A PROJECT REPORT ON

PREVALENCE OF OSTEOPOROSIS IN OSTEOARTHRITIC PATIENTS

UNDER THE GUIDANCE OF DR.G.VARADHRAJULU M.P.Th. Principal, Krishna college of physiotherapy, Karad.

BYMr.ANIS AZIZ AMALANI Final Year B.P.Th

CERTIFICATE

This is to certify that candidate No.10450 has satisfactorily Carried Medical Karad out his/her project as per , curriculum given by Krishna Institute Of Sciences for Deemed Fourth University Year B.P.Th.

examination.

External Examiner Internal Examinar

CERTIFICATE

This is to certify that MR AMALANI ANIS AZIZ has satisfactorily carried out his project work under my guidance as per curriculum given by Krishna Institute Of Medical Sciences Deemed University , Karad for JV year B.P.Th.examination.

Project Guide and Principal

ACKNOWLEDGEMENT
Ability and ambition are not enough for many able person fail to achieve anything worthwhile because he or she not been properly guided and directed. Success of our project depends solely on support guidance.Encouragement received from our guide and our all staff members and friends.We have been fortunate to have more than one pillars of strength in our humble effort to make the project successful. We would like to thank Honourable PRINCIPAL and GUIDE DR.G.VARDHARAJULU sir for the opportunity to work on this project and present it. I owe sense of gratitude to them for their co-operation

without which completion of the project would have been difficult. Their contribution have been important in so many different to ACKNOWLEDGE them in a specified manner. Gratitude is often hardest emotion to express and often does not find adequate words to convey that entire one feels. MR.ANIS AZIZ AMALANI FOURTH B.P. Th.

Index

Sr.No 1 2 3 4 5 6 7 8 9 10 11

Contents Page No Introduction 1 Aims & Objectives 14 Literature Review 15 Hypothesis 18 Materials & Methodology 20 Data analysis & interpretation 25 Discussion 28 Conclusion 34 Suggestion 36 Limitation 38 Recommendation 40

12 13 14

Bibliography Annexure Master chart

42 45 48

GRAPH 2 X-ray Findings

Positive Negative

No.Of Individuals
18 12

In %
60 40

20 15 10 5 0

POSITIVE NEGATIVE

NO. OF INDIVIDUALS

INFERENCE:No. of osteoarthritic individuals having positive x-ray findings for osteoporosis are more.

27

GRAPH 1 Area Affected

Knee Hip Spine Hand18
16 14 12 10 8 6 4 2 0 No. of Individuals Knee Hip Spine Hand

No. of Individuals
18 04 06 02

In %
60 13.33 20 06.67

Inference:Knee is the most affected joint in osteoarthritic patients.

26

MASTER CHART

Sr.No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Name Age Sex AJA NKH AJA LAP KHK RSA SJA MKP YDD LAA DDK MAA YNH SAH PFP 63 57 60 55 67 60 70 55 55 50 57 58 64 66 58 M M M F M F M F F F M F M M F

Occupation Rt.Farm S.K. S.K. H.W. Rt.S.K. H.W. Rt.Buss H.W. H.W. Buss Off. H.W. S.K. S.K. Maid ser.

Basis of Suspection SRC Med Med SRC Med SRC Med SRC Med SRC Med Med Med Med Med

Area Affected Knee Hip Knee Knee Spine Knee Hip Knee Knee Spine Spine Knee Knee Knee Knee

X-ray finding For OP

-ve +ve -ve +ve -ve +ve -ve +ve +ve +ve +ve -ve +ve +ve -ve
X-ray finding For OP

49
Sr.No. 16 Name Age Sex Occupation LFH 50 F H.W. Basis of Area Suspection Affected (OA) Med Hip

+ve

17 18 19 20 21 22 23 24 25 26 27 28 29 30

MH MP SBK BK SJA KSA FSA PPP PRK DD TAK TGV SCN CIH

49 61 54 69 70 64 70 68 62 64 60 59 68 57

F F M F F F M M F M M M F F

Teach H.W. Peon H.W. H.W. H.W. Rt.Ind Rt.Farm H.W. Sec.Gaurd Peon Rt.Clerk Teach. H.W.

H/O FF SRC Med Med Med Med SRC Med Med Med Med SRC H/O FF Med

Hand Spine Knee Knee Knee Knee Spine Spine Knee Knee Knee Hand Hip Knee

+ve +ve +ve -ve +ve -ve -ve +ve +ve -ve -ve +ve +ve -ve

ABBREVATION:-

Rt.-Retired,Farm-Farmer,S.K.-Shopkeeper,H.W.-Housewife, Buss-Bussiness,Off.-Officer,Ser.-Servent,Teach.-Teacher,Ind.-Industry, Sec.-Security,S.R.C.-Self Reported Cases,H/O FF-History of fragility #, Med.-Medications(Biphosphates),OA-Osteoarthritis,OP-Osteoporosis.

50

INTRODUCTION

OSTEOPOROSIS

Osteoporosis is a common disease in the elderly . With increasing number of elderly people , it is anticipated that this disease will become an epidemic in the years to come .

Definition
Osteoporosis is a loss of bone mass to the level below the range of an individual of a similar race and sex . The World Health Organisation has defined osteoporosis as an individual whose bone mass is more than two and a half times below that of a young adult of the same sex .

Classification
Osteoporosis is classified in three ways :

Primary idiopathic , having no known cause . Secondary more common in men than in women ; may be due to drug therapy [ anticonvulsants , 2 glucocorticoids ] , life style factors

[ alcoholism , smoking , sedentary ] or medical conditions [ GI disorders , hypogonadism ] . Senile - occurring after 70years of age ; caused by imbalance in bone breakdown new bone formation , inadequate calcium and vitamin D intake and lack of physical activity

Pathogenesis
Bone consists of an organic component [ primary cells , blood vessels and proteins such as collagen ] and an inorganic mineral component , primarily a crystalline calcium phosphate compound [ hydroxyapatite ].Osteoporosis is a disease in which both organic and inorganic components are deficient , resulting in a decrease in total bone mass . As a 3

result of this , the microarchitecture is disrupted with loss of trabaculae and an increase in the size of the pores / spaces within the bone .

Fig.:Above figure shows osteoporotic changes of reduced bone density . 4

Causes of osteoporosis
Hereditary Osteogenesis imperfecta Rheumatological Reumatoid arthritis , ankylosing spondylitis Disuse Paralysis , polio Respiratory Chronic obstructive lung disease Hormonal Hypogonadism , cushings disease Lifestyle Alcoholism , smoking , inactivity / sedentary Drugs Steroids

Changes in bone mass with age

Bone mass increases during growth of childhood and reaches a peak in young adult life . The response of the skeleton to the exercise is most marked during phase of rapid growth . Therefore it is vital that children take part in exercise so that they achieve an adequate peak bone mass . The mass remains relatively constant during early life , but then at approximately 50 years an age related changes starts to occur this is accelerated in women at the time of menopause and is related 5

to loss of ovarian function [ type I osteoporosis ] , grade II osteoporosis refers to the bone loss that occurs as a consequence of an exaggerated normal ageing process .

Fig. :- Shows gradual reduction in height of an individual due bone loss as age advances .

OSTEOARTHRITIS
Osteoarthritis is the most common disease of the joints and one of the most widespread of all chronic diseases . Frequently described as wear and tear , its prevalence increases steadily with age and by retirement age the associated radiological changes can be observed in over half the population .

Definition
Osteoarthritis is defined as a degenerative condition of a diarthrodial synovial type of joint where process of degeneration is followed by regeneration characterized by regeneration is followed by destruction of articular cartilage , subchondral cyst formation and lateral osteophytes formation .

Classification
Primary When the etiology is unknown . Secondary When it follows some known cause eg. Trauma , infection , etc. 7

In epidemiological studies , osteoarthritis is often graded on radiographs according to the criteria of Kellgren and Lawrence , using an ordinal scale of five levels : Grade 0 : Normal radiograph . Grade 1 : Doubtful narrowing of the joint space and possible osteophytes .

Grade 2 : Definite osteophytes and absent or questionable narrowing of the joint space . Grade 3 : Moderate osteophytes and joint space narrowing , some sclerosis , and possible deformity .

Grade 4 : Large osteophytes , marked narrowing of Joint spaces , severe sclerosis snd definite Deformity .

Epidemiology
Osteoarthritis is extremely common condition after 40 years of age . It is widespread in adults older than 65 years of age and affect men more than women before age of 50 but reverses after age of 50 .

Etiology
No single factor that predisposes an individual to osteoarthritis . Although ageing is indeed strongly associated with osteoarthritis , it must be emphasized that ageing in itself does not cause osteoarthritis nor osteoarthritis be considered synonymous with the normal ageing process . Trauma prior to adulthood may initiate a remodelling of bone that alters joint mechanics and nutrition in a way that becomes problematic only later in life . Repetative microtrauma especially occupational tasks such as repetitive bending have been linked to development of osteoarthritis . Obesity have been shown to risk factor for the development of osteoarthritis in later life .

Pathology
The first change is in articular cartilage is an increase in water content [ suggesting proteoglycans have been allowed to swell with water ] . In addition , there are changes in composition of newly formed proteoglycans . In later stages proteoglycans are lost , articular cartilage loses its compressive stiffness and elasticity , which inturn results in transmission of compressive forces to 9

Fig. :- Shows an osteoarthritic joint .

underlying bone . As articular cartilage is destroyed , the joint space narrows . 10 The cartilage may degenerate to point that subchondral bone is exposed . Subchondral bone in turn can then become

sclerotic and stiffer than normal bone . These changes result in increased function , decreased shock absorption and greater impact loading of the joint .

Fig. :- Showing sclerotic subchondral bone .

The process of osteophyte formation is not well understood . The current hypothesis have implicated increased vascularity in degenerated cartilage , venous congestion from subchondral cysts and thickened subchondral trabaculae and continued sloughing of articular cartilage . 11

Signs and Symptoms

In upper extremity the DIPs , PIPs and CMC of thumb are commonly involved . The cervical and lumbar spine , hips , knees and first MTP are also sites for osteoarthritis . Crepitus is common encountered clinical finding . Pain in osteoarthritis may be attributed to incongruent articulations of joint surfaces , periosteal elevation , abnormal pressure on subchondral bone , trabaculae microfractures and distension of joint capsule . The pain is likely to occur or worsen only with motion except in later stages of disease . Osteoarthritis can impose functional limitations to a greater degree , accounts for a substantial proportion of the burden of disability among community living elders .

12

NEED FOR STUDY

Osteoarthritis and osteoporosis are conditions related to elderly age group and affects bone . This can be associated with pain , decreased ROM , various gait abnormalities and all these factors sum up to cause increased expenditure of energy . Osteoarthritis can impose functional limitations to a greater degree and accounts for a substantial proportion proportion of burden of disability among community living elders . So by finding out oseoporosis as prevalent for osteoarthritic changes , we can carry out measures to prevent these changes and thus help the elders of our community to cherish and live a fruitful independent social life .

13

AIM AND OBJECTIVE

To determine prevalence of osteoporosis in osteoarthritic patients .

14

LITERATURE REVIEW

15

Prevalence of osteoporosis in patients with osteoarthritis

Lingard EA , Mitchell SY , Francis RM , Rawlings D , Peaston R , Birrell FN , Mc Caskie AW .

The presence of osteoporosis in patients with hip and knee osteoarthritis has important implications for understanding disease progression and providing optimal management . Patients with osteoarthritis aged between 60 to 80 years of age were selected and lumbar spine , bilateral femoral , forearm bone mineral density measurements [ BMD ] were obtained using dual energy X-ray absorptiometry . Study consisted of 199 patients . The overall rate of osteoporosis at any site was 66% . In summary a significant patients with osteoarthritis have osteoporosis .

16

Prevalence of osteoporosis in osteoarthritic patients .

Labuda A , Papaioannou A , Pritchard J , Kennedy C , De Beer J , Adachi JD .

Prevalence of osteoporosis was determined by review of self reported survey , and defined by (1) self reported diagnosis of osteoporosis , (2) history of fragility fractures or (3) current treatment for osteoporosis using biphosphonates . Conclusion : Osteoporosis is common in the osteoarthritic population with prevalence at least equal to that in general population . Due to self reported nature of the study , the prevalence of osteoporosis in this population is likely significantly higher .

17

HYPOTHESIS

18

Null hypothesis
There is no prevalence of osteopororosis in osteoarthritic patients .

Alternate hypothesis
There is prevalence of osteoporosis in osteoarthritic patients .

19

MATERIALS AND METHODOLOGY

20

Type of study : Survey

Place of study :

Karad Sample size : 30 osteoarthritic patients Purposive sampling

Sampling method : Materials used :

Radiographs , History of fragility fractures , Details of current medications .

21

Inclusion criteria
-

Age group of 45 to 75 years of age .

Both males and females suffering from osteoarthritis . Radiological features supporting osteoarthritis present [ osteophytes or joint space narrowing or subchondral sclerosis ] .

22 -

History of fragility fractures or current medications for osteoporosis [ biphosphonate ] or a self reported case .

Exclusion criteria - Previous history of major trauma or

fracture of a healthy bone . - Limb length discrepancies .

Procedure The subjects were selected from Karad community and some from Phsiotherapy department of Krishna hospital . Subjects were selected who were suffering from osteoarthritis . This was confirmed by going through X-ray reports showing osteoarthritic features such as presence of osteophytes , joint
23

space narrowing , subchondral bone sclerosis . Subjects were further inquired about history of fragility fractures [ bone fracture occurring as a result of a fall from standing height or less after age of 50 years ] or medications for osteoporosis [ biphosphonates ] . Presence of osteoporosis was suspected

by fulfilling atleast one of the following criteria : (1) self reported diagnosis of osteoporosis , (2) history of fragility fractures , (3) current treatment for osteoporosis using biphosphonates . Further osteoporosis was confirmed on X ray findings of decreased bone mass by area of increased density on X ray film and thinning of margin of bone or reduction in number of trabaculae evident .

24

DATA ANALYSIS AND INTERPRETATION

25

DISCUSSION

28

The main finding in this study of osteoarthritic patients is prevalence of osteoporosis of 60 % . It was higher in case of women i.e. 61 % as compared to those of men which is 39 % . The reason behind this could be post

menopausal changes of bone resorption due to lack of oestrogen which is a part of climacteric changes . The joint most commonly affected by osteoarthritic changes was knee joint with 60 % of population of study followed by spine [ in spine lower thoracic and lumbar region were more affected ] and hip with 20 % and 13 % respectively . X ray findings were positive for osteoporosis [ overall reduction in mass of bone were evidenced by denser look and thining of cortical boundaries and reduction in number of trabaculae was evidenced ] in 60 % osteoarthritic population of the study . 29 Of the total osteoarthritic subjects included in the study 67 % were suspected on basis of medications taken of biphosphonates , 27 % were self reported cases and 6 % were with history of fragility fractures. Of the total subjects positive , 33 % subjects on medications had positive findings on X ray and of those with self reported diagnosis and history of fragility fractures

formed 20 % and 6 % of total positive cases in the study . Based on limitations of self reported nature and inclusion of only X ray findings it cannot be overviewed that there could be difference in exposure to the rays and could result in false negative reports . Interestingly 60 % is a very high figure , when compared to 1995 South Australian Health Survey , which showed only self reported osteoporosis prevalence of 16 % and 8 % for women and men respectively . This vast difference could be somewhat

30 biased in our population , because the patients over there have been under better medical care for musculoskeletal complaints and thus are better informed regarding osteoporosis as compared to our patients .

31

RESULTS

32

Results : From the study 60 % of osteoarthritic patients were classified as having osteoporosis according to the criteria selected [ on basis of X ray findings for osteoporosis ] , of which 33 % patients were

those on medications of biphosphonate , 20 % those which were self diagnosed and 6 % with history of fragility fractures .

33

CONCLUSION

34

Conclusion Osteoporosis is highly prevalent in osteoarthritic patients. Therefore alternate hypothesis is accepted .

35

SUGGESTIONS

36

If sample size could have been extended results could have been appreciable . Early reporting will help in early diagnosis of problem and less disability .

 While using radiographs to estimate bone mass would be considered technologically inappropriate considering the availability of dual photon and dual x ray bone densitiometry techniques , it is the only method available to characterize the longitudinal relationship between bone mass and osteoarthritis .

37

LIMITATIONS

38

There could be variations in film exposure leading to false negative reports . Using only x ray findings for confirming osteoporosis and self reported nature is technologically in appropriate considering

availability of advanced techniques such as dual photon and dual x ray bone densitiometry . Impact of disease vary according to area affected .

39

RECOMMENDATIO NS

40

The relationship between osteoarthritis and osteoporosis may be modified by the site affected . Hence study recommends further explorations using localized study to a particular joint instead of generalized study .

Future studies finding whether medications for osteoporosis cause osteoarthritis .

Studies of underlying metabolic process associated with arthritic inflammation should also consider evaluation for impact on bone .

41

BIBLIOGRAPHY

42 Bibliography

Physical Rehabilitation [ 5th edition ] by Susan B. OSullivan , Thomas J. Schmitz

Adams Outline of Fractures by David L Hamblen and A Hamish R W Simpson

 Handbook of Diseases by Springhouse Essentials of Orthopaedics And Applied Physiotherapy by Jayant Joshi and Prakash Kotwal

Websites

www.medworm.com www.wrongdiagnosis.com www.pubmedi.gov 43

Abbreviations OA : Osteoarthritis OP : Osteoporosis DIP : Distal Interphalangeal Joint

 PIP : Proximal Interphalangeal Joint CMC : Carpo Metacarpal Joint MIP : Metatarso Phalangeal Joint ROM : Range of Motion H/O : History Of .

44

ANNEXURE

45

The subjects were selected from Karad community and some from Phsiotherapy department of Krishna hospital . Subjects were selected who were suffering from osteoarthritis . This was confirmed by going through X-ray reports showing osteoarthritic features such as presence of osteophytes , joint space narrowing , subchondral bone

sclerosis . Subjects were further inquired about history of fragility fractures [ bone fracture occurring as a result of a fall from standing height or less after age of 50 years ] or medications for osteoporosis [ biphosphonates ] . Presence of osteoporosis was suspected by fulfilling atleast one of the following criteria : (1) self reported diagnosis of osteoporosis , (2) history of fragility fractures , (3) current treatment for osteoporosis using biphosphonates .

46 Further osteoporosis was confirmed on X ray findings of decreased bone mass by area of increased density on X ray film and thinning of margin of bone or reduction in number of trabaculae evident .

47

MASTER CHART

48