Osteoporosis

Symptoms Of Osteoporosis

Osteoporosis is also called a "silent" disease" because it has no specific clinical signs and symptoms unless there is a fracture. Spine fractures can induce severe back pain, loss of height, or spine deformities such as a stooped or hunched posture, also known as kyphosis. Bones affected by osteoporosis can become so fragile that fractures occur spontaneously or for the following reasons:

• Minor falls generally do not cause a fracture in a healthy bone.
• Everyday stresses such as bending, lifting, or even coughing.

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Types Of Osteoporosis

Osteoporosis can be classified into the following categories:

1. Primary osteoporosis: It is the most common form of the disease and is often associated with age and sex hormone deficiency. This type includes:

• Postmenopausal osteoporosis (type I): This subtype is associated with a deficiency of estrogen (hormones responsible for normal sexual and reproductive development in women) seen in women after menopause.
  
• Senile osteoporosis (type II): Occurs in both men and women aged above 70 yrs due to the progressively negative balance between bone formation and resorption.

2. Secondary osteoporosis: It is characterized by a low bone mass due to alterations in bone, leading to fragility fractures in the presence of an underlying disease or medication.

Causes Of Osteoporosis

Normal bone turnover involves a balance between bone resorption and bone formation processes. In postmenopausal women, the rate of bone turnover increases dramatically and remains elevated after cessation of ovarian function, leading to continuous bone loss. 

Bones are strongest in early adulthood, and you slowly start losing bone from around the age of 35 years. This is a common phenomenon and happens to everyone. However, certain risk factors may increase the risk of the development of osteoporosis or can increase the likelihood that you will develop the disease.

Risk Factors For Osteoporosis

Osteoporosis is a multifactorial disease, where no single factor can completely account for its occurrence. The most common risk factors include:

Non-modifiable risk factors 

• Family history: Studies have shown that family history is a significant risk factor for fracture, along with low bone density.

• Race: Osteoporosis is a chronic health condition affecting primarily white women.

• Advanced age: Research has shown that age is a high-risk factor for osteoporosis, as Vitamin D insufficiency and reduced calcium absorption are common in the elderly. 

• Female sex: Studies suggest osteoporosis is commonly encountered in older women with no underlying risk factors. Women tend to have a younger onset of bone loss compared with men.

• Amenorrhea: It is the absence of menstruation. This happens to die to low estrogen levels, which can cause osteoporosis.

• Early menopause: Menopause in less than 45 years of age, surgical removal of both ovaries, and prolonged perimenopausal absence of periods can lead to osteoporosis.

• Hormone-related disorders: Diseases that can trigger osteoporosis due to overproduction or underproduction of certain hormones include:

  • Overactive thyroid gland

  • Reduced amounts of sex hormones (estrogen and testosterone)

  • Disorders of the pituitary gland

  • Overactivity of the parathyroid glands (hyperparathyroidism).

  • Primary and secondary hypogonadism (when sex glands produce little or no hormones) in men.

• Diabetes: It can increase bone cell destruction and decrease bone formation, leading to accelerated bone loss.
  
  

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• Malabsorption: This can be due to problems, as in Coeliac disease (an autoimmune disease in which the immune system attacks your tissues when you eat gluten) and Crohn's disease (an inflammatory bowel disease that causes swelling of your digestive tract).

• Chronic kidney disease: Studies suggest that chronic kidney disease (CKD) is associated with the development of osteoporosis and fragility fractures.

• Blood disorders: Studies show that hematological diseases like thalassemia (when the body doesn't make enough of a protein called hemoglobin) and pernicious anemia (a decreased production of red blood cells due to lack of vitamin B12) represent a frequent cause of secondary osteoporosis.

• Rheumatoid arthritis (RA): It is an inflammatory disease associated with osteoporosis due to active inflammation and glucocorticoids.

• Dementia: It is a group of symptoms affecting memory, thinking, and social abilities. Dementia can lead the patients to have decreased activity levels and lower sunlight exposure, predisposing them to osteoporosis.

• Depression: Research shows that depression is a risk factor for low bone mineral density (BMD) and fractures. This has been shown in middle-aged women and elderly subjects of both genders.

• Cancer: Bone metastases (spread of cancer) are a common consequence of cancer, leading to decreased bone density and pathologic fractures.

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• Long-term bed rest: Studies have concluded that bone loss is more evident in elderly patients advised with prolonged bed rest. 

• Spaceflight: Astronauts who travel in outer space tend to lose bone mass density due to microgravity, which can lead to osteoporosis.

Modifiable risk factors

• Smoking: Studies have shown a direct relationship between tobacco use and decreased bone density and hence, as a risk factor for osteoporosis and bone fracture.

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• Low BMI: Body mass index (BMI) estimates body fat based on height and weight. A low BMI is an important and modifiable risk factor for osteoporosis and osteoporotic fracture development.

• Inadequate physical activity: This is because a sedentary lifestyle encourages the loss of bone mass, leading to osteoporosis.

• Low dietary calcium intake: Osteoporosis is more likely to occur in people with low calcium intake, and a lifelong lack of calcium plays a role in the development of osteoporosis.

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• Vitamin D deficiency: Vitamin D plays a crucial role in the absorption of calcium and phosphorus from the food you eat, and a lack can lead to osteoporosis.

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• Alcoholism: Alcohol consumption compromises bone health and increases the risk of osteoporosis as excessive alcohol interferes with calcium balance in the body.

• Medications: Many drugs can affect bone metabolism. Medications that can cause bone loss include

  • Heparin

  • Warfarin

  • Cyclosporine

  • Glucocorticoids

  • Medroxyprogesterone acetate

  • Cancer drugs

  • Thyroid medications

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Women can get predisposed to a number of health conditions with advancing age.

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Diagnosis Of Osteoporosis

Osteoporosis may not show definite symptoms, but recurrent falls can indicate it, as osteoporosis may cause muscle weakness. The diagnosis consists of the following:

Screening and history 

Older adults at higher risk of osteoporosis must be screened periodically and evaluated for fracture risk. During regular check-ups, a patient's previous history of fractures due to falls, smoking, and alcohol intake details, menopausal status, and medication history must be taken and recorded.

Physical examination

The physical examination must include height, weight, and body mass index to determine any loss of height. BMI less than 21 kg/m² and loss of 5 cm or more are considered risk factors for osteoporosis. The presence of walking disorders, weakness, and postural instability increase the risk of fractures and falls. 

Imaging tests

1. Bone mineral density (BMD): This test gives a snapshot of bone health by estimating the amount of calcium and other minerals in bones. This is the gold standard for diagnosing osteoporosis, and it utilizes an x-ray, known as a DXA scan, especially in the hip and spine, to determine bone loss. 

T-Scores and WHO diagnostic criteria for osteoporosis include:

• Normal: 1.0 and higher

• Osteopenia (loss of BMD): 1.0 to −2.5

• Osteoporosis: −2.5 and lower

• Severe osteoporosis: −2.5 and lower with one or more fragility fractures

Note: FRAX (Fracture Risk Assessment Tool) considers risk factors and BMD measurements to predict the probability of major osteoporotic fractures.

2. QCT: Quantitative computed tomography (QCT) is a test to measure bone mineral density d using computed tomography (CT). It is generally used to measure BMD of the spine or peripheral sites.

Laboratory tests

To determine other causes of osteoporosis, blood tests may be needed. They include:

• Calcium tests

• Vitamin D tests

• Tests for specific hormones(as discussed in risk factors)

Biochemical markers of bone turnover

These have been used widely in clinical research and help determine the bone formation and resorption products released into the circulation. These include various bone-formation markers and bone-resorption markers.

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Specialists To Visit

Doctors that can help detect and treat osteoporosis include:

• Rheumatologist

• Endocrinologist

• Orthopedic surgeon

A rheumatologist is a specialist who treats patients with age-related bone diseases. An endocrinologist sees patients with hormone-related issues, and an orthopedic surgeon fixes fractures.

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Prevention Of Osteoporosis

Your genes may affect your height, weight, and bone density, but a healthy lifestyle can protect your bones. Here are a few tips to prevent osteoporosis:

Early screening is vital

Early screening can identify the risk factors for osteoporosis, which can help you make the right lifestyle changes to prevent it.

Bask in the sunlight

Insufficient exposure to sunlight may be associated with many disorders, and getting sufficient and healthy sunlight helps strengthen teeth and bones, which in turn helps in preventing osteoporosis.

Optimize calcium and Vitamin D intake

Calcium is essential for maintaining bone health. Vitamin D is vital for healthy bones and teeth as it aids in the absorption of calcium in the body. However, it can be hard to get enough from food alone. So, consider taking vitamin D and calcium supplements.

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Stop smoking and drink alcohol in moderation

Smoking and alcohol are associated with an increased risk of osteoporosis. So quitting smoking and limiting your alcohol intake can help prevent osteoporosis.

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No excuses for not exercising 

Exercises like walking, dancing, low-impact aerobics, elliptical training machines, and stair climbing work directly on the bones in your legs, hips, and lower spine and can slow mineral loss. 

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Treatment Of Osteoporosis

Treatment recommendations are often based on the risk of breaking a bone and slowing down the bone loss process. It consists of the following:

Non- pharmacological management

This includes making specific lifestyle changes like increasing calcium and vitamin D intake, weight-bearing exercise, smoking cessation, limiting alcohol/caffeine consumption, and preventing falls.

Pharmacological management

The goal of pharmacological therapy is to reduce the risk of fractures. It includes medications like:

1. Antiresorptive agents: These drugs slow down the resorption of the bone. They include:

• Bisphosphonate: These decrease bone resorption by limiting the activity of bone destruction cells.

Note: Oral bisphosphonates should be administered with a full glass of water in the morning on an empty stomach 30 minutes before a meal or other medications.

• Denosumab: This drug is used as first-line therapy for patients at high risk of fracture and for patients who are not able to use oral therapy as denosumab is available as an injectable formulation

2. Hormonal therapies: These use synthetic hormones to manage osteoporosis. They include:

• Estrogen agonists/antagonists: This class of drugs is also known as selective estrogen receptor modulators (SERMs). It includes:

  • Raloxifene

  • Conjugated estrogens/bazedoxifene

• Estrogen-progestin therapy: In osteoporotic management, estrogen therapy is FDA-approved only for the prevention of osteoporosis in high-risk postmenopausal women.

• Testosterone therapy: This therapy is recommended for those for whom antiosteoporotic treatment is contraindicated, whose testosterone levels are less than 200 mg/dL, or those at borderline high risk for fracture.

• Calcitonin: It is a synthetic polypeptide hormone with properties similar to natural calcitonin. It is FDA approved treatment for osteoporosis in women who have been postmenopausal for more than five years when alternative therapies are not feasible.

• Parathyroid hormone analogues: These are synthetic forms of parathyroid hormones used to treat osteoporosis. Drugs include;

  • Teriparatide 

  • Abaloparatide

3. Newer drugs: These include: 

• Romosozumab

• Odanacatib

• Lasofoxifene

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Home-care For Osteoporosis

The best home remedies to reduce the risk of osteoporosis and to strengthen the bones is to eat foods rich in calcium and Vitamin D. These include:

1. Milk: It is a rich source of calcium and vitamin D, the two essential nutrients for bone growth and development.

2. Apple cider vinegar: It is abundant in nutrients like calcium, potassium, and magnesium, which can help enhance your bone health.

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3. Cheese: Studies suggest that cheese, especially Parmesan is an excellent food for bone health and osteoporosis prevention.

4. Eggs: Research demonstrated that whole eggs could prevent osteoporosis and reduce the risk of fractures in the elderly.

5. Fish: Fatty varieties such as salmon, mackerel, tuna, and sardines are rich in Vitamin D and can help individuals with osteoporosis.

6. Citrus fruits: Fruits rich in Vitamin C, like oranges, can help your body produce what it needs for strong bones. 

7. Green leafy vegetables: Dark leafy greens like Chinese cabbage, kale, and turnip greens are rich sources of calcium.

8. Sesame (Til): It contains copper, calcium, manganese, magnesium, and selenium and is ideal for people with calcium deficiencies.

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9. Soy: Soy sprouts contain coumestrol (a potent phytoestrogen), which can decrease the risk of osteoporosis by increasing estrogen levels.

Complications Of Osteoporosis

If osteoporosis is detected early and treated, the outcomes are good. However, if the condition remains untreated, it can lead to chronic pain and fractures. Complications of osteoporosis include:

1. Recurrent falls: Studies show that people with osteoporosis have a higher risk of falls due to muscle weakness, spine kyphosis, or decreased postural control.

2. Pathological fractures: These are the most severe complication of osteoporosis, particularly in the hip or spinal column.

• Hip fractures often result from falls and can lead to disability and even increased mortality risk in the first following the injury. 
• Vertebral fractures: These can cause kyphosis (hunchback), chronic pain, respiratory issues, and a high risk of developing pneumonia.

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Alternative Therapies For Osteoporosis

The main aim of alternative therapies is to work with conventional treatment to provide relief. Always talk to your doctor before starting anything new. Alternative therapies that work best for osteoporosis include:

Massage therapy

Massages can alleviate symptoms of osteoporosis, like pain and swelling, by relaxing your muscles. According to a study, taking a massage, significantly Thai massage can help you to increase your bone formation.

Acupuncture

Acupuncture is a therapy used in traditional Chinese medicine that involves placing very thin needles at strategic points on the body. Studies show that acupuncture could be an effective therapy for treating osteoporosis as it promotes healing.

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Tai chi

Tai chi improves muscle strength and coordination and reduces muscle or joint pain and stiffness. This ancient Chinese practice uses a series of body postures that flow smoothly and gently from one to the next. However, there needs to be precise data available on the effectiveness of Tai chi for osteoporosis.

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Living With Osteoporosis

You can lead an active and fulfilling life even if you have osteoporosis. All you need to do is make specific lifestyle changes. Tips that can help you if you are living with osteoporosis include: 

Prevent falls

The major complication of osteoporosis is fracturing due to falls. Things to keep in mind to prevent falls include:

• Wear shoes with non-slip bottoms

• Make sure there is nothing slippery on the floor

• Always grab bars in the bathrooms and railings on stairs

• Do not keep throw rugs and loose wires and cords lying around

• Always keep the lighting bright so that you can see well

Use hip protectors

This is a different approach to the prevention of hip fractures. Hip protectors are rigid inserts used to prevent direct trauma to the hip. Hip protectors must be helpful in the bedridden elderly population.

Take extra care of broken bones

Fractures usually take 6 to 8 weeks to heal, and osteoporosis does not affect how long this takes. Recovery depends on the type of fracture; while some fractures heal efficiently, others may require more intervention. 

Note: You may need a physiotherapist's help to recover as much as possible.

Manage your pain

Pain is subjective and different for every individual. Ways to manage pain include:

• Take pain medications

• Try warm baths or hot packs and cold packs

• Opt for relaxation techniques and hypnosis.

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