Evidence Based Prevention of Osteoporosis and Fracture

1. Evidence Based Prevention of Osteoporosis and Fracture Dato’Sri Dr.N.Premchandran Hospital Tengku Ampuan Afzan Kuantan, Pahang

2. Out line • Definition of OP • Role/Mechanism of Hormones in homeostasis • Causes of OP • Description of Levels of evidence • Exercises • Calcium supplementation • Vit D Supplementation

3. Introduction • Osteoporosis is a systematic skeletal disease • Characterized by low bone mass and micro-architectural deterioration of bone tissue, resulting in bone fragility and susceptibility to fracture • Bone mineral density (BMD) T -2.5 standard deviation. NIH Concensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis and therapy. JAMA 2001;285:785-95.

5. Estrogen and Osteoporosis Source: T.Okman-Kilic. 2015

6. Primary Osteoporosis

7. Primary Osteoporosis

8. Bone homeostasis • Parathyroids – Parathyroid hormone • Thyroid - Calcitonin • Vit D – [7 Hydroxycholesterol > • Cholechalciferol > • 25 Hydroxy cholechalciferol > • 1,25 Dihydroxy cholechaciferol

9. Parathyroid and Calcitonin Calcium level regulation

10. PTH & Vitamin D [Increases calcium ] LOW CALCIUM 7-hydroxycholesterol Vitamin D3 [Cholecaciferol] Parathyroid H 1,25 dihydroxy vit D Ca absorption • Ca resorption • PO4 excretion Ca resorption

11. Calcitonin [Decreases Calcium in blood]

12. Mass per Unit Volume

14. DEXA – Dual Energy X ray Absorptiometry • A T-score of  -1.0 or above is normal • A T-score between -1.0 and -2.5 means osteopenia.

15. Intertrochanteric fractures

16. Colles Fracture fixation

17. Epidemiology world wide Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992 Nov;2(6):285-9

18. Prevalence of osteoporosis in Asia 2007 China – 16.1% Taiwan – 10.08% Thailand – 12.6% Hong Kong – 10 per 1000 population Malaysia – 24.1% Loh KY, Shong HK. Osteoporosis: Primary Prevention in the Community. Med J Malaysia. 2007;62(4):355-358.

19. Secondary causes of osteoporosis Loh KY, Shong HK. Osteoporosis: Primary Prevention in the Community. Med J Malaysia. 2007;62(4):355-358.

20. Risk Factors National Osteoporosis Foundation. Clinician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014.

21. Prevalence • Prevalence of osteoporosis in Asian population is higher than the western countries due to: 1. Lower body mass index 2. Shorter height Babbar RK, Handa AB, Lo CM et al. Bone health of immigrant Chinese women living in New York City. J Community Health.2006; 31: 7-23.

22. Treatment of Osteoporosis • Aim: to reduce future fracture, not just improve BMD. • Indentify the modifiable and non-modifiable risk factors. • Assessment to exclude secondary causes of osteoporosis and treat accordingly.

23. Prevention of osteoporosis and fracture • Non pharmacological – Exercise • Pharmacological – Supplements • Drugs

24. LEVELS OF EVIDENCE [1 toV11] & Quality guides [ A,B, C ]

25. Level 1 Evidence A systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results.

26. LEVELS OF EVIDENCE • Level 2 - Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT). • Level 3 - Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental).

27. Levels of evidence • L 4 - Evidence from well-designed case-control or cohort studies. • L 5 - Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).

28. Levels of evidence • L 6 Evidence from a single descriptive or qualitative study. • L 7 - Evidence from the opinion of authorities and/or reports of expert committees.

29. Quality Guides A, B, C • A High quality: • Consistent, generalizable results; • Sufficient sample size for the study design; adequate control; • Definitive conclusions; consistent recommendations based on comprehensive literature review • Includes thorough reference to scientific evidence

30. Quality Guides A, B, C • B Good quality: • Reasonably consistent results; • Sufficient sample size for the study design; some control, • Fairly definitive conclusions; • Reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence

31. Quality Guides A, B, C • C Low quality • Major flaws: • Little evidence with inconsistent results;

32. Level of evidence Non-pharmacological 2009 Scottish Intercollegiate Guidelines Network grading system Howe TE et. Cochrane Database Syst Rev 2011 Jul 6;7:CD000333 Tang BM et al. Lancet 2007;370:657e66. Bischoff-Ferrari HA et al. J Bone Min Res 2009;24:935e42. Jensen J et al. Ann Intern Med 2002;136:733e41

33. Exercise • Exercise has a two fold contribution to reducing fracture risk: • 1. Enhance bone strength by optimizing BMD and improve bone quality by promoting adaptive changes in bone geometry and architecture. • 2. Reduce the risk of falling through enhancement of muscle strength and postural stability. N.K Henderson et al. Endocrinology and Metabolism Clinics of North America. 1998

34. Type of exercise • 1. Aerobics • 2. Weight bearing • 3. Resistance exercises • 4. Postural training D Bonaiuti et al. Cochrane Database Syst Rev 2002

35. 1. Aerobic exercise • Walking • Jogging • Endurance exercise

36. Aerobic Exercises • 43 Osteopenic Postmenopausal Women • 48 -65 years • Efficacy of a 24-Week Aerobic Exercise • December 2000, Volume 67, Issue 6, pp 443–448| Calcified Tissue InternationalDecember 2000

37. Exercises Exercises • Selection criteria BMD < 1 SD of the mean of premenopausal women, • spine (L2–L4) • & • Right femoral neck

38. Aerobic Exercises • Exercise (Nos.22) – Treadmill walking • 70% of maximal oxygen consumption (VO2max) for 30 minutes • 10 minutes of stepping exercise using a 20-cm-high bench • 3 times a week for 24 weeks • Control group (Nos.21) – Nothing

39. Evidence Aerobic Exercises • BMD • Exercise group . • L2–L4 increased 2.0% (P > 0.05) • Femoral neck increased 6.8% (P < 0.05) • Control group • L2 – L4 decreased 2.3% (P < 0.05) and • Femoral neck 1.5% (P > 0.05)

40. Evidence Aerobic Exercises • Conclusion • aerobics combined with high-impact exercise at a moderate intensity was effective in offsetting the decline in BMD in osteopenic postmenopausal women. 

41. 2] Weight Bearing exercises •  1] Bones work harder against gravity, such as walking or climbing stairs resulting in new bone tissue to form, and this makes bones stronger. • 2] Bones become stronger when muscles push and tug against bones during physical activity. • Feb 8, 2011

42. Weight bearing exercise

43. Weight-bearing Exercise • Weight-bearing means your feet and legs support your body’s weight. • High Impact • Hiking • Dancing. • Stair climbing • Jogging/running. • Jumping Rope.

44. Weight-bearing Exercise • Low Impact • Walking • Stair step machine • Rowing machines • Water aerobics

45. Weight bearing for Elderly • Toe stand • Wide leg squat • Standing leg curl • Side hip raise • Knee extension • Overhead press

46. Weight bearing exercise

47. Weight bearing exercise • Yoga is a body-weight-bearing exercise. • Yoga improves flexibility, balance, bone density, endurance, muscle mass, agility and energy level.

48. Weight bearing exercises • A 12-month randomized controlled trial of effects on bone mineral density in healthy postmenopausal [6 years] women • Bone • Volume 16, Issue 4, April 1995, Pages 469-476

49. Weight bearing exercises • RCT 44 Post menopausal women • BMD at 0, 6 and 12 months of • Prox Femur + Spine [L2 - L3] • The test group was required to perform 50 “heel drops” daily at home (raising the body weight onto the toes and then letting it drop to the floor keeping the knees and hips extended)

50. Weight bearing exercises • Control group • Weekly exercise class • Low-impact activity, • Flexibility exercises at home daily.