Osteoporosis Clinic

What is the aim of the Osteoporosis Clinic?

• To diagnose osteoporosis (bone loss)
• To identify causes of osteoporosis
• To teach rehabilitation principles to patients with osteoporosis (arrangement of diet, teaching of exercises, prevention of falls, prevention of risk factors)
• To organize patient follow-up
• To enlighten patients about principles of protection from osteoporosis
• To program and follow up treatments focused on causes of osteoporosis
• To collect and publish necessary documents and statistical data

Work order

• Patients who apply to the outpatient clinic are reviewed and examined in terms of osteoporosis. Risk factors are identified.
• All patients who go through menopause or have the following risk factors are required to have their BMD (Bone Mineral Density) measured.
• A spinal and lower back x-ray is required for fractures.
• To identify secondary reasons likely to cause osteoporosis, routine blood and urine tests are performed.
• If necessary, bone tissue production and destruction indicators and advanced laboratory tests are required.
• Among the mentioned tests, the necessary ones may be repeated at certain intervals.

Osteoporosis Working Group

• Physical Therapy and Rehabilitation Specialist
• Physical Therapy and Rehabilitation Specialist
• Endocrinologist
• Geriatrician
• Dietician
• Physical Therapist

What is osteoporosis?

Osteoporosis is a systemic disease in which bone density is reduced and bones become more porous and fragile due to reduction of bone quality and which affects the entire skeletal system. Osteoporosis has now become one of the most prevalent diseases due to the increase in life expectancy and increase in elderly population. While studies show the fact that 1 out of every 3 women and 1 out of every 5 men over 50 experience a fracture in any period of their lives, specialists underline the fact that the best treatment is protection.

Symptoms, diagnosis and treatment of osteoporosis

The most important indication of osteoporosis is fracture. People mistakenly think that osteoporosis may cause pain. Pain associated with osteoporosis is rarely seen unless fracture occurs. Due to a spinal fracture, height is reduced, postural disorders and lordosis occur. Due to lordosis, bones cause pressure on the abdominal cavity and the chest. Organs are negatively affected, and the patient's body appearance deteriorates. This in return triggers psychological problems and isolation of the patient with osteoporosis from the society.

Why is osteoporosis important?

• It is regarded as the most common bone disease.
• Subject to the increase of life expectancy and aged population in the world, the prevalence of osteoporosis and osteoporosis-related fractures significantly increased.
• Today, osteoporosis has become an important economic and social problem.
• It is a preventable and treatable disease.
• Half of the patients with osteoporosis or low bone density in US are not aware of this fact.
• 1.5 million fractures occur a year in US due to osteoporosis, including 300,000 hip fractures, 700,000 vertebral fractures, 250,000 wrist fractures and 300,000 other fractures.
• About 20% of those with a hip fracture die in the 1st year, and more than 30% become disabled.
• Lifelong death risk in post menopausal women aged 50: Coronary heart disease 31.0%, hip fracture.8%, breast cancer 2.8%, cervical cancer 0.7%.
• Hip fracture in the world: 1.7 million in 1990s, and expected to reach 6.3 million by 2050.

Is osteoporosis only observed in women?

Although osteoporosis is known as a disease which mostly women suffer, it is an important health issue also affecting men. The most important known risk factor of osteoporosis is ageing. Positive developments in the diagnosis and treatment of diseases in the current century prolong life expectancy, however, several diseases that increase with age, including osteoporosis, occupy the first ranks of the medical agenda. With the increase of the aged population in the world, the prevalence of osteoporosis and osteoporosis-related fractures significantly increase. Today, death due to hip fractures occupies the third place after death subject to coronary diseases and cancer.

Should men undergo osteoporosis screening?

While studies show the fact that one out of every three women and one out of every five men over 50 experience a fracture in any period of their lives, specialists underline the fact that the best treatment is “protection”. Specialists recommend that all women over 65 should undergo osteoporosis screening, and bone density measurements should be performed generally between 40 and 50 years of age. Also, postmenopausal women over 65 who have additional osteoporosis risk factors or have recently suffered a fracture should undergo osteoporosis screening.

On the other hand, there is no official information that shows when men should undergo osteoporosis screening. Specialists recommend that some elderly men should have routine osteoporosis screening. According to a new research published by the Journal of the American Medical Association, routine testing and treatment of osteoporosis is essential for men of certain age. In the research, a computer program was used to estimate hip fracture risk in men over 65, which represents the group of men having the highest risk of osteoporosis. In the research, indirect and direct medical costs such as low efficiency accompanied by osteoporotic fracture in this group of men were also calculated. As a result of the research, it was determined that men over 65 should undergo routine bone mineral density test if they have fracture in the early period, and men over 80 should undergo routine test, irrespective of history of fracture.

At what age bone loss starts in osteoporosis?

Bones are in fact live tissues which are continuously regenerated through production and destruction activities. This production and destruction process follows a balanced course until the age of 30 in women, however, the balance changes in favor of destruction after that age. After the age of 30 when bone mass reaches the climax, an irrevocable bone loss of 0.5 percent a year starts. This loss speeds up especially after menopause, and the amount of bone tissue lost becomes one of the most important factors that determine whether a woman will experience bone fracture in the future or not.

Which organs does osteoporosis affect?

Osteoporosis mostly affects the vertebral bones that bear the body weight. Of all osteoporosis cases, 47 percent occurs in vertebral bones, 20 percent in the hip, 13 percent in the wrists and 20 percent in other bones. Subject to compression fractures in the vertebral bones, height reduction may occur especially at advanced ages. Fatal fractures may also develop in other bones including the hip in particular, due to mild falls or spontaneously.

What are the consequences of osteoporosis?

The most important consequences of osteoporosis are fracture and disability caused by fracture. Risk of fracture in hip, vertebra and wrist particularly after the age of 50 is considered to be 40 percent in women and 13 percent in men. These statistical data show that 4 out of every 10 patients over 50 face the risk of hip, vertebra or wrist fracture. When the cost and social aspects of fracture is reviewed, major problems occur. Today, 1.5 million fractures occur a year in US, including 300 thousand hip fractures, 700 thousand vertebral fracture, 250 thousand wrist fractures and 300 thousand other fractures. Unfortunately, 20 percent of the patients who suffer a hip fracture die in the first 1 year, and more than 30 percent become disabled. The number of hip fractures which was 1.7 million in early 1990s is expected to rise to 6.5 million by 2050.

What are the risk factors in osteoporosis?

Risk factors are classified under two headings, including major and minor risk factors. Major risk factors include, inter alia, very low bone density. For this reason, bone density measurement should be performed between the ages of 45 - 50, which are regarded as osteoporosis ages. After evaluating risk factors, the doctor should decide at what intervals these measurements have to be repeated.

Another risk factor is age. The possibility of fracture risk is different a patient aged 50 and a patient 80 even if they have the same bone density. It is because bone quality deteriorates with age. The reduction in quality increases the risk of fracture irrespective of density. Contrary to what we knew in the past, fracture risk is now evaluated by reviewing not only bone density but also micro-architectural structure and quality of bone.

Fractures suffered in the past also increase fracture risk. If the patient has a vertebral fracture in his/her past, it is possible to say that he/she is 5 times more likely to experience a new vertebral fracture in 1 year, and 2 times more likely to experience a new hip fracture in 3 years. If the mother, any sibling or aunt has history of fracture, the risk to have a new fracture in 1 year is increased by 1.5 to 2 times.

Minor risk factors in osteoporosis:

Gender is the primary minor risk factor in osteoporosis. 4 out of every 5 fractures are observed in women. The fracture risk of white women is higher than that of African women. Today it is believed that genetic characteristics have a 70 to 80 percent effect on bone structure. Excessive alcohol and caffeine consumption, long-term use of corticosteroids and drugs used in thyroid treatment are causes that elevate the risk of osteoporosis. Estrogen deficiency is another trigger of osteoporosis.

Early menopause or menopause caused by surgical intervention break bone production and destruction balance in favor of production. For this reason, women who go through menopause at or before the age of 38 for any reason should be examined in terms of osteoporosis. Also, diseases of the thyroid gland, severe lung and renal diseases, some rheumatic diseases are among the minor factors.

How is osteoporosis diagnosed?

The golden standard in the diagnosis and treatment of osteoporosis is bone mineral density measurement. In addition, spinal and lower back x-rays of patients are required on a routine basis in order to understand whether there is fracture or not. Also, to review other diseases likely to cause osteoporosis, blood and urine tests are important.

How is osteoporosis treated?

In the past, one would first recall hormone therapy when osteoporosis treatment was concerned. However, this method is not recommended much in the recent years. Hormone therapy should only be used when other symptoms of menopause such as sweating, hot flush, sleeplessness, irritability, are intensively experienced. Hormone therapy has no other role in osteoporosis treatment. The aim in osteoporosis treatment should be to prevent fractures, to protect and even increase bone mineral density, struggle with complaints due to fracture and postural dysfunction, to maximize daily activities and improve life quality. Instead, elements such as bisphosphonates, strontium, selective estrogen receptor modulators, i.e. SERMs, calcitonin, parathormone, and drugs containing estrogen of herbal origin are preferred. The treatment should include calcium which is the building block of bone and vitamin D to increase calcium absorption.

Osteoporosis prevention

• Prevention of falls
• Arrangement of diet
• Inducing physical activities and exercise
• Protection from risk factors
• Sufficient calcium intake
• Sufficient vitamin D intake

Why do we fall?

Facts about falls

• One out of every 3 elderly aged 65 and over falls.
• Falling rate is clearly higher in women than in men.
• 30-70 percent of those who fall fear falling again, and have to continue their lives with that fear. People who fall are highly likely to experience depression, social isolation and hopelessness.
• Arms, legs, ribs and ankles are the parts of the body that suffer fractures most.
• Fractures constantly increase in the group aged 75 and above.
• 75% of deaths associated with falls is observed in people aged 65 and above.
• Hip fracture develops in 1% of those who fall.
• Hip fracture related death rate (one out of every 3 persons with a hip fracture die in 1 year) and disability rate (1 out of every2 persons with a hip fracture become disabled) are quite high.

Why do we fall?

A- Personal reasons

• Gait disorders
• Diseases of the nervous system
• Ear diseases
• Ophthalmologic disorders
• Loss of muscle power
• Old age
• Use of walking sticks and crutches
• Balance disorders
• Medications used

B- Environmental factors

• Improperly placed house furniture, clothes and shoes
• Stairs
• Traffic lights
• Failure to take measures on wet floor
• First days in new living areas
• Selection of inappropriate shoes

Who do fall more frequently?

• People with insufficient muscle power
• People with a history of fall (people who had fallen in the past are more likely to fall again)
• People with gait disorders
• People with balance disorders
• People who use walking sticks and crutches
• People with visual impairment
• People with joint diseases
• People aged 80 and above
• People who use four or more drugs

With age, postural impairment (scoliosis), reduced strength (weakness of muscles surrounding the hip and the knee), gait disorders (walking with small and frequent steps), weakened reflexes (insufficiency of reaction shown against an unexpected obstacle), activities such as extension, bending, sitting and standing frequently cause falls.

How can falling be prevented?

A- Exercise programs

• Flexibility, strength, balance and aerobic exercises
• Fixed and active balance exercises
• Group exercises (1 hour 2-3 times a week and for maximum 10 weeks)
• Thai Chi exercise program
• Use of suitable shoes

B- Evaluating and changing environmental factors

• Evaluation of patients who are under high risk
• Removing potential hazards from the environment
• Assuring safety of mobility
• Use of auxiliary equipment

C - Taking multi-factorial measures

• Arranging medicinal treatment after the evaluation of falling risk
• Exercise, education and environmental arrangement

Evaluation in terms of nursing homes and hospitals

• Room doors should have warning cards
• Rooms should be close to the nurse station
• Patient / Attendant rate should be balanced
• Closer observation should be stipulated
• Beds, toilets, and bathrooms should be suitable for use of alarms
• Use of hip protectors should be increased

Osteoporosis risk test

1) Has your mother or father experienced a hip fracture after a simple strain or a mild fall?

- Yes – No

2) Have you ever experienced a hip fracture after a simple strain or a mild fall?

- Yes – No

3) Have you taken any cortisone-containing drugs for longer than 3 months?

- Yes – No

4) Has there been a reduction more than 3 centimeters in your height?

- Yes – No

5) Do you consume excessive alcohol?

- Yes – No

6) Do you smoke more than 20 cigarettes a day?

- Yes – No

7) Do you frequently experience diarrhea? (Do you have Celiac or Crohn’s disease?)

- Yes – No

For women

8) Have you gone through menopause before the age of 45?

- Yes – No

9) Has your menstruation period been delayed or interrupted for 12 months?

- Yes – No

For men

10) Have you ever experienced loss of impotency or libido due to reduction in your testosterone level?

- Yes – No

If you have given the answer yes to one or more of these questions, you should consult a doctor.