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Osteoporosis By Jody Vulk PA-C Northwest Iowa Bone, Joint & Sports Surgeons.

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Presentation on theme: "Osteoporosis By Jody Vulk PA-C Northwest Iowa Bone, Joint & Sports Surgeons."— Presentation transcript:

1 Osteoporosis By Jody Vulk PA-C Northwest Iowa Bone, Joint & Sports Surgeons

2 Osteoporosis “Porous bone“ Bones lose protein & mineral content

3 Clinical Definitions of OP Vertebral height loss of > 25% of the vertebral body 2 compression fractures 2 or more fragility fractures

4  A fracture from forces that would not ordinarily cause fracture in a healthy young adult.  Quantified as forces equivalent to a fall from a standing height or less. FRAGILITY FRACTURES

5 Types of Fragility Fractures  Compression Fractures of the Vertebra  Proximal Humerus  Distal Radius Fractures  Hip Fractures

6 True or False #1 Spine #2 Wrist #3 Hip Most Common Fragility Fractures are:

7 True Spine 27% Wrist 19% Hip 14%

8 Bone Cells

9 Osteoclasts ■ Remove or retire old bone. ■ Active throughout lifetime. Osteoblasts ■ Create new bone ■ Best before age 35 & before menopause

10 Osteo c lasts Remove Old Bone ( Classic ) Osteo b lasts Create new bone (having a Blast! )

11 In Osteoporosis More of these working…than these.

12 Osteoclasts ■ Remove or retire old bone. ■ Active throughout lifetime. Osteoblasts ■ Create new bone ■ Best before age 35 & before menopause

13 Dual Energy X-ray Absorptiometry

14 BMD Levels Normal = 0 to T-Score Osteopenia = - 1 to -2.4 T- Score Osteoporosis = -2.5 T-Score

15 Who needs a BMD?  A woman nearing menopause (for baseline)  Men over the age of 70  Women 65 or older (& have never had one)  Those with risk factors for osteoporosis

16 How often to Test  Normal BMD=15 years  Osteopenia=5 years  Severe Osteopenia=1 year  85 or older=3 years

17 Bone Minerals

18 True or False To avoid Osteoporosis-- just is drink more milk.

19 False Calcium + Vitamin D + Magnesium+ Phosphorus + Alkaline Phosphatase = Good Quality Bones

20 Foods for Healthy Bones

21 Calculate Need mg Daily

22 Calcium supplements Calcium Citrate  Take with or without food  21% Calcium  More frequently causes gas, bloating, constipation Calcium Carbonate  Requires stomach acid, take with food  40% Calcium  Fewer side effects  Inexpensive

23 Zappers Calcium Zappers

24 Osteoporosis & Vitamin D Deficiency  1 Billion worldwide  1/3 of OP patients also Vitamin D deficient  Vitamin D deficiency is not age dependent.

25 Vitamin D is created through the skin by exposure to sunlight

26 Vitamin D and Sunlight You must live near the equator to rely on its benefits.

27 True or False Caucasians are more prone to Vitamin D deficiencies than those with darker skin.

28 False Darker skin does not absorb Vitamin D as well.

29 Vitamin D Rich foods Fatty fish *Cod Liver oil(1360 IU) Swordfish(566 IU) Salmon(sockeye)(447 IU) Tuna(154 IU) *avoid Cod liver oil Fortified foods: Milk (115 IU) Orange juice (137 IU) Egg yolks (41 IU).

30 Vitamin D Supplements Ergocalciferol (Vitamin D2)  Fungal derivative  Vegan supplement Cholecalciferol (Vitamin D3)  Synthesized in the skin  Wool oil  Preferred supplement

31 New Guidelines AgeDosage Adults < 50*400 to 800 IU daily Adults > 50*800 to 1,000 IU daily Normal Vitamin D level, do not exceed 4,000IU daily. *Do not commit these to long term memory, follow-up research pending.

32 Vitamin D Deficiency Risk Factors

33 Risk Factors of Vitamin D deficiency  Northern Latitudes  <15 minutes of sun  African American, or dark skinned  Elderly  Obesity

34 Vitamin D  Vitamin D is fat soluble, stored in fat  Testing is on blood  Loose weight, boost Vitamin D

35 Who is at risk?

36 True or False Men do not need to be tested for Osteoporosis.

37 False  2 million men have OP  Men are more likely to die in the first year after hip fracture.  Men who fracture are less likely to be tested.

38 Early Signs of Osteoporosis

39 Joan Surber  Age 68  Pelvic Fracture 1/28/2012  T-Score of -2.5 in her Lumbar Spine, in the Right hip and a -2.2 in the Left hip.  Vitamin D=12ng/mL

40 Severe Osteoporosis T-score –2.5 or less & a fragility fracture has occurred.

41 Leg braces as a child Menopause at age 34 Calcaneus Fracture at age year history of GERD with medication use

42 Risks factors & Prevention Don’t have it in your genes Hormone replacement (at the guidance of your PCP) Not recommending to avoid this one. Avoid long-term use of bone depleting medications Heredity/Ethnicity Hormonal Changes (Estrogen & Testosterone) Aging Pharmaceuticals

43 (Cont.) Risk Factors & Prevention Low BMI History of Fracture EAT! -a diet rich in colors and eat real foods! Bubble wrap

44 (Cont.) Risk Factors & Prevention Malabsorption Poor Diet Smoking Alcohol in excess Lack of Exercise Avoid Gastric Bypass, Celiac Sprue, Anorexia… Eat FOODs rich in Vitamins and minerals Don’t do that! Limit alcohol to no more than 2 beverages daily Weight bearing exercises such as walking, tia chi, & weight lifting/resistance exercises

45 Types of Osteoporosis Primary Relatively unknown cause other than advancing age and postmenopausal Secondary Has a known cause or reason for having developed (i.e.=oral corticosteroid use, other medications, diseases or conditions)

46 True or False Kyphosis of the spine is “normal for aging.”

47 False Decreasing height and humped back are not normal. They are indications of compression fractures.

48 NWIA Bone Approach

49 But orthopedists fix bones, Right?

50 Anyone over 50 with a fractured bone from ground height. We Evaluate


52 Own The Bone  Nutrition Counseling Calcium Vitamin D  Physical Activity Counseling Weight-bearing and muscle-strengthening exercise Fall prevention education  Lifestyle Counseling Smoking Cessation Limiting excessive alcohol intake  Pharmacology For the treatment of osteoporosis  Testing Dual Energy X-Ray Absorptiometry (DXA)  Communication Physician referral letter Follow-up note and educational material to patie

53 Step-wise Approach  Remove Bisphosphonates  Fracture immobilization/  fixation  Draw Labs/BMD  Vitamin D Correction  Heal the Fracture Initially After a Fracture

54 Step-wise Approach  Check Vitamin D  Increase bone mass if warranted  Fracture Risk Assessment  Educate patients on calcium, Vitamin D, exercises  Resume Bisphosphonates Through the OP Clinic

55 Medications

56 National Osteoporosis Foundation Recommends treatment: T-score is less than -2.0 Or Less than -1.5 with a risk factor (after the fracture has healed )

57 MedicationRoute and FrequencyUse AlendronateOral; Daily or WeeklyPrevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction CalcitoninIntranasal; DailyManagement IbandronateOral or IV; Daily/Monthly/q 3 mo. Prevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction RaloxifeneOral; DailyPrevent/Manage +Breast CA prevention RisedronateOral; Daily or WeeklyPrevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction TeriparatideInjection; DailyManagement DenosumabSubQ; q 6 mo.Management +Breast CA prevention Zoledronic acidInjection; yearlyManagement


59 Forteo: Anabolic Action

60 Exercises

61 True or False Swimming is a great exercise to prevent osteoporosis.

62 False Swimming does not prevent osteoporosis. Only weight bearing exercises prevent osteoporosis.

63 Balance Training & Good Posture

64 Resistance Training & Stretching

65 Weight Bearing Exercise

66 Review Calcium + Vitamin D + Magnesium+ Phosphorus + Alkaline Phosphatase = Good Quality Bones Vitamin D 3 Calcium Carbonate

67 Game Time


69 What are the top three types of compression fractures? #1

70 #1) Spine 27% #2) Wrist 19% #3)Hip 14%

71 What are the top three definitions of clinical osteoporosis? #2

72 Clinical Definitions of OP #1) Vertebral height loss of > 25% of the vertebral body #2) 2 compression fractures #3) 2 or more fragility fractures

73 What are the top objective (laboratory/radiological) definitions of good bone health? (I have 6 answers) #3

74 Good Bone Health  BMD with T-score from  Vitamin D > 30ng/mL  Calcium (within local lab normal limits)  Magnesium (within local lab normal limits)  Alkaline Phosphatase (within local lab normal limits)  Phosphorus (within local lab normal limits)

75 List the top sources of Vitamin D. (7 were listed) #4

76 Vitamin D sources 1. Sunlight 2. Cod liver oil 3. Swordfish 4. Salmon 5. Tuna 6. Fortified Milk 7. Fortified Orange Juice (Eggs also pictured)

77 What are some great exercises for preventing bone loss? (I have listed 6) #5

78 Exercises to prevent bone loss  Walking  Yoga  Tai Chi  Weight or Strength/Resistance training  Balance training  Good Posture

79 What are the top risk factors for developing OP? ( I discussed 11) #6

80 OP Risk Factors 1. Hereditary/ Ethnic background 2. Hormonal changes 3. Age 4. Medications 5. Low BMI 6. Previous Fractures 7. Malabsorption 8. Poor diet 9. Smoking 10. Alcohol 11.Lack of exercise

81 References  Adi Cohen, MD, MHS Columbia University, May 18-21,2011 Osteoporosis in Premenopausal Women: diagnosis and Treatment Issues, ISO9 course, Las Vegas Nevada.  Bone Health. "Make Every Bite Bone-Friendly." Health monitor 2012: Web. 07 May  "Clinical Practice Comparison of Clinical Efficacy and Safety between Denosumab and Alendronate in Postmenopausal Women with Osteoporosis: a Metaanalysis.", n.d. Web. 20 Mar  Conde Nast Digital. "Foods Highest in Vitamin D." Conde Nast Digital, 01 Aug Web. 03 Aug  Dr. Norman. "High Blood Calcium (too Much Calcium in the Blood)." Norman Parathyroid Center, 23 Feb Web. 20 Mar  Ehrlich, Steven D. "University of Maryland Medical Center | Home." University of Maryland Medical Center. VeriMed Healthcare Network, 17 June Web. 08 May  Epocrates. "Epocrates Home | Epocrates." Epocrates Home | Epocrates. Epocrates, Web. 03 Feb  Google. "Google Images." Google Images. N.p., n.d. Web. 20 Apr  Gronholz, DO, M. J. "JAOA: Journal of the American Osteopathic Association." JAOA: Journal of the American Osteopathic Association. JAOA, 1 Oct Web. 03 Mar  "Higher Magnesium Intake Linked to Higher Bone Density Effect Seen in Older White, But Not Black, Adults." Health in Aging. The AGS Foundation for Health in Aging, n.d. Web. 03 Feb

82 References (Continued)  "International Osteoporosis Foundation | Bone Health." International Osteoporosis Foundation | Bone Health. International Osteoporosis Foundation, Jan Web. 03 Mar  Calcium rich foods  Livestrong. "What Foods Raise Alkaline Phosphatase Levels." N.p., n.d. Web. 20 Mar  Mason, Moya K. "Calcium." N.p., Web. 20 Mar  Mosner, RD,CDN, Michelle. "NYSOPEP." Community Education. Proc. of International Symposium of Osteoporosis, Las Vegas. N.p.: n.p., n.d. N. pag. Print.  NIH Consensus Development Panel. "Osteoporosis Prevention, Diagnosis, and Therapy." NIH Consensus Development Program. U.S. Department of Health and Human Services, 27 Mar Web. 22 Mar  NIH. "Dietary Supplement Fact Sheet: Magnesium." National Institute of Health, n.d. Web. 20 Mar  NIH. "Vitamin D Factsheet." N.p., n.d. Web. 22 Mar  NOF. "About Osteoporosis | National Osteoporosis Foundation." About Osteoporosis | National Osteoporosis Foundation. N.p., n.d. Web. 30 Apr  NOF. "Why Bone Health Is Important | National Osteoporosis Foundation." Why Bone Health Is Important | National Osteoporosis Foundation. N.p., n.d. Web. 30 Apr  Watts, Dr. Nelson,MD Bone Health and OP Center University of Cincinnati, May 18-21, 2011 International Symposium of Osteoporosis, Las Vegas, Nevada (IOF course)

83 Referral Sources Currently:  Post Fracture  In-house Osteoporosis/Osteopenia Patients Future: ?

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