Osteoporosis - risk factors, pharmaceutical and non-pharmaceutical treatment - European Review for Medical and ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
European Review for Medical and Pharmacological Sciences 2021; 25: 3557-3566
Osteoporosis – risk factors, pharmaceutical and
non-pharmaceutical treatment
W. TAŃSKI1, J. KOSIOROWSKA2, A. SZYMAŃSKA-CHABOWSKA3
1
Department of Internal Medicine, 4th Military Teaching Hospital, Wrocław, Poland
2
Research Office, 4th Military Teaching Hospital, Wrocław, Poland
3
Department of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology,
Wrocław Medical University, Wrocław, Poland
Abstract. – Osteoporosis is a metabolic dis- bral, followed by hip fractures and distal forearm
ease of the skeletal system which currently af- fractures. Osteoporosis typically has a silent,
fects over 200 million patients worldwide. The insidious course1.
WHO criteria define osteoporosis as low bone
mineral density, with a T-score ≤ −2.5 found in
According to data from the International Os-
the spine, the neck of the femur, or during a full teoporosis Foundation, the disease currently af-
hip examination. Osteoporosis considerably re- fects over 200 million women. It mostly affects
duces a patient’s quality of life. QoL should be women above 60 (60%) and men above 70 years
carefully evaluated before fractures occur to en- of age (20%). Approx. 30% of women and 20%
able the development of an appropriate treat- of men aged 50 and above experience osteopo-
ment plan. The progression of osteoporosis rosis-related fractures. In 2010, 21 million men
may be significantly inhibited by following a
proper diet, leading a healthy lifestyle, taking and 137 million women were at risk of osteopo-
dietary supplements, and receiving appropriate rotic fractures. The number of patients at high
treatment. Education and the prevention of the risk of osteoporosis fractures is expected to rise
disease play a major role. Potentially modifiable from 158 million in 2010 to 319 million in 2040.
risk factors for osteoporosis are vitamin D defi- According to a 2010 report, 22 million women
ciency, smoking, alcohol consumption, low cal- and 5 million men had been diagnosed with os-
cium intake, low or excessive phosphorus in-
take, protein deficiency or a high-protein diet,
teoporosis in EU member states, and the number
excessive consumption of coffee, a sedentary of fractures stood at 3.5 million. In Poland, there
lifestyle or lack of mobility, and insufficient ex- are approx. 2 million patients aged 50 and above
posure to the sun. Pharmaceutical treatment for with osteoporosis. When it comes to osteoporotic
osteoporosis involves bisphosphonates, calci- fractures, they occur in 30% of women and 8%
um and vitamin D3, denosumab, teriparatide, of men in the same age group. According to es-
raloxifene, and strontium ranelate. Data indi- timates, overall one in three women and one in
cates that 30%-50% of patients do not take their
medication correctly. Other methods of treat- five men over 50 will experience an osteoporotic
ment include exercise, kinesitherapy, treatment fracture. Fracture risk increases with age and is
at a health resort, physical therapy, and diet. much higher in women2,3.
The World Health Organization (WHO) cri-
Key Words: teria define osteoporosis as low bone mineral
Osteoporosis, Risk factors, Treatment, Physiother- density, with a T-score ≤ −2.5, found in the
apy, Diet.
spine, the neck of the femur, or during a full hip
examination. However, the definition does not in-
clude cases of patients with normal bone mineral
Introduction density who have experienced an osteoporotic
fracture, among others. This is extremely import-
Osteoporosis is a metabolic disease of the skel- ant, as 75% of these fractures occur in patients
etal system. It is a widespread public health issue with signs of osteopenia. Bone strength depends
that may lead to disability, especially among both on bone mineral density and on bone tissue
the elderly. Due to its insidious, asymptomatic quality. Therefore, in 2001, the National Institute
course, it is often first diagnosed when a fracture of Health (NIH) developed a definition of osteo-
occurs. The most common fractures are verte- porosis as a generalized skeletal system disease
Corresponding Author: Anna Szymańska-Chabowska, MD, Ph.D; e-mail: aszyman@mp.pl 3557W. Tański, J. Kosiorowska, A. Szymańska-Chabowska
associated with decreased bone strength and an modifiable and non-modifiable.
increased risk of fractures3-5. Non-modifiable factors account for most of the
Osteoporosis considerably reduces the patient’s risk of osteoporosis and include:
quality of life (QoL) and is associated with high • Advanced age
rates of morbidity and mortality from comorbid- • Female sex
ities. It may result in greatly reduced physical • Familial predisposition
performance and permanent disability. The pro- • Caucasian race
gression of osteoporosis, especially in its initial • History of fractures in adulthood
stages, may be significantly limited by following • Dementia
a proper diet, leading a healthy lifestyle, taking • Poor health
dietary supplements, and receiving appropriate • Delicate constitution
treatment. Education on the disease and its pre-
vention plays a major role6-9. Table I provides the Potentially modifiable risk factors for osteopo-
clinical classification of osteoporosis. rosis include:
• Vitamin D deficiency
Risk Factors • Smoking
Bone tissue loss, occurring progressively with • Alcohol consumption
age, is a natural process associated with slowing • Low calcium intake
metabolic processes in the body. The process may • Low or excessive phosphorus intake
be accelerated by certain adverse factors, both • Protein deficiency or high-protein diet
Table I. Osteoporosis classification – by stage of disease progression.
Stage Symptoms Clinical features Radiographic features
Early • Pain in the spine and • Postural defects that may be • No lesions typical for osteoporosis
upper extremities actively corrected by the patient • Osteopenia in densitometric
• Feeling down, • Increased paraspinal muscle examination
sometimes depression tension
• Possible intercostal pain • Abdominal and gluteal
at maximum inspiration muscle weakness
• Paraspinal muscle tenderness
• Painful but unrestricted
active spine movement
Advanced • Pain in the spine • Postural abnormalities, increased • Decreased vertebral body
typically increasing cervical and lumbar lordosis and saturation
during movement thoracic kyphosis • Loss of horizontal trabecular
• Feeling down, • Active posture correction is not pattern
often depression fully possible • Thinning of the cortical layer
• Abdominal wall laxity and • Sometimes — reduced vertebral
depression of the ribs body height
• Skin folds on the back arranged • Osteoporosis in densitometric
in a herringbone pattern examination
• Less pronounced waist
indentation
Late • Constant spinal • Fixed thoracic kyphosis • Lesions typical for osteoporosis
pain increasing • Pain while trying to • Healed fracture sites
with movement correct the kyphosis • Osteoporosis in densitometric
• Abnormal posture • Increased cervical lordosis examination
• Loss of height and forward head tilt
• Avoidance of social • Abdominal wall laxity
contacts and • Depression of the rib cage,
physical effort at times with ribs in
• History of lower contact with the ala
and/or upper • Weakened abdominal, gluteal,
extremity fractures leg, and arm muscles
• Hips and knees bent • Tenderness of paraspinal muscles
when standing and spinous processes of vertebrae
3558Osteoporosis – risk factors, pharmaceutical and non-pharmaceutical treatment
• Excessive consumption of coffee • Minimizing gaps in treatment.
• Sedentary lifestyle or lack of mobility • Using new, safer and more effective medica-
• Insufficient sun exposure10-13. tions.
• Providing optimal pharmaceutical and non-phar-
In Table II the consequences of osteoporosis maceutical treatment (interventions including
are presented. specific exercises to improve muscle strength
and balance, reduce pain, and improve subjective
Treatment of Osteoporosis QoL).
Physical, emotional, and psychological disabil- • Using new treatment strategies: defining and
ity, combined with the pain experienced after a targeting high-risk patients5.
hip, spine, or wrist fracture, considerably affect
the patient’s QoL. QoL in men and women with Pharmaceutical Treatment
osteoporosis should be carefully evaluated before Pharmaceutical treatment for osteoporosis
fractures occur, so as to enable the development most commonly involves the use of bisphospho-
of an appropriate treatment plan with a view to nates, which must be accompanied by calcium
alleviating patients’ symptoms at all stages of the and vitamin D3 supplements and regular blood
disease. Specialists treating osteoporosis within a tests. Another drug used in the treatment of
comprehensive treatment plan have identified two osteoporosis, both in first-line therapy and at
stages of intervention: subsequent stages, is denosumab. It inhibits os-
Stage I – primary care including: (1) screen- teoclast activity, producing a rapid but reversible
ing: taking the patient’s history and carrying antiresorptive effect. In severe osteoporosis with
out a physical examination, an assessment of fractures, once other drugs have proven ineffec-
muscle strength, assessing clinical risk factors tive, teriparatide may be used. It is a parathyroid
for fractures (FRAX) and risk factors for falls; hormone derivative and a strong promoter of
(2) early prevention; (3) further diagnostics for bone formation. However, due to its high price
osteoporosis. and the fact that it is non-refundable through the
Stage II – specialist care: (1) differential diag- National Health system, the drug is virtually un-
nosis; (2) detailed evaluation of all fracture available in Poland. The situation is similar with
risk factors, including sarcopenia and frailty raloxifene, which may additionally cause compli-
syndrome; (3) education; (4) effective phar- cations such as thrombosis and hot flushes. The
maceutical and non-pharmaceutical treatment risk of fracture may be effectively reduced by
(physical therapy, fall prevention, vitamin D strontium ranelate, which inhibits bone resorp-
supplementation, diet modification, monitor- tion and promotes bone formation. However, the
ing of treatment). drug has adverse cardiovascular effects and is not
available in Poland5,14. The medications applied in
Osteoporosis prevention includes: osteoporosis have been summarized in Table III.
• Optimizing peak bone mass in young adults. Despite the high risk of death, with the mor-
• Implementing a four-stage diagnostics plan for tality rate within one year of the femoral frac-
patients with clinical risk factors for osteopo- ture reaching 15-40%, poor patient compliance
rotic fractures. is common. Epidemiological data indicates that
• Accurately measuring bone strength. approximately 30-50% of patients do not take
Table II. Consequences of osteoporosis.
Consequences of osteoporosis
Physical Social and psychological
Fractures Sleep disorders
Reduced physical performance Quality of life deterioration
Difficulty performing daily activities Depression
Chronic pain Social isolation
Upper back kyphosis – “dowager’s hump” Deterioration of economic and financial standing
Gastrointestinal disorders: bloating, pain, difficulty in passing Disability
stools, sense of fullness
Loss of height
3559W. Tański, J. Kosiorowska, A. Szymańska-Chabowska
Table III. Medications in osteoporosis treatment.
Drug Dosage form Additional information
Alendronate Tablets –
Ibandronate Tablets/prefilled syringe Only used in postmenopausal osteoporosis, to reduce
the risk of spinal fracture. Not recommended for men
Risedronate Tablets –
Zoledronate Solution for infusion –
Denosumab Prefilled syringe Not effective in glucocorticoid-induced osteoporosis
Raloxifene Tablets Only used in postmenopausal osteoporosis to reduce
the risk of spinal fracture. Not recommended for men.
Rarely used due to the possible adverse effects
Teriparatide Solution for injection Does not improve the risk of femoral neck fracture.
Strontium ranelate Granules for oral solution Not effective in glucocorticoid-induced osteoporosis.
Use restricted due to possible thromboembolic complications.
their medication correctly. Most patients discon- often are shown to be clearly more persistent.
tinue treatment within the first three months, but Patients are also more likely to take medica-
some do not even start the prescribed treatment tions that cause fewer restrictions in their daily
at all or stop it soon after starting. Only one in activities. Bisphosphonates must be taken on
two patients still continue treatment after a year, an empty stomach and require the patient to
and one in three – after two years. As shown remain upright for at least 30 minutes, which
by published analyses, only one in four patients makes weekly administration far preferable to
comply with the treatment recommendations they daily administration.
receive. The main reasons for non-compliance
include: lack of motivation to continue treat- Other Treatment Methods
ment, lack of symptoms at the initial stage after Other treatment methods for osteoporosis, used
diagnosis, progression of the disease while on in conjunction with pharmaceutical treatment:
medication, adverse effects of treatment or fear Exercise with osteoporosis: As the percentage
of adverse effects, lack of knowledge regarding of elderly individuals in society continues to
the consequences of non-compliance, and lack increase, more physicians are becoming in-
of belief that the medication is helping. Problems terested in osteoporosis. Recent research has
with communication between the physician and confirmed the significant role of physical activ-
the patient are reported as another reason for ity in the rehabilitation of patients with osteo-
inadequate compliance with treatment in this pa- porosis. Expected benefits of regular exercise
tient group. According to physicians, lack of un- include:
derstanding on the part of the patient is the main • Reduction of pain,
cause for the discontinuation of treatment in 12% • Prevention of falls and fractures,
of cases. However, among the 85% of physicians • Activation of the sensorimotor system,
who reported having patients who had discontin- • Improved mobility,
ued their osteoporosis treatment, as many as 71% • Improved subjective QoL15.
did not know the reason for this. The vast major-
ity of physicians do not know how to effectively Kinesitherapy in the early stages of osteopo-
motivate their patients. They mostly discuss the rosis: These interventions include education
consequences of non-compliance but are unable on maintaining proper posture and doing an-
to improve patients’ motivation. According to ti-kyphosis exercises, including individual and
patients, the best motivator is the possibility of group exercises for spinal unloading, comple-
keeping one’s independence and autonomy if they mented with resistance exercises. The load on
regularly take their medication. bone structures associated with an upright po-
One factor that often adversely affects ad- sition is considered to improve mineralization.
herence is difficulty with medication protocol There is no unanimity on the effectiveness of
and the frequency of dosage. Research demon- kinesitherapy with bodyweight unloading (in
strates that a switch from daily to weekly dos- a pool). Water at 25-30°C enables free move-
es significantly improves treatment outcomes. ment and perfectly complements the therapy.
Patients who can take their medication less At lower temperatures, muscles may become
3560Osteoporosis – risk factors, pharmaceutical and non-pharmaceutical treatment
cold and stiff, while higher temperatures may must be performed correctly so as to improve
accelerate the onset of fatigue, especially in oxygen uptake and distribution to tissues. Pain
the elderly. Important aspects at this stage also can interfere with breathing and movement.
include coordination and balance training, as Inhalations and exhalations are shallow, with
well as gait improvement. These interventions’ minimal engagement of the respiratory mus-
main objectives include increasing patients’ cles and only slight chest movements. Accu-
independence, delaying aging, and promoting mulation of mucus and problems with evacu-
the principles of ergonomics, including the ating it is also a problem. Breathing exercises
correct ways to sit down, stand up, lie down, must increase the patients’ respiratory perfor-
and lift and carry objects. mance and vital lung capacity and teach them
to expectorate and cough without exacerbating
Kinesitherapy in advanced osteoporosis: At pain. During these exercises, care must be
this stage, the bone structure becomes altered. taken to ensure patient safety and protect the
Exercises should focus on promoting bone weakened bone structures.
tissue regeneration, delaying demineralization, 2. Exercises to improve posture and joint mobil-
and improving muscle strength and physical ity – the weakening of bone structures associ-
function. Orthopedic appliances are used at ated with osteoporosis leads to the alteration
this stage, and patients are taught to stand of the normal curvature of the spine, and the
back up after a fall. Besides crutches, walking resulting pain restricts the patient’s movement,
sticks, and walking frames, neck braces may interfering with physical activity and perpetu-
be used to reduce cervical spine overload due ating the abnormalities. Movement is also hin-
to spinal muscle strain. dered by contractures in the limbs and joints.
Initially, passive and semi-passive exercises
Kinesitherapy in late osteoporosis: Fractures are advised as they can improve joint mobility.
and changes in body shape make it impossible They should be followed by a gradual recovery
to restore correct posture, but continued cor- of proper posture and the elimination of bad
rective exercises suited to each patient’s condi- postural habits.
tion can still be helpful. These exercises focus 3. Resistance exercises for all muscle groups.
on reducing pain by regulating muscle tension Proper posture during exercise is of the utmost
and unloading bone structures. Kinesitherapy importance, as it ensures that bone structures
involves exercises to improve lung ventilation, are not overstressed. All exercises are per-
and isometric exercises to relax muscles in the formed slowly, with a gradual increase in both
limbs and torso. In patients with fractures, it is load and range.
crucial to accelerate healing and enable safe, 4. Balance exercises – disorders connected with
independent walking using supports such as balance can be caused by: impaired function-
walking frames and orthotics. These supports ing of the vestibular system, neuromuscular
are used for a period of time, depending on the conduction and vision, vertigo, and muscle.
severity of pain and how fracture healing pro- These disorders may prevent the patient from
gresses. They must be combined with exercises reacting correctly to balance disturbances,
to maintain bone density. In many cases, the leading to particularly dramatic falls in elderly
only appropriate solution involves the constant people. Therefore, these exercises aim to im-
use of neck and back braces, protecting the prove the patient’s ability to verify the sensory
patient from subsequent trauma. information coming from their environment,
The effectiveness of physical exercises in promoting neural flexibility and strengthening
terms of maintaining appropriate bone min- the coordination between proprioception, vi-
eral density and preventing fractures has been sion and the vestibular sense.
demonstrated in research. 5. Training for everyday activities – exercises to
improve joint mobility, muscle strength and
Most Commonly Used Exercises coordination, so as to ensure physical fitness
1. Breathing exercises – these are particularly sufficient for independent functioning in life
important in the elderly population, as they and to improve QoL.
reduce the extent of involutional changes that 6. Water exercises – the recommended water
have already occurred in the respiratory sys- temperature of 25-33°C allows for a greater
tem, causing restrictions in activity. Exercises range of motion, and buoyancy in water reduc-
3561W. Tański, J. Kosiorowska, A. Szymańska-Chabowska
es pain, enabling the patient to overcome any smoking, alcohol abuse), an increase in phys-
psychological barriers more easily. ical activity, and adhering to a healthy diet.
Additionally, physical therapy should be im-
In a study by Angin et al4, there was a signifi- plemented to reduce pain, increase functional
cant increase in bone mineral density in patients performance and minimize the risk of fracture.
who participated in Pilates-based exercises for 6 In addition to pharmaceutical treatment and
months. Moreover, exercise has been shown to physical therapy, social support and psycho-
be as effective as a pharmaceutical treatment in therapy play a significant role, as the disease is
reducing the risk of osteoporosis in postmeno- often accompanied by depression, loneliness,
pausal women. Additionally, Pilates exercises and social isolation. A physical rehabilitation
prevent musculoskeletal injury by strengthening specialist must assess a patient’s fall risk and
pelvic and upper body muscles. Active par- plan a program of physical therapy and educa-
ticipants also had significantly greater muscle tion accordingly. Comprehensive rehabilitation
strength, flexibility and endurance, compared to therapy is provided to prevent falls and frac-
controls. tures and to limit their consequences if they
Another study on postmenopausal women with do occur. Promoting daily physical activity,
osteopenia evaluated the impact of 24 weeks of raising awareness of individual risk factors,
aerobic dance exercises on bone mineral density, and monitoring the patient for gait and balance
physical fitness, and QoL. Findings indicated that disorders, consequences of any falls that do oc-
participation in aerobic dance exercises could cur, and frailty syndrome are important aspects
result in fewer fractures due to higher bone min- in this area. Safety awareness in every day ac-
eral density and a reduced risk of falling. There tivities is particularly important.
were statistically significant differences between In Poland, there is a system of health re-
active participants and controls in terms of pain, sort medicine that takes advantage of the health
levels of physical activity, social life, and per- benefits of local climate and natural medicinal
ceived health. All of the patients regularly took resources. Health resorts combine pharmaceuti-
bisphosphonates, calcium, and vitamin D. Those cal treatment, physiotherapy, psychotherapy, and
who engaged in osteoporosis-focused exercises dietary interventions. The use of these multiple
had a significantly better QoL than those who methods enables comprehensive therapeutic and
did not16. preventive management. In health resort medi-
There are various exercise programmes ded- cine, treatments must be repeated in prescribed
icated to osteoporosis patients, which are de- cycles, and effects tend to develop over time.
signed to help improve bone mineral density and However, these beneficial effects typically persist
prevent falls and fractures. Their effectiveness longer than those resulting from pharmaceutical
in this regard has been demonstrated through treatment, and adverse effects are considerably
research. Positive outcomes were observed after less common. In addition, health resort treat-
aerobic exercises, weight training, and resistance ments are typically less costly and more pleasant
band training. Research has shown that patients for the patient18.
with osteoporosis who performed exercises us- In Poland, health resorts providing osteoporo-
ing TRX exercise bands experienced less pain, sis treatments are located, e.g., in Ciechocinek,
became more physically fit, and achieved a better Cieplice Śląskie Zdrój (part of the town of Jelenia
QoL17. Góra), and Duszniki Zdrój.
Physical treatments provided in health resorts
include natural therapeutic procedures (balneo-
Health Resort Medicine and therapy) and hydrotherapy, psychotherapy, kine-
Physical Therapy sitherapy, and massage therapy.
Complications connected with osteoporosis, Balneotherapy is one of the most important
such as fractures, are common in the popula- methods used in health resorts. Mineral waters
tion and early identification of at-risk patients are used for therapeutic baths, as well as for
is extremely important. Early diagnosis is the drinking and inhalation. Peloids, such as peat, are
best way of preventing fractures. Besides phar- used for massages, wraps, baths and sitz baths.
maceutical treatment, therapy for osteoporo- In hydrotherapy, water at a specific pressure and
sis patients should include lifestyle changes temperature is used. Examples of hydrotherapy
such as the cessation of harmful habits (e.g., treatments include: showers and jets, bubble and
3562Osteoporosis – risk factors, pharmaceutical and non-pharmaceutical treatment
whirlpool baths, aquatic massages and hydro Diet
massages. Physicotherapy uses various forms Nutritional deficiencies are a common cause
of energy, such as electrical currents, magnetic of muscle dysfunction and adverse qualitative
fields, light and ultrasounds19,20. changes in bone tissue. The most dangerous defi-
Bone mineral density can be improved with ciencies are those occurring in childhood and ad-
the use of low-frequency alternating magnetic olescence, during skeletal development and peak
fields (LFAMF). Research has demonstrated that bone mass accumulation.
such interventions positively affect bone heal- Normal functioning of the skeletal system is
ing. Some publications have confirmed improved significantly affected by the intake of calcium,
bone mineral density in patients with osteoporo- vitamin D3 and protein. A sufficient intake of
sis after magnetic field therapy. these substances ensures that bone tissue has the
A major role in the treatment and prevention of required mechanical strength and in the elderly
osteoporosis is also played by light therapy and reduces the risk of falls and fractures.
UV phototherapy, which stimulates the produc- The recommended daily intake of calcium and
tion of vitamin D3 in the skin. A wavelength of vitamin D is 1200 mg and 800 IU, respectively.
280-315 nm is recommended12. These doses reduce the risk of fracture in individ-
Osteoporosis rehabilitation guidelines main- uals over 65 years and postmenopausal women21.
ly focus on the selection of appropriate kine-
sitherapy exercises. Thermotherapy treatments Calcium
should be avoided, as they may exacerbate A balanced diet is the best way to ensure
the symptoms. Chronic pain in osteoporosis adequate calcium intake. The required calcium
is alleviated by such treatments as massages, intake depends on age, lifestyle, sex, and physio-
galvanic treatment, iontophoresis, diadynam- logical state, and ranges between 1000 and 1300
ic currents, interference currents, ultrasound, mg daily. Good sources of this mineral include
magnetotherapy, and – in a health resort setting dairy products (yogurt, cheese, buttermilk), sesa-
– peloidotherapy (peat pulp baths) and cren- me seeds, nuts, almonds, and pulses.
otherapy (curative water drinking). Table IV To increase the dietary intake of calcium, sup-
lists the guidelines for these various treatments plements with organic or inorganic compounds
for osteoporosis. containing calcium ions may be used. Dietary
Patients with osteoporosis require comprehen- supplements vary greatly in efficacy and absorb-
sive management by a specialized rehabilitation ability, based on their content of calcium ions,
team, physicians, physical therapists, psycholo- their chemical form and the excipients used. The
gists, occupational therapists, nutritionists and bioavailability of calcium is better when organic
others. All their interventions aim at inhibiting forms are used, e.g. gluconate, citrate or lactate.
the progression of the disease and improving Organic calcium compounds are also present in
the patients’ QoL. Further follow-up, popula- food, and therefore the body’s absorption and re-
tion-based studies, and randomized clinical trials tention of Ca2+ ions is better in the case of dietary
are warranted in this area. sources. Calcium ions are only absorbed in the
Table IV. Role of physical therapy in osteoporosis.
Procedure Intensity Duration (min) Frequency Series Notes
Galvanic currents Low 10-20 Daily or every other day 10-20
moderate
Iontophoresis Locally 20 Daily or every other day 10-20 Calcium – anode
Diadynamic currents 1-3 mA DF – 1CP – 4 Daily or every other day 10 1-week break
Interference currents 0-10, 10-15 Daily or every other day 10-15 Alternately with
0-100 diadynamic
Ultrasound 0.2 W/cm 2 3-65-8 Daily or every other day 6-8 Paraffin (water,
10-15 local/segmental)
Magnetotherapy 15 mT 12 × 3 Daily 60 Alternating
magnetic field
Peloidotherapy 37°C 15-20 Every other day 10-15 Peat pulp bath,
total or partial
3563W. Tański, J. Kosiorowska, A. Szymańska-Chabowska
presence of vitamin D (calcitriol), which is why Table VI. Calcium content per 100 g in selected foods.
both calcium and vitamin D intake is important
Product Calcium content per 100 g*
for the prevention of osteoporosis14. Table V lists
the adequate daily intake of calcium in adults, Poppy seeds 1266 mg
and Table VI – the calcium content in selected Sardines in oil 330 mg
foods5,22,23. Soybean seeds, dry 240 mg
Almonds 239 mg
Dried figs 203 mg
Vitamin D Linseeds 195 mg
In Poland, vitamin D3 deficiencies are com- Parsley leaves 193 mg
mon. During the autumn and winter, supplemen- Hazelnuts 186 mg
tation is required due to insufficient synthesis of White beans, dry 163 mg
the vitamin in the skin. Deficiencies are particu- Plain yogurt 170 mg
Cow’s milk 120 mg
larly common in people with joint diseases and Low-fat cottage cheese 96 mg
in the elderly. Supplementation should follow Hard cheese 867 mg
the applicable guidelines developed for the Cen-
tral European population. However, the dosage
should not be lower than 800-1000 IU/day in
adults, as this dose reduces the risk of fracture – with lower muscle strength. Difficulty getting
in postmenopausal women and in individuals of up from a chair or climbing stairs, or chronic
both sexes aged 65 or above. Patients with osteo- muscular pains, are symptoms of major vitamin
porosis who are found to have a low serum level D deficiency.
of vitamin D3 require compensation with ther- In the context of osteoporosis in postmenopaus-
apeutic doses. In such cases, the recommended al women, the use of vitamin D supplements has
dose may be as high as 7000 IU per day for 8-12 been shown to increase calcium absorption in the
weeks, followed by 2000 IU per day to maintain gut. However, it is not recommended for routine
the effect. use in healthy women with normal calcidiol levels.
Vitamin D has a number of health benefits, Small quantities of vitamin D are found in
including: food, mainly in fat-rich animal products. Ta-
• Reduction of bone resorption, ble VII lists the vitamin D content in selected
• Improvement of bone quality, foods5,24.
• Reduction of fall risk due to better balance,
muscle strength, joint mobility, coordination,
and quality of life. Protein
Protein is considered to be another significant
Vitamin D deficiencies result in a loss of factor in the pathogenesis of osteoporosis. Both
muscle strength, grip strength, and mobility. Re- an excessive and an insufficient dietary intake of
search shows that serum levels of vitamin D be- protein may contribute to bone loss. Protein de-
low 50 nmol/L are associated with a higher risk ficiency impairs the synthesis of collagen, which
of balance disorders, and levels below 30 nmol/L accounts for a considerable part of bone mass.
It also adversely affects the synthesis of IGF-1,
Table V. Adequate intake of calcium in adults. a growth factor necessary for normal bone tis-
Daily calcium intake – AI*
Table VII. Vitamin D sources.
Men and women aged 19-50 years 1000 mg
Women and men aged > 51 years 1300 mg Product Vitamin D content
Pregnancy and lactation < 19 years 1300 mg
Pregnancy and lactation ≥ 19 years 1000 mg Fresh eel 1200 IU/100 g
Pickled herring 480 IU/100 g
*Adequate intake (AI) – the recommended average daily in- Herring in oil 808 IU/100 g
take level based on observed or experimentally determined Fresh cod 40 IU/100 g
approximations or estimates of nutrient intake by a group Baked salmon 540 IU/100 g
of apparently healthy and well-nourished people that are as- Canned sardines/tuna 200 IU/100 g
sumed to be adequate for most in this group. This recom- Hard cheese 7.6-28 IU/100 g
mendation is used when the average requirement cannot be Breast milk 1.5-8 IU/100 ml
calculated. Cow’s milk 0.4-1.2 IU/100 ml
3564Osteoporosis – risk factors, pharmaceutical and non-pharmaceutical treatment
sue growth in adolescents. The currently recom- 2) IOF Compendium of osteoporosis, 2019; 34-62.
mended protein intake is 1.2 g/kg of body weight. 3) Dardzińska J, Chabaj-Kędroń H, Małgorzewicz
Notably, the balance of animal and plant pro- S. Osteoporosis as a social disease – prevention
tein in one’s daily diet is key in preventing methods. Hygeia Public Health 2016; 51: 23-30.
osteoporosis. Excessive consumption of animal 4) Angin E, Erden Z, Can F. The effects of clinical
pilates exercises on bone mineral density, physi-
protein results in the release of phosphates and cal performance and quality of life of women with
carbonates stored in bone, and with them, a cer- postmenopausal osteoporosis. J Back Musculo-
tain amount of calcium. This process can lead skelet Rehabil 2015; 28: 849-858.
to decreased bone mineral density. Therefore, 5) Lorenc R, Głuszko P, Franek E, Jablonski M, Ja-
pulses should be used as an alternative source of worski M, Kalinka-Warzocha E, Karczmarewicz
protein. Diets with a high ratio of animal to plant E, Kostka T, Księzopolska-Orłowska K, Marcin-
kowska-Suchowierska E, Misiorowski W, Więcek
protein have been found to be associated with the A. Guidelines for the diagnosis and management
highest incidence of osteoporotic fractures. of osteoporosis in Poland. Update 2017 Endokry-
Phytoestrogens also have a demonstrated posi- nol Pol 2017; 68: 604-609.
tive impact on bone tissue. In a study on a group 6) Tadic I, Vujasinovic Stupar N, Tasic L, Stefanovic D,
of postmenopausal women, the consumption of Dimic A, Stemenkovic B, Stojanovic S, Milenkovic
soy isoflavones was positively correlated with S. Validation of the osteoporosis quality of life ques-
bone mineral density. Phytoestrogens in combi- tionnaire QUALEFFO-41 for the Serbian population.
Health Qual Life Outcomes 2012; 10: 74.
nation with vitamin D are thought to activate os-
7) Yilmaz F, Sahin F, Dogu B, Osmaden A, Kuran
teoblasts, making them an important contributor B. Reliability and validity of the Turkish version of
to postmenopausal osteoporosis prevention5,25. the mini Osteoporosis Quality of Life Question-
naire. J Back Musculoskelet Rehabil 2012; 25:
89-94.
Conclusions 8) Yilmaz F, Dogu B, Sahin F, Sirzai H, Kuran B. In-
vestigation of responsiveness indices of generic
Osteoporosis is a social issue that will continue and specific measures of health related quality of
life in patients with osteoporosis. J Back Muscu-
to grow in severity along with population ageing. loskelet Rehabil 2014; 27: 391-397.
Due to the high incidence of osteoporotic frac- 9) Hernlund E, Svedbom A, Ivergard M, Compston
tures, primary and secondary prevention is essen- J, Cooper C, Stenmark J, McCloskey EV, Jons-
tial. To curb the development of osteoporosis and son B, Kanis JA. Osteoporosis in the European
counteract its consequences (including disabili- Union: medical management, epidemiology and
ty), a comprehensive approach to treatment is re- economic burden. A report prepared in collabora-
tion with the International Osteoporosis Founda-
quired, including pharmaceutical treatment, exer- tion (IOF) and the European Federation of Phar-
cise, physical therapy, and adherence to a proper maceutical Industry Associations (EFPIA). Arch
diet, with supplementation when necessary. Osteoporos 2013; 8: 136.
10) Rottermund J, Knapik A, Saulicz M, Saulicz E. Ki-
nesiterapy in treatment of osteoporosis. Zdravot-
Conflict of Interest nicke studie: vedecko odborny casopis fakulty
The Authors declare that they have no conflict of interests. zdravotnictva Katolickej univerzity v Rożomberku
2014; 7: 28-34.
11) Kutsal YG. Still a major concern: osteoporosis
Authors’ Contribution has a serious impact on quality of life. Turk J Os-
The Authors declare that they have no conflict of interests. teoporos 2020; 26: 1-5.
12) Kuliński W. Physiotherapy in the prevention and
treatment of osteoporosis in elderly patients.
ORCID Gerontol Pol 2016; 24: 214-218.
Wojciech Tański: 0000-0002-2198-8789. Anna Szymańs- 13) Janiszewska M, Kulik T, Dziedzic M,
ka-Chabowska: 0000-0003-3615-6923. Żołnierczuk-Kieliszek D, Barańska A. Osteopo-
rosis as a social problem – pathogenesis, symp-
toms and risk factors of postmenopausal osteo-
References porosis. Probl Hig Epidemiol 2015; 96: 106-114.
14) Smektała A, Dobosz A. Osteoporosis – patho-
1) Sewerynek E, Stuss M. The current indications physiology, symptoms, prevention and treatment.
for the prevention and treatment of postmeno- Farm Pol 2020; 76: 344-352.
pausal osteoporosis-a million fractures disease. 15) Kuru P, Akyüz G, Cerşit HP, Çelenlioğlu AE, Cum-
Gin Perinat Prakt 2016; 1: 45-55. hur A, Biricik Ş, Kozan S, Goksen A, Ozdemir M,
3565W. Tański, J. Kosiorowska, A. Szymańska-Chabowska
Luleci E. Fracture history in osteoporosis: risk 20) Chwieśko Z, Chwieśko S, Sierakowski S, Kita K,
factors and its effect on quality of life. Balkan Med Lewandowski B. Physiotherapy and balneothera-
J 2014; 31: 295-301. py in treatment of osteoporosis. New Med 2004;
16) Kastelan D, Vlak T, Lozo P, Gradiser M, Mijic S, 3: 18-25.
Nikolic T, Miskic B, Car D, Tajsic G, Dusek T, Ja- 21) Gumiela D, Dudek D. The impact of diet com-
jic Z, Grubisic F, Poljicanin T, Bakula M, Dzubur F, ponents and physical activity on the skeleton
Strizac-Ujevic M, Kadojic M, Vugrinec M, Kuster of older people. Polish Nursing 2019; 3: 306-
Z, Pekez M, Radovic E, Labar Lj, Crncevic-Orlic 311.
Z, Korsic M. Health-related quality of life among 22) Jarosz M, Bułhak-Jachymczyk B. Human nutri-
patients with postmenopausal osteoporosis treat- tion standards. The basics of obesity and non-in-
ed with weekly and monthly bisphosphonates. fectious disease prevention. Food and Nutrition
Endocrine Res 2010; 35: 165-173. Institute. PZWL. Warsaw 2008.
17) Schröder G, Knauerhase A, Kundt G, Schober 23) Kunachowicz H, Przygoda B, Nadolna I, Iwanow
HC. Effects of physical therapy on quality of life in K. Tables of composition and nutritional value of
osteoporosis patients--a randomized clinical trial. food. PZWL. Warsaw, 2017.
Health Qual Life Outcomes 2012; 10: 101. 24) Jasik A, Tałałaj M, Paczyńska M, Walicka M,
18) Drobnik J, Malcewicz M, Józefowski P, Kurpas D, Wasowski M, Marcinkowska-Suchowierska E. Vi-
Steciwko A. Health resort medicine – contempo- tamin D and osteoporosis. Progress in Medicine
rary resort health care in Poland. Fam Med Pri- 2019; 32: 8-13.
mary Care Rev 2011; 13: 103-108. 25) Wang Q, Ge X, Tian X, Zhang Y, Zhang J,
19) Helbin J, Kolarzyk E. Natural environment ad- Zhang P. Soy isoflavone: the multipurpose phy-
vantages in pharmacological treatment support. tochemical (Review). Biomed Rep 2013; 1: 697-
Probl Hig Epidemiol 2005; 86: 22-26. 701.
3566You can also read
