AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to bone fracture.

Pathophysiology

Bone tissue undergoes constant remodeling. Under the physiologic conditions, bone formation and resorption are in a fair balance. After the third decade of life, bone resorption exceeds bone formation and leads to osteopenia and, in severe situations, osteoporosis. Women lose 30-40% of their cortical bone and 50% of their trabecular bone over their lifetime, as opposed to men who lose 15-20% of their cortical bone and 25-30% of trabecular bone.

Frequency

United States

According to the National Institutes of Health (NIH), more than 25 million people in the United States are affected by osteoporosis. Women make up 80% of the people affected by this disease.

International

Osteoporosis is by far the most common metabolic bone disease in the world.

Mortality/Morbidity

• Osteoporosis is the leading cause of fractures in the elderly. Women aged 50 years have a 40% lifetime fracture rate due to osteoporosis. Osteoporosis is associated with 80% of all the fractures in people aged 50 years or older.
• More than 250,000 hip fractures are attributed to osteoporosis each year. Approximately 50% of the patients who have had a hip fracture never recover fully, and data support an excess mortality rate of 20% within a year of the hip fracture.
• According to 1993 statistics, 1.3 million fractures occur annually at a direct cost of over $10 billion spent for hospitalization, rehabilitation, and long-term care.

Race

Caucasians are at higher risk for osteoporosis than people of other races.

Sex

Women are at a significantly higher risk for osteoporosis. In primary osteoporosis, the female-to-male ratio is 5:1.

Age

Bone loss begins in the fourth decade of life. Bone loss is slow in the fourth decade, followed by a rapid loss in the fifth and sixth decades.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

A complete medical history should be obtained, including the patient's age, medical problems, medications, family history of osteoporosis, information on menarche and menopause, smoking history, and any recent fractures.

• Social factors
• • People who smoke are at higher risk for osteoporosis.
  • A definite correlation has been observed between an increased incidence and a family history of osteoporosis.

• Sex
• Postmenopausal women are at high risk for osteoporosis. Women who have undergone hysterectomy and oophorectomy are at higher risk for osteoporosis. They are also at risk for developing the disease earlier in life.
• Men with hypogonadism secondary to any genetic or other conditions are at higher risk for osteoporosis.
• Medications
• Glucocorticoids, heparin, cyclosporine, high-dose methotrexate, and high-dose medroxyprogesterone acetate can increase bone resorption, contributing to osteoporosis.
• Certain studies found an association between excess ingestion of vitamin A and an increased incidence of fractures.
• Individuals taking systemic steroids for diseases such as chronic obstructive pulmonary disease (COPD), lupus, or rheumatoid arthritis are at increased risk for osteoporosis.
• Persons taking selected anticonvulsants for a long duration are at increased risk for osteoporosis.
• Evidence suggests an increased incidence of osteoporosis in people who are receiving thyroid supplements or heparin.
• Diseases: Patients with hyperthyroidism, hyperparathyroidism, inflammatory bowel disease, celiac disease, cystic fibrosis, malnutrition, or chronic liver disease are at increased risk for osteopenia and osteoporosis.
• Cancer: Evidence suggests that people who have undergone chemotherapy are at a higher risk for osteoporosis.
• Diabetes mellitus: Recent literature from European studies shows that individuals who are receiving long-term insulin therapy are at higher risk for osteoporosis, compared with the general population.
• Immobility in spinal cord injury and stroke
• Immobility increases the risk for osteoporosis.
• Spinal cord injury and stroke cause physical impairment and are common causes of immobility.

Physical

Physical examination should focus on any loss of height, kyphosis, and the patient's overall stature.

Causes

Risk factors for osteoporosis include the following:

• Caucasian race
• Age of 50 years or older
• Early menopause and late menarche
• Amenorrhea
• Post menopausal state
• Thin build or small stature
• Use of drugs
• • Anticonvulsants
  • Systemic steroids
  • Thyroid supplements
  • Heparin
  • Chemotherapy agents
  • Insulin
• Genetic factors, eg, family history of osteoporosis
• Environmental factors
• • Smoking
  • Immobilization

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Pathologic fractures secondary to bone metastases from cancer
Hyperthyroidism
Hyperparathyroidism
Multiple myeloma
Osteomalacia

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Thyroid stimulating hormone (TSH) and parathyroid hormone (PTH) tests may be used to evaluate for hyperthyroidism and hyperparathyroidism.
• Serum protein electrophoresis (SPEP) may be performed to rule out plasma cell dyscrasias.
• Alkaline phosphatase, calcium, phosphate levels may be obtained to rule out osteomalacia.
• Serum osteocalcin levels, if high, indicate a high turnover type of osteoporosis.
• According to the National Osteoporosis Foundation, evaluating the bone density on a periodic basis is the best way of monitoring bone density and future fracture risk.

Imaging Studies

• Plain radiography is recommended to assess the overall skeletal integrity.
• • Findings may include osteopenia and compression fractures.
  • Plain radiography is a poor diagnostic tool for the evaluation of osteoporosis because bone loss of 30-40% must occur before osteoporosis is detectable with this imaging modality.
  • CT scanning may be used for an evaluation of metastatic bone disease.
• Dual-energy x-ray absorptiometry (DEXA) is currently the criterion standard for the evaluation of bone density.
• • DEXA can measure bone density in both the axial skeleton and the vertebrae in less than 5 minutes.
  • DEXA is cost-effective (with an approximate cost is $130) and performed on an outpatient basis.
  • No special requirements (eg, dye injection) are needed to perform this test.
  • Radiation exposure is kept to a minimum.
  • Regarding the interpretation of bone densitometric findings, a T-score of more than 1 standard deviation (SD) but less than 2.5 SDs below the mean peak value confirms osteopenia and a level more than 2.5 SDs below the mean peak value is diagnostic of osteoporosis.
• Quantitative CT scanning is another method to measure spinal bone density. Quantitative CT scanning is seldom used now because it is more expensive, less reproducible, and requires a higher radiation dose than DEXA scanning.

Histologic Findings

Bone biopsy is rarely needed to rule out neoplasms and other metabolic bone diseases. Biopsy is sometimes used to quantitate bone loss, using quantitative histomorphometric techniques.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Goals of physical therapy focus on improving the patient's strength, flexibility, posture, and balance to prevent falls and maximize his or her physical function. Postural retraining is key in this population, and strengthening of the back extensors should be emphasized. The bone density of the spine is directly correlated with the strength of the back extensors; therefore, maintaining the muscular strength of the back extensors is essential.

Regular weight-bearing exercises are essential for the maintenance of bone mass. Activities such as walking, hiking, stair climbing, jogging, and resistive/weight training are helpful in maintaining or increasing bone mass. (Swimming does not involve weight bearing; therefore, it is not helpful in promoting bone formation.) The physical therapist must address balance training because fall prevention is also important to eliminate the complication of fracture. Improving one's balance can significantly lower the risk of falling. Balance training incorporates strengthening of various parts of the body (eg, trunk, legs), proprioception, and vestibular input.

Proper therapy for osteoporosis includes 3-5 sessions a week of weight-bearing exercises such as walking or jogging, with each session lasting 45-60 minutes. The patient should be instructed in a home exercise program that incorporates the necessary elements for improving his or her posture and overall physical fitness.

Occupational Therapy

Training for activities of daily living (ADLs) and for the proper use of adaptive equipment are essential to prevent future falls.

Medical Issues/Complications

Patients with osteoporosis are at a high risk for recurrent fractures of the hips, vertebrae, ribs, and wrists. Patients with multiple fractures have significant pain, which leads to a poor quality of life (QOL) and functional decline. They also are at risk for all the complications of immobility, including deep vein thrombosis (DVT) and pressure ulcers. Patients with osteoporosis develop spinal deformities and a dowager's hump, and they may lose 1-2 inches of height in their sixth and seventh decades of life. These patients also lose their self-esteem and are at increased risk for depression.

Consultations

The most important consultation for a patient with osteoporosis in both the diagnostic and therapeutic phases is a consultation with an endocrinologist. Endocrinologists are helpful in the diagnosis of osteoporosis; they can help in obtaining the proper laboratory tests and imaging studies to rule out causes of secondary osteoporosis. In patients with uncontrolled pain that does not respond to conventional therapies, an invasive pain specialist may be consulted for proper interventional procedures.

Other Treatment

• Vertebroplasty is performed by interventional radiologists, invasive physiatrists, and spine specialists who inject methyl methacrylate into the fractured vertebrae. This procedure is performed on an outpatient basis, and initial studies report good results.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medications used in the treatment of osteoporosis are classified into 2 primary categories. The first includes medications that help stimulate bone formation include vitamin D and bisphosphonates. The second includes medications that reduce bone resorption include estrogen, bisphosphonates, calcitonin, calcium, and vitamin D.

Drug Category: Hormone replacement

Hormones are used to increase serum estrogen levels, which in turn decrease the rate of bone resorption.

Drug Category: Calcitonin analogs

These inhibit osteoclastic bone resorption. Although no research data support the idea that use of intranasal calcitonin reduces the incidence of fractures, studies do show increase in bone density with the use of calcitonin.

Drug Category: Bisphosphonates

These agents progressively reduce bone loss and increase bone mass.

Drug Category: Selective estrogen receptor modulators

These are antiresorptive agents, like estrogen. However, because of their selective receptor modulating property, they provide the beneficial effects of estrogens without the adverse effects.

Drug Category: Nutritional supplements

These supplements are used to increase calcium levels.

Drug Category: Parathyroid hormone

Parathyroid hormone promotes new bone formation, leading to increased bone mineral density. Teriparatide is a biologic product containing a portion of human parathyroid hormone, which primarily regulates calcium and phosphate metabolism in bones. Teriparatide is approved for men or women at high risk of fracture due to primary or hypogonadal osteoporosis or postmenopausal osteoporosis, respectively.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Follow-up bone density measurement may be performed 6 months to 1 year after starting treatment.
• Orthotics are used to decrease the flexion forces to prevent the worsening of kyphosis and to reduce the pressure on the fracture site in the acute phase of disease.
• Common orthotics used include the following:
• • Thoracolumbar spinal orthosis (TLSO)
  • Cruciform anterior spinal hyperextension (CASH) brace
  • Jewett brace
• See the article on Spinal Orthotics for more detailed information on these devices.

Deterrence

• In terms of nutrition, calcium and vitamin D supplementation reduce the incidence of osteoporosis.
• Regular monitoring may be helpful.
• • Periodic bone densitometry helps in diagnosing osteoporosis in the early phase and in preventing fractures.
  • According to the National Osteoporosis Foundation, evaluating the bone density on a periodic basis is the best way of monitoring bone density and future fracture risk.
• Bone density checks are recommended every 2 years in postmenopausal women.
• Consider bisphosphonates (alendronate or risedronate) and raloxifene as first-line treatments for prevention of osteoporosis, and consider bisphosphonates as first-line therapy for the treatment of osteoporosis.
• Estrogen-progestin therapy is no longer considered a first-line approach for the treatment of osteoporosis in postmenopausal women because of the increased risks of breast cancer, stroke, venous thromboembolism, and perhaps coronary disease.
• Regular weight-bearing exercises and back extensor strengthening help delay bone loss.

Complications

• Fractures are the most common and serious complication of osteoporosis.
• Fractures can cause further complications, including chronic pain, disability, hospitalization, depression, and physical deconditioning.

Prognosis

• The prognosis is good if bone loss is detected in the early phases and proper intervention is undertaken.
• Worsening of the patient's medical status can be prevented by providing appropriate pain management and orthotic devices if indicated.

Patient Education

• Education is important in the prevention of osteoporosis.
• Patients should be educated about the risk factors for osteoporosis with a special emphasis on family history and the effects of menopause. They also need to be educated about the benefits of calcium and vitamin D supplements.
• All postmenopausal women should be offered bone densitometry, and they should understand the benefits of monitoring the bone density.
• Society at large also should be educated about the benefits of exercise with regard to osteoporosis.
• For excellent patient education resources, visit eMedicine's Bone Health Center. Also, see eMedicine's patient education articles Osteoporosis and Understanding Osteoporosis Medications.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• When dealing with reduced bone density, always rule out the other possible causes of symptoms before treating the patient for osteoporosis.
• Metastatic bone disease should always be ruled out when one is treating multiple fractures.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Canalis E. New treatments in osteoporosis. Bone. Sep 2001;29(3):296.
• Consensus Development Conference. Diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med. Jun 1993;94(6):646-50. [Medline].
• Cook DJ, Guyatt GH, Adachi JD, et al. Quality of life issues in women with vertebral fractures due to osteoporosis. Arthritis Rheum. Jun 1993;36(6):750-6. [Medline].
• Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. Mar 23 1995;332(12):767-73. [Medline].
• Gosfield E 3rd, Bonner FJ Jr. Evaluating bone mineral density in osteoporosis. Am J Phys Med Rehabil. May-Jun 2000;79(3):283-91. [Medline].
• Hulley SB, Grady D. The WHI estrogen-alone trial--do things look any better?. JAMA. Apr 14 2004;291(14):1769-71.
• Kirshblum SC. Spinal and upper extremity orthotics. In: Gans BM, Delisa JA. Rehabilitation Medicine: Principles and Practice. Philadelphia: Lippincott Williams & Wilkins;1998: 635-50.
• National Institutes of Health. NIH Consensus conference. Optimal calcium intake. NIH Consensus Development Panel on Optimal Calcium Intake. JAMA. Dec 28 1994;272(24):1942-8. [Medline].
• National Osteoporosis Foundation. Guidelines for the prevention, diagnosis and treatment of osteoporosis: Cost-effective analysis and review of the evidence. National Osteoporosis Foundation; 1998.
• Riggs BL, Melton LJ 3rd. The prevention and treatment of osteoporosis. N Engl J Med. Aug 27 1992;327(9):620-7. [Medline].
• Sinaki M. Postmenopausal spinal osteoporosis: physical therapy and rehabilitation principles. Mayo Clin Proc. Nov 1982;57(11):699-703. [Medline].
• Sinaki M. Exercise and osteoporosis. Arch Phys Med Rehabil. Mar 1989;70(3):220-9. [Medline].
• Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-6. [Medline].
• Stillo JV. Low back orthoses. Phys Med Rehab Clin North Am. 1992;3:57-94.
• Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med. Apr 20 1989;320(16):1055-9. [Medline].
• World Health Organization Study Group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser. 1994;843:1-129. [Medline].

Article Last Updated: Dec 6, 2006