Bone Health Arthritis and Osteoporosis

1. Bone HealthArthritis and Osteoporosis Myra Siminovitch, BSc. PT, M.B.A.

2. Importance of Bone Health • Osteoporosis and Arthritis • Affect significant numbers of the adult population • With the aging of the population the numbers of individuals affected will continue to rise exponentially • Often result in pain, loss of mobility and independence • Can seriously limit activity and impact the quality of life • Osteoporosis is a preventable disease • Certain forms of arthritis can be better managed with life style changes

3. What is Arthritis? • Arthritis is derived from the Greek words • Arth meaning “JOINT” • Itis meaning “Inflammation or Infection” • Arthritis, therefore, means • Inflammation of the Joint • In many kinds of Arthritis….there is no inflammation • Arthritis refers to conditions that affect Joints and the surrounding tissues Did you Know That? • More than 4 million Canadians suffer from arthritis…...1 in 6 adults • Expect an increase of 1 million per decade • 60% of sufferers are under 65 years of age • One of the leading causes of disability • 20 thousand Canadians are on the waiting list for joint replacement • Arthritis costs Canada $4.4 billion/year

4. What is Osteoporosis? Osteoporosis is a metabolic bone disease characterized by low bone mass and micro-architectural deterioration of bone tissue leading to enhanced bone fragility leading to increased risk of fracture Osteoporosis results from not having enough bone tissue, low bone density, or low bone mass, as well as from having bone with a weakened structure

5. Osteoporosis Often called the “silent thief” because there are no symptoms associated with the deterioration of bone until a fracture occurs Did you Know That? • 1.4 Million Canadians Have Osteoporosis • There are 25,000 Hip Fractures a Year • 70% are Osteoporosis related • 20% result in death • 35% are sustained by men • 50% of survivors experience disability • More women die each year as a result of an Osteoporotic Fracture than from Breast and Ovarian Cancer combined

6. Who Gets osteoporosis? • 1 in 4 women over the age of 50 • 1 in 8 men over the age of 50 • Men & Osteoporosis • Under-diagnosed, under-reported and inadequately researched • More likely to develop secondary to lifestyle or another medical condition • long-term glucocorticoid treatment.. prednisone • low levels of male hormone..hypogonadism • low peak bone density • prolonged immobility & lack of weight bearing exercises • excessive alcohol consumption or smoking

7. The loss of bone density and structural weakness lead to bones that can break under the slightest strain • Hip • Spine • Wrist • Most common fracture sites: Hip Most Devastating >up to 20% of women and an even higher percentage of men will die as a result of complications following fracture Wrist Most Common type of fracture in women under 75 Vertebral Fractures Frequently Undiagnosedunless there is pain or an observed loss of height

8. Bone Remodeling Process • Bone is a living tissue and constantly being repaired • Osteoclasts, bone eroding cells invade the bone’s surface dissolving the mineral and causing small cavities in the bone • Osteoblasts, the bone forming cells, fill in the cavities with new bone until the bone surface is completely restored Normal Growth and Development of Bone • Most individuals achieve their peak bone mass by age 20 and maintain it until 35-40 • Then both men and women begin losing bone mass at a rate of ½ to 1% per year • Women lose bone at an accelerated rate during the first 10 years after menopause-2 to 5% per year • Men lose bone more slowly with a higher rate of loss after 65

9. Four Factors that contribute to Bone Health • Nutrition • Physical Activity • Genetics • Hormones

10. Risk Factors • Female • Age 50 or older • Prolonged hormonal imbalances • Past Menopause • Early or surgical menopause • Not enough calcium in your diet • Insufficient Vitamin D • Not enough physical activity • Low body weight (thin, “small boned”) • Caucasian or Asian ancestry • Smoking • Caffeine (consistently >3 cups of coffee, tea or cola / day) • Alcohol (consistently >2 drinks / day) • Family history of osteoporosis • Excess use of certain medications (prednisone, anticonvulsants, thyroid hormone) • Primary hyperparathyroidism (excessive functioning of the parathyroid glands) • History of hyperthyroidism • The more risk factors you have, the greater your risk of developing osteoporosis

11. Risk factors You Cannot Change Gender Age Genetics Ethnicity Risk Factors You Can Change Lifestyle Nutrition Smoking Physical Activity

12. How is Osteoporosis Diagnosed? • Bone Densitometry Test • Safe, painless and the most common test • Gives a snapshot of one’s bones • Detects low bone density • Very low dose x-ray is directed through the bones • Two sites measured • Hip • Spine

13. How is Osteoporosis Diagnosed? • Bone density test results are similar to interpreting an IQ score • Results are rated above, equal or below a statistically determined average • T Test • Bone mass is compared with that of an average young adult • Z Test • Bone mass is compared with that of individuals in similar age group • Score Ranges • Normal scores range between (+1) and (-1) with 0 being the score of an average young adult • Osteopenia scores range between (-1) and (-2.5) • The score is 1 to 2.5 standard deviations below average peak mass • Osteoporosis scores range from (-2.5) or less • The score is more than 2.5 standard deviations below average peak bone mass

14. Drug Therapies • Drugs currently used to treat osteoporosis fall into two methods of action • Slow down bone erosion (action on osteoclasts) • Promote bone building (action on osteoblasts) • Biphosphonates • Bind to the surfaces of the bones and slow down the bone-eroding cells (osteoclasts) • Fosamax, Actonel, Didronel/Didrocal • Hormones • Estrogen plays a major role in maintaining the balance between the osteoblasts (bone builders) and osteoclasts (bone excavators) by slowing bone erosion • SERMS (selective estrogen receptor modulator) • Affects the bones much the same way estrogen does without having the same effects on the uterus and breast • Raloxifene

15. How to Prevent Osteoporosis Choose a Healthy Lifestyle Ensure Good Nutrition • Eat foods high in Calcium • Dairy sources • Milk products, cheese and yogurt • Vegetables • Broccoli, collards, kale, bok choy • Fish • Salmon, sardines • Certain foods increase calcium loss Salt, caffeine, protein, phytates and oxalates Calcium Requirements Up to 9 700mg. 10-12 boys 900mg. 10-12 girls 1200-1400mg. 13-16 1200-1400mg. 17-18 1200mg. 19-49 1000mg. 50+ 1000-1500mg. • Calcium Supplements • If unable to get enough calcium from foods a supplement is required • Two best sources: • Calcium carbonate • Inexpensive • Highest percentage of elemental calcium/tablet • Easily absorbed • Calcium citrate • Less constipating • May be better absorbed

16. Vitamin D • Calcium is not efficiently absorbed in older adults without Vitamin D • Vitamin D Requirements • 800 IU for older adults >50 years of age • Sources of Vitamin D • Sunlight (15 minutes a day of summer sun exposure) • Milk fortified with vitamin D (100 IU per 250 ml. glass) • Salmon, sardines, herring, mackerel and fish oils contain small amounts • Multi- vitamins • Vitamin D Supplements

17. How to Prevent OsteoporosisThe Benefits of Being Physically Active • Healthier bones • Better coordination and balance • Improved muscle strength and flexibility • Increased endurance for activities of daily living • Improved posture

18. Bone Building Exercises • Two Types • Weight Bearing Exercise: exercises where the weight of the body is transmitted through the bones, working against gravity e.g. walking, jogging, stair climbing, dancing, racquet sports • Resistance Exercise: exercises that strengthen the muscles e.g. weight lifting • Free weights or machines • Tension and pressure transmitted to the bone through weight bearing and the action of muscles stimulates bone growth and repair • Frequency • Weight bearing exercise->2-3X/week • Resistance training->2-3X/week • Intensity • Resistance training..80% of maximal effort • Duration • Weight bearing exercise..30 minutes/day • Resistance training..3 sets of 8-10 reps/muscle Balance Exercises • Prevent Falls • Prevent fractures • Easy to retrain balance • standing with eyes closed • standing on 1 foot..eyes open ..eyes closed • jumping up & down on 1 foot • 5 minutes of balance training/day can significantly reduce risk of falls

19. Posture & Osteoporosis • Dramatic postural deformities • Forward head posture with chin poking forward • Significant rounding of upper back • Flat and even rounded lower back • Protruding Abdomen • Difficult respiration & digestion • Increased risk of falls • Body’s center of gravity displaced • Back & neck pain • Loss of function • Postural Exercises • Tailored to the individual • Decrease harmful stresses on the spine • Reduce the risk of spinal fractures & rounded shoulders • Strengthen the postural muscles • Back extensors..Scapular retractors..abdominal muscles • Stretch tight muscles • Pectoral stretch..tight chest muscles • Chin Tuck

20. Exercise Precautions For People with Osteoporosis • Exercises must be tailored to the individual and their health status • Excessive compressive stresses must not be put on weakened bones • Avoid high-impact exercises..jumping, jogging • Avoid activities where there is a high risk of falling • Avoid flexion & rotationof the trunk • Initially, exercise program should be supervisedby a competent health care practitioner

21. Most Common Forms ofArthritis • Rheumatoid Arthritis • Progressive, systemic, inflammatory disorder • Most destructive kind of arthritis • Often associated with deformities • Polymyositis • Inflammation in the muscle ->destruction of muscle fibers • Characterized by weakness, affects upper arms, thighs, neck • Polymalgia Rheumatica • Inflammatory condition which affects the joint lining…Synovium of the joint • Pain in many muscles • Infectious Arthritis • Bacterial infection of the joint, e.g. Staphylococcus/Gonococcus • Usually 1 joint involved • Gout • Crystals • Inflammation within the joint space • Disease of life style, affected by: • body weight, diet and alcohol • Spondyloarthropathies • Ankylosing Spondylitis Psoriatic Arthritis • “Attachment” Arthritis-> inflammation occurs where ligaments and tendons attach to the bone • Osteoarthritis/Osteoarthrosis

22. Osteoarthritis • Most Common form of arthritis • Affects 3 million Canadians • Progressive destruction of the articular cartilage • Formation of new bone at the margins of the joint (osteophytes) • Chief complaints->pain, stiffness, deformity and loss of function • Referred to as the “wear and tear” of joints • Most commonly seen in the hips, knees and the spine • Cartilage wears off the end of the bone and then it hurts with every step Obesity: • Overweight people are at greater risk for developing OA than people of average-weight • Weight-reduction is likely to cause reduction in OA symptoms. • Weight-bearing joints have strong correlation with obesity. • Surprisingly, OA of hand also has positive association with obesity, making it a systemic risk factor for OA.

23. Management of Osteoarthritis • To alleviate pain • To prevent further strain or damage to affected joints…slow progression rate • To improve movement • To improve muscle strength & endurance • To maintain or improve functional independence • To maximize quality of life

24. Protection of Affected Joints • Reduction of activities that increase pain • Improvement of posture • Selection of an appropriate walking aid • Orthotics/ Braces • Pacing & prioritizing • Orthotics • An appliance that is applied to a body part to correct a deformity or maintain a body segment (brace, splint innersole) • to protect against further injury or pain • to assist in movement by reducing the forces placed on a joint

25. Why Exercise? • Vital to improvement of symptoms • Regular physical activity is linked to a wide array of physical and mental health benefits • To increase strength, endurance, flexibility, balance and coordination • To relieve pain • lubricates joints • stimulates nerve endings other than pain endings Types of exercises Range Of Motion Exercises • To improve movement, range of joint movement • To improve flexibility Exercises To Increase Muscle Strength & Endurance • Strong muscles maintain good bone position • Critical in carrying out everyday activities • How To Exercise • MODERATION • Joint exercised too much->arthritis aggravated • Joint exercised too little->motion becomes limited, joints become stiff and more painful

26. Poor Sitting PostureThe Slouched Position • Causes over stretching of posterior spinal ligamentous structures • The more flexed the posture the greater the pressure on the discs • Causes some back and neck pain and all neck and back pain is aggravated by • POOR SITTING POSTURE

27. Nonpharmacologic Therapy • Patient Education: • Arthritis Self-Help courses administered by Arthritis Foundation • Hydrotherapy->aqua fitness • Physical Therapy: • Pain Control • Exercises, modalities( TENS, Heat, Cold) • Occupational Therapy: • Splints. • Ambulation devices (braces, walkers, patellar taping and canes). • Lateral heel and sole wedge insoles. • Weight Reduction: • Referral to Dietitian. • Enrollment in aerobic exercise program.

28. Surgery • Patients whose symptoms are not controlled with above interventions and have moderate to severe pain should be considered for surgery. • Debridement of the joint. • Total/Partial joint arthroplasty. • Osteotomy. • Arthrodesis.

29. Conclusion • Osteoporosis and Arthritis affect significant numbers of individuals. • Both males and females are affected. • If not treated or managed, can negatively impact quality of life. • Prevention of Osteoporosis should begin in childhood and continue throughout life. • Arthritis can be better managed through healthier lifestyle choices.