
patellofemoral compartments resulting in varus or valgus deformities
• Restriction of movement, e.g., limitation of internal rotation of hip
• Objective neurologic abnormalities may be seen with spine
involvement (may affect
intervertebral disks, apophyseal joints, and paraspinal ligaments)

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Evaluation

• Routine lab work usually normal.

• ESR usually normal but may be elevated in pts who have synovitis.
• Rheumatoid factor, ANA studies negative.
• Joint fluid is straw-colored with good viscosity; fluid WBCs <1000/μL;
of value in
ruling out crystal-induced arthritis, inflammatory arthritis, or infection.
• Radiographs may be normal at first but as disease progresses may
show joint space
narrowing, subchondral bone sclerosis, subchondral cysts, and
osteophytes. Erosions are distinct from those of rheumatoid and
psoriatic arthritis as they occur
subchondrally along the central portion of the joint surface.

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Diagnosis

Usually established on basis of pattern of joint involvement.

Radiographic features, normal laboratory tests, and
synovial fluid findings can be helpful if signs suggest an
inflammatory arthritis.

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Aims Of
OA Treatment

• Pain relief
• Preservation and restoration of joint function
• Education

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Osteoarthritis
Management
FEW
Legend

Target Current care Third-line:

Group delivered Surgery

SOME
Second-line: Pharmacological
symptom management, aids and
devices, passive treatments given by a
health care professional

First-line: Education, self-management, exercise ALL

(therapeutic exercise and physical activity) and
weight management

Numbers of people

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Non-Pharmacologic
Treatment of OA
• Patient education
• Weight loss (if overweight)
• Aerobic exercise programs
• Physical therapy
• Range-of-motion exercises / Muscle-strengthening
exercises
• Assistive devices for ambulation: Patellar taping,
Appropriate footwear, Lateral-wedged insoles (for genu
varum)
• Bracing
• Occupational therapy
• Joint protection and energy conservation 48
Pharmacologic
Treatment Of OA
• Oral Systemic Medical Agents
- Analgesics (acetaminophen)
- NSAIDs
- Opioid analgesics

• Intraarticular agents:
Hyaluronan
Glucocorticoids (effusion)

• Topical agents

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Symptomatıc
Treatment Of OA
• Decrease of joint loading
- Weight control
- Splinting
- Walking sticks
• Exercises
- Swimming
- Walking
- Strengthening
• Patient education
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Indications Of Surgical
Intervention
• Severe joint pain which is resistant to conservative
treatment methods
• Limitation of daily living activities
• Deformity, angular deviations, instability

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Invasive Methods

• Joint lavage
• Arthroscopy
• Cartilage grefting- genetic engineering
• Surgery:
Osteotomy
Joint replacement

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Primary prevention

These are measures to prevent the condition from

occurring. There are only a few effective primary
prevention strategies for osteoarthritis. These include:
– Weight control: Obesity is considered a risk factor for OA. Thus,
maintaining or reducing weight can lower the risk for certain
arthritic conditions.
– Occupational injury prevention: Avoiding repetitive joint use and
its injuries can help prevent arthritis.
– Sports injury prevention: Taking the necessary precautions to
prevent injury such as warming up and using proper equipment
can help reduce joint injuries.

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Secondary prevention

This involves early diagnosis so that appropriate early

intervention can be utilized. However, this is difficult in
OA since no effective biomarkers are available to
determine the progression of the disease. Furthermore,
radiographic evidence is often needed to identify and mark
disease progression. Access to health care facilities and
availability of X-rays is problematic in many parts of the
world.

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Tertiary prevention

This focuses on reducing the consequences of a disease.

Goals of these prevention strategies are to reduce, delay
the onset of complications and disability.
Tertiary prevention strategies for osteoarthritis are aimed at
reducing pain and disability, and improving quality of life.
The following encompass tertiary prevention strategies:
self-management (weight control, physical activity,
education); home help programs; cognitive behavioral
interventions; rehabilitation services and medical surgical
treatments.

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Thank you!

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