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Osteoporosis ( Bone Weakness)
What is osteoporosis? Osteoporosis is a condition in which bones become weak due to decrease in the amount of mineral & bony material in a particular bone characterized by low bone mineral density (BMD). It is one of the most common bone diseases in human being and, while traditionally thought of as a problem primarily of post-menopausal women, it is also significant problem for men. In osteoporosis bone becomes porous from inside & it has less calcium & other minerals, less strength & thus more prone to fracture & deformity .Thus osteoporotic bones are weak bones. Normally bones are made up of inner honeycomb like lamellar bone surrounded by a thick outer shell called cortical bone. In osteoporosis there is decrease density of bone and bone becomes fragile. The osteoporosis of bone weakens the bone leading to an increase in the risk of bone fracture. Bones that are affected by osteoporosis can fracture with only a minor fall or injury that normally would not cause a bone fracture.
From childhood till the age of 35 years, more bone is laid down than is removed thus bone density keeps on increasing and an individual’s peak bone mass is typically achieved by around age 35. After peak bone mass is reached, the remodeling process (the process of laying down new bone and removing old bone) takes away more bone than is replaced. Hence making the bones more prone to osteoporosis (and consequently to fracture). Thus, the process of bone loss typically begins after 35 years. Starting from about that age to the onset of menopause, women lose a certain amount of bone steadily every year. Calcium and phosphate are two minerals that are essential for normal bone formation. Throughout youth, your body uses these minerals to produce bones. If you do not get enough calcium, or if your body does not absorb enough calcium from the diet, bone production may suffer. As you age, calcium and phosphate may be reabsorbed back into the body from the bones, which makes the bone tissue weaker. This can result in brittle, fragile bones that are more prone to fractures, even without injury. Usually, the loss occurs gradually over years. Many times, a person will have a fracture before becoming aware that the disease is present. Osteoporosis occurs when the body fails to form enough new bone or too much old bone is reabsorbed by the body, or both. Fractures may occur as a result of osteoporosis. For your knowledge we’ll like to explain you that there are two types of cells which are constantly at work in our bones. One set builds up new bone (called osteoblastic i.e. bone forming activity) whereas another set break down old bone (called osteoclastic i.e. bone resorption activity). Up to our 35 year the construction cells work harder building strength into our skeleton. Thus in initial years of life there is more construction of bone than breakdown of old bone so that bone density as well as bone strength keeps on increasing. Our bones achieve maximum strength by the age of 35 years. From the age of 35 onwards, the demolition cells overtake and our bones gradually lose their density as a natural part of ageing. After the age of 35 year bone resorption i.e. destruction supercedes the new bone formation so bone strength & bone mineral content including amount of bone material in a particular bone starts gradually decreasing. This gradual decline in bone content occurs in every body. But in some people the bone loss is very fast compared to other people so that in few years there bone becomes very weak & becomes prone to easy fracture even on minor trauma. The osteoporosis which occurs due to aging or not due to well defined cause is called primary osteoporosis. There are many diseases which lead too rapid degradation of bone leading to significant osteoporosis more than what is expected at that age due to aging. Osteoporosis due to these diseases is called secondary osteoporosis.
What are the symptoms of osteoporosis? There are no symptoms in the early stages of the disease & the patient with osteoporosis may remain silent for decades. Many people have decreased bone mineral i.e. osteoporosis from lone time but they are not aware of it because it does not causes any symptoms in the beginning. Symptoms occurring late in the disease are Bone pain, back pain or pain on compression of the bone, Fracture with little or no trauma as fall on ground, Loss of height of spine due to forward bending because of vertebral fractures over time leading to decrease in height of vertebra, Low back pain due to fractures of the spinal bones, Neck pain due to fractures of the spinal bones or forward bending Stooped posture In many osteoporsis doesn't cause symptoms unless some acute bone fracture occurs. Once fracture occurs this causes severe acute pain in the affected areas. In most cases it often remains undetected until the time of this first broken bone. The most common fractures are of wrists, hips and spinal bones in people with osteoporosis. In
some patient may even have fracture of spine but because it is
gradual onset patient may not have any symptom thus may escape
detection until years later which is then detected during a routine
x-ray of spine. Therefore, patients may not be aware of their
osteoporosis until they suffer a painful fracture. Then the symptoms
are related to the location of the fractures as back pain when crush
fracture of vertebra occurs. Sometimes fractures of the spinal
vertebrae can cause severe "band-like" pain that radiates around
from the back to the side of the body. Over the years, repeated
spine fractures can cause chronic back pain as well as loss of
height or curving of the spine leading to stooping forward posture
which is typically seen in many older women, 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. Some persons with osteoporosis become severely disabled as a result of weakened bones. Hip fractures leave about half of patients unable to walk independently. This is one of the major reasons people are admitted to nursing homes. Although osteoporosis is debilitating, it does not affect life expectancy. Common complications of osteoporosis are: Fracture of various bones: The fracture can be either in the form of hip or wrist fracture or collapse of the vertebra 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. · compression fractures of the spine · Disability caused by severely weakened bones · Hip and wrist fractures · Loss of ability to walk due to hip fractures
How is osteoporosis diagnosed? Diagnostic Tests in Osteoporosis: 1) X-ray Spine: 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. X-ray is useful also in severe cases where it may show fracture or collapse of the spinal bones. Thus simple x-rays of bones are not very accurate in predicting whether someone is likely to have osteoporosis. 2) Bone Densitometry (Dexa Bone Scan): Bone mineral density testing (specifically a densitometry or DEXA scan (i.e. dual energy x-ray absorptiometry scan) measures how much bone patient have. This is the best test the diagnosing osteoporosis. This test measures bone density in the hip and the spine. The test is performed by passing low energy x-rays through a bone (e.g. spine, hip or wrist). The test takes only 5 to 15 minutes to perform, uses very little radiation exposure (less than one tenth to one hundredth the amount used on a standard chest x-ray), and is quite precise. This test tells about what is bone mineral strength of patient compared to normal population. The bone mineral density & bone mineral content is expressed as age matched control called Z score or compared to young adult expressed as T score. BMD of patient compared to Young adult population is called "T score". 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 at 35 year. This T-score measures the bone strength of patient compared to young adult of same sex at the age of 35 years i.e. between the patient and the young adult at which age bone strength of the person is at peak level. Normal bone density is defined as bone density expressed as T score with in – 1SD (standard deviation) from the normal peak bone density as in adult. A score above -1 is considered normal; a score between -1 and -2.5 is considered osteopenia; and a score below -2.5 is considered osteoporosis. For each -1 standard deviation in T score there is a 3 times increased risk of hip fracture and a 2.5 times risk of spine fracture. 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. DEXA scan results can indicate if someone is at increased risk of sustaining a fracture. BMD of patient compared to same age normal population called "Z score" measures the bone density of patient compared to general population of same age & sex. The control group consists of other people in the patient’s age group of the same size and gender. An unusually high or low score may indicate that patient may be suffering with some secondary cause of osteoporosis thus additional tests need to be performed to find out the cause Who should have bone density testing? All postmenopausal
women below age 65 who have risk factors for osteoporosis. Abnormal spine x-rays suggesting osteoporosis Long-term steroid use Hyperparathyroidism (over-active parathyroid gland) 3) Quantitative computed tomography (QCT) is also very good test to evaluate bone density very accurately.
Once osteoporosis diagnosis is made we must try to find out whether osteoporosis is due to primary cause or is secondary to another disease. Therefore, a thorough history and physical examination, as well as the appropriate diagnostic tests, need to be obtained. It is important to distinguish primary from secondary because the treatments are often different.
Detailed History: First we take detail history about diet,
past illness & other relevant history to reach on probable cause for
osteoporosis, Dietary intake (in present & past)
INVESTIGATIONS TO FIND OUT CAUSE OF
OSTEOPOROSIS: 1. Complete hormone profile tests as sex hormone as total testosterone in male & estradiol in female , thyroid tests (Free T4, Free T3, TSH), prolactin, FSH, LH, & other hormone tests 2 Calcitropic Hormone & Factor tests: a) Parathyroid hormone (intact) b) 25 hydroxy vitamin D c) 1,25 Hydroxy Vitamin –d d) osteocalcin e) Urinary calcium 3. Bio-chemical test: (Hemoglobin, ESR, GBP, Alkaline Phosphatase, Calcium, Ionized Calcium, Phosphorus, Urea, Creatinine, Urine Protein, M/E ,Fasting urinary ph , Serum bicarbonate, Serum Potassium ,Serum protein, SGPT Stool 4. Tests to diagnose other systemic diseases. 5.
Other tests which may be required to find out the cause of the any
of the above hormone disorders are as follows: Treatment & Prevention of osteoporosis:
Now there are lot many newer drugs are available for
osteoporosis as treatment of cause, calcium, Vitamin D, female
hormone, raloxifene, Tibolon & Biphosphonates & synthetic PTH given
with good results. A.
Medications that stop bone loss and
increase bone strength, such as alendronate, risedronate, raloxifene,
ibandronate, calcitonin ; 1. Bisphosphonates: Bisphosphonates are a type of drug used for both the prevention and treatment of osteoporosis. Several bisphosphonates are approved for the treatment of osteoporosis. Most are taken by mouth, usually once a week or once a month. In severe cases bisphosphonates can be given through a vein (intravenously). This class of medications includes Alendronate, Ibandronate and Risedronate is used to prevent and treat osteoporosis in both women and men. Bisphosphonates slows the rate of bone destruction by osteocalsts thus prevents the development of osteoporosis. Thus it leads to gradual strengthening of bone denisity & mineral content leading to gradual normalization of bone denisity. It also reduces the risk of bone fracture in osteoporotic patients. They are mostly taken orally. These drug shifts bone balance toward bone formation by inhibiting bone resorption i.e. bone destruction and has been shown to increase bone mass. These drugs have ability to prevent fractures. Alendronate is taken daily or weekly. Ibandronate is taken once per month. Risendronate ( actonel or risofos) is given once a week. 2. CALCITONIN : Calcitonin is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray or injection. The main side effects are nasal irritation from the spray form and nausea from the injectable form.While calcitonin slows bone loss and reduces the risk of fractures, it appears to be less effective than bisphosphonates. 3. PARATHYROID HORMONE( Forteo) : Teriparatide (Forteo) is approved in the United States for the treatment of postmenopausal women who have severe osteoporosis and are considered at high risk for fractures. The medicine is given through daily shots underneath the skin. The course of forteo is very effective & bone strength normalizes in most patients.
4. RALOXIFENE : Raloxifene is used for
the prevention and treatment of osteoporosis. Raloxifene is similar
to the breast cancer drug tamoxifen. Raloxifene can reduce the risk
of spinal fractures by almost 50%. However, it does not appear to
prevent other fractures, including those in the hip. It may have
protective effects against heart disease and breast cancer, though
more studies are needed. 5. HORMONE REPLACEMENT THERAPY: for women female hormone estrogen replacement is given & in men male hormone testosterone replacement is given. a) In Women: Estrogens are still used to prevent osteoporosis but are not approved to treat a woman who has already been diagnosed with the condition. · A woman's age · The age menopause started · The dose of hormone therapy being considered · Prior hormone replacement therapy taken in the past · Quality of life issues b) In Men: Testosterone therapy is given
6. SURGERIES : There are no surgeries
for treating osteoporosis itself. However, a procedure called
vertebroplasty can be used to treat any small fractures in your
spinal column due to osteoporosis. It can also help prevent weak
vertebra from becoming fractured by strengthening the bones in your
spinal column. 7. EXERCISE : Regular exercise can reduce the likelihood of bone fractures associated with osteoporosis. Some of the recommended exercises include- · Weight-bearing exercises -- walking, jogging, playing tennis, dancing · Resistance exercises -- free weights, weight machines, stretch bands · Balance exercises -- tai chi, yoga · Riding stationary bicycles · Using rowing machines · Walking · Jogging Avoid any exercise that presents a risk of falling. 8. DIET : Get at least 1,200 milligrams per day of calcium, and 800 - 1,000 international units of vitamin D3. Vitamin D helps your body absorb calcium.Your doctor may recommend a supplement to give you the calcium and vitamin D you need. Follow a diet that provides the proper amount of calcium, vitamin D, and protein. While this will not completely stop bone loss, it will guarantee that a supply of the materials the body uses to form and maintain bones is available. High-calcium foods include: · Cheese · Ice cream · Leafy green vegetables, such as spinach and collard greens · Low-fat milk · Salmon · Sardines (with the bones) · Tofu · Yogurt 9. STOP UNHEALTHY HABITS : Quit smoking, if you smoke. Also limit alcohol intake. Too much alcohol can damage your bones, as well as put you at risk for falling and breaking a bone. Avoid drinking excess alcohol, Don't smoke 10. PREVENT FALLS : It is critical to prevent falls. Avoid sedating medications and remove household hazards to reduce the risk of fractures. Make sure your vision is good. Other ways to prevent falling include: · Avoiding walking alone on icy days · Using bars in the bathtub, when needed Wearing well-fitting shoes
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