Osteoporosis

Question 1

Whta is the difference between Z scores and T scores?

Answer 1

• Z scores are age matched controls
• T scores are compared to young normal adults of same sex
• There are no Z and T scores for males for bone density

Question 2

a measure of disease that allows us to determine a person’s probability of being diagnosed with a disease during a given period of time; the number of newly diagnosed cases of a disease

Answer 2

incidence

Question 3

a measure of disease that allows us to determine a person’s likelihood of having a disease; the total number of cases of disease existing in a population

Answer 3

prevalence

Question 4

What is the mortality rate after 1 year following hip fracture?

Answer 4

20%

• 25% require LT care
• 50% are functionally impaired forever

Question 5

What are the SD that define normal, osteopenia, osteoporosis, and severe osteoporosis?

Answer 5

• Normal = BMD within 1 SD of “young normal” adult (T-score at -1.0 and above)
• Osteopenia = 1-2.5 SD of “young normal” adult (t-score between -1 and -2.5)
• Osteoporosis = >2.5 SD
• Severe = >2.5 AND 1 or more fragility fractures exist

Question 6

Where are the most common sights of fracture?

Answer 6

1. distal forearm
2. vertebral bodies
3. hip

Question 7

What are the determinants of peak bone mass?

Answer 7

1. genotype
2. mechanical stress
3. endocrine factors
4. nutrition

Question 8

What has more demineralizing effect on bone than decrease in estrogen after menopause?

Answer 8

decreased physical activity

• lose the most of trabecular bone (inner network of thin calcified trabeculae)
• cortical = main fxn is structure and protection, forms external parts of long bone, dense, calcified tissue, calcium makes 80-90%

Question 9

Produces bone matrix (collagen and ground substance); Bone formation

Answer 9

osteoblasts

Question 10

orchestrator of bone remodeling through regulation of both osteoclast and osteoblast activity; compose 90% to 95% of all bone cells in adult bone

Answer 10

Osteocytes

- regulates the building

Question 11

Responsible for bone resorption

Answer 11

osteoclasts

Question 12

What is the hormonal regulation of:
Decreased bone resorption
Increased bone resorption
Increased bone formation
Decreased bone formation

Answer 12

• Decrease Bone Resorption = Calcitonin, Estrogens
• Increase Bone Resorption = PTH/PTHrP, Glucocorticoids, Thyroid Hormones, High dose vitamin D
• Increase Bone Formation = Growth Hormone, Vitamin D Metabolites, Androgens, Insulin, Low-dose PTH/PTHrP
• Decrease Bone Formation = Glucocorticoids

Question 13

what gland monitors calcium levels?

Answer 13

parathyroid gland

Question 14

What are the types of osteoporosis?

Answer 14

1. Postmenopausal - accelerated and disproportionate loss of trabecular bone usually in decade after menopause; 6x greater women than men; Increased bone resorption, reduced production of PTH, decreased vit D activation. From age 50-80, women’s BMD decreases 30%
2. Age-related - 2x greater women than men; Onset for women 1 decade earlier (70-80); Rate of loss in trabecular and cortical bone equal; Hip fractures common; Gradually resorption exceeds accretion and bone loss occurs; Loss approximately .5%/year
3. Secondary – occurs in response to certain medical conditions. Women = men (Grave’s dz, hyperparathyroidism, cushing’s syndrome, chronic renal failure, malnutrition, diabetes, SCI with immobility, RA, liver dz, malignancy and malignancy-related conditions, hypercalciuria, hyperthyroidism, alcoholism, osteogenesis imperfecta, marfan’s syndrome, turners, klinefelters, glucocoritcoids, anticoagulants, thyroid hormone (excessive), anti-seizure meds, prolonged total parenteral nutrition, radiation, cyclosporin taken for organ transplant, lithium, methotrexate and prednisone

Question 15

What are risk factors for osteoporotic fx?

Answer 15

1. Low bone density
2. > 65 years
3. Personal hx of fracture >40 with min trauma
4. Hx of fx in first-degree relative
5. Low body weight (<132 lbs) post-menopause
6. Caucasian or Asian race
7. Female
8. Poor health/frailty
9. Inadequate physical activity
10. Recurrent falls
11. Estrogen deficiency
12. Low CA+ intake (lifelong)
13. ETOH and smoking
14. Impaired eyesight (despite correction)
15. Gluco-corticoid use
16. Stroke
17. Current cigarette smoking

Question 16

What is the definition of a fragility fx?

Answer 16

fracture that results from trauma less than or equal to that from a fall from a standing height

Question 17

What should your daily Ca+ and vit D intake be?

Answer 17

Children 1-10 = 800-1200 mg
11-24 = 1200-1500
25-64 = at least 1200
Pregnant/lactating = at least 1200
Postmenopausal with HRT = at least 1000
Postmenopausal w/o HRT = at least 1500
Men/women >65 = at least 1200
Vit D 65+ years = 600-800 IU/day

Question 18

When should BMD testing be recommended?

Answer 18

1. All postmenopausal women under 65 who have 1 or more additional risk factors
2. All women 65 and older regardless of risk factors
3. Postmenopausal women who present with fractures
4. Women who are considering therapy for osteoporosis if BMD testing would facilitate the decision
5. Women who have been on HRT for prolonged periods

• Medicare pays for testing every 2 years

Question 19

What is the gold stander for measuring BMD?

Answer 19

DXA - only method with enough accuracy to determine change associated with drug Rx; Difficult to assess change assoc with exercise with 2 dimensional (DXA); spine/ hip

Other tests:

• pDXA use for hyperparathyroidism as loss typically greater in cortical bone; forearm, finger, heel
• SXA – single energy x-ray
• RA – radiographic absorptiometry
• QCT – quantitative computerized tomography; density of spine/hip
• QUS - speed of sound at heel, tibia, patella

Question 20

What are clinical signs of osteoporosis?

Answer 20

1. Loss of Height - normal only to lose 1” height
2. Spinal changes (cervical, thoracic, lumbar)
3. Pain (Rib Pain) <2 fingers
4. SOB
5. Hiatus Hernia
6. Protuberant Stomach

Question 21

What medications are used for osteoporosis?

Answer 21

1. Bisphosphonates (Fosamax, Boniva and Actonel, Reclast) - GI problems, osteonecrosis of jaw; Must be taken on empty stomach, remain upright 30-60 min, wait 30-60 min to eat; or IV
2. Calcitonin - Less effective than other therapies; intranasal; Will decrease pain from vertebral fractures
3. Estrogen/Hormone Therapy - Approved for prevention of osteo and menopausal sx; Health risks = lowest effective dose recommended; ERT 5-7x incr risk endometrial CA
4. Estrogen Agonist/Antagonist (aka SERM) (Raloxifene, (Evista)
   Prevention and treatment in postmenopausal women; Can be associated w/increased vasomotor S/S; Is associated with decreased risk of invasive breast CA; incr risk DVT
5. PTH (Forteo) - Approved for Rx for high risk men/women; Daily subcutaneous injection; Used maximum 2 years

• most drugs work by decr bone resorption, but doesn’t return mass to normal (incr of 5-10%)
• medication for jaw osteonecrosis = Fosamax

Question 22

What evidence exists for best practices for primary, secondary and tertiary prevention/wellness?

Answer 22

1. Primary – stopping it before it starts; Starting in children! Proper nutrition, especially in teens in sports
2. Secondary – at risk population; Women in 50s-60s; Lift weights!; Proper nutrition
3. Tertiary – clients you see that are already diagnosed; Education on falls, preventing falls, screening for falls

Question 23

What should education on osteoporosis include?

Answer 23

1. Risk Factors
2. Medical/Pharmaceutical Management, Bone Densitometry, HRT
3. Pain Management/self-help techniques
4. ADLs - fx during this; sneezing = brace hand on one thigh; hip hinge for bending
5. Exercise
6. Nutritional Information
7. Prevention of Falls
8. Team Approach

Question 24

How does exercise build bone?

Answer 24

1. Load with high peak forces (60-80% 1RM) and high strain rates
2. Vary strain distributions in the bone
3. Brief ex sessions 2-3x/week
4. Low reps (1-3 sets of 6-8 reps)
5. Progressive long term duration

Question 25

What are the basic principles of exercise to benefit bone health?

Answer 25

1. Mechanical stress is site specific and load dependent 2. Exercise must by dynamic and weight-bearing/impact or resistant in nature 3. Exercise load must exceed normal usage 4. Exercise should provide variable or unusual loading patterns 5. Short, intermittent bouts are preferable to longer, continuous bouts 6. Exercise must be accompanied by adequate energy, calcium, and vit D intake.

Question 26

What have sport specific BMD studies found?

Answer 26

- BMD highest in high strain/odd impact sports, e.g. VB, BB, gymnastics, karate compared to repetitive impact/individual sports (distance running) - BMD higher in soccer, field hockey players, and runners compared to low impact sports - BMD lowest in swimmers and cyclists

Question 27

What should be included in PT assessment for pt with osteoporosis?

Answer 27

1. Musculoskeletal 2. Risk Factors (fall prevention) 3. Current Activity Levels 4. Balance/Coordination (20 sec. Stand, Tinetti, reach test) 5. Current Pain Levels 6. Mobility Analysis 7. Cardiovascular (6 min walk) 8. Gait (timed up and go) 9. REEDCO - Look ahead; posture check that is specific template for examination 10. Stadiometer 11. Flexicurve Tracing (multiple studies, inexpensive, time efficient, patient feedback) - C7-L2; mold to spine, put onto grid for a thoracic kyphotic index divided by lumbar index 12. Forward head measurement (tragus to wall) 13. CROM 14. Grid Photo 15. Total scapular distance (sum of distance from T3 to lat. Aspect of left acromion and T3 to lat. Aspect of right acromion) 16. Rib/iliac crest distance – 4 fingers normal 17. lateral basal expansion – tape measure, 4-6 cm. Differential in/expiration (t-band for ex) 18. Timed loaded standing – 3 min. with 2 lbs in each hand, shoulders 90 deg. Flexion 19. Grip strength – assoc. with fall risk and lower BMD 20. Abdominal Strength 21. Trunk Extension Strength 22. Osteoporosis QOL questionnaire 23. Function (Functional Status Questionnaire, SF 36)

Question 28

You cannot flex high risk patients. How do we test for strength?

Answer 28

- Isometrics - Modified plank maintained for __s - Trunk extension strength - We need them to get into prone

Question 29

What type of exercises should be prescribed with vertebral fx?

Answer 29

- Spinal extension (back arches/lifts) - Spinal flexion (crunches) - Combined flexion and extension - No exercise - crunches = highest risk for fx

Question 30

What are LT management goals of osteoporosis?

Answer 30

1. Maintain/Slow loss or increase BMD in at-risk patients, dg. Patients without fracture, and those with fracture 2. Reduce Pain 3. Prevent spinal deformity/vertebral fractures 4. Prevention of falls/maintain mobility 5. Education

Question 31

What are the management of vertebral fx?

Answer 31

1. Mobility and Transfers 2. Pain Management 3. Bracing 4. Surgery - Vertebroplasty (cement injection), kyphoplasty (ballon, then cement) ; greatly improve QOL with reduction in pain

Question 32

Bone adapts positively to mechanical loading by increasing mass and strength: - For patient and prevention care: frequent, short bouts of ______________ physical activity promote osteogenesis - Competitive sports: encourage ____________ on bone rather than repetitive, single plan activities

Answer 32

- high impact/unusual strain | - cross-training for different strain

Question 33

_______ exercise plays a vital role in enhancing peak BMD during childhood/adolescence, and maintaining bone mass in adults

Answer 33

Impact - OA for girls in middle and HS are key - prevent FAT in HS athletes - Stress fractures in adolescent athletes multifactorial; Training error, menstrual dysfunction and low bone mass have most evidence