Osteoporosis is a prevalent disease that affects the skeleton. In osteoporosis, the bones start to lose their minerals and support beams. As a result, the skeleton is left brittle and susceptible to fractures.

In the U.S. alone, it is estimated that 10 million people already have osteoporosis and nearly 34 million more have low bone mass, putting them at a higher risk for osteoporosis. Of the 10 million osteoporosis patients, eight million are women and the rest are men. Majority of these patients are above the age of 65.

Bone fractures as a result of osteoporosis are very costly. About 50 per cent of all bone fractures have links to osteoporosis. In the U.S., over 300,000 hip fractures occur each year. In fact, patients with hip fractures have a 20 per cent chance of death within six months. Numerous patients with osteoporosis-related fractures spend a significant amount of time in the hospital and in rehabilitation. Most of the time, they also need to spend some time in a nursing home.

In this article, we will cover:

• The development of osteoporosis
• How osteoporosis is diagnosed
• Treatment for osteoporosis

Many people think that their bones are totally solid and unchanging. However, that is not the case. Our bones are always changing as a response to how one uses their body. As the muscles increase in strength, so do the bones underneath them. Thus, as the muscles weaken, the bones underneath weaken as well. In addition, changes in hormone levels or the immune system can also change the way the bones degenerate and rebuild themselves.

In children, the bones are always growing and increasing in density. A person reaches their peak bone mass around the age of 25. Adults can maintain this peak bone mass by staying active and consuming enough calories, vitamin D and calcium. However, maintaining this bone mass gets increasingly difficult as we age. This is because ageing makes it difficult to build bone mass. This is even tougher for women, whose loss of estrogen at menopause can cause the bone density to decrease very quickly.

Osteoblasts are bone cells that are in charge of building new bone. Stimulating the formation of osteoblasts can help the body build bone and increase bone density. Osteoclasts are bone cells that are involved in the degeneration of bone. Interfering with the action of the osteoclasts can slow down bone loss.

In high-turnover osteoporosis, the osteoclasts reabsorb bone cells rapidly. The osteoblasts are unable to produce bone cells quickly enough to keep up with the osteoclasts. As a result, there is a loss of bone mass, especially in the trabecular bone. The trabecular bone is the spongy bone inside the vertebral bones at the end of the long bones. High-turnover osteoporosis, also known as primary type one osteoporosis, is especially common in postmenopausal women. This is because of the abrupt decrease in the production of estrogen after menopause. Patients suffering from high-turnover osteoporosis are more susceptible to wrist and spine fractures.

In low-turnover osteoporosis, osteoclasts work at their normal pace. However, the osteoblasts do not form sufficient new bone. Also referred to as primary type two osteoporosis, this kind of osteoporosis is more common in ageing adults. Patients with low-turnover osteoporosis are more susceptible to hip fractures.

Secondary osteoporosis refers to bone loss that is caused by or linked to another medical condition. These other issues can interfere with cell function of osteoblasts and cause overactivity of osteoclasts. Such examples include medical conditions that cause inactivity, imbalance in hormones and certain bone diseases and cancers. Certain medications, particularly extended use of corticosteroids, have proven to cause secondary osteoporosis because of their effects on bone turnover.

Osteoporosis causes bones to weaken. Fractures can occur when these weak bones are injured or stressed. These fractures typically occur in the hip or vertebrae. In addition, they can also occur in the wrist, upper arm, knee and ankle.

Ageing is one of the most common risk factors for osteoporosis and osteoporotic fractures. Those who live longer lives have a higher risk of developing osteoporosis. In women, the loss of estrogen during menopause results in bone loss of up to 2 per cent every year. In fact, white women above the age of 50 have a 50 per cent chance of fracture. This number increases as one ages.

There are many factors that can lead to osteoporosis:

• Ageing
• Gender (females are at a higher risk)
• Race (Asian and Caucasians are more at risk)
• History of fractures (individual or family)
• Low body weight or a thin and slender build
• Recent weight loss
• Poor nutrition and general health
• Lack of exercise
• Use of tobacco and caffeine
• Alcohol abuse
• Prolonged use of certain medications such as thyroid medicine, anticonvulsants and corticosteroids

In addition to determining low bone mass, these factors are also important in determining how likely one is to suffer from a fracture. People with low bone mass but no extra risk factors usually do not develop fractures. Instead, those with small amounts of bone loss but multiple risk factors have a higher chance of developing fractures. 

Usually, osteoporotic fractures are painful. However, osteoporosis itself has no symptoms. This is why it is crucial to get tested if one has any of the above risk factors or is a woman past menopause. Women above the age of 65 should be tested regardless of whether they fit the other risk factors. In addition, people with other bone issues or who consume drugs that weaken the bones should also be tested. There is not much to fear, as the initial screening for osteoporosis is easy and painless.

Osteoporosis screenings are widely available. Most screenings use a machine that scans the heel bone. This is a quick and straightforward method to gauge one’s bone density. However, this is not entirely accurate. The test may show normal bone density in the heel even though the hip bones or spine may have a low bone density. If the foot scan shows a low bone mass, one should consult the doctor.

First, the doctor will discuss the patient’s medical history to help determine their risk factors for osteoporosis. Additional information regarding one’s diet and lifestyle can also help in the development of a plan to help the patient build or maintain bone density.

Next, more precise testing methods may be recommended. The most widely used method of measuring bone density is known as dual-energy X-ray absorptiometry (DEXA). A DEXA test uses special X-rays of the bones in the hip and spine to determine the bone mass in those areas. Afterwards, the bone mass result is compared to that of a healthy 30-year-old, known as a T score. If the result is within one standard deviation (SD) for bone density, then the bone is normal. (SD is a statistic used to measure variations in how a group is distributed.) If the result is between one and 2.5 SDs below ideal levels, the patient will be deemed osteopenic. To be osteopenic means that they have a mild form of osteoporosis. Lastly, if the result is more than 2.5 SDs below ideal levels, the patient will be diagnosed with osteoporosis.

However, one should take note that DEXA scans are not 100 per cent precise. Different technicians or equipment can produce differing results. If more accurate data is required, additional kinds of ultrasound tests or bone scans may be suggested.

A single DEXA scan is unable to determine whether the bone mass is stable, increasing or decreasing. Thus, the patient may need to take certain medications that create markers in the blood or urine to show what is happening in the bones. These tests can help the doctor determine if the patient has high-turnover or low-turnover osteoporosis. 

If the bone density test results show that a patient has weakened bones, other causes will have to be ruled out. In certain cases, issues with bone marrow or hormone levels can cause bone loss. Blood tests can help with determining if one has these conditions.

In other cases, the bone weakening might be caused by a condition known as osteomalacia. In osteomalacia, the bones are softened due to a lack of vitamin D. Humans get our vitamin D through food and sunlight. Nearly 10 per cent of people with hip fractures in the northern parts of the world have osteomalacia instead of osteoporosis. This is due to a lack of sunlight. To rule out osteomalacia, urine and blood tests can be done.

Lastly, in certain cases, there may still be considerable bone loss while on medication to prevent bone resorption. In such cases, the patient may be referred to a specialist. A referral is also recommended for patients who have repeated, unexplained fractures or recurring fractures during therapy. For each individual situation, the right specialist will be sent.

The aim of treatment for osteoporosis is to prevent fractures. This is particularly crucial if one has already had an osteoporotic fracture. To prevent fractures, the bone mass needs to be increased. For patients with high-turnover osteoporosis, rapid bone reabsorption also needs to be prevented.

To increase bone mass, there are several steps one should take:

• Exercise. The bones in our body are always adjusting to the demands placed on them. Even low-intensity exercises are able to help maintain better bone mass, stimulate osteoblasts and slow down reabsorption. Such exercises include climbing the stairs, brisk walking and safe forms of dance.
• Consume sufficient calories to maintain a healthy weight. Having too thin a frame puts one at a higher risk for osteoporotic fractures.
• Receive sufficient vitamin D and calcium. Vitamin D helps the body absorb calcium. According to research, it is said that calcium intake alone may reduce the instance of fractures by 10 per cent. An increasing number of people do not receive sufficient vitamin D and calcium. This is especially so as we age. Because it is hard to receive the recommended levels of vitamin D and calcium from food intake alone, supplements are likely to be needed. One should discuss what kinds of supplements to take. There are several types of calcium supplements such as calcium phosphate, calcium citrate, calcium carbonate and calcium from bone meal. Certain kinds of calcium need to be consumed with food, while others with specific types of food. Furthermore, consuming extra vitamin D and calcium increases the effectiveness of other osteoporosis treatments.
• Premenopausal women should avoid overtraining and some eating disorders, which can cause missed periods, known as amenorrhea.
• Alcohol should be consumed moderately.
• Smokers should quit smoking at once.

What kinds of medication are used to treat osteoporosis?

If the steps above are followed but the patient still shows a considerable amount of bone loss, medications may be prescribed to slow down the body’s reabsorption of bone.

There are several drugs available for the prevention and treatment of osteoporosis. To determine the right drug for each individual, the benefits and risks of each drug must be considered. These are then taken into consideration along with each patient’s specific characteristics and risk factors. All in all, the most effective drug is one that is taken consistently and correctly. Treatment for osteoporosis is most effective when medication is consumed in the most beneficial way.

For women past the menopause stage, hormone replacement therapy has proven to be very effective. Calcitonin and bisphosphonates can also slow down bone reabsorption.

In fact, studies have proven that bone mass in 80 per cent of women on estrogen replacement therapy actually increases up to two per cent every year. Estrogen is able to decrease the occurrence of fractures in the vertebrae by half and fractures in the hip by 25 per cent. On top of that, hormone replacement therapy has also proven to relieve certain symptoms of menopause, cause lower rates of coronary artery disease and possibly even prevent or postpone Alzheimer’s disease.

However, many women are concerned about hormone replacement therapy. This is because it has shown to possibly increase the risk of breast cancer. Hormone replacement therapy might not be suitable for women who have had a stroke or blood clots (thrombophlebitis) or with a family history of breast cancer. Other women are encouraged to at least consider this option as it has proven to be effective in treating osteoporosis. Osteoporotic fractures are estimated to be reduced by 50 to 75 per cent if estrogen is widely used.

It is important to continue hormone replacement therapy in order for it to be effective. If one stops taking estrogen, bone mass will be lost at an incredibly fast rate. Within seven years, the bone density may even be as low as someone who never took estrogen.

Calcitonin is often prescribed to patients with fractures. Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts and reduces their quantity and activity levels. In the past, calcitonin was given only via injection. Nowadays, it is available in a rectal suppository and nasal spray. Most of the time, nasal calcitonin is used for female patients with osteoporosis who are five years or more past menopause and not able to take other approved agents. It is not known why calcitonin seems to be able to relieve pain. Calcitonin from salmon is more effective as compared to calcitonin from humans.

Both the patient and doctor need to work together to monitor the effects of calcitonin. Because it is a relatively new drug, its benefits and long-term effects are still not entirely known. However, over 20 per cent of patients develop a resistance to calcitonin over time.

In addition, bisphosphonates have also proven to slow reabsorption by targeting the osteoclasts. There are a variety of biphosphonates approved by the FDA for the treatment of osteoporosis. Some of these include Ibandronate (Boniva), Risedronate (Actonel) and Alendronate (Fosamax).

Certain biphosphonates have to be taken orally in pill form once a day. Others are taken once a week or once a month. Zoledronate is a new injectable bisphosphonate that can be given once a year. Boniva, on the other hand, can be injected once every three months, but it is also available in pill form. For postmenopausal osteoporosis, the injectable form of Boniva is usually given.

Bisphosphonates have proven to prevent fractures and increase bone mass. Its long term effects are unknown. However, stopping use of the drug does not seem to cause rapid bone loss as when the use of estrogen is stopped. Because these medications may produce certain side effects, it is important to work closely with one’s doctor while taking them.

Several drugs that may be used to treat osteoporosis are currently being studied by the FDA. Some of these drugs, like sodium fluoride, are effective in treating low-turnover osteoporosis and may be available in the near future. Such drugs are able to target the osteoblasts in ways that make them produce more bone. In addition, there are other FDA-approved drugs that are now available for the treatment of osteoporosis. One such example is Raloxifene (Evista), an anti-estrogen. Also known as selective estrogen-receptor modifiers (SERMs), they can prevent fractures and improve bone density. They are similar to estrogen, except they do not increase the chances of hormone-related cancer, which is their main benefit.

Most commonly, Raloxifene is prescribed to postmenopausal females below the age of 65. They suffer from cardiovascular disease or be at risk for blood clots. On the other hand, men may be prescribed the only anabolic agent (Teriparatide/Forteo) approved for the management of osteoporosis. Typically, anabolic refers to hormones that build up muscle or bone mass. Forteo is a type of parathyroid hormone given to patients with a high risk of fracture. Most of the time, it is followed by an agent with antiresorptive effects like a bisphosphonate.

To sum up, changes in lifestyle, hormone replacement therapy, exercise prescription and recent advances in drug therapy are able to help one take control of their osteoporosis. Together with a doctor, one should be able to find methods to prevent the crippling fractures of osteoporosis.

What kinds of physical therapy is used to treat osteoporosis?

Physical therapy has proven to be beneficial for numerous patients. In physical therapy, patients are taught safe ways of moving, lifting and exercising. This also helps them to improve their posture and strengthen their muscles.

To determine the right treatment, the physical therapist will study the test results and information provided by the patient and doctor. The therapist will also examine the patient’s posture, strength, body height, flexibility, balance and risk of falling.

It is crucial to take accurate measurement and record of the patient’s body height during evaluation. This is so the therapist can get an idea of how osteoporosis is affecting the bones and posture. On top of that, the patient’s progress and success with treatments can be tracked by comparing recordings over a period of time.

Posture exercises can help patients regain lost body height due to osteoporosis. This training is especially helpful for patients who have stooped posture, known as kyphosis, in the upper part of the spine. In healthy spine posture, one’s head is balanced at the top of the spine instead of jutted forward.

The aim of posture exercises is to align the body from head to toe with weight going through the hips. In patients with advanced osteoporosis, the upper body is normally bent forward at the hips. This prevents the hip bones from bearing the right amount of weight and stress. As such, the bones become weakened and more susceptible to fracture.

The therapist will teach the patient ways to practice good posture. This is known as body mechanics — how the body is aligned when taking part in activities. Healthy posture is balanced with the body aligned from the head to the toes. This posture should be maintained when bending forward to pick things up. Instead of rounding out the shoulders and upper back, the back should be kept in healthy alignment as one bends forward at the hip joint. This keeps the back in a safe position and prevents the vertebrae from pinching forward. Rounding the spine forward when bending and lifting increases the risk of a spine fracture, especially for bones weakened due to osteoporosis. As the back rounds forward, the front section of the vertebrae gets pinched, which can lead to a fracture.

Together with the patient, the therapist will work to come up with a safe exercise program. Weight-bearing exercises help to strengthen existing bones and muscles around the joints. Such exercises include performing resistance training, doing safe forms of dance and walking outdoors or on a treadmill.

Some characteristics of safe exercises for osteoporosis include being consistent, using good body mechanics, refraining from bending or heaving twisting of the trunk and building up the amount of weight and number of repetitions gradually. Exercises that curl one’s trunk should be avoided. These include knee to chest exercises, sit-ups, toe touches and stationary bike riding. Rowing machines and abdominal crunch machines should also be avoided. Instead, patients should focus on exercises that promote upright posture of the spine like walking. Upper body exercises should also be done with the back supported in proper alignment.

Lastly, one’s physical therapist will also check for good balance. Poor balance can cause dangerous falls. When osteoporosis patients fall, it often results in a bone fracture, which is a potentially fatal situation. Exercises for balance improvement can be as simple as standing on one foot. As the patient’s balance improves, more challenging kinds of exercises may be taught.

Other beneficial exercises for patients with balance issues include tai chi, an exercise form originating in China. On top of improving balance, it has also shown to improve strength, posture and flexibility.

The therapist will consistently compare the patient’s strength, balance, posture and height to evaluate improvement. The therapist’s aim is to help the patient become proficient and safe with their exercises to improve flexibility, strength and stature. They will also provide tips and advice on how to prevent future issues.

Once a patient is well underway, there will be no more need for regular therapist visits. Although the therapist will continue to be a resource, patients are now responsible for carrying out their exercises as part of their ongoing home program.