Osteoporosis: description, symptoms, therapy, prevention

Osteoporosis is one of the most important widespread diseases. In the world, millions of people suffer from it, especially older women. In those affected, the bone substance is degraded to a greater extent. This makes the bones more and more unstable and fragile. Here you can read everything important about the causes, symptoms, therapy and prevention of osteoporosis!

Brief overview

• What is osteoporosis? Metabolic disease of the bones, in which more and more bone tissue is broken down (bone loss). The bones can break more easily.
• Symptoms: initially often no complaints. In the further course of the disease, persistent pain such as back pain, bone fractures in the case of minor injuries or without any recognisable cause (spontaneous fractures), increasing hunchback (“widow’s hump”) and decreasing height.
• Causes: Primary osteoporosis occurs at an advanced age and after menopause (estrogen deficiency!). Secondary osteoporosis is the result of other diseases or medication (hyperthyroidism, cortisone, etc.).
• Treatment: non-drug measures such as sufficient exercise (sports, physiotherapy) and proper nutrition; calcium and vitamin D supplements; osteoporosis medication (bisphosphonates etc.); treatment of underlying diseases (in secondary osteoporosis); possibly surgery for bone fractures
• Prognosis: Osteoporosis is not curable so far. This makes early diagnosis and treatment all the more important. Otherwise the bone loss will continue to progress. This then means increasing pain and more frequent bone fractures.

Osteoporosis: symptoms

Osteoporosis usually develops slowly. Initially, therefore, those concerned generally have no complaints. Only in the further course of the disease does pain occur, for example back pain and knee pain. They are often not recognized as the first symptoms of osteoporosis.

Some patients also suffer bone fractures: they are often the result of minor injuries. Even a small, harmless fall can result in a forearm fracture. Spontaneous bone fractures without any apparent cause are also possible initial symptoms of osteoporosis.

In the advanced stage of osteoporosis, bone fractures occur more frequently without cause. Typical symptoms of osteoporosis are often fractures of the bones near the hip (such as fractures of the femoral neck), fractures of the upper and lower arm and the vertebral bodies (vertebral body fracture).

Vertebral body fractures

Sometimes vertebral bodies collapse slowly in osteoporosis. Those affected often do not notice anything. These “creeping fractures” do not cause any pain. They are therefore often not recognized and remain untreated. However, they cause the body size to decrease. In the case of several vertebral body fractures, it can even shrink by several centimetres! In addition, a hunchback can develop (“widow’s hump”).

Acute vertebral body fractures are also possible signs of osteoporosis. Pain does occur here – in contrast to creeping fractures – and it does occur clearly. In addition, mobility in everyday life is considerably restricted.

In general, the following symptoms may indicate vertebral body collapse:

• severe, local, stabbing to burning back pain
• persistent back pain
• Body height reduction
• Hunchback formation

Femoral neck fracture

Femoral neck fractures are among the most serious complications of osteoporosis. Symptoms such as severe pain in the hip joint and a malposition of the affected leg indicate such a femoral neck fracture. Furthermore, the affected hip joint can no longer be loaded.

Vicious Circle

With each fracture, the risk of further fractures increases. For fear of renewed fractures, osteoporosis patients often become insecure and anxious when walking and often support themselves. This increases the risk of falling.

In addition, muscle strength diminishes with age. In addition, many older people can hear and see less well. This affects the balance, which further increases the risk of falling. This increases the risk of bone fractures even further. Those affected fall into a vicious circle of fear and insecurity, increased risk of falling and new bone fractures, which further fuel the fear.

Osteoporosis: causes and risk factors

In principle, two groups of osteoporosis are distinguished: primary osteoporosis and the much rarer secondary osteoporosis.

Primary osteoporosis: causes

Primary osteoporosis occurs in post-menopausal women and in both sexes at an advanced age:

The bone loss after menopause (postmenopausal osteoporosis) is hormonal: the female sex hormones (estrogens) regulate the formation and effect of calcitonin and vitamin D. These two hormones are important for bone formation. During the menopause, estrogen production decreases. This is the reason why many women develop bone loss after their last menstrual period (menopause).

Sex hormones (such as testosterone) are also important for bone metabolism in men. However, they do not stop producing testosterone in middle age. Therefore osteoporosis is less common in men than in women.

At an advanced age, every person loses more and more bone mass. This can cause osteoporosis in both men and women. Doctors speak of senile osteoporosis.

Overall, various risk factors favour the development of osteoporosis. Nutrition that is not very bone-friendly (e.g. low-calcium diet) and lack of exercise are the first things to be mentioned here.

Especially from the age of 70 onwards, a nutritional deficiency of calcium and vitamin D leads to bone loss. For example, excessive diets, excessive coffee consumption, the misuse of laxatives and too much phosphate in food cause the bones to receive too little calcium and vitamin D. This promotes osteoporosis.

Excessive alcohol and nicotine consumption are also considered risk factors for bone loss.

Osteoporosis is also more common in certain families. Experts therefore suspect that genetic factors also play a role.

Secondary osteoporosis: causes

In contrast to primary osteoporosis, secondary osteoporosis is the result of other diseases or their treatment (drugs).

For example, secondary osteoporosis can be caused by too much cortisone in the body. Such an excess of cortisone is caused either by diseases such as Cushing’s syndrome or by long-term therapy with cortisone.

Hyperthyroidism can also trigger osteoporosis: The excess of thyroid hormones accelerates the metabolism and promotes bone resorption. Overactive parathyroid glands also often lead to osteoporosis. This is because too much parathyroid hormone is released. This hormone is an antagonist of calcitonin and vitamin D: it dissolves calcium from the bones and thus promotes their breakdown.

Other secondary causes of osteoporosis are

• hormone-related diseases such as hypofunction of the gonads (ovaries, testicles), hyperactivity of the adrenal cortex, type 1 diabetes
• Stomach and intestinal diseases such as Crohn’s disease, ulcerative colitis, lactose intolerance, coeliac disease: the utilization of important nutrients such as calcium is disturbed.
• malignant tumours (such as bone metastases)
• severe chronic kidney weakness (renal insufficiency): Here the body excretes a lot of calcium. To prevent the calcium level in the blood from falling too low, calcium is released from the bones and absorbed into the blood.
• Inflammatory rheumatic diseases like rheumatoid arthritis (“rheumatism”)
• other diseases such as anorexia or cirrhosis of the liver (malnutrition promotes osteoporosis)
• Medication: Apart from cortisone, other drugs can also promote osteoporosis, for example antispasmodics (antiepileptic drugs), cyclosporine (after organ transplants, for skin diseases, etc.), heparin (long-term therapy to prevent thrombosis) and certain hormone therapies (for example for prostate cancer).

Osteoporosis: examinations and diagnosis

If there is the slightest suspicion of osteoporosis such as a bone fracture without any apparent cause (spontaneous fracture), you should see a doctor. The earlier the bone loss is treated, the sooner the progression of the disease can be stopped. In addition, a basic osteoporosis diagnosis is recommended for all people with an increased risk of bone fracture. It consists of several parts:

Doctor-patient consultation

First of all, the doctor will take the patient’s medical history (anamnesis). The doctor inquires about the general condition of the patient. He also asks if there are any complaints or restrictions in everyday life. These include, for example, back pain, difficulty climbing stairs, lifting heavy objects or pain when walking for long periods.

It is also important for the doctor to have information about any broken bones or falls in the past. In addition, the doctor will inquire whether the patient is suffering from a disease or is using medication.

Physical examination

This is followed by a physical examination. The doctor also measures the height and weight of the patient.

Tests are used to check physical fitness and mobility. An example is the “Timed-up-and-go” procedure:

The doctor stops the time it takes the patient to get up from a chair, walk three meters, turn around, go back and sit down again. He may also use any walking aids that he otherwise uses in everyday life.

If the patient needs more than 30 seconds for the task, his mobility is probably impaired. Then there is an increased risk of falling.

Measurement of bone density

Bone density measurement (osteodensitometry, DXA measurement) is also an important part of osteoporosis diagnostics. Low-dose X-rays are used to determine the bone density at the lumbar spine, the entire femur and the neck of the femur. The measured values (T-values) are compared with the typical mean values in the respective age group. If they are 2.5 units or more below the age-typical mean values, the osteoporosis definition is fulfilled: The patient has osteoporosis.

Overall, the World Health Organization (WHO) distinguishes four stages of bone loss depending on the T-value of the bone density measurement:

• Grade 0 osteopenia. In this preliminary stage of osteoporosis, the mineral content of the bones is reduced by a value of 1 to 2.5.
• Grade 1: Osteoporosis. The mineral content of the bones is reduced by more than 2.5. However, fractures (fractures) are not yet present.
• Grade 2: Manifest osteoporosis. It is present when the bone mineral content is reduced by more than 2.5 and the patient has already had one to three vertebral body fractures.
• Grade 3: Advanced osteoporosis. All patients in whom the mineral content of the bones is more than 2.5 units below the average value and multiple vertebral body fractures are present have advanced osteoporosis.

X-ray examination

Possible bone fractures (fractures) can be detected on an X-ray image. Osteoporosis often leads to vertebral body fractures, among other things. They can be caused by a single event (such as a fall) or be the result of long-lasting subliminal mechanical effects.

The second case involves creeping fractures. They cause the vertebral body in question to deform. Experts call this sintering or creep deformation. The following applies: The more severe the deformations, the more pronounced the osteoporosis. This can be determined by measuring the vertebral body heights between the fourth thoracic vertebral body and the fifth lumbar vertebral body using X-rays. The measured value obtained (vertebral deformity score) indicates how pronounced the osteoporosis is.

Blood tests

The patient’s blood is also examined as part of the osteoporosis diagnosis. On the one hand a blood count is made. Other parameters are also determined, such as liver and kidney values and calcium and phosphate levels. The main purpose of the examination is to clarify possible causes of secondary osteoporosis.

In addition, the blood values help the doctor in planning the therapy: if, for example, the calcium level in the blood is very low, the patient must not be treated with certain osteoporosis drugs.

Osteoporosis basic diagnostics: For whom is it recommended?

All people with an increased risk of fractures should have a basic osteoporosis diagnosis. These risk groups generally include women and men over the age of 70.

Osteoporosis clarification is also recommended for people over 50 years of age with various risk factors for osteoporosis-related bone fractures. These include, for example:

• Vertebral body fractures after minor injuries (such as falling from a standing position)
• fracture of the femur close to the hip of mother or father
• Immobility, for example due to prolonged bedriddenness or plaster cast after operations or accidents
• Underweight (body mass index below 20), weight loss and anorexia nervosa
• Smoking and chronic obstructive pulmonary disease (COPD)
• high alcohol consumption
• hormone-related diseases such as Cushing’s syndrome, hyperthyroidism, growth hormone deficiency due to a dysfunction of the pituitary gland (hypophysis), diabetes mellitus type 1 and type 2
• rheumatological diseases (rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis)
• Gastro-intestinal diseases such as celiac disease, also stomach surgery (complete or partial removal of the stomach)
• neurological / psychiatric diseases such as epilepsy, schizophrenia, Alzheimer’s, Parkinson’s, stroke, depression
• Heart failure (cardiac insufficiency)
• alcohol-related liver diseases
• certain drugs such as high-dose cortisone, antispasmodics, antidepressants, glitazones (for type 2 diabetes), aromatase inhibitors (for breast cancer), antihormone treatment for prostate cancer, opioids (strong painkillers)

Further investigations

In addition to the basic osteoporosis diagnosis, the physician may in certain cases perform further examinations. Sometimes, for example, computer tomography (CT) or magnetic resonance imaging (MRI) is necessary to rule out other possible causes for the patient’s symptoms. These imaging techniques can also be important for therapy planning, for example when a bone fracture first needs to be clarified in more detail.

In rare cases, the doctor will take a sample of the bone tissue (bone biopsy). It is being examined more closely in the laboratory. This can be helpful, for example, if the other examinations have only revealed unclear findings.

Osteoporosis: treatment

Osteoporosis therapy consists of several components. It is individually adapted to the patient. When planning therapy, the doctor takes into account, among other things, what caused the bone loss and how pronounced it is.

General information on osteoporosis therapy

The most important basic measures of any osteoporosis therapy include sufficient exercise and the right diet. If necessary, the patient is given additional medication against bone loss.

Fall prevention is also important: Osteoporosis patients break their bones easily. Here are some tips to reduce the risk of falls and accidents:

• The apartment should be adequately lit and furnished in such a way that it is not so easy to stumble and fall. For example, remove tripping hazards such as slipping carpets and exposed cables.
• If the eyes deteriorate, patients should wear a suitable visual aid.
• High-heeled shoes and those with smooth soles are not suitable. Flat shoes with non-slip soles are more advisable.
• As far as possible, osteoporosis patients should not take any medication that limits their attention and ability to react. These include sleeping pills, allergy medication and antidepressants.

In case of secondary osteoporosis as a result of another disease (such as hyperthyroidism), this basic disease must be treated. Otherwise the osteoporosis therapy might not bring the desired success.

If certain drugs have triggered secondary osteoporosis, it is best to switch to more “bone-friendly” preparations – i.e. drugs that have a less negative effect on bone density. This is recommended, for example, for women who are treated with glitazones due to type 2 diabetes.

Movement as osteoporosis therapy

With regular exercise, bone loss can be both prevented and treated. It is very important to choose the right form of exercise or sport.

First of all, osteoporosis therapy does not require competitive sports! Efficient osteoporosis treatment, for example, starts with regular walks. This promotes bone formation and inhibits bone resorption. Even light running training such as jogging or walking are very effective.

Swimming is also recommended as an osteoporosis therapy. A half hour back or breaststroke twice a week is ideal. In doing so, other muscle groups are also trained than when walking, for example the back muscles.

Water gymnastics and light weight training are also suitable for treating osteoporosis. Gymnastics outside the pool and simple osteoporosis exercises can be done independently at home. Here, too, you can achieve good effects with just a half-hour training session twice a week. Tips for suitable exercises can be obtained, for example, from your doctor, sports physician or in a special sports group for osteoporosis patients.

In general: Discuss with your doctor which form of exercise and/or type of sport as well as which training intensity is most sensible in your case.

Nutrition as osteoporosis therapy

In addition to sufficient exercise, every osteoporosis therapy also includes the right diet. Here are the most important tips:

Eat a balanced diet. Make sure that you supply your body with sufficient calcium. The mineral is important for healthy, strong bones. Adults should take 1,000 milligrams of calcium per day with their diet. It is mainly found in dairy products, but is also found in green vegetables such as spinach and broccoli, and in some types of mineral water. Calcium is also added to some foods, for example juices.

In some patients it cannot be guaranteed that they will absorb sufficient calcium through their diet. Then the doctor prescribes additional calcium preparations (for example effervescent tablets).

In addition to calcium, vitamin D is also very important for osteoporosis patients (and other people): it ensures that the body can absorb calcium from the intestines and incorporate it into the bones. Good sources of vitamin D are fatty fish, eggs, butter and milk.

You should also regularly expose your skin to sunlight: With the help of UV light, the body can produce vitamin D itself. With this own production he even covers the largest part of his demand. In the summer you should spend 5 to 15 minutes in the sun every day, in spring and autumn 10 to 25 minutes. It is sufficient to “irradiate” the face and hands. Depending on the temperature, the sun can also be applied to the uncovered arms and legs.

Doctors often prescribe vitamin D supplements for osteoporosis. This is to ensure the supply. Such preparations are particularly useful for patients with a high risk of falling or fracturing who are not exposed to much sunlight. The daily dose is 800 to 1,000 International Units (IU) of vitamin D3.

For solid bones, phosphate is also needed, but in the right proportion to the calcium supply. An excess of phosphate binds calcium so that it can no longer be incorporated into the bones. Phosphate-rich foods and drinks such as meat, sausage, processed cheese and cola drinks should therefore be avoided.

Phosphates can be identified by the numbers E 338-341 and E 450 in the list of ingredients on food and drink packages.

Medicines for osteoporosis

If osteoporosis patients have a high risk of fractures, the doctor will also prescribe a drug therapy for osteoporosis. The following active ingredients are available:

1. Bisphosphonates: Bisphosphonates such as alendronate and zoledronate are the first choice in osteoporosis therapy. They prevent excessive bone resorption and strengthen the remaining bone mass. Bisphosphonates are taken in tablet form daily, weekly or monthly or are administered in the form of injections or infusions.
2. Selective estrogen receptor modulators (SERM): Raloxifene is approved for osteoporosis therapy from this group of active ingredients. It binds to special docking sites (receptors) that are actually intended for estrogens, thus inhibiting bone resorption. Raloxifen is taken daily in tablet form.
3. Strontiumranelate: This active ingredient also inhibits bone resorption and also increases the activity of bone-building cells. It is taken daily as a powder solution.
4. Teriparatide: Teriparatide is a derivative of the endogenous hormone parathyroid hormone. It promotes bone formation and the formation of new bone structures. The active ingredient is injected under the skin once a day.
5. Denosumab: Denosumab is a so-called monoclonal antibody. It interferes with bone metabolism and inhibits the bone-destroying cells (osteoclasts). Denosumab is administered as an injection under the skin.

In individual cases, other drugs can be used for osteoporosis therapy, such as female sex hormones or calcitonin.

Pain therapy

The doctor can initiate a suitable pain therapy against the pain of osteoporosis. Painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, acetylsalicylic acid (ASS) or diclofenac are often used. For severe pain, the doctor may also prescribe so-called opiates. In some cases, other medications are useful, for example muscle relaxants (muscle relaxants).

Physical therapy measures often help against osteoporosis pain. These include, for example, cold or heat treatments, massages or even acupuncture. For some patients, the complaints can be sufficiently alleviated by this. For others, physical therapies can supplement treatment with painkillers.

In the case of prolonged pain due to vertebral fractures, the doctor may also prescribe the patient a semi-elastic girdle.

Operation

In the case of vertebral body fractures, surgical intervention may be advisable. In the so-called vertebroplasty, the surgeon inserts bone cement into the fractured vertebral body. This is stabilized by this. In a kyphoplasty, the vertebral body is first expanded with a small balloon. This can straighten the bone somewhat and also makes it easier to insert cement.

Other bone fractures resulting from osteoporosis also sometimes require surgery. For example, some patients receive an artificial hip joint after a fracture of the femoral neck.

Further tips on osteoporosis therapy

• Avoid underweight.
• Abstain from nicotine and alcohol.
• In everyday life, take care to behave in a way that is gentle on your back (e.g. upright sitting position, regular change of sitting posture, no carrying of heavy loads, no stooping when doing housework, replacement of worn mattresses).

It is also helpful to join a support group for osteoporosis patients. Such groups offer advice, help and exchange with other patients. Take advantage of this offer if you have the opportunity!

Osteoporosis: course of disease and prognosis

Osteoporosis is not curable so far. This makes it all the more important to detect and treat them as early as possible. Because without treatment, osteoporosis progresses further and further. Patients increasingly suffer from bone pain (such as back or neck pain). The fractures are piling up. Especially at an advanced age, many people have difficulty recovering from more severe fractures.

The femoral neck fracture is particularly feared. It can lead to serious complications and secondary diseases such as secondary bleeding and wound healing disorders. The necessary operation (such as the use of an artificial hip joint) involves further risks for those affected. Many of the elderly patients have limited mobility afterwards or even become nursing cases. Approximately 10 to 20 percent of all patients with femoral neck fractures die from secondary diseases or the risks of surgery.

Osteoporosis: Prevention

If you want to prevent osteoporosis, you should minimize the known risk factors. These include, for example, a lack of exercise and a lack of calcium and vitamin D. Here are the most important tips:

• Make sure you eat a calcium-rich diet with dairy products and calcium-rich water. Adults should take 1,000 to 1,500 milligrams of calcium per day.
• Regularly eat products with a lot of vitamin D, for example high-fat fish (such as herring), fish oil and egg yolk.
• Expose your face and hands (and if possible other uncovered parts of your body) to sunlight regularly: In summer, five to 15 minutes daily, in spring and autumn ten to 25 minutes daily. Then the body can cover a large part of its vitamin D requirement by producing the vitamin itself.
• Avoid foods that are high in phosphate. They inhibit the absorption of calcium in the intestines and promote the release of calcium from the bones. Examples of products rich in phosphates are meat and sausage products, processed cheese and cola drinks.
• Avoid tobacco and alcohol and do not drink too much coffee. These stimulants are also bad for the bones.
• Another indispensable component of osteoporosis prevention is regular exercise. Be physically active regularly, preferably several times a week. This strengthens the bones.