Physiotherapist Meena Sran has a special interest and is highly qualified to treat patients suffering from osteoporosis. To book an appointment with Dr. Meena Sran please call our Shelbourne Physiotherapy Cook Street Clinic at 250-381-9828.
What is osteoporosis?
Osteoporosis is a common condition affecting many Canadians in which bones become fragile and brittle leading to a higher risk of fractures, than in normal bone. Osteoporosis occurs when bones lose minerals, such as calcium, more quickly than the body can replace them, leading to a loss of bone thickness (bone density or mass).
Osteoporosis can lead to fractures
As bones become thinner and less dense, even a minor bump or fall can cause serious fractures. These are known as ‘minimal trauma’ fractures. A ‘fracture’ is a complete or partial break in a bone. Any bone can be affected by osteoporosis, but the most common sites are the hip, spine, wrist, upper arm, ribs or forearm. Fractures in the spine due to osteoporosis can result in losing height or changes in posture (and in more serious cases it can result in a Dowager’s hump in the back). Osteoporosis usually has no symptoms until a fracture occurs – this is why osteoporosis is often called the ‘silent disease’. It is therefore very important for anyone with specific risk factors for osteoporosis to be investigated by their doctor. It is also important for anyone over 50 who experiences a fracture from a minor bump or fall to be investigated to check if the fracture was caused by osteoporosis. Fractures can lead to chronic pain, disability, loss of independence and even premature death. So preventing fractures and managing bone health becomes a priority.
The Fracture Cascade
Managing and treating osteoporosis to prevent fractures is vitally important. This is because about 50% of people with one fracture due to osteoporosis will have another. And often a person’s osteoporosis is not diagnosed until after they experience their first fracture. The risk of future fractures rises with each new fracture – this is known as the ‘cascade effect’. For example: The ‘cascade effect’ means that women who have suffered a fracture in their spine are over 4 times more likely to have another fracture within the next year, compared to women who have never had an osteoporotic fracture. The challenge remains identifying fractures caused by osteoporosis. For example two thirds of fractures of the spine are not identified or treated, even though they nearly all cause some pain. People can mistakenly believe that the symptoms of spine fractures – back pain, height loss or rounding of the spine – are just due to ‘older age’.
It is essential that fractures caused by osteoporosis are identified and osteoporosis is diagnosed and treated to prevent further fractures. Our Victoria Physiotherapist will help guide you through the proper exercise and treatement regime to maximize your mobility and help prevent further bone damage.
Filling in the Gaps Before Clients Fall Through the Cracks: Physiotherapists Have the Skills to Help Clients Preserve Bone and Prevent Falls
Meena M. Sran
Osteoporosis imposes an enormous personal and societal burden. In clinical practice, most clients with low bone density or osteoporosis are mid-life adults or seniors, and therefore they typically present with other comorbidities or chronic conditions that may influence their bone health and their risk of falls and fractures.
Consider the 55-year-old postmenopausal woman who presents to the physiotherapist for recommendations on exercise for bone health. The physiotherapist recognizes that this woman needs exercise aimed at bone preservation, and gives her options including a jumping routine, a walk–jog programme, and recommendations on appropriate fitness classes. But what the physiotherapist does not know is that this woman also has frequent stress urinary incontinence; the client did not mention it, and the physiotherapist did not ask. The client leaves knowing that she won’t be able to comply with the exercise prescription without the undesirable consequence of leaking urine. Incontinence is a deterrent to this woman’s being physically active.
She is not alone. A recent study conducted in the Osteoporosis Clinic at the BC Women’s Health Centre found that almost 40% of all new female patients seen in 1 year (163/412) reported leakage one time per week or more, and 10% reported urgency without any leakage.1 These data suggest that the prevalence of at least weekly urinary incontinence (UI) in this population is much higher than that reported in studies of other older adult female populations. We know that physical activity is an important part of osteoporosis treatment aimed at preserving bone mass and preventing falls, and we aim to prescribe appropriate exercise for all individuals presenting with osteoporosis or low bone density. But UI can significantly limit a woman’s ability to be physically active2 and is an independent risk factor for falls and low-trauma fractures in older women.3,4 The presence of UI should therefore influence our exercise prescription for women with osteoporosis—yet it is not routine for physicians5 or other health care professionals to ask about incontinence,6 and it is typically only after symptoms have been present for 6 to 10 years that women mention UI to a health care professional.7 So when we don’t ask, they don’t tell, and we prescribe and hope for compliance.
In this case, hope is not enough. We can do better. Knowing that UI is prevalent in our osteoporosis clinic population should lead to changes in our clinical practice. By routinely asking if UI is present, then following up with more detailed questions as necessary, the physiotherapist can provide more useful exercise prescription for bone health while at the same time helping to guide the client toward conservative treatment options for UI that have been shown to be effective.8–11
While the majority of Canadian physiotherapists do not have the full arsenal of skills to comprehensively assess and treat incontinence and pelvic-floor disorders, we do have physiotherapy colleagues with just that specific skill set. Notably, there is strong (Level A) evidence for the use of supervised individual pelvic floor muscle (PFM) training as a primary treatment of UI in women,8–11 and clinical practice guidelines recommend conservative management for UI in older women.9 More specific to this population, our research group recently completed a randomized controlled trial (RCT) of physiotherapy for UI in women with osteoporosis. The results are convincing with respect to the effectiveness of physiotherapy in this population and may suggest a new standard of care.12
The relationship between osteoporosis and UI is not clear, but a previous study found that self-reported osteoporosis was associated with use of disposable pads (OR=2.01).13 Spinal curvature may play a role; one study found that spinal curvature was related to prolapse of pelvic organs.14 Individuals with osteoporotic spinal compression fractures may also present with impaired pulmonary function,15 which in turn may influence PFM activity.
Thus, UI screening is relevant for fall prevention and exercise prescription in individuals with osteoporosis, but it is also part of providing comprehensive care for women’s health issues. In a large-population survey, women identified “being seen as a whole person” as their highest psychosocial-related health priority.6 Women with UI are more likely to suffer from depression and low self-esteem than women without UI,16 and UI can result in isolation from family and friends.17 Given the high prevalence of UI in women with osteoporosis, helping them to regain continence will be important if they are to optimally manage their bone health.
1. Sran MM. Prevalence of urinary incontinence in women with osteoporosis. J Obstet Gynaecol Can. 2009;31(5):434–9.Medline:19604424. [PubMed]
2. Nygaard I, Girts T, Fultz NH, et al. Is urinary incontinence a barrier to exercise in women? Obstet Gynecol. 2005;106(2):307–14. doi: 10.1097/01.AOG.0000168455.39156.0f. Medline:16055580. [PubMed]
3. Boele van Hensbroek P, van Dijk N, van Breda GF, et al. Combined Amsterdam and Rotterdam Evaluation of FALLs (CAREFALL) study group. The CAREFALL Triage instrument identifying risk factors for recurrent falls in elderly patients. Am J Emerg Med. 2009;27(1):23–36. doi: 10.1016/j.ajem.2008.01.029. Medline:19041530. [PubMed]
4. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc. 2000;48(7):721–5.Medline:10894308. [PubMed]
5. Swanson JG, Skelly J, Hutchison B, et al. Urinary incontinence in Canada. National survey of family physicians’ knowledge, attitudes, and practices. Can Fam Physician. 2002;48:86–92.Medline:11852616. [PMC free article][PubMed]
6. Tannenbaum C, Mayo N. Women’s health priorities and perceptions of care: a survey to identify opportunities for improving preventative health care delivery for older women. Age Ageing. 2003;32(6):626–35.Medline:14600004. doi: 10.1093/ageing/afg119. [PubMed]
7. Hägglund D, Walker-Engström ML, Larsson G, et al. Reasons why women with long-term urinary incontinence do not seek professional help: a cross-sectional population-based cohort study. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14(5):296–304. discussion 304. Medline:14618304. doi: 10.1007/s00192-003-1077-9. [PubMed]
8. Bélisle S, Blake J, Basson R, et al. Canadian Consensus Conference on menopause, 2006 update. J Obstet Gynaecol Can. 2006;28(2) Suppl 1:S7–94.Medline:16626522. [PubMed]
9. Fantl J, Newman D, Colling J, et al. Urinary incontinence in adults: acute and chronic management (Clinical Practice Guideline 96-0682) Rockville (MD): Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996.
10. Hay-Smith EJ, Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2006;(1):CD005654.Medline:16437536. [PubMed]
11. Wilson PD, Hay-Smith J, Nygaard I, et al. Adult Conservative Management. In: Abrams P, Cardozo L, Khoury S, editors. Incontinence. 3rd ed. France: Health Public Publication Ltd; 2005. pp. 856–1059.
12. Sran MM, Wilson P, Lieblich P, et al. Regaining urinary continence in postmenopausal women with osteoporosis: preliminary results of a randomized controlled trial. IOF World Congress on Osteoporosis, Florence, Italy. Osteoporos Int. 2010. p. S368.
13. Johnson TM, II, Kincade JE, Bernard SL, et al. Self-care practices used by older men and women to manage urinary incontinence: results from the national follow-up survey on self-care and aging. J Am Geriatr Soc. 2000;48(8):894–902.Medline:10968292. [PubMed]
14. Mattox TF, Lucente V, McIntyre P, et al. Abnormal spinal curvature and its relationship to pelvic organ prolapse. Am J Obstet Gynecol. 2000;183(6):1381–4. discussion 1384. doi: 10.1067/mob.2000.111489. Medline:11120500. [PubMed]
15. Schlaich C, Minne HW, Bruckner T, et al. Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int. 1998;8(3):261–7. doi: 10.1007/s001980050063. Medline:9797911. [PubMed]
16. Heidrich SM, Wells TJ. Effects of urinary incontinence: psychological well-being and distress in older community-dwelling women. J Gerontol Nurs. 2004;30(5):47–54.Medline:15152744. [PubMed]
17. Miner PB., Jr Economic and personal impact of fecal and urinary incontinence. Gastroenterology. 2004;126(1) Suppl 1:S8–13. doi: 10.1053/j.gastro.2003.10.056. Medline:14978633.
Physiother Can. 2011 Summer; 63(3): 261–262. Published online 2011 August 10. doi: 10.3138/physio.63.3.261PMCID: PMC3157983
Prevalence of urinary incontinence in women with osteoporosis.
Source: BC Women’s Hospital and Health Centre, Osteoporosis Program, Vancouver BC; Simon Fraser University, Injury Prevention and Mobility Laboratory, Burnaby, BC.
OBJECTIVE: To investigate the prevalence and frequency of urinary incontinence in women presenting to a specialist osteoporosis clinic.
METHODS: Participants included 412 female patients aged 22 to 94 years (mean 62 years) presenting to a hospital-based specialist multidisciplinary osteoporosis clinic over one year. The presence or absence of urinary incontinence, urgency without leakage, type of symptoms (stress, urge, mixed) and frequency of urinary incontinence were recorded.
RESULTS: Sixty-seven percent of patients (277/412) reported some symptoms of urinary incontinence, 23% reported no symptoms and 10% reported urgency without any leakage. Of those who reported some urinary incontinence, 51% reported symptoms of stress incontinence, urgency, and urge incontinence. Almost 40% of all patients (163/412) and 59% of those with any urinary incontinence (163/277) reported leakage at least once per week.
CONCLUSION: The prevalence of at least weekly urinary incontinence in this population is much higher than that reported in studies of other older adult female populations. There is also a high prevalence of incontinence accompanied by urgency in women with osteoporosis. Based on these results and because urinary incontinence can limit a woman’s ability to be physically active and increase the risk of falls and fractures, screening for incontinence should be a routine part of osteoporosis management. Clinicians seeing patients for osteoporosis should consider the presence of incontinence when prescribing exercise for bone health and fall prevention.
Postmenopausal Women with Osteoporosis and Osteoarthritis Show Different Microstructural Characteristics of Trabecular Bone in Proximal Tibia using High-Resolution Magnetic Resonance Imaging at 3 Tesla.
BMC Musculoskelet Disord. 2013 Apr 15;14(1):136. Shen Y, Zhang YH, Shen L.
BACKGROUND: Osteoporosis (OP) and osteoarthritis (OA) are two common musculoskeletal disorders that affect the quality of life in aged people. An inverse relationship between OP and OA was proposed four decades ago. However, the difference in microstructure of the trabecular bone of these two disorders by high-resolution MRI (HR-MRI) has not been compared. The primary objective of the study is to explain the actual relationship between OA and OP based on differences between bone microstructure of these two diseases. The secondary objectives are to find out the significance of Euler number and its relationship with other structural parameters, and important role of HR-MRI to reveal the microstructure of trabecular bone directly.
METHODS: Totally, 30 women with OP and 30 women with OA (n = 60) were included in this study. Primary OA of hip, knee, as well as spinal arthrosis were diagnosed according to plain X-ray film findings. Osteoporosis was defined based on the latest criteria of World Health Organization (WHO). Structural and textural parameters derived from HR-MRI images of proximal tibia were calculated and compared with special software.
RESULTS: There were significant differences in apparent bone volume fraction, trabecular thickness, mean roundness, Euler number, entropy and inverse different moment between OP and OA patients. In OP group, apparent trabecular separation (Tb.Sp), inertia, absolute value and contrast were positively correlated with Euler number, whereas apparent trabecular number (Tb.N), mean trabecular area, inverse difference and inverse different moment were negatively correlated. Apparent trabecular bone volume fraction (BV/TV), mean trabecular area, mean trabecular perimeter and mean skeleton length negatively correlated with Euler number in OA group. Inverse different moment was the texture parameter, which influenced bone mineral density (BMD) of femoral neck, meanwhile contrast influenced BMD of both great trochanter and Ward’s triangle in OP group. While in OA group, Euler number was the exclusive parameter, which affected BMD of femoral neck and Ward’s triangle.
CONCLUSIONS: We found significant differences in microstructure parameters derived from HR-MRI images between postmenopausal women with OP and OA. It convincingly supports the hypothesis that there might be an inverse relationship between OP and OA.
Meen Sran Osteoporosis Physiotherapist Shelbourne Physiotherapy-Cook Street Victoria Clinic