McGovern Physical Therapy Associates - The Personal Care Professionals

WHAT IS OSTEOPOROSIS?

Osteoporosis is condition that features loss of the normal density of bone and fragile bone. Osteoporosis leads to literally abnormally porous bone that is more compressible like a sponge, than dense like a brick. This disorder of the skeleton weakens the bone leading to an increase in the risk of breaking bones (bone fracture). Normal bone is composed of protein, collagen, and calcium. Bones that are affected by osteoporosis can fracture with only a minor fall or injury that normally would not cause a bone fracture. The fracture can be either in the form of cracking (as in a hip fracture), or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, and wrists are common areas of osteoporosis-related bone fractures, although osteoporosis-related fractures can also occur in almost any skeletal bone area.

There are currently an estimated 10 million Americans suffering from osteoporosis, as well as another 34 million who have low bone mass, or osteopenia. Researchers estimate that about 20% of American women over the age of 50 have osteoporosis with one in two white women experiencing a bone fracture due to osteoporosis in her lifetime.

Causes and risk factors:

Osteoporosis is the most common type of bone disease, and women, especially those with a family history of osteoporosis, have a greater-than-average risk of developing this disease. Other risk factors include smoking, eating disorders, low body weight, too little calcium in the diet, heavy alcohol consumption, early menopause, absence of menstrual periods (amenorrhea) and use of certain medications, such as steroids. Having less than 15% body fat, under or over-exercising, smoking, gastrointestinal disorders, advanced age, elevated blood acid levels, and stress are also contributors to the disease.

The leading causes are a drop in estrogen in women at the time of menopause, and a drop in testosterone in men. Women, especially those over the age of 50, get osteoporosis more often than men.

Symptoms:

The osteoporosis condition can operate silently for decades because osteoporosis does not cause symptoms unless bones fracture. Some osteoporosis fractures may escape detection until years later. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. Then, symptoms are related to the location of the fractures.

Fractures of the spine (vertebra) can cause severe pain that radiates around from the back to the side of the body. Over the years, repeated spine fractures can cause chronic lower back pain as well as loss of height or curving of the spine, which gives the individual a hunched-back appearance. A fracture that occurs during the course of normal activity is called a minimal trauma fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality.

What are the risk factors for developing osteoporosis?
Factors that will increase the risk of developing osteoporosis are:

• Female gender
• Caucasian or Asian race
• Thin and small body frames
• Family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture)
• Personal history of fracture as an adult
• Cigarette smoking
• Excessive alcohol consumption
• Lack of exercise
• Diet low in calcium
• Poor nutrition and poor general health
• Malabsorption (nutrients are not properly absorbed from the gastrointestinal system)
• Low estrogen levels (such as occur in menopause or with early surgical removal of both ovaries)
• Chemotherapy, which can cause early menopause due to its toxic effects on the ovaries
• Amenorrhea (loss of the menstrual period) in young women also causes low estrogen and osteoporosis. Amenorrhea can occur in women who undergo extremely vigorous training and in women with very low body fat (anorexia nervosa)
• Chronic inflammation, due to diseases such as rheumatoid arthritis
• Immobility, such as after a stroke, or from any condition that interferes with walking;
• Hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease)
• Hyperparathyroidism, a disease wherein there is excessive parathyroid hormone production by the parathyroid gland (a small gland located near the thyroid gland). Normally, the parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis
• Vitamin D deficiency. Vitamin D helps the body absorb calcium. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium to prevent osteoporosis.
• Certain medications can cause osteoporosis. These include long-term use of heparin (a blood thinner), anti-seizure medications phenytoin (Dilantin) and phenobarbital, and long term use of oral corticosteroids (such as Prednisone)

What factors determine bone strength?
Bone mass (bone density) is the amount of bone present in the skeletal structure. The higher the density is, the stronger the bones are. Bone density is strongly influenced by genetic factors, which in turn are sometimes modified by environmental factors and medications. For example, men have a higher bone density than women. African Americans have a higher bone density than Caucasian or Asian Americans.

Normally, bone density accumulates during childhood and reaches a peak by around age 25. Bone density is then maintained for about ten years. After age 35, both men and women will normally lose 0.3 to 0.5% of their bone density per year as part of the aging process.

Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause, bone loss accelerates. During the first five to ten years after menopause, women can suffer up to two to four percent loss of bone density per year. This can result in the loss of up to 25 to 30% of their bone density during that time period. Accelerated bone loss after menopause is a major cause of osteoporosis in women.

How is osteoporosis diagnosed?
A routine x-ray can reveal osteoporosis of the bone, which appears much thinner and lighter than normal bones. Unfortunately, by the time x-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, x-rays are not accurate indicators of bone density. The appearance of the bone on x-ray is often affected by variations in the degree of exposure of the x-ray film.

The National Osteoporosis Foundation, the American Medical Association, and other major medical organizations are recommending a dual energy x-ray absorptiometry scan (DXA, formerly known as DEXA) for diagnosing osteoporosis. DXA measures bone density in the hip and the spine. The test takes only 5 to 15 minutes to perform, uses very little radiation (less than one tenth to one hundredth the amount used on a standard chest x-ray), and is quite precise.

The bone density of the patient is then compared to the average peak bone density of young adults of same sex and race. This score is called the "T score," and it expresses the bone density in terms of the number of standard deviations (SD) below peak young adult bone mass.

• Osteoporosis is defined as bone density T score of –2.5 SD or below
• Osteopenia (between normal and osteoporosis) is defined as bone density T score between –1 and –2.5 SD

Who should have bone density testing?
The National Osteoporosis Foundation guidelines state that there are several groups of people who should consider DXA testing:

• All postmenopausal women below age 65 who have risk factors for osteoporosis
• All women aged 65 and older
• Postmenopausal women with fractures, although this is not mandatory because treatment may well be started regardless of bone density
• Women with medical conditions associated with osteoporosis
• Women whose decision to use medication might be aided by bone density testing.

The National Osteoporosis Foundation guidelines state that bone density testing does not need to be performed if a person has a known osteoporotic fracture because the condition will be treated with or without bone density results. In addition, bone density testing is not appropriate if the person undergoing the test is not willing to take any treatment based on the results. Therefore, if bone density testing is done, it should be performed on people willing to take some specific action based on the results.

How is osteoporosis treated and prevented?
The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment. The most important osteoporosis treatment and prevention measures are life style changes, including exercising regularly, medications that stop bone loss and increase bone strength and medications that increase bone formation.

Exercise has a wide variety of beneficial health effects. However, exercise alone does not bring about substantial increases in bone density. The benefit of therapeutic exercise for osteoporosis is to decrease the risk of falls by improving balance and muscle strength, improving coordination and range of motion and trying to make people more stable in relation to gravity by maintaining proper posture.

Some recommended, daily exercises include:

• Weight-bearing exercises
• Resistance exercises - free weights, weight machines, stretch bands
• Balancing exercises
• Riding stationary bicycles
• Using rowing machines
• Walking, jogging, treadmill

However, it is very important to avoid exercises that can injure already weakened bones. In patients over 40, and those with heart disease, obesity, diabetes mellitus, and high blood pressure, exercise should be prescribed and monitored by their physical therapists and doctors. Also, any exercise that presents a risk of falling should be avoided; supervision by a licensed physical therapist is always recommended.

In addition to therapeutic exercise, physical therapists may use other treatment modalities such as:
Heat Therapy –warm heat packs are used to relieve pain by increasing blood flow and relaxing tissues
Cold Therapy - ice packs or ice massage reduces swelling and pain
Therapeutic Ultrasound - ultrasound waves neutralize pain while increasing circulation
Aquatic Therapy – exercising in water allows for reduced pain, joint protection, reduced exercise stress, decreased swelling, increased circulation, increased strength and endurance, increased range of motion, flexibility, balance and coordination, and increased muscle tone.
Manual Therapy – manual techniques including myofascial release, massage and muscle energy techniques can help increase flexibility and circulation
Paraffin Baths – a form of moist heat that helps pain and stiffness in your hands or feet. It is especially useful before exercise.

McGovern Physical Therapy Associates, the personal care professionals, is a multispecialty provider of outpatient physical therapy care. Voted “Best PT Practice 2004” by ADVANCE for Directors in Rehabilitation magazine, our clinicians offer personalized manual therapy and exercise expertise, including a variety of customized treatment options. Combining innovation, experience and excellence, our staff of clinicians, as well as dedicated office personnel, work as a team to provide caring, convenient and professional service for total patient recovery.

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