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BSMS204 Theme 2 Musculoskeletal > Osteoperosis, nutrition and fragility > Flashcards

Osteoperosis, nutrition and fragility Flashcards

(48 cards)

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1
Q

What is a fragility (low energy) fracture?

A

A fracture which occurs without excess force
or
follows a fall from standing height or less

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2
Q

Are fractures common?

A 
They are very common! In The EU someone fractures their Hip Every 30 secs
1/3 women > 50 years
2/3 women > 80 years 
1/12 men    > 50 years
1/5 men  eventually
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3
Q

Serious consequences of hip fracture

A

20% death within one year
30% permanent disability
40% unable to walk independently
80% unable to carry out at least one independent activity of daily living

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4
Q

The aging population

A

Population > 65 years in Europe
12-17 % in 2002
20-25 % by 2025
& it will get worse!

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5
Q

Vertebral fractures

A

Clinical and silent vertebral fractures increase pain and reduce activity

Only 1/3 vertebral fractures come to clinical attention. All vertebral fractures impact on quality of life.

Lose height

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6
Q

Cost of fractures

A 
Fractures / year (UK)
 Hip     70,000
 Wrist  50,000
 Spine  120,000
COST = £ 2 billion / year 
   = > £5 million / day!
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7
Q

Fragility fractures: basics

A 
Common
Cause  significant
 Morbidity
 Mortality
Expensive
Partly preventable
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8
Q

Why do people break bones?

A 
Bone strength is reduced
Sub optimal peak bone mass
Reduced bone quality
Reduced bone Mineral ( Calcium )
Deteriorating architecture
Change in crystal size & composition
Abnormal collagen
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9
Q

Why do people break bones?

A

Bone strength is reduced

They fall

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10
Q

Fracture prevention

A

Children / Adolescents / Young Adults: optimise peak bone Mass

Adults: prevent deterioration of bone quality

Prevent falls

£ Identify the elderly at high risk £

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11
Q

Optimising peak bone mass

A

Diet
Exercise
Sex hormones

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12
Q

How to identify fracture risk in older people - history and examination

A 
Increasing Age
Previous Fracture 
Light weight ( BMI < 18 )
Family History of osteoporosis
Smoking
Alcohol
Many medical Disorders
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13
Q

Predicting fragility fracture

A

Steroids > 3 months
65 years
Use Preventative Treatment

Cushings sydrome, or more commonly treatment with pharmacological doses of glucocorticoids are potent causes of osteoporosis.

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14
Q

Effect of inflammatory conditions on fragility fracture

A

Inflammatory conditions may be associated with reduced BMD. This is seen even in those not treated with Steroids. High levels of inflammatory cytokines may stimulate osteoblast activity.

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15
Q

Androgen deprivation therapy e.g. in prostate cancer

A

Men with prostate cancer are often treated with long acting GnRH analogues – these lower the testosterone concentration to castrate levels resulting in loss of bone density in the same way as when a women goes through the menopause.

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16
Q

Other medical disorders predisposing to osteoperosis

A 
Endocrine disorders
Thyrotoxicosis
Hyperparathyroidism
Pituitary disease
Conditions causing Nutritional Deficiency
Malabsorption conditions
Eating disorders
Alcoholism
Inflammatory conditions
Many chronic general medical conditions
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17
Q

Using technology to prevent risk

A

DEXA scan
Heel ultrasound scanning devise

WHO FRAX risk calculator

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18
Q

Fracture prevention

A 
FRACTURE PREVENTION
EXERCISE – bone build 
FALLS PREVENTION
Identify risk of…
Education
Posture &amp; balance classes
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19
Q

Management of fracture

A

MANAGEMENT OF FRACTURE
(Hip, spine, shoulder, wrist, ankle)

Decrease Pain Increase Confidence

, Increase Function = Decreased risk of further fracture

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20
Q

Biggest areas of impact in osteoperosis

21
Q

Thoracic kyphosis effects

Study These Flashcards
A

backache
extensor muscles of back overworked
front abdominal muscles become baggy

22
Q

Vertebral fractures cause pain

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A 
Vertebral fractures cause pain
Bones - these heal
Muscles
Nerves
Ligaments
23
Q

Personal impact of vertebral fractures

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A 
Social  - drive/washing/isolation
Family 
Depression -fragile/chronic pain
Body image
Sleep deprivation
General health – bowel, urine, swallowing, breathing, decrease activity = weight/cardiac ……….List goes on..
24
Q

What do physiotherapists do?

Study These Flashcards
A

Assurance
Relaxation/mindfulness
Education – Safety (falls/high impact/forced flexion)
Empower patient, increase confidence
Pain relief (tens, acupuncture, acupressure, heat, soft tissue mobilisation, pacing, medication, heat)
Hydrotherapy
Exercises Classes – gentle, higher level, falls based, back reconditioning
Spinal supports
Referrals – orthotics, pain management team, vertebroplasty, exercise in community

25
Hip fracture
95% caused by falls 1 in 5 dies within a year of fracture Half of patients do not regain ability to function independently Expensive Recovery depends on anatomical location of fracture Orthopaedic surgery & long rehabilitation Problems - Muscle adaptations/permanent nerve or ligament damage/muscle wasting/leg length/decrease confidence = long term balance & gait problems
26
Personal impact of hip fractures
Role in society / family Unable to drive Carer Decrease confidence Isolation = depression = decrease activity levels = poor physical recovery Effect of long hospital stay Can age someone very quickly
27
Physiotherapy for hip fractures
Day 1 post op → Long term management ICT, Outpatient, Falls Services Improve Gait & Balance Muscle symmetry (lengthen & strengthen) Confidence – Exercise & education Education – Falls safety (eyes, ears, feet, house) Exercise – classes, community, one to one Hydrotherapy Walking aids Other joint/medical issues limiting exercise/balance Referrals – pain/podiatrist/medication
28
Prescribing exercise
Patient Specific: Goal ↓pain, ↓ falls, ↑ bone loading ENJOYABLE, REGULAR, SUSTAINABLE
29
Weight bearing exercises
Activity where you are supporting the weight of your own body. Increase BMD: 30 mins, 5 x week – ideally short bursts to activate osteoblasts E.g. Jogging, aerobics, racquet sports, tennis, dancing, brisk walking, stair climbing etc.
30
Strength training
Muscles generate large forces in the tendons and the bones respond to this extra stress by becoming stronger. Site specific – higher loads / smaller rep 3 x week PROGRESS SLOWLY….. E.g. Weights or body weight, therabands, resistance exercises, back reconditioning classes, Pilates, hydro etc.
31
Falls prevention
Posture, flexibility, co-ordination, balance . | E.g. Swimming/hydro, Tai Chi, yoga, OTAGO, balance classes, Pilates, Alexandra technique etc.
32
Role of physio in osteoperosis and fractures
Decrease pain Decrease fracture risk Increase function Exercise and education very powerful in giving a sense fo control to the patient Fractures huge impact on patient not just their bones!
33
Objectives of drug treatment
``` Prevent bone breakdown Inhibit Osteoclasts Stimulate Bone Build up Stimulate Osteoblasts Modify Osteocyte activity ```
34
Clinical objectives of drug failure
``` Prevent ALL types of fracture Vertebral Nonvertebral Hip Others ```
35
bisphosphonates
inhibit osteoclast action | by inhibiting an important enyme
36
Oral nitrogen containing bisphosphonates
``` Prevent Hip & Spine fracture Generic Alendronate ( weekly ) Generic Risedronate ( weekly ) Prevention of spine fracture only Ibandronate ( monthly ) ```
37
How to take alendronate, risedronate and oral ibandronate
``` Take In the morning With a full glass of water Standing up Do not lie down after No food for 30 minutes Food inhibits absorption ```
38
Side effect of nitrogen-containing bisphosphonates
Contact stomatitis if chewed | Oesophageal ulcer if not taken stood up with full glass of water
39
What can impede alendonrate absorption?
proton pump inhibitors
40
Zoledronat
IV - 5mg infused over 15 minutes annually Reduced fractures: spine, hip and non-spine reduced mortality
41
Rare side effects of nitrogen containing bisphosphonates
Jaw osteonecrosis - 1/10,000 on long term use Atypical femoral shaft fracture - 1/10,000 - ask about femoral shaft pain!
42
Rank ligand and osteoclasts
Rank ligand can be used Osteoblast makes a cytokine called a RANK ligand which binds to osteoclast and stimulates it to breakdown bone Osteoblasts also makes another substance which blocks rank ligand Can use monoclonal antibody against RANK to block it
43
Denosumab 60 mg S/C
``` Fully Human Monoclonal antibody IgG2 isotype Binds to RANK Ligand Decoy Receptor High affinity High specificity No complement activation Rapidly absorbed Long half-life - 26 days ( 34 days with max dose ) 6 monthly injection Cleared by Reticuloendothelial system No renal excretion Reduces spine & Hip Fractures ```
44
Osteoporosis - AnabolicTreatment
``` Helps build up bone S/C PTH 1-34 Daily s/c Injection Pulse of PTH Anabolic to bone Reduces Fractures Vertebral ```
45
Other therapies for treating fractures
HRT in 50-60 year olds Selective oestrogen receptor modulators e.g. raloxifene Testogel for hypogonadism in men Tostran - testosterone 2% gel, beware contamination of partners & children Nebido - injection testosterone uncercanoate 1000mg IM every 10-14 weeks
46
Antiremodelling Drugs with evidence Prevention of HIP & Vert. FRACTURE
``` ALENDRONATE (weekly) RISEDRONATE (weekly) ZOLENDRONATE IV ( annually) DENOSUMAB s/c ( 6 monthly ) HRT ( Not Tibolone ) Calcium & Vitamin D (In elderly ) ```
47
Anabolic Drugs with Evidence
``` Teriparatide ( PTH 1-34 ) Abaloparatide PTH / PtHRP analogue Rososumab Antisclerostin antibody Increases Wnt Signaling in bone ```
48
Sclerostin antibody
Sclerostin inhibits WnT signalling which ACTIVATES osteobast, so sclerostin antibody inhibits sclerostin leading to WnT signalling and ACTIVATION of osteoblast

BSMS204 Theme 2 Musculoskeletal (22 decks)

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