Osteoporosis What You Should Know

Osteoporosis What You Should Know

What is Osteoporosis? A condition in which the infrastructure of bone becomes thin and weakened. Weakened bone is at higher risk for fracture to occur from minimal stresses. 2

Normal & Osteoporotic Bone Architecture Normal Bone Osteoporotic Bone Reproduced from J Bone Miner Res 1986;1:15-21 with permission of the American Society for Bone and Mineral Research. 1986 by Massachusetts Medical Society. All rights reserved. 3

Who Gets Osteoporosis? ANYONE could be at risk for Osteoporosis Most people are identified after age 50 Some diseases & conditions increase risk Even men & children are at risk 4

Risk Factors You Can’t Change Age Gender (4/5 cases are female) Postmenopausal status Family history, race (Caucasian or Asian), Vit D genetics Small frame ( 127 lb osteoporosis risk) Hyperparathyroidism, RSD, cancer, organ replacement Necessary medications (steroids, antiseizure, anticoagulants, synthroid, many chemotherapies, some diuretics) 5 (National Osteoporosis Foundation, 2002) 5

Additional Risk Factors Diseases that Are Often Treated with Glucocorticoid Medications* Asthma Bursitis Crohn’s Disease Chronic Active Hepatitis Dermatitis (Severe) *Partial List (National Glaucoma Lupus Erythematosus Multiple Sclerosis Osteoarthritis Psoriasis Rheumatoid Arthritis Osteoporosis Foundation, 2002) 6

Risk Factors You Can Change Diet – inadequate calcium and vitamin D, too much or too little protein Some bone-damaging medications Unhealthy lifestyle choices Alcohol (more than 2 drinks/day) Smoking (any!) Too little exercise Under-eating ( 127 lb osteoporosis risk) (National Osteoporosis Foundation, 2002) 7

Bone Development Bones build mass beginning at birth and peak by age 20-30 Peak bone mass is attained between 25 & 30 y/o 50% accrued during teen years Declines by 1 – 1.5%/ year after peak Declines by 3 – 5%/ year 1st 5 yr/ menopause Active Growth 10 20 Slow Loss 30 Rapid Loss Less Rapid Loss 40 50 60 70 Age in Years 80 90 (National Osteoporosis Foundation, 2002) 8

Calcium and Bone Recommended daily calcium intake Children and Young Adults 1-10 years 800 mgs 11-24 years 1,200 mgs Adults 1,000 mgs Pregnant and Lactating Women 1,200 mgs Postmenopausal Women Not on ERT 1,500 mgs Men over the age of 65 1,500 mgs (National Osteoporosis Foundation, 2002) Excess salt displaces calcium – Is added to almost all canned foods! High phosphates leach calcium from bone! – Soda – the worst culprit 9

Bone Nutrition - Beyond Calcium Vitamin D At least 800 units daily (Boonen S et al, 2006; Pfeifer M et al, 2002) 30 minutes of sun to hands & face daily sufficient in sub-tropical latitudes but only the “sunny” 6 months in temperate latitudes Magnesium 400-600/day – allows calcification as a natural calcium chelator (Barzel US, 1998) Depleted by stress, physical exertion Protein Intake and Bone - moderation is the key Women (35-59 y/o) w/ protein intake 95g/day (5 servings red meat/wk) vs those 59 g/day had increased risk of forearm fractures (Feskanich D et al, 1996) High amounts of protein intake ( 200 g/day) associated with decreased bone density (Barzel US 1998) Low protein diets ( 50g/day) associated with decreased bone density (Chiu JF et al 1997) 10

Drug Options – FDA approved Anti-resorptives (slow bone resorption) Bisphosphonates (alendronate, risedronate, ibandronate, pamidronate) (Wasnich RD et al, 2004; Chestnut III CH et al, 2004, Chan SS et al, 2004) Selective estrogen receptor modulators (raloxifene) Calcitonin (Miacalcin) Estrogen (Writing Group WHI, 2002; Nerhood RC 2001) Risks with long-term use may outweigh benefits, may be safer with lower doses Always needs to be given with progesterone when uterus present Anabolic (bone forming) Parathyroid hormone (teraparatide) (Heaney RP, 2003) 11

Why Do Bones Weaken? Bones depend on calcium, other chemicals, and vitamins to keep them strong. Bones grow as a response to physical stress being put on them. The density (hardness) of bones requires a good diet, some sunlight, and exercise in order to stay strong and not break. 12

It’s a Big Problem Osteoporosis affects more than 10 million people in the US 8 million women 2 million men (but they are catching up) 24 million others have low bone mass, called osteopenia Osteopenia is a precursor to osteoporosis (National Osteoporosis Foundation, 2002) 13

Why is It a Problem? Osteoporosis, by itself, is not a problem. It doesn’t cause pain and you will not know you have it! The problem is that it makes bones very brittle and brittle bones can break easily. A broken bone is called a FRACTURE. 14

Fracture Numbers Every year there are 1.5 million bone fractures in this country 300,000 hip fractures 700,000 vertebral fractures 250,000 wrist fractures Women have a greater lifetime risk of sustaining a hip fracture than breast, ovarian , and uterine cancer combined Fracture care costs 3 BILLION every year! (National Osteoporosis Foundation, 2002) 15

Fractures HURT Fractures cause: Pain Limited mobility Prolonged bedrest causes: Loss of strength Pneumonia Disability Death 20% of those with hip fractures die within one year Increased mortality with each vertebral fracture (National Osteoporosis Foundation, 2002) 16

Determinants of Osteoporotic Fracture Number of osteoporosis risk factors Forward bending (trunk flexion) Poor balance, or accidents resulting in falls Vertebral Fracture Hip Fracture 17

Fracture Force Risks During Bending and Lifting Compression loads imposed on the L3 motion segment (lower back) by 30º of trunk flexion – 1800 N with arms at chest – 2610 N with arms in front, holding 2 kg in each hand (Schultz et al 1982) 300 to 1200 N enough to fracture an osteoporotic vertebra (Edmondston et al 1997) Practical Application - bend and lift in everyday life with the trunk in relative neutral! 18

Exercise and Vertebral Fractures (for women with a previous fracture) Type of Exercise Spinal Extension (Back arches/lifts) New Fractures 16% Spinal Flexion (Crunches) 89% Combined Flexion and Extension 53% No exercise 67% (Sinaki and Mikkelson, 1984) 19

How Do I Know if I Have It? There are many types of screening tests available in the community. Many use a finger or a foot to estimate possible risk. The gold standard (the absolute test) for determining the amount of bone density an individual has is a DEXA test. It is like an X-ray without the radiation. You lie on a table and a scanner passes over you. A computer determines how much bone you have by the information read by the scanner. 20

What’s a T-score? The amount of bone you have is determined by how much has been lost since childhood, assuming you had lots of calcium and activity at that time A T-score is a statistical number which says whether you are above or below “normal” T-scores are such numbers as -1.4 or -3.0 or even 1.0 sometimes. 21

T-scores Normal T-scores range from 1 to -1 Osteopenia T-scores -1.0 to -2.5 Osteoporosis T-score less than -2.5 (up to -6.0) 22

What Should I Do First? There are 3 major things you can do 1. Talk to your doctor about a Bone Density Test 2. Talk to a physical therapist about your activity level and an exercise program to combat osteoporosis 3. Talk to a dietician to make sure your diet is providing your bones with enough calcium and is balanced correctly 23

What If I Already Have Osteoporosis? Talk to your physician and pharmacist about medications available to help you Make sure your diet includes enough calcium, not too much caffeine or alcohol, and adequate, but not excessive, protein. Spend at least 30 minutes/day in sunlight and/or eat foods which are fortified with Vitamin D and . 24

See a Physical Therapist PTs are able to develop an exercise program for you that will be appropriate for your condition PTs will evaluate your posture, your strength, your range of motion, your balance, and your general endurance status PTs will develop a balanced program which should help keep you fit as well as safe PTs can answer your questions or refer you to others who will 25

Studies on Exercise Appropriate exercise may slow the rate of bone loss Sedentary lifestyles and immobility lower bone density Effects of exercise are improved when combined with proper nutrition and medication 26

Exercise Effect on Bone – Works only when “Regular” Postmenopausal women exercised 3 times per week for 9 months Stair-climbing for 30 minutes each session Spinal bone density 4% in exercisers Spinal bone density to baseline within 9 months for those who stopped exercising (Dalsky 1988) 27

Resistance Training Increases Bone Density Best Landmark study (Nelson & Fiaterone 1994) – Sedentary 50-70 y/o postmenopausal women – Resistance training 2 X/wk on 5 machines for 1 year – Significant bone density increases in spine, hip, total body Many other studies validate, including: – – – Cussler EC 2003 Kerr D 2001 Kelley GA 2001 28

Principles of Exercise for People with Lowered Bone Mass Posture is critical in all activities Weight bearing is important Walking, Dancing, Stair climbing Resistance exercise is the best way to strengthen bone & muscle groups Balance exercise to decrease fall risk Avoid activities or positions that move the body into bent (flexed) postures 29

Exercise Intervention Works After Vertebral fracture – 6 months of supervised exercise back strength and psychological status (Gold et al: 2004) For kyphosis and balance – 12 weeks of SAFE yoga (no forward bending!!!) improves balance & posture (Greendale et al, 2002) For osteoporosis and back pain – 10 weeks of combination group and individual exercise increases height, improves back posture and strength (Lindsey et al, 1995) 30

Eclectic Treatment Focus Essential Frailty Injury Cooperative Interventions Trial Analysis revealed that a year after the intervention: – Fall rate decreased 10% in those who did strength exercises only – Fall rate decreased by 17% in those who received “balance” exercises only – Fall rate decreased by 31% in those who did both plus the Tai Chi. (Wolfson L et al: Balance and strength training in older adults: intervention gains and Tai Chi maintenance. 1996) – Those who increase all balance scores show a 60% reduction in fall risk. (Tinetti ME et al: A multifactorial intervention to reduce the risk of falling among elderly people living in the community. 1994) 31

Prevention of Bone Loss and Minimizing Fracture Risk Healthy lifestyle choices – Exercise – Nutrition Early treatment – – Screening Individualized therapies Physical Therapy – – – – Resistive weight bearing exercise Correct body mechanics Balance interventions Treat mechanical pain & dysfunction 32

See a Physical Therapist for More Details! http://www.apta.org Click the “Find a PT” button

Find Out More About Osteoporosis Web sites for up to date information: www.geriatricspt.org/clients/resources.cfm www.nof.org www.surgeongeneral/library/bonehealth www.osteo.org www.fore.org 34

References 1. Barzel US, Massey LK. Excess dietary protein can adversely affect bone. J Nutr. Jun 1998;128(6):1051-1053. 2. Boonen S, Vanderschueren D, Haentjens P, Lips P. Calcium and vitamin D in the prevention and treatment of osteoporosis - a clinical update. J Intern Med. Jun 2006;259(6):539-552. 3. Chan SS, Nery LM, McElduff A, et al. Intravenous pamidronate in the treatment and prevention of osteoporosis. Intern Med J. Apr 2004;34(4):162-166. 4. Chesnut III CH, Skag A, Christiansen C, et al. Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis. J Bone Miner Res. Aug 2004;19(8):1241-1249. 5. Chiu JF, Lan SJ, Yang CY, et al. Long-term vegetarian diet and bone mineral density in postmenopausal Taiwanese women. Calcif Tissue Int. Mar 1997;60(3):245-249. 6. Cussler EC, Lohman TG, Going SB, et al. Weight lifted in strength training predicts bone change in postmenopausal women. Med Sci Sports Exerc. Jan 2003;35(1):10-17. 7. Dalsky GP, Stocke KS, Ehsani AA, Slatopolsky E, Lee WC, Birge SJ Jr. Weight-bearing exercise training and lumbar bone mineral content in postmenopausal women. Ann Intern Med. Jun 1988;108(6):824-828. 8. Edmondston SJ, Singer KP, Day RE, Price RI, Breidahl PD. Ex vivo estimation of thoracolumbar vertebral body compressive strength: the relative contributions of bone densitometry and vertebral morphometry. Osteoporos Int. 1997;7(2):142-148. 9. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Protein consumption and bone fractures in women. Am J Epidemiol. Mar 1 1996;143(5):472-479. 35

References (Cont) 10.Gold DT, Shipp KM, Pieper CF, Duncan PW, Martinez S, Lyles KW. Group treatment improves trunk strength and psychological status in older women with vertebral fractures: results of a randomized, clinical trial. J Am Geriatr Soc. Sep 2004;52(9):1471-1478. 11.Greendale GA, McDivit A, Carpenter A, Seeger L, Huang MH. Yoga for women with hyperkyphosis: results of a pilot study. Am J Public Health. Oct 2002;92(10):1611-1614. 12.Heaney RP. Advances in therapy for osteoporosis. Clin Med Res. Apr 2003;1(2):93-99. 13.Herbold NH, Frates SE. Update of nutrition guidelines for the teen: trends and concerns. Curr Opin Pediatr. Aug 2000;12(4):303-309. 14.Kelley GA, Kelley KS, Tran ZV. Resistance training and bone mineral density in women: a meta-analysis of controlled trials. Am J Phys Med Rehabil. Jan 2001;80(1):65-77. 15.Kelley GA, Kelley KS, Tran ZV. Exercise and lumbar spine bone mineral density in postmenopausal women: a meta-analysis of individual patient data. J Gerontol A Biol Sci Med Sci. Sep 2002;57(9):M599-604. 16.Kerr D, Ackland T, Maslen B, Morton A, Prince R. Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women. J Bone Miner Res. Jan 2001;16(1):175-181. 17.Lindsey C, Reisine S, Fertig J. Evaluation for the effects of exercise on posture, back strength, pain & mood in postmenopausal women with osteoporosis & back pain. Paper presented at: WCPT, 1995; Washington, DC. 18.National Osteoporosis Foundation. America's Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation; 2002. 36 36

References (cont) 19.Nelson ME, Fiatarone MA, Morganti CM, Greenberg RA, Evans WJ. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures: a randomized controlled trial. JAMA. Dec 28 1994;272(24):19091914. 20.Schultz AB, Andersson GBJ, Haderspeck K, et. al. Analysis and measurement of lumbar trunk loads in tasks involving bends and twists. J Biomechanics. 1982;15(9):669-675. 21.Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. Jun 2002;30(6):836-841. 22.Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-596. 23.Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. Sep 29 1994;331(13):821-827. 24.Wasnich RD, Bagger YZ, Hosking DJ, et al. Changes in bone density and turnover after alendronate or estrogen withdrawal. Menopause. Nov-Dec 2004;11((6 Pt 1)):622-630. 25.Wolfson L, Whipple R, Derby C, et al. Balance and strength training in older adults: intervention gains and Tai Chi maintenance. J Am Geriatr Soc. May 1996;44(5):498-506. 26.Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. Jul 17 2002;288(3):321-333. 37