WHAT IS

OSTEOPOROSIS?
 Osteoposis is a disease of
bones that leads to an
increased risk of fracture.
 Osteoporosis literally
means ‘porous bones’’.
 In osteoporosis the bone
mineral density(BMD) is
reduced, bone micro
architecture is disrupted.
 Risk factors for development of osteoporosis are
divide Modifiable and Non-modifiable factors.
 in addition, there are some specific diseases and
disorders in which osteoporosis is a recognized
complication.
 AGE- advanced age or ageing combined with many
other factors contribute to the osteoporosis.
 HEREDITARY- those with a family history of osteoporosis
are at an increased risk. There are at least 30 genes
associated with the development of osteoporosis.
 GENDER SPECIFIC FACTORS- osteoporosis can be
present in both males and females but is more common
in females. Where 1 in 3 females are suffering from
osteoporosis there 1in 12 males suffer from
osteoporosis.
FEMALE FACTORS
In females osteoporosis is
related with deficiency of
oestrogen hormone which is
caused due to
Early menopause or following
menopause
Early hysterectomy(before age
of 45)
Missing periods for six months
or more (except pregnancy) as a
result of over exercising or over
dieting.
MALE FACTORS
In Males, low level of
testosterone hormone can lead
to osteoporosis. Testosterone
deficiency is caused by
 Andropause
 Turner’s syndrome
 Klinefelter syndrome
After surgical removal of the
testes.
 SMOKING AND ALCOHOL CONSUMPTION- smoking and
chronic heavy drinking cause reduced BMD and increases
risk of osteoporosis.
 NUTRITIONAL FACTORS- nutrition has an important role in
maintenance of good bone.
• Vitamin D deficiency (less skin exposure to sunlight)
• Deficiency of certain vitamins and minerals like calcium,
phosphorus, magnesium, zinc, boron, fluoride, copper, VIT
A, K, E & C.
• Excess of sodium (Na)
• Inadequate protein diet- both low and excess protein diet
can result in low BMD and increased urinary Ca loss
respectively.
• High blood acidity is known antagonist of bone.
• Underweight or malnourished people are more prone to
osteoporosis than overweight people.
 PHYSICAL ACTIVITY OR EXERCISE- inadequate amount
of physical activity can lead to development of
osteoporosis.
• Decreased physical activity or physical inactivity
(IMMOBILITY) leads to significant bone loss.
• Excessive exercise can lead to constant bone damage to
the bones which can cause exhaustion of bone
structure.
• Also intensive training without proper compensatory
increased nutrition increases the risk of osteoporosis.
 GASTROINTESTINAL DISORDERS- celiac disease, lactose
intolerance, billiary cirrhosis, or surgery like
gastrectomy, intestinal bypass surgery or bowel
resection.
 ENDOCRINE DISORDERS- cushing’s syndrome,
hyperparathyroidism, thyrotoxicosis, hypothyroidism,
diabetes mellitus type 1&2, acromegaly and adrenal
insufficiency.
 RHEUMATOLOGICAL DISORDER like rheumatic arthiritis,
ankylosing spondylitis, systemic lupus erythmatous, and
polyarticular juvenile idiopathic arthiritis
 SYSTEMIC DISEASES such as amyloidosis and
sarcoidosis
 RENAL INSUFFICIENCY
 HEMATOLOGICAL DISORDERS like multiple
myeloma, lymphoma, leukemia, mastocystosis,
hemophilia, thalaessemia.
 People with SCOLIOSIS of unknown cause,
complex regional pain syndrome have a higher
risk of osteoporosis.
 Osteoporosis is also more frequent in people
with Parkinson's disease and COPD
 Certain medications have been associated with an increase in
osteoporosis risk.
 CORTICOSTEROIDS OR GLUCOCORTICOIDS like prednisone or
hydrocortisone
 ANTIEPILEPTICS such as barbiturates, phenytoin
 L-THYROXIN REPLACEMENT THERAPY. This can be relevant in
subclinical hypothyroidism.
 ANTICOAGULANTS- long term use of heparin or warfarin is
associated with osteoporosis.
 PROTON PUMP INHIBATOR DRUGS- these drugs inhibit the
production of stomach acid. These drugs interfere with calcium
absorption hence develop risk of osteoporosis.
Osteoporosis is a silent condition
often giving no indication of its
presence.
Osteoporosis itself has no
specific symptoms.
Its main consequence is the
increased risk of bone fractures.
Osteoporotic fracture can occur
at three most common site:
• The Wrist
• The Spine
• The Hip
 WRIST FRACTURES
Wrist fractures are the third most
common type of osteoporotic
fractures. Fracture of distal forearm
are called colles’ fracture. Risk of
sustaining a colles’ fracture is about
16% in women. Wrist fractures are
nearly always consequence of fall on
outstretched hand.
 SPINAL OR VERTEBRAL
FRACTURES
Fractures of the vertebrae can happen
spontaneously and silently(no
symptoms), often leaving the victim
unaware of their presence until they
discover that they have been gradually
losing height or developing kyphosis.
Vertebrae that are most commonly
involved tend to correspond with the
weakest regions in the spine: T8, T12
and L1
STRESS FRACTURE OF WRIST
 HIP FRACTURES
Hip fracture represent the most serious consequence of osteoporosis.
They are associated with considerable mortality and morbidity.
Hip fractures may require surgery or hospitalization, and all require a
long period of recovery and rehabilitation.
Hip fractures most commonly occur following a fall from standing
height. The risk of falls also increases with age. Reduced
neuromuscular coordination, reduced muscle tone, strength and
balance, poorer eyesight, and general increased frailty all combine
to increase the likelihood of someone falling.
The diagnosis of osteoporosis can be made using conventional
radiography and by measuring the bone mineral density (BMD).The
most popular method of measuring BMD is dual energy x-ray
absorptiometry (DXA or DEXA).
CONVENTIONAL RADIOGRAPHY
Conventional radiography is useful, both by itself and in conjunction
with CT or MRI,
• for detecting complications of osteopenia (reduced bone mass;
pre-osteoporosis)
• for differential diagnosis of osteopenia;
• for follow-up examinations in specific clinical settings, such as soft
tissue calcifications, secondary hyperparathyroidism, or
osteomalacia in renal osteodystrophy.
However, radiography is relatively insensitive to detection of early
disease and requires a substantial amount of bone loss (about 30%)
to be apparent on x-ray images.
 DUAL ENERGY X-RAY ABSORPTIOMETRY
Dual energy X-ray absorptiometry (DXA, formerly DEXA) is considered
the ’’gold standard’’for the diagnosis of osteoporosis. Osteoporosis is
diagnosed when the bone mineral density is less than or equal to 2.5
standard deviations below that of a young adult reference population.
This is translated as a T-score. The World Health Organization has
established the following diagnostic guidelines:
 T-score -1.0 or greater is "normal"
 T-score between -1.0 and -2.5 is "low bone mass" (or "osteopenia")
 T-score -2.5 or below is osteoporosis
 SINGLE ENERGY X-RAY ABSORPTIOMETRY
This may be performed on either the distal forearm or the
calcaneus. SXA scan can use the same T-score system and can
indicate a person’s need for treatment (T-score at -2.5) or need
for a hip or spine DEXA scan(T-score is between -1 and -2.5).
Owing to the varying amount of trabecular and cortical bone in
these sites at different positions, these scans are not able to
diagnose osteoporosis.

 ULTRASOUND SCAN
The modality is small. Measurements can be made quickly and
easily, and the cost of the device is low compared with DXA and
QCT devices. The calcaneus is the most common skeletal site for
quantitative ultrasound assessment because it has a high
percentage of trabecular bone that is replaced more often than
cortical bone, providing early evidence of metabolic change. Also,
the calcaneus is fairly flat and parallel, reducing repositioning
errors. The method can be applied to children, neonates, and
preterm infants, just as well as to adults.
 QUANTITATIVE CT SCAN
Quantitative CT is different for DXA in that it gives separate
estimates of BMD for trabecular and cortical bone as a true
volumetric mineral density in mg/cm3. The technique can be
performed at axial and peripheral sites, has sensitivity to changes
over time, can analyze a whole area, and exclude irrelevant
structures. Disadvantages are that it requires a high radiation
dose, the scanners are expensive and large and are operator-
dependent. The peripheral QCT has been developed to improve
on the limitations of DXA and axial QCT.
 Q FRACTURE SCORE
The Q-Fracture score was developed in 2009 and is based on age,
BMI, smoking status, alcohol use, rheumatoid arthritis,
cardiovascular disease, type 2 diabetes, asthma, use of tricyclic
antidepressants or corticosteroids, liver disease, and a history of
falls in men. In women hormone replacement therapy, parental
history of osteoporosis, gastrointestinal malabsorption, and
menopausal symptoms are also taken into account. A website
www.qfracture.com is available to help apply this score.
 Methods to prevent osteoporosis include changes of
lifestyle. However, there are medications that can be
used for prevention as well. Certain lifestyle factors,
such as diet and exercise, have an influence on bone
density and bone health in general.
 As a different concept there are osteoporosis ortheses
which help to prevent spine fractures and support the
building up of muscles. Fall prevention can help prevent
osteoporosis complications.
 Diet plays a major role in bone health. The protein component of bone,
the osteoid, needs to be mineralized give the bone its hardness and
strength. The key mineral required in this process is calcium.
 Calcium is freely available in our diets with many rich food sources
available mostly in milk and milk products.
 A bone friendly diet should give more than adequate amount of all the
other nutrients that we require, such as boron, copper, zinc,
magnesium, manganese, potassium, vitamin B6, C and K, and essential;
fatty acid.
 Also vitamin D is essential for bone health which can be obtained by
adequate skin exposure to sun.
 There are several things like caffeine, excess salt, protein and
phosphates which should be avoided as they can inhibit our natural
ability to absorb calcium.
 Exercise has two important roles in the prevention of fractures.
Firstly it is to aid bone density, and secondly it tones and
strengthens muscles, thereby ensuring good balance,
coordination and skeletal support.
 Weight – bearing exercise is important when considering
osteoporosis prevention. Loading the skeleton with physical
weights or bodyweight stimulates the osteogenic cells, giving rise
to a maintenance or possible increase in BMD.
 High impact exercise such as jogging will target the hips and
spine.
 Resistance exercise like lifting weight can target specific areas
such as wrist.
 AIMS
• Increase in peak bone mass and bone mineral density(BMD).
• Improve muscle strength, balance, cardiovascular fitness
• Improve posture
• Improve psychological well being
• Provide education
 Exercise management for bone health
• High impact exercise, e.g. skipping and jogging, has the greatest
potential to improve BMD in pre-menopausal group.
• Low to medium impact exercise, such as step aerobics,
intermittent jogging is more appropriate for those not used to
exercising and those over 50 years of age.
• Integrate high impact with medium and/or low impact activities for a
well- designed and safe programme. People should be instructed in the
use of rebound techniques, i.e. give or bend in the knees on take off
and landing 4
• Strength training is useful in sedentary young individuals provided it is
of a high enough intensity i.e. 70–80% 1RM. It not only improves
strength, but is accompanied by improvements in BMD.
• All exercise programmes should start at an easy level and be progressive
in terms of intensity and impact.
 Precaution

All high impact exercise is inappropriate and unsafe if:

• People suffer from joint conditions
• People cannot perform exercise with correct technique i.e. unable to
rebound effectively
• People with pelvic floor problems
• The design of the programme is unsafe, e.g. all of the exercise occurs on
the spot, and if the programme does not incorporate medium and low
impact exercise
 AIMS
• Maintain bone strength
• Prevent fractures
• Improve muscle strength, balance, cardiovascular fitness
• Improve posture
• Improve psychological well-being
• Provide education
• Aim to reduce falls
 Exercise management for bone health

• Strength training. It should be applied through a high load and

low repetitions regime and it should be site specific i.e. targeting
areas such as the muscle groups around the hip, quadriceps,
dorsi-plantar flexors, rhomboids, wrist extensors and back
extensors.
• Weight bearing exercises should be targeted to loading bone sites
predominantly affected by osteoporotic change i.e. hip, vertebrae
and wrist.
• Exercise should be used in combination with both adequate
calcium intake and some type of hormone replacement therapy
or other clinical therapy for maintaining and/or increasing bone
mineral density in post-menopausal women at risk from
osteoporosis.
• All exercise programmes should start at an easy level and be
progressive in terms of intensity and impact
 PRECAUTIONS
The following activities should be avoided:
• High impact exercise

• Trunk flexion

• Trunk rotational torsion movements with any loading

• Lifting

• The pelvic floor precautions listed for the osteopenic and

prevention group, also apply.
 AIMS
• Falls reduction
• Prevention of further fractures
• Balance/co-ordination
• Improvements in muscle strength, flexibility, aerobic capacity,
posture
• Gait re-education
• Psychological well-being and increased confidence
• Reduce/control pain
 Exercise Management
• Exercise training must start at a very low intensity using low
impact exercises
• For strength training initially use very short levers or body
resistance
• Exercises that patients find difficult on dry land may be more
easily carried out in water. For example, trunk extension will
be impossible for some of these patients on dry land but can
be achieved in water and resistance can gradually be
increased
• All exercise programmes should be progressive in terms of
intensity and impact. A very gentlel ow impact programme
using gravity and body resistance exercise is recommended
 PRECAUTIONS
• No high intensity exercise
• All the precautions listed for the ostoepenic and prevention group
and the osteoporotic group also apply to this group.
 PAIN MANAGEMENT
The following modalities may be effective for osteoporosis and apply
to all those with associated pain in any of the target groups.
• Heat. Patients should be instructed on how to use heat therapy
safely at home to relieve pain symptoms.
• Transcutaneous Electrical Nerve Stimulation (TENS). TENS should
be considered as a modality for the osteoporotic patient with
intractable pain, especially those with chronic back pain and
recent vertebral fractures
• Interferential Therapy. The mechanism for pain relief is the same
as for TENS
• Hydrotherapy. Hydrotherapy should be considered as a
treatment modality where the patient has pain from recent
vertebral fractures, and/or postural and balance problems.
Hydrotherapy is also a very useful modality to build confidence in
very disabled people and those afraid of further falls.
• Relaxation. The use of relaxation should be discussed with/off e
red to patients with osteoporotic intractable pain.
 Back extension exercises are very important for this group.
Kyphosis can often be improved as it is not totally dictated by the
shape of the bones but also by muscle weakness and/or pain.
 Exercises should concentrate on encouraging chest excursion,

rhomboid exercises and balance.

 Stretching to improve flexibility should be part of every exercise

programme for all of the patient groups. Stretching of all the

major upper and lower limb muscle groups should be carried out.
 PRECAUTION

Ballistic stretching should always be avoided.

 A thorough falls risk assessment should be made and risk factors
eliminated as far as possible
 Co-ordination and balance exercises appropriate to the severity of
the disease should be encouraged, i.e. simple balance exercises
such as supported one leg stands can be effective.
 Also balance exercises with the help of gym ball can be effective.
 The use of hydrotherapy is frequently indicated to reduce pain,
and to provide a safe environment for balance exercises.