Osteoporosis: current modes of prevention and treatment

Treatment Strategies in the Osteoporotic Spine

This article reviews the appropriate assessment and management of osteoporotic compression fractures and discusses the implications of osteoporosis on initial patient evaluation, medical optimization for surgery, selection of instrumentation, and surgical technique. Adverse outcomes associated with osteoporosis are discussed. Failure to appropriately evaluate, optimize, and treat spine patients with osteoporotic bone can lead to disastrous complications. Weakened bone can lead to implant failure through cage subsidence and screw pullout, as well as, peri-implant fractures, failure of deformity correction, and proximal kyphosis. These risks must be taken into account when considering operative interventions in these patients.

Hounsfield Unit Values as an Adjunct Diagnostic Tool: Investigating Its Relationship with Bone Mineral Density and Vertebral Bone Quality in Lumbar Degenerative Disease Patients

OBJECTIVE

With an increasing prevalence of osteoporosis due to demographic shifts, accurate diagnostic methods are vital, particularly before spinal surgeries. This research investigated the correlation between bone mineral density T-scores of the lumbar spine and femoral neck, Hounsfield Unit (HU) values from computed tomography (CT), and vertebral bone quality (VBQ) scores from Magnetic Resonance Imaging (MRI) in patients with lumbar degenerative disease.

METHODS

We analyzed data from 100 patients with lumbar degenerative disease who underwent CT, dual-energy X-ray absorptiometry (DXA), and MRI between 2019 and 2023. HU values were measured individually from L1 to L4, while T-scores were obtained from DXA scans of the lumbar spine and the femoral neck. The VBQ scores were derived from T1-weighted MRIs.

RESULTS

A notable association between the lumbar and femoral neck T-scores and HU values was found. The VBQ score had a faint correlation with HU values and lacked any with the T-score. Notably, the HU values derived via the Youden index and regression closely matched. Lumbar spine HU values related to T-scores of 85.6 and 84.4 and femoral neck T-scores of 98.9 and 103.6, with a low T-score at 98.9 and 104.6.

CONCLUSIONS

This study underscores a strong correlation between bone mineral density and HU values from CT scans in lumbar degenerative disease patients, suggesting the utility of HU measurements as an adjunct diagnostic tool for osteoporosis. However, the correlation with the VBQ score remains weak. Further multicenter studies are essential for more robust validation.

Quantitative Ultrasound Examination (QUS) of the Calcaneus in Long-Term Martial Arts Training on the Example of Long-Time Practitioners of Okinawa Kobudo/Karate Shorin-Ryu

Quantitative research of bone tissue related to physical activity (PA) and sport has a preventive dimension. Increasing the parameters of bone tissue strength, especially reaching the maximum value of peak bone strength in childhood, adolescence, and early adulthood due to practicing sports can contribute to maintaining bone health throughout life. Practicing martial arts (tai chi, traditional karate, judo, and boxing) can effectively improve the quality of bone and reduce the risk of falls and fractures. The study aimed to evaluate the calcaneus bones among Okinawa Kobudo/Karate Shorin-Ryu practitioners using the quantitative ultrasound method as an indicator for assessing bone fracture risk. Forty-four adult martial arts practitioners with a mean age of 36.4 participated in this study. Quantitative ultrasound (QUS) with a portable Bone Ultrasonometer was used in this study. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and the stiffness index (SI) were measured. Subjects were assigned to two groups of black and color belts, according to the advancement in Kobudo/karate practice. The measurements of the SI, BUA, SOS, T-score, and Z-score were significantly higher in subjects from the advanced, long-term practice (black belts) (p < 0.05). The long-term martial arts training in traditional karate and Kobudo significantly impacts the parameters of the calcaneus quantitative ultrasound measurements. Significantly higher bone density was observed among the black belt holders. Long-term practice subjects achieved results far beyond the norm for their age groups. Further studies using non-invasive methods of bone quantification are needed to determine the specific conditions for preventing osteoporosis through physical activity, sports, and martial arts, particularly the duration of the activity, the magnitude of loads, and other related factors.

Efficacy of Hounsfield Units Measured by Lumbar Computer Tomography on Bone Density Assessment: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

This work aimed to compare the Hounsfield units (HU) value obtained from computed tomography and the t score of dual-energy x-ray absorptiometry (DXA) in the prediction of the lumbar spine bone mineral density (BMD).

SUMMARY OF BACKGROUND DATA

Several reports have found a correlation between HU and BMD values based on DXA. Using HUs to infer bone quality has a thorough clinical relevance as it could triage patients at risk for osteoporotic and fragility fractures or modify surgical indications.

METHODS

A systematic review in Cochrane Library, Medline, Scopus and Web of Science was performed, using the following query: "hounsfield units" AND ("osteoporosis" OR "spine" OR "bone mineral density" OR "dual x-ray absorptiometry"). We included 18 cohort studies that compared HU value obtained from computed tomography and t score of DXA for predicting regional BMD.

RESULTS

A total of 18 studies were included, enrolling 5307 patients. The HU measurement was most frequently made at L1 (N = 3; 18.8%). The mean HU values differentiated based on BMD measured through DXA were reported in seven studies, with values from 54.7 to 130 for osteoporotic, 78.8 to 146 for osteopenic, and from 120.8 to 230 in normal patients. Eight studies identified thresholds for diagnosing osteoporosis through receiver-operating characteristic (ROC) curves, with values ranging from 0.66 to 0.96. Medium HU values reported as diagnostic of osteoporosis ranged between 110 and 150, after exclusion of the two papers presenting outlier values. We infer an HU interval value of 90.9 to 138.7 (95% CI, P  < 0.001) for the diagnosis osteoporosis.

CONCLUSIONS

Present data evidence favorable results regarding the possibility of establishing a threshold value for osteoporosis diagnosis from CT measurements of HU. Prospective large-scale studies are needed to more robustly infer the possibility of quantifying BMD based on CT as a screening test and infer a prognostic value of the CT-based evaluation.Level of Evidence: 2.

Special Considerations to Improve Clinical Outcomes in Patients with Osteoporosis Undergoing Spine Surgery

BACKGROUND

Osteoporosis is a condition that is commonly encountered, with increasing diagnosis by the medical community with the aging population. Osteoporosis leaves patients susceptible to fragility fractures in the vertebrae and is also associated with degenerative changes, both of which may require intervention from a spine surgeon. The goal of this review is to concisely outline special nonoperative adjuncts, as well as preoperative, intraoperative, and postoperative considerations of osteoporotic patients undergoing spine intervention.

METHODS

A literature analysis was completed for this narrative review. A database search of PubMed and Google Scholar was conducted using "osteoporosis" combined with "spine," "spine surgery," and "spinal fusion" without exclusion based on publication date. Articles were screened to exclude duplicate articles and screened for their full text and English language availability.

RESULTS

The database search yielded recent publications from which the narrative review was completed.

CONCLUSIONS

Preoperatively, screening is traditionally completed with dual-energy x-ray absorptiometry (DEXA). Pharmacological therapy modalities currently include teriparatide, raloxifene, denosumab, bisphosphonates, and calcitonin. In order to prevent operative complications associated with osteoporosis, surgeons have found success in increasing the diameter and the length of pedicle screws, limiting pedicle tapping, achieving bicortical or even tricortical purchase, augmenting with polymethyl methacrylate, using iliosacral stabilization, preventing positive sagittal balance, and using adequate fusion products when necessary. Postoperatively, it is important to implant a care plan that includes adequate pain control and necessary care, and to understand risks associated with falls may increase risk of postoperative fragility fractures as well as instrumentation displacement. At this time there are no recommendations in regard to bracing in the postoperative setting.

CLINICAL RELEVANCE

This review article outlines the most current evidence-based medicine with regard to considerations in spine surgery of the osteoporotic patient, and aims to bring about new questions to be investigated in that paradigm.

Assessing the Value of Routine Pathologic Examination of Resected Femoral Head Specimens After Femoral Neck Fracture

INTRODUCTION

The purpose of this study was to evaluate the efficacy of routine pathologic examination (PE) of femoral head (FH) specimens after arthroplasty for acute femoral neck fractures and to determine the cost.

METHODS

This was a retrospective chart review of 850 acute femoral neck fractures treated with hemiarthroplasty or total hip arthroplasty These were evaluated to determine whether the FH was sent for PE, the resultant findings, alterations in medical treatment, and cost.

RESULTS

A total of 466 FH specimens (54.8%) were sent to pathology. Four (0.9%) were positive for a neoplastic process. All four had a known history of cancer, antecedent hip pain, or an inappropriate injury mechanism. None of the findings resulted in an alteration in medical treatment. The average cost of PE was $195 USD.

DISCUSSION

The routine PE of FH specimens after arthroplasty for femoral neck fractures is not warranted and uneconomic. Sending the FH for PE, only when clinically indicated, rather than routine, will result in notable savings for the healthcare system.

LEVEL OF EVIDENCE

Level IV.

A retrospective analysis of bone mineral status in patients requiring spinal surgery

Background

Impaired bone quality is associated with poor outcome of spinal surgery. The aim of the study was to assess the bone mineral status of patients scheduled to undergo spinal surgery and to report frequencies of bone mineral disorders.

Methods

We retrospectively analyzed the bone mineral status of 144 patients requiring spinal surgery including bone mineral density by dual-energy X-ray absorptiometry (DXA) as well as laboratory data with serum levels of 25-hydroxyvitamin D (25-OH-D), parathyroid hormone, calcium, bone specific alkaline phosphate, osteocalcin, and gastrin. High-resolution peripheral quantitative computed tomography (HR-pQCT) was additionally performed in a subgroup of 67 patients with T-Score below − 1.5 or history of vertebral fracture.

Results

Among 144 patients, 126 patients (87.5%) were older than 60 years. Mean age was 70.1 years. 42 patients (29.1%) had suffered from a vertebral compression fracture. 12 previously undiagnosed vertebral deformities were detected in 12 patients by vertebral fracture assessment (VFA). Osteoporosis was present in 39 patients (27.1%) and osteopenia in 63 patients (43.8%). Only 16 patients (11.1%) had received anti-osteoporotic therapy, while 54 patients (37.5%) had an indication for specific anti-osteoporotic therapy but had not received it yet. The majority of patients had inadequate vitamin D status (73.6%) and 34.7% of patients showed secondary hyperparathyroidism as a sign for a significant disturbed calcium homeostasis. In a subgroup of 67 patients, severe vertebral deformities were associated with stronger deficits in bone microarchitecture at the distal radius compared to the distal tibia.

Conclusions

This study shows that bone metabolism disorders are highly prevalent in elderly patients scheduled for spinal surgery. Vertebral deformities are associated with a predominant deterioration of bone microstructure at the distal radius. As impaired bone quality can compromise surgical outcome, we strongly recommend an evaluation of bone mineral status prior to operation and anti-osteoporotic therapy if necessary.

Core level regulatory network of osteoblast as molecular mechanism for osteoporosis and treatment

To develop and evaluate the long-term prophylactic treatment for chronic diseases such as osteoporosis requires a clear view of mechanism at the molecular and systems level. While molecular signaling pathway studies for osteoporosis are extensive, a unifying mechanism is missing. In this work, we provide experimental and systems-biology evidences that a tightly connected top-level regulatory network may exist, which governs the normal and osteoporotic phenotypes of osteoblast. Specifically, we constructed a hub-like interaction network from well-documented cross-talks among estrogens, glucocorticoids, retinoic acids, peroxisome proliferator-activated receptor, vitamin D receptor and calcium-signaling pathways. The network was verified with transmission electron microscopy and gene expression profiling for bone tissues of ovariectomized (OVX) rats before and after strontium gluconate (GluSr) treatment. Based on both the network structure and the experimental data, the dynamical modeling predicts calcium and glucocorticoids signaling pathways as targets for GluSr treatment. Modeling results further reveal that in the context of missing estrogen signaling, the GluSr treated state may be an outcome that is closest to the healthy state.

Diagnosing the Undiagnosed: Osteoporosis in Patients Undergoing Lumbar Fusion

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

The aim of the study was to report the incidence of undiagnosed osteoporosis in patients undergoing lumbar spine fusion using computed tomography (CT) Hounsfield units (HU).

SUMMARY OF BACKGROUND DATA

We used a recent technique utilizing HU to estimate bone mineral density (BMD) of the lumbar spine and hypothesized that this technique would reveal a high percentage of undiagnosed osteoporotic patients undergoing transforaminal lumbar interbody fusion (TLIF).

METHODS

We reviewed patients older than 50 years undergoing TLIF from a single-center and multiple surgeons. We determined the mean HU of L4 on axial CT. Average HU values for patients with diagnosed lumbar osteoporosis (DEXA BMD <0.75 g/cm) were compared to patients with osteopenia and normal BMD (between 0.75 and 0.9 g/cm and >0.9 g/cm, respectively). The percentage of patients with HU values consistent with osteoporosis, but without any formal evaluation, was also calculated.

RESULTS

Over 10 years, 143 patients older than 50 years underwent TLIF, and 128 had available perioperative lumbar CT scans. Men and Women comprised 60.2% and 39.8% of the population, respectively. Average age was 61.5 years (range: 50.0-83.5 years). Twenty-nine patients had both dual-energy X-ray absorptiometry and CT data available for analysis. There was a significant association with decreased HU in patients with lumbar BMD less than 0.75 g/cm (105.6 HU, 95% confidence interval [CI] 6.76) in comparison to patients with osteopenia (146.0 HU, 95% CI 4.09) and with normal BMD (165.9, 95% CI 21.35). Ten men (7.8%) and 15 women (11.7%) had HU values consistent with osteoporosis. Sixty-four percent of patients with osteoporotic HU values had never been formally evaluated for the disease.

CONCLUSION

HU may be an alternative to screening preoperative dual-energy X-ray absorptiometry scan and can minimize costs and resource utilization. We found a large proportion of patients older than 50 years undergoing TLIF had HU levels consistent with undiagnosed osteoporosis of the lumbar spine.

LEVEL OF EVIDENCE

4.

The Effectiveness of Gelfoam Technique before Percutaneous Vertebroplasy: Is It Helpful for Prevention of Cement Leakage? A Prospective Randomized Control Study

Objective

Preinjection gelfoam embolization during percutaneous vertebroplasty (PVP) has been thought alternative technique to prevent the leakage of bone cement. The goal of this study was to evaluate whether the gelfoam techniques are useful to reduce bone cement leakage.

Methods

Total 100 PVPs of osteoporotic spine compression fractures were performed by 1 spine surgeon who experienced more than 500 PVP cases under prospective control study. Operation was done in T-L junction (T10-L2) fractures with bi-transpedicular approach. Preinjection gelfoam PVP was done in the 50 levels. As control group, PVP without gelfoam was done in the 50 levels. We did not perform preoperative venography. We inserted normal saline-mixed gelfoam to the anterior third of vertebral body via PVP needle, and then 3mL of polymethylmetacrylate (PMMA) was injected. We prospectively evaluated the incidence and leakage pattern of PMMA by postoperative computed tomography.

Results

Between gelfoam and control groups, there were 11 leaks (22%) versus 12 leaks (26%). The mean operation time was 7.00 minutes versus 6.30 minutes. In gelfoam group, there were 6 spinal canal leaks, 4 paravertebral venous leaks, and 1 soft tissue leaks. In control group, there were 4 spinal canal leaks, 8 paravertebral venous leaks, and 1 disc space leak. In spite of cement leakage, there was no symptomatic case in both groups. Statistically, gelfoam technique was not related to decrease the incidence of leakage (p=0.64).

Conclusion

Our prospective study showed that it did not significantly decrease cement leakage when vertebroplasty is performed by experienced spine surgeon.

Management of osteoporosis in spine surgery

Osteoporosis is a burgeoning clinical problem that is characterized by decreased bone strength and density. It predisposes patients to fragility fractures and debilitating spine deformities. Several complications are associated with spine surgery in patients with osteoporosis, and there is currently no treatment algorithm to guide the spine surgeon. A multidisciplinary approach to treatment of patients with osteoporosis and spine deformity or fracture is encouraged, and preoperative planning is crucial for successful surgical outcomes. Several surgical techniques have been developed to treat osteoporosis-related deformities, including posterior instrumentation with fusion. However, achieving fixation and fusion in these patients can be difficult secondary to poor bone stock. Augmentation methods to improve pedicle screw fixation have evolved, including instrumentation at multiple levels, bioactive cement augmentation, and fenestrated or expandable pedicle screws, but their impact on clinical outcomes remains unknown. Management of osteoporosis in patients undergoing spine surgery is challenging, but with appropriate patient selection, medical optimization, and surgical techniques, these patients can experience pain relief, deformity correction, and improved function.

Osteoporotic vertebral fractures: current concepts of conservative care

INTRODUCTION

Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966-2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures.

AREAS OF AGREEMENT

Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing.

AREAS OF CONTROVERSY

A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials.

GROWING POINTS

Randomized controlled trials are being performed worldwide on vertebral augmentation techniques.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Effects of Sigma Anti-bonding Molecule Calcium Carbonate on bone turnover and calcium balance in ovariectomized rats

This study was conducted to evaluate the effect of Sigma Anti-bonding Molecule Calcium Carbonate (SAC) as therapy for ovariectomy-induced osteoporosis in rats. Three weeks after surgery, fifteen ovariectomized Sprague-Dawley rats were divided randomly into 3 groups: sham-operated group (sham), ovariectomized group (OVX) and SAC-treatment group (OVX+SAC). The OVX+SAC group was given drinking water containing 0.0012% SAC for 12 weeks. Bone breaking force and mineralization as well as blood parameters related to the bone metabolism were analyzed. In OVX animals, blood concentration of 17β-estradiol decreased significantly, while osteocalcin and type I collagen C-terminal telopeptides (CTx) increased. Breaking force, bone mineral density (BMD), calcium and phosphorus in femurs, as well as uterine and vaginal weights, decreased significantly following OVX. However, SAC treatment (0.0012% in drinking water) not only remarkably restored the decreased 17β-estradiol and increased osteocalcin and CTx concentrations, but also recovered decreased femoral breaking force, BMD, calcium and phosphorus, although it did not reversed reproductive organ weights. It is suggested that SAC effectively improve bone density by preventing bone turnover mediated osteocalcin, CTx and minerals, and that it could be a potential candidate for therapy or prevention of postmenopausal osteoporosis.

Is osteoporosis in postmenopausal female patients related to previous pregnancies and/or miscarriages?

OBJECTIVE

To investigate if osteopenia and osteoporosis in postmenopausal female patients are related to previous pregnancies and/or miscarriages.

PATIENTS AND METHODS

We studied 81 postmenopausal female patients, 40 with osteopenia or osteoporosis and 41 without osteopenia or osteoporosis, carefully matched for age (control group). In the two groups, the presence or not of osteopenia, osteoporosis, or both, were analyzed and compared with the number of childbirths and/or miscarriages.

RESULTS

Overall, no statistical difference was found among the 40 patients with one, two, three or more than three childbirths and osteopenia or osteoporosis compared with the control group (p=0.5363, p=0.5782, p=0.0763, p=0.1931, respectively). Similarly, no differences were found between the osteopenia/osteoporosis group and the control group in relation to previous one, two, three or more than three miscarriages. When both childbirths and miscarriages were added together (three, four, five, six, more than six), again no statistical difference was found between the osteopenia/osteoporosis group and the control group.

CONCLUSIONS

In postmenopausal women, the obstetric history of previous childbirths and/or miscarriages, independent of the number, did not seem to be a risk factor for osteopenia or osteoporosis.

Preventative effect of exercise against falls in the elderly: a randomized controlled trial

SUMMARY

The present study was conducted to determine the effect of 5-month exercise program on the prevention of falls in the elderly. The exercise training, which consisted of calisthenics, body balance training, muscle power training, and walking ability training 3 days/week improved the indices of the flexibility, body balance, muscle power, and walking ability and reduced the incidence of falls compared with non-exercise controls. The present study showed the beneficial effect of the exercise program aimed at improving flexibility, body balance, muscle power, and walking ability in preventing falls in the elderly.

INTRODUCTION

The present study was conducted to determine the effect of exercise on the prevention of falls in the elderly.

METHODS

Sixty-eight elderly ambulatory volunteers were randomly divided into two groups: the exercise and control groups. The daily exercise, which consisted of calisthenics, body balance training (tandem standing, tandem gait, and unipedal standing), muscle power training (chair-rising training), and walking ability training (stepping), were performed 3 days/week only in the exercise group. No exercise was performed in the control group.

RESULTS

After the 5-month exercise program, the indices of the flexibility, body balance, muscle power, and walking ability significantly improved in the exercise group compared with the control group. The incidence of falls was significantly lower in the exercise group than in the control group (0.0% vs. 12.1%, P = 0.0363). The exercise program was safe and well tolerated in the elderly.

CONCLUSIONS

The present study showed the beneficial effect of the exercise program aimed at improving flexibility, body balance, muscle power, and walking ability in preventing falls in the elderly.

Bone volume fraction explains the variation in strength and stiffness of cancellous bone affected by metastatic cancer and osteoporosis

Preventing nontraumatic fractures in millions of patients with osteoporosis or metastatic cancer may significantly reduce the associated morbidity and reduce health-care expenditures incurred by these fractures. Predicting fracture occurrence requires an accurate understanding of the relationship between bone structure and the mechanical properties governing bone fracture that can be readily measured. The aim of this study was to test the hypothesis that a single analytic relationship with either bone tissue mineral density or bone volume fraction (BV/TV) as independent variables could predict the strength and stiffness of normal and pathologic cancellous bone affected by osteoporosis or metastatic cancer. After obtaining institutional review board approval and informed consent, 15 patients underwent excisional biopsy of metastatic prostate, breast, lung, ovarian, or colon cancer from the spine and/or femur to obtain 41 metastatic cancer specimens. In addition, 96 noncancer specimens were excised from 43 age- and site-matched cadavers. All specimens were imaged using micro-computed tomography (micro-CT) and backscatter emission imaging and tested mechanically by uniaxial compression and nanoindentation. The minimum BV/TV, measured using quantitative micro-CT, accounted for 84% of the variation in bone stiffness and strength for all cancellous bone specimens. While relationships relating bone density to strength and stiffness have been derived empirically for normal and osteoporotic bone, these relationships have not been applied to skeletal metastases. This simple analytic relationship will facilitate large-scale screening and prediction of fracture risk for normal and pathologic cancellous bone using clinical CT systems to determine the load capacity of bones altered by metastatic cancer, osteoporosis, or both.

Effect of whole-body vibration exercise and muscle strengthening, balance, and walking exercises on walking ability in the elderly

The present study was conducted to determine the beneficial effect of whole-body vibration (WBV) exercise in addition to muscle strengthening, balance, and walking exercises on the walking ability in the elderly. Sixty-seven elderly participants were divided into two groups; the WBV exercise plus routine exercises group (n=40) and the routine exercises alone group (n=27). WBV exercise was performed on a Galileo machine (Novotec, Pforzheim, Germany) at an intensity of 12-20 Hz, for a duration of 4 minutes, once every week. All the participants in both the groups were similarly instructed to undergo routine exercises such as balance and muscle strengthening training, and take walking exercise twice a week. The period of this study was 2 months to evaluate the acute effects of WBV exercise. The mean age of the participants was 72.0 years (range, 59-86 years). At baseline, there were significant negative correlations between age and the walking speed, step length, and maximum standing time on one leg. After the 2-month exercise program, the walking speed, step length, and the maximum standing time on one leg were significantly improved in the WBV exercise plus routine exercises group, while no significant changes in these parameters were observed in the routine exercises alone group. Thus, the present study showed the beneficial effect of WBV exercise in addition to muscle strengthening, balance, and walking exercises in improving the walking ability in the elderly. WBV exercise was safe and well tolerated in the elderly.

Prediction and discrimination of osteoporotic hip fracture in postmenopausal women

Osteoporotic hip fractures increase dramatically with age and are responsible for considerable morbidity and mortality. Several treatments to prevent the occurrence of hip fracture have been validated in large randomized trials and the current challenge is to improve the identification of individuals at high risk of fracture who would benefit from therapeutic or preventive intervention. We have performed an exhaustive literature review on hip fracture predictors, focusing primarily on clinical risk factors, dual X-ray absorptiometry (DXA), quantitative ultrasound, and bone markers. This review is based on original articles and meta-analyses. We have selected studies that aim both to predict the risk of hip fracture and to discriminate individuals with or without fracture. We have included only postmenopausal women in our review. For studies involving both men and women, only results concerning women have been considered. Regarding clinical factors, only prospective studies have been taken into account. Predictive factors have been used as stand-alone tools to predict hip fracture or sequentially through successive selection processes or by combination into risk scores. There is still much debate as to whether or not the combination of these various parameters, as risk scores or as sequential or concurrent combinations, could help to better predict hip fracture. There are conflicting results on whether or not such combinations provide improvement over each method alone. Sequential combination of bone mineral density and ultrasound parameters might be cost-effective compared with DXA alone, because of fewer bone mineral density measurements. However, use of multiple techniques may increase costs. One problem that precludes comparison of most published studies is that they use either relative risk, or absolute risk, or sensitivity and specificity. The absolute risk of individuals given their risk factors and bone assessment results would be a more appropriate model for decision-making than relative risk. Currently, a group appointed by the World Health Organization and lead by Professor John Kanis is working on such a model. It will therefore be possible to further assess the best choice of threshold to optimize the number of women needed to screen for each country and each treatment.

Osteoporotic compression fractures of the spine; current options and considerations for treatment

BACKGROUND CONTEXT

Vertebral compression fractures affect at least one-fourth of all postmenopausal women. The most significant risk factor is osteoporosis, most commonly seen among Caucasian women a decade or so after menopause. Osteoporosis typically results from inadequate accumulation of bone mass during childhood and early adulthood followed by rapid resorption after menopause. Primary treatment of osteoporosis includes consideration of underlying metabolic abnormalities and provision of supplemental calcium/vitamin D in conjunction with bisphosphonates or calcitonin, or both. Routine hormone replacement therapy has fallen out of favor because of concerns regarding adverse effects identified in long-term follow-up studies. Acute osteoporotic vertebral compression fracture management includes bracing, analgesics, and functional restoration. Patients with chronic pain beyond 2 months may be appropriate candidates for vertebral body augmentation, ie, vertebroplasty or balloon tamp reduction. Open surgical management with decompression and stabilization should be reserved for the rare patient with neural compression and progressive deformity with neurologic deficits.

PURPOSE

To review current principles in the evaluation and treatment of osteoporotic compression fractures of the spine.

STUDY DESIGN/SETTING

A literature review on management of the osteoporotic spine.

METHODS

MEDLINE search of all English-language literature published between 1981 and 2005 on surgical and nonsurgical treatment of the osteoporotic spine. The references selected for listing at the conclusion of this review are those containing specific information cited within the text.

RESULTS

Over 200 separate scientific and clinical studies addressing the epidemiology, pathophysiology, diagnosis, and treatment of osteoporotic vertebral compression fractures were reviewed.

CONCLUSIONS

Osteoporotic vertebral compression fractures are a common presenting complaint to spinal care specialists. Thorough differential diagnosis should be considered before attributing fractures to osteoporosis. Appropriate evaluation and medical treatment of underlying osteoporosis should be recommended or instituted. Nonsurgical management of the spinal fracture should focus on pain control and maximizing functional outcome. The role of surgical treatment remains controversial and should be reserved for patients who fail initial nonsurgical management options.

Discordantly high spinal bone mineral density values in patients with adult lumbar scoliosis

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purposes of this study were: 1) to investigate the validity of bone mineral density measurements with DEXA in patients with adult lumbar scoliosis and 2) to investigate the association between osteoporosis and adult lumbar scoliosis.

SUMMARY OF BACKGROUND DATA

Osteoporosis and lumbar degenerative scoliosis are phenomena encountered with increased frequency in aging, often concurrently. It has been suggested that scoliosis predisposes to osteoporosis, but degenerative scoliosis could falsely elevate spinal bone mineral density measurements.

METHODS

The feasibility of measuring Cobb's angle in DEXA scans was established in 48 surgical candidates with standing anteroposterior lumbar radiographs and supine DEXA scans. Charts and radiographs of 454 consecutive adult patients evaluated at an osteoporosis center were reviewed thereafter. The association between age, lumbar curve, and various bone density measurements was investigated. Bone density measurements between nonscoliotic and scoliotic patients with and without a history of adolescent scoliosis were compared.

RESULTS

Cobb's angle on DEXA scan was measured with an error of 4 degrees and correlated highly with the plain lumbar radiographs. The prevalence of scoliosis was 9.47% in this cohort of patients. Advancing age was associated with an increase in osteoporosis in both scoliotic and nonscoliotic patients. Scoliotic patients demonstrated increased spinal bone mineral density (BMD) measurements compared with nonscoliotic patients, resulting in discrepancies between hip and spine BMD values. This discrepancy correlated with aging and curve magnitude (up to 30% for curves of 43 degrees ). Scoliotic patients demonstrated significantly lower hip BMD values than nonscoliotic. Curve magnitude did not correlate with severity of osteoporosis.

CONCLUSIONS

Cobb's angle measurements on DEXA scans are reliable and comparable to conventional radiographs. Spinal BMD values are less valuable for monitoring osteoporosis than hip values in scoliotic patients; an increasing discrepancy with age was noted. Scoliotic patients exhibited discordantly high spinal BMD values, despite significant hip osteoporosis. The discrepancy correlated with aging and curve magnitude. Scoliosis was common among the osteoporotic population (9.47%). Lumbar scoliosis is a useful clinical marker for osteoporosis, irrespective of scoliosis history and magnitude. Viable alternatives for osteoporosis evaluation of adult patients with lumbar scoliosis are hip DEXA values, in conjunction with other BMD measurements.

The effects of the antiresorptive agents calcitonin and pamidronate on spine fusion in a rabbit model

BACKGROUND CONTEXT

As the population ages, the number of individuals undergoing pharmacotherapy to prevent or treat osteoporosis is increasing. Drugs of the bisphosphonate family prevent bone resorption, as does calcitonin, though by different mechanisms. Bisphosphonates are deposited in bone, preventing resorption by osteoclasts. Calcitonin is a direct inhibitor of osteoclasts, but is not itself incorporated in bone. The same late middle-aged and elderly patients who are being treated for osteoporosis frequently come to spine fusion. Bone remodelling is a vital part of graft incorporation. Interventions that interfere with remodelling may have a detrimental effect on the rate, time course, and strength of the fusion mass.

PURPOSE

To delineate the effects of these anti-osteoporosis medications on the fusion process.

STUDY DESIGN

Randomized, prospective, double-blind, animal model.

METHODS

Posterolateral arthrodesis was performed at L5/6 in 60 skeletally mature 4.0-4.5 kg New Zealand white rabbits, using 3 cc of autologous iliac crest graft per side. Rabbits were randomized to one of three groups: PAM--pamidronate 1.2 mg subcutaneously 3 times/week for 4 weeks preoperatively, then 0.6 mg/day via miniosmotic pump for 4 weeks postoperatively; CAL--calcitonin 14 IU/day via pump for 4 weeks postoperatively only; CON--no drug intervention. All animals were killed 5 weeks after surgery. Fusion, defined by absolute lack of intersegmental motion, was assessed by manual palpation by two spine surgeons. Where there was disagreement, a third surgeon made the final determination. Stiffness and peak load to failure were determined by mechanical testing of each operated motion segment, and normalized to the adjacent, unoperated level.

RESULTS

Four rabbits excluded (1 each: death; euthanasia for hind-limb palsy; infection; incorrect level). Number fused at 5 weeks: CON 10/18 (56%), PAM 7/19 (37%), CAL 13/19 (68%). Fisher exact test showed no significant differences between groups. Analysis of variance (ANOVA) showed no significant differences in mechanical testing between CAL and CON, but PAM specimens had significantly less peak load than CON or CAL animals (p<.01) and were less stiff than CON (p<.01) or CAL (p<.05) animals.

CONCLUSIONS

Though one must be careful in extrapolating animal data to humans, this study suggests that calcitonin is not detrimental to spine fusion. Pamidronate, however, does lead to a mechanically less robust fusion. Based on this study, there is no evidence to support a recommendation to stop antiresorptive therapy for osteoporosis in the spine fusion patient.

Ground contact characteristics of Tai Chi gait

BACKGROUND

To date, no direct measurement has been done that quantitatively characterizes the foot-ground contact during Tai Chi Chuan movements. The goal of this study was to quantify the biomechanical characteristics of foot-ground contact during a Tai Chi gait (TCG), one of the basic but common Tai Chi Chuan movements.

METHODS

The ground reaction force profiles, center of pressure (COP) and plantar pressure patterns under the stance foot of TCG were directly measured in a sample of 10 healthy young individuals.

RESULTS

The medial force reached a peak value of 12 +/- 2% body weight (BW) during early stance. The vertical force reached and maintained a peak value of 109 +/- 2% BW during single stance, and shifted within a range of 10% and 70% BW during double stance phases. There was a uniformly small rate of loading in all three directions throughout stance. The peak plantar pressure was fairly constant throughout stance in the rear-foot region (maximum value of 0.27 +/- 0.07 kPa/kg), but changed from 0 to 0.16 +/- 0.04 kPa/kg in the fore-foot region. The peak pressure difference between the fore-foot and rear-foot regions was less than 0.06 +/- 0.01 kPa/kg during single stance and the second double stance. The maximum plantar contact area during TCG was 60 +/- 9% of the foot area. The foot COP displaced largely during the early and late part of the stance and maintained fairly stationary during single stance. The maximum COP displacement in the medial-lateral direction was 64 +/- 8% of foot width.

CONCLUSIONS

TCG had a low impact force, a fairly evenly distributed body weight between the fore-foot and rear-foot regions, and a large medial-lateral displacement of the foot COP.

Risk factors associated with osteoporosis in Hispanic women

This study examined risk factors for osteoporosis in Hispanic women. Factors examined included ethnicity, gender, age, height, weight, family and personal history of fractures, height loss, exercise, diet, time since menopause or hysterectomy, hormone replacement therapy (HRT), calcium supplementation, hypertension, thyroid disease, diabetes, arthritis, chemotherapy, family history of breast cancer, use of water pills, fosamax, steroids, alcohol, and smoking. Most results found parallel those found in the Caucasian population. Heavier patients had greater bone density, as well as patients who exercised and those using HRT. Older patients had lower bone density as did diabetic patients. Results not anticipated were higher bone density in patients not taking calcium supplements, and in patients who consumed alcohol.

Prevention of postmenopausal osteoporosis with pharmacological therapy: practice and possibilities

Postmenopausal osteoporosis (PMO) is a common disease that will become more prevalent in the future, with costly implications for public health. Prevention of the disease and its consequences, namely fractures, is therefore, important for both the individual and society. This review discusses: the goals of PMO prevention; the identification of women at risk, including the use of bone mineral density and bone turnover markers; the relevance in the prevention setting of various current guidelines for PMO management; recent data on therapeutic options for the treatment and prevention of PMO, in particular bisphosphonates, hormone replacement therapy and several other new pharmacological agents. It concludes that it is crucial for PMO prevention to start before disease onset and that, in the light of recent evidence, the existing guidelines need updating if they are to continue to be relevant.

Efficacy of training program for ambulatory competence in elderly women

The optimal prevention of osteoporotic fractures in the elderly consists of increasing the bone density and preventing falls. We report on the efficacy of training program to promote ambulatory competence in elderly women. Twenty-five elderly women were enrolled in our training program, which is a three-month program consisting of dynamic balance training with Galileo 900 (Novotec, Pforzheim, Germany) once a week, combined with daily static balance (standing on one leg like a flamingo) and resistance (half-squat) training. The mean age of the participants was 72.8 years (range, 61-86 years). After 3 months of training, the step length, knee extensor muscle strength, and maximum standing time on one leg were significantly increased, while the walking speed and hip flexor muscle strength were not significantly altered. During the study period, no serious adverse events such as new vertebral fractures or adverse cardiovascular symptoms were observed in any participant. The present preliminary study shows that our training program may have the potential to promote ambulatory competence in elderly women.

The aging spine: new technologies and therapeutics for the osteoporotic spine

Osteoporosis results in low-energy fractures of the spine. The load necessary to cause a vertebral fracture is determined by the characteristics related to the vertebral body structure, mineral content, and quality of bone. Radiographic techniques centered on dual X-ray absorptiometry (DXA) permit a determination of bone mass and fracture risk. Current medical therapies principally using bisphosphonate and pulsatile PTH profoundly decrease the risk of fracture (50+%). Fall prevention strategies can further decrease the possibility of fracture. A comprehensive approach to osteoporosis can favorably alter the disease.

A Simpler Eight-Form Easy Tai Chi for Elderly Adults

Low-impact exercise that appeals to elderly adults and can be done almost anywhere provides both societal and individual benefits. One such program is Tai Chi, a traditional Chinese dancelike conditioning exercise. The article presents an easily adopted and adapted 8-form Tai Chi program (Easy Tai Chi) designed for older adults or individuals with mobility challenges or physical impairments. Derived from a simplified 24-form Yang-style Tai Chi, it stresses postural control and body-limb rotational movements. Easy Tai Chi can be performed either standing or sitting, depending on the physical and functional limitations of participants. Preliminary data indicate a number of health benefits of Easy Tai Chi compared with a traditional exercise program. Although subject to further empirical evaluation, Easy Tai Chi can be applied in research settings to investigate prevention or amelioration of hypokinetic diseases and in clinical settings to treat physically frail seniors or others with functional impairments of the musculoskeletal or cardiovascular system.

Osteoporosis and diabetes

Osteoporosis is the most prevalent metabolic bone disease in the United States. Although the disease has historically been reported mostly in white women, it can affect individuals of both sexes and all ethnic groups. The presence of osteoporosis related to diabetes is not well acknowledged and the impact of osteoporosis in a diabetic patient is often not considered. Routine screening or initiation of preventive medications for osteoporosis in all patients with type 1 or type 2 diabetes is not recommended at the present time. However, in all patients with diabetes, besides optimal glycemic control, general recommendations regarding adequate dietary calcium intake, regular exercise, and avoidance of other potential risk factors such as smoking should be given. In patients who have positive risk factors for osteoporosis, or in those who present with fractures, evaluation of bone density should be done and respective preventive or therapeutic interventions should be applied.

Bony pathology in the cancer patient

Bony pathology in the cancer patient represents a significant source of morbidity and mortality. Complications include insufficiency and pathological fractures resulting from either medical treatments or bony metastases that can cause significant functional limitations. Additional complications include spinal cord compression, hypercalcemia, and bone marrow failure. Rehabilitation management of such conditions is reviewed, with an emphasis on diagnostic and therapeutic management. Bracing and focused rehabilitation programs facilitate maximal participation and functional outcomes, which can result in an enhanced quality of life. Specific rehabilitation goals and strategies are discussed, with an emphasis on tailoring these according to the functional staging of the patient.

An Overview of Four Nonpharmacologic Complementary and Alternative Medicine Modalities

Objective

To provide an overview of 4 nonmedical complementary and alternative medicine (CAM) modalities with an emphasis on 1 mind-body approach (yoga), 2 alternative systems (acupuncture, tai chi), and 1 energy therapy (therapeutic touch). Support in the scientific literature for the usefulness of each technique is presented.

Data Sources

Primary articles on alternative medicine were obtained by performing a MEDLINE search. An online book search was conducted on the Ohio Library and Information Network, a consortium of 79 Ohio colleges, universities, and community colleges and the State Library of Ohio.

Data Synthesis

All 4 CAM modalities had a scientific basis and were supported in the literature. Main drawbacks to many scientific studies were in methodologic flaws such as small sample sizes, variable interventions, and the absence of controls. Many researchers are beginning to include evidence-based and scientific techniques in their studies that more closely meet established scientific standards. This will lead to more robust, valid, reliable, and uniform methodologic approaches.

Discussion

Many patients use both CAM and mainstream therapies for their medical conditions. As the quality of scientific studies improves, pharmacists can gain confidence in using the results to provide pharmaceutical care to such patients. It is the pharmacists' responsibility to educate themselves about CAM therapies.

Conclusions

Embracing a holistic approach to care may enable pharmacists to optimize the pharmaceutical care they provide to all their patients.

Evaluation of the effectiveness of Tai Chi for improving balance and preventing falls in the older population--a review

One of the challenges faced by people with advancing age is decreased postural stability and increased risks for falls. There has been an increased interest over the last decade in using Tai Chi as an intervention exercise for improving postural balance and preventing falls in older people. Despite the increased number of studies in recent years relating Tai Chi to balance and fall prevention, results are scattered and inconsistent. There is wide variation in the use of balance measures, subject population, type and duration of Tai Chi exercise, and type of study. This paper provides a systematic review/analysis of currently available study reports. The goal of the review is to address the following concerns: how the effect of Tai Chi on balance or fall prevention has been evaluated to date, what level of evidence exists supporting Tai Chi as an effective exercise for improving balance or preventing falls, and what factors could possibly affect the benefit of Tai Chi on balance or falls. This review also helps identify directions for future research.

Osteoporose

A osteoporose é uma doença ósteo-metabólica que atinge especialmente mulheres após a menopausa. Segundo a Organização Mundial de Saúde 1/3 das mulheres brancas acima dos 65 anos são portadoras de osteoporose. Entretanto estima-se que um homem branco de 60 anos tenha 25 % de chance de ter uma fratura osteoporótica. O diagnóstico e planejamento terapêutico são baseados na densitometria óssea e na dosagem laboratorial dos marcadores de formação e reabsorção óssea. A densitometria também é o melhor preditor de fraturas. Os medicamentos atualmente disponíveis atuam mais na inibição da reabsorção óssea. A principal forma de tratamento da osteoporose é a prevenção: deve-se evitar o fumo; álcool e café devem ser consumidos com moderação; a atividade física e ingestão adequada de cálcio são fundamentais; o treinamento proprioceptivo pode colaborar para prevenir quedas e, conseqüentemente, as fraturas.

Expanding the role of the orthopaedic surgeon in the treatment of osteoporosis

Osteoporosis is an increasingly prevalent disease among the aging population, and osteoporotic features account for substantial morbidity, mortality, and healthcare costs associated with this disease. Because the disease is silent until a fracture occurs, the orthopaedic surgeon often may be the physician in the best position to establish the diagnosis and consider the initiation of appropriate treatment. Historically, osteoporosis has been underdiagnosed and treated, but new methods allow accurate diagnosis using bone densitometry, and a range of effective treatment options that can reduce fracture risk. Diagnosis and treatment of osteoporosis fits readily into an efficient algorithmic approach in the office practice of orthopaedics. Orthopaedic surgeons can play a major role in improving the treatment of osteoporosis and decreasing morbidity from this disease. In addition, this can augment the office practice of orthopaedics with a large yet relatively underserved patient population. Finally, densitometry services can provide modest supplemental revenue sources for an orthopaedic practice.

Treatment with human parathyroid hormone (1-34) for 18 months increases cancellous bone volume and improves trabecular architecture in ovariectomized cynomolgus monkeys (Macaca fascicularis)

A key feature of postmenopausal osteoporosis is the loss of trabecular bone mass and connectivity. The current study focuses on these parameters in the assessment of long-term (12 and 18 months) parathyroid hormone (PTH) therapy and its withdrawal (6 months) in the ovariectomized cynomolgus monkey (Macaca fascicularis), a well-characterized model for bone changes associated with postmenopausal osteoporosis. We used static and dynamic histomorphometric parameters to assess the amount and architecture of cancellous bone in four clinically important sites for osteoporotic fractures, including the lumbar vertebra, femoral neck, distal radius, and iliac crest. Recombinant human PTH(1-34) was administered daily to two groups for 18 months at 1.0 microg/kg per day (n = 19) and 5.0 microg/kg per day (n = 21). To study the effects of PTH withdrawal, two groups were administered PTH(1-34) daily for 12 months at 1.0 microg/kg per day (n = 20) and 5.0 microg/kg per day (n = 20), followed by daily administration of vehicle for 6 months. Sham-ovariectomized and ovariectomized (ovx) groups each received daily injections of vehicle for 18 months. Treatment with PTH had minimal effects on bone formation rates at the timepoints studied, but markedly increased cancellous bone volume relative to ovx monkeys in iliac crest biopsies at 6 and 15 months, as well as in terminal specimens of lumbar vertebrae, femoral neck, and distal radius after 18 months. At all sites, PTH significantly improved trabecular architecture, as evidenced by increased trabecular number (Tb.N) and decreased trabecular separation (Tb.Sp), with no significant change in trabecular thickness (Tb.Th). The mechanism of these structural changes is suggested by qualitative observations of trabecular tunneling observed in the iliac crest and vertebra. Longitudinal tunneling of thickened individual trabeculae is hypothesized to convert them into multiple trabeculae, resulting in a normalization of Tb.Th, but an increase in Tb.N. A significant positive effect on cancellous bone volume was still apparent after a 3-6 month withdrawal period following 12 months of PTH treatment in the iliac crest, vertebra, and femoral neck. Corresponding increases in Tb.N and decreases in Tb.Sp also remained significant after PTH withdrawal at these three sites. The distal radius was relatively insensitive to PTH treatment or its withdrawal, compared with the other bones. In summary, PTH therapy dramatically improved cancellous bone mass and architecture in both axial and appendicular sites.