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Osteoporosis: Diagnosis and Conservative Management

Osteoporosis: Diagnosis and Conservative Management

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Published by rapannika
Narrative review on the diagnosis and conservative physical therapy management of patients with osteoporosis
Narrative review on the diagnosis and conservative physical therapy management of patients with osteoporosis

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Published by: rapannika on May 07, 2009
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02/01/2013

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 Address all correspondence and request for reprints to:Peter A. HuijbregtsOlympic Physiotherapy and Hand Therapy#245-3066 Shelbourne Street Victoria, BC V8R 6T9 Canadahuijbregts_peter@hotmail.com
Osteoporosis: Diagnosis and Conservative Treatment
 Abstract:
Osteoporosis is diagnosed by identification of risk factors, diagnostic imaging modali-ties, and urinary or serum levels of certain bone biomarkers. Treatment goals for patients at riskfor or diagnosed with low bone mineral density are achieving and maintaining peak bone massand attenuating or reversing pathologic, age-related, and postmenopausal bone loss. To achievethese goals, medical treatment may consist of nutritional and pharmacological interventions; physi-cal therapy treatment consists of exercise. Current research allows for tentative conclusions withregards to optimal exercise parameters.
 Key Words:
Osteoporosis, Diagnosis, Treatment, Exercise
 Peter A. Huijbregts, DPT, OCS, FAAOMPT 
I
n the first article of this two-part series on osteoporo-sis, I discussed the epidemiology of osteoporosis, thehistology of bone, the influences on bone remodeling,and a classification of osteoporosis into primary and sec-ondary forms. This second article uses that informationas a basis for discussion of diagnosis and management of patients at risk for or diagnosed with decreased bone mineraldensity (BMD). The goal of this article is to enable thephysical therapist to effectively screen patients for lowBMD and to develop appropriate exercise interventionsfor patients at risk for or diagnosed with low BMD. Thisarticle is also meant to increase the therapist’s knowl-edge of diagnostic modalities and interventions outsideof the scope of physical therapy practice in order to fa-cilitate and improve on patient education by the thera-pist. Conservative and surgical management of osteoporosis-related fractures is outside the scope of this article.
Diagnosis
The diagnosis of osteoporosis is often first establishedby documenting a typical osteoporotic fracture
1
. Identify-ing the patient prior to such a fracture is much prefer-able. Identification of risk factors associated with osteoporosis,the use of appropriate diagnostic imaging modalities, andmeasuring the serum and urinary levels of certain bonebiomarkers may allow for earlier diagnosis.
Risk Factors
As stated in the first article, the physical therapistmay be confronted with a patient with undiagnosed lowBMD. Forces applied normally within a therapeutic ses-sion may exceed the lowered fracture threshold and causeharm to the patient. Identifying the patient at risk fordecreased BMD may help the therapist make safer choices when selecting interventions used and forces applied duringthese therapeutic sessions. The identification of risk factors
Osteoporosis: Diagnosis and Conservative Treatment / 143
The Journal of Manual & Manipulative Therapy Vol. 9 No. 3 (2001), 143 - 153
 
associated with osteoporosis (Table 1) is the only diag-nostic tool available that is within the scope of practiceof the physical therapist.A structured history may reveal the dietary deficien-cies, endocrine disorders, gastrointestinal diseases, bonemarrow diseases, connective tissue diseases, medicationuse, and miscellaneous causes of secondary osteoporosisas discussed in the first article (Table 2), including theinfluence of caffeine, tobacco, and alcohol, and the ef-fects of diet on calcium absorption and excretion.Female gender is another risk factor: peak bone mass(PBM) is generally higher in men
2
. Bone mass also cor-relates positively with skin pigmentation
2
. Bone mass isequal in blacks and whites until adolescence, but there-after it increases to a greater level in blacks
3
. Darker-skinned races also have slower bone turnover, higherintestinal calcium absorption, and higher blood calciumlevels
4,5
. Bottomley
4
hypothesized that these differencesmay be the result of increased vitamin D production dueto less refraction of sunlight. The combination of genderand race puts black men at the lowest risk and white womenat the greatest risk for developing osteoporosis
2
. Asian women are in the same risk category as white women;Hispanic women are less at risk than white women butare not as protected as black women
5
.Body build is related to bone fragility: thin womenhave less cortical bone and are, therefore, at greater riskfor fractures
2
. Obesity may protect women from osteoporosisin multiple ways. Increased body weight will cause in-creased gravity-induced strain on the bone, which mayresult in increased PBM
2,6
. Adipose tissue is the site whereandrogens are converted into estrogen; it also acts as astorage unit for estrogen
5,6
. Low body fat may result ininsufficient estrogen production
3
, while obesity may increasethe amount of biologically available estrogen
2
.Women with a family history of osteoporosis run ahigher risk for developing osteoporotic fractures
2
. BMDseems at least partly genetically determined: monozygotic
Table 1.
Risk factors for osteoporosis
2-6
Age 50 and olderFemaleCaucasian or AsianPostmenopausalNorthern European ancestrySmall, bony body frameLow body fatFamily history of osteoporosisFailure to gain weight normally in pubertyPregnancy at an early ageLong periods of inactivityMedical history positive for secondary causes ofosteoporosis as outlined in Table 2
Table 2.
Secondary causes of osteoporosis
1-5,11,14
Dietary deficiencies
Insufficient intake calcium and/or vitamin DExcessive consumption of phosphates,oxalates, alkalis, fatty acids, dietary fibers,proteins, refined sugar, caffeine, alcohol, andsodium
Endocrine diseases
Female hypogonadismHyperprolactinemiaHypothalamic amenorrheaAnorexia nervosaPremature and primary ovarian failureOophorectomyMale hypogonadismIdiopathic hypogonadotropic hypogonadismHyperprolactinemiaKlinefelter’s syndromePrimary gonadal failureDelayed pubertyCystic fibrosisHyperthyroidismHyperparathyroidismHypercortisolism (Cushing’s disease)Growth hormone deficienciesUntreated diabetes mellitus
Gastrointestinal diseases
Subtotal gastrectomyMalabsorption syndromesChronic obstructive jaundicePrimary biliary cirrhosis and other cirrhosesAlactasia
Bone marrow disorders
Multiple myelomaLymphomaLeukemiaHemolytic anemiasSystemic mastocytosisDisseminated carcinoma
Connective tissue diseases
Osteogenesis imperfectaEhlers-Danlos syndromeMarfan’s syndromeHomocystinuria
Medication
HeparinGlucocorticoidsThyroxineAnticonvulsantsGnRH agonistsCyclosporineChemotherapy
Miscellaneous causes
ImmobilizationRheumatoid arthritisSmoking
144 / The Journal of Manual & Manipulative Therapy, 2001
 
twins have been shown to have a significantly greatersimilarity in bone density of the radius than do dizygotictwins
6
. A failure to gain weight normally during pubertypredisposes the individual to decreased PBM and osteoporosisin later life
4
. Pregnancy at an early age, when the skel-etons of both the mother and the fetus are maturingsimultaneously, may also result in lower BMD and in-creased risk for perimenopausal bone loss
5
.
Diagnostic Imaging
Ordering diagnostic imaging modalities is usuallyoutside the scope of practice of the physical therapist.Knowledge of the modalities available may, however, facilitatesuggestions to primary care providers, especially whenmultiple risk factors have been identified during a struc-tured history taking. It may also improve patient educa-tion regarding the diagnostic imaging modalities used.Correct interpretation of BMD measurements can guidephysical therapy treatment decisions
7
.Mass screening for osteoporosis is not warranted
8
.However, Seeger
8
noted that bone densitometry may beindicated for the following select patient groups:Perimenopausal women with several identifiedrisk factors Young premenopausal women with prolongedamenorrhea (of more than six month’s duration)Patients with diseases or on medications, thatmay adversely affect BMDPremenopausal women with a high number of risk factors, for whom a low BMD value isexpected to assist in positive lifestyle changes,thus reducing the risk of fracture in later lifeMultiple imaging methods are available to determinebone density. Nuclear scanning techniques were amongthe earliest imaging techniques used for bone densitom-etry.
 Single-photon absorptiometry
(SPA) uses iodine-125 as a gamma ray source
8
and operates on the prin-ciple that density of cortical bone is inversely propor-tional to the quantity of photons passing through. Theradio-isotope emits a single-energy beam of photons thatpasses through the bony structures of the forearm, whilea sodium-iodide scintillation counter is moved across theopposite side of the forearm to detect photons transmit-ted through the bone
3
. SPA is limited to use in appen-dicular areas with minimal soft tissue, such as the ra-dius and calcaneus. A water bath may be used to correctfor overlying soft tissues
8
.
 Dual-photon absorptiometry
(DPA) uses an isotope source that emits two discrete energyphotons. This allows for correction for overlying soft tissues;a water bath as with SPA is not necessary. DPA can beused to determine BMD in the spine and proximal fe-mur
8
. Scanning time with SPA and DPA are long and nuclearscanning has been largely replaced by other methods
8
.Plain radiography has been used to determine thepresence of osteopenia. However, sensitivity is low: a bonemass decrease of at least 30% is needed before it can bedetected on plain radiographs
2,3,9
. Overexposure andunderexposure alter apparent radiodensity; this decreasesthe reliability of densitometry by plain radiographs
9
. The
 Singh index
grades osteoporosis based on the finding thatthe five major trabecular groups of the proximal femurare resorbed in a predictable, sequential manner as thedisease progresses
9
; recent studies, however, have shownno correlation between the Singh index and the more widely used dual-energy X-ray absorptiometry (DEXA)measurements
8
.
 Radiographic absorptiometry
assessescompact and cancellous bone of the second to fourthmetacarpal bones measured against an aluminum refer-ence wedge
8
. X-ray absorptiometry uses an X-ray ratherthan the isotope-based projection system of SPA and DPA
3
.
 Single-energy X-ray absorptiometry
uses a water bathas does SPA to correct for overlying soft tissue; as withSPA, it can only be used at the radius and the calcaneus
8
. As discussed in the first part of this series, the WorldHealth Organization (WHO) has adopted
dual-energy X- ray absorptiometry
as its standard imaging techniquefor the classification of osteopenia and osteoporosis
10
.Compared to DPA, DEXA has superior precision, lowerradiation doses, shorter examination times, higher im-age resolution; and it is technically easier to do
3
. Tradi-tionally, evaluation of the spine with DEXA has beenperformed in an anteroposterior direction: prevertebral vascular calcifications and osteophytosis may result inan artificially high BMD
8
. Lateral DEXA scans avoid theseimaging pitfalls
1,8
. DEXA converts a three-dimensionalbody into a two-dimensional image: the measurement iscalculated by dividing total bone mineral content (BMC)by the projected area of a specific region. BMD measure-ments using DEXA, therefore, do not measure true volu-metric density, but rather integrated areal density of bothcompact and cancellous bone
7
. DEXA scans are widelyused. The therapist needs to be able to interpret thesescans as they can guide physical therapy intervention.There are three ways for reporting BMD from DEXAmeasurements: an unadjusted score in grams per centimer-squared, a T-score, or a Z-score. To get the T-score, thedeviation of the patient’s BMD score from the mean BMDof the young adult reference population, used by the WHOto define osteoporosis, is divided by the standard devia-tion of this same reference group. (See the discussion of the WHO classification in the first article.) The Z-scoreuses the same mathematical formula but compares thepatient to an age- and sex-matched reference population
7
. 
Quantitative computed tomography
(QCT) is the onlyimaging modality that generates a three-dimensionalmeasurement representing a true density measurementrather than reflecting a surface area as do the othermodalities
8
. QCT allows for specific visualization of themetabolically more active cancellous bone of the verte-bral bodies mainly affected in type-I osteoporosis; thismay make it more sensitive for diagnosing this type of 
Osteoporosis: Diagnosis and Conservative Treatment / 145

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