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Osteoporosis
- Low bone mass
- Structural deterioration of bone tissue leading to fragility
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How many males will have an osteoporotic fracture?
1 in 8
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How many females will have an osteoporotic fracture?
1 in 2
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Estrogen in osteoporosis
- Estrogen levels drop postmenapaus, which leads to osteoporosis
- Bone spairing
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Who has osteoporosis
- 20% white women 50 and older
- 5% black women 50 and older
- 10% hispanic women 50 and older
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Osteopenia
- Low bone mass
- T score of -1 to -2.5
- 68% fall w/in stan. dev
- 95% w/in 2 stan. dev
- 99% w/in 3 stan. dev
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Mesenchymal cell
- leads to pre-osteoblast
- eventually leading to mature osteoblast
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Increase in blood calcium leads to...
- Increased secretion of calcitonin which stimulates osteoblasts
- Osteoblasts decrease the calcium in blood
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Decreased blood calcium leads to...
- Increased secretion of parathyroid hormone
- This leads to increases in osteoclast activity and increase in blood calcium levels
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How does an osteoclast break down bone?
- Suction to bone, creates acetic environment through proton pumping
- Seals off by useing alphav-beta3 integrin
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RANKL'D
- Stimulation of RANKL protein stimulates osteoclast production
- Parathyroid is stimulated by low blood calcium levels
- Osteoprotegrin blocks RANKL protein preventing stimulation of osteoclast activity
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Maintaining homeostasis in blood calcium levels
- High levels of calcium stimulate thyroids release of calcitonin which is a powerful inhibitor of osteoclasts
- Low levels of calcium stimulates parathyroid gland to secrete parathyroidhormone which stimulates osteoclasts
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Vit D and osteoporosis
Vitamin D increases calcium absorption from GI tract
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Wolff's Law
Overload principle applied to bone - A bone will respond to the load imposed on it
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BMD w/ resistance training
BMD increases
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What activities increase BMD?
Activities that require constant loading - plyometric type activities best
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Primary osteoporosis
Associated with the process of normal aging (0.5-1.0% loss/yr after 30 y.o.
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Type I osteoporosis
- Menopause related (post-menopausal)
- -2 to -6.5% bone loss per year (trabecular bone)
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Type II osteoporosis
- Age related (senile)
- 50-70 y.o., trabecular loss, vertebrae, wrist, and femoral neck fractures
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Secondary osteoporosis
- Caused by certain medical conditions and medications
- Acromegaly, cushing's syndrome, hyperparathyroidism, intestinal malabsorption, Marfan's syndrome, scurvy
- Also can be caused by antacids, cortisone therapy, heparin, lasix, methotrexate, and thyroid hormone
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Hypothalamic adenoma and osteoporosis
May cause stimulation of GHRH which causes GH release of pituitary leading to acromegaly, and hypothalamus may also release CRH which stimulates release of cortisol which breaks down protein, which is found in the bone matrix
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Heparin and osteoporosis
Heparin increases release of thyroid hormone which causes universal breakdown of tissue
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Methetrexate and osteoporosis
chemo drug which inhibits bone growth
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Which bone goes first in osteoporosis
Trabecular bone
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Risk factors for osteoporosis
- Female
- Advancing age
- Caucasian race
- Low body mass
- premature menopause or prolonged premature amenorrhea
- Low calcium intake
- Chronic smoking and/or excessive alcohol
- Chronic corticosteroid
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Fractures
- >70% in people > 70 y.o
- Each 1 SD decrease in bone mass increases fracture risk by 15%
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When should BMD be tested?
- Women over the age of 65
- Women with post menopause bone fracture
- Women on HRT for prolonged periods
- Men with low testosterone levels
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Antacids and osteoporosis
Large antacid use leads to low BMD
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HRT
hormone replacing therapy is associated with increase risk of cancer
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Osteoporotic symptoms
- Collapsed vertebrae
- Kyphosis posture
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Wedge fracture
Kyphosis can cause decreased space in the anterior component of the disk
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Which sites are most common for fracture
- Wrist
- Vertebrae
- Femoral neck
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What percent of hip fracture patients over the age of 50 die within a year
25%
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Slipped disk
Gel portion of disk is pushed thru cartilage and puts pressure on the spinal nerves
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Estrogen
- inhibits bone remodeling behavior (osteoclast behavior)
- Also endothelial protecting, decreasing risk of CAD
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Calcitonin
- Reduces blood Ca++ levels
- decreases Ca++ resoprtion
- decreases osteoclast activity
- decreases Ca++ reabsorption
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SERM (Selective estrogen receptor modulator)
- Not estrogen, but binds to estrogen receptors
- Increase BMD
- Decrease risk of CAD
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Bisposphates
Inhibit osteoclast activity
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Calcium supplementation
- > 60 y.o. take 1200 mg/day
- But remember, you can only absorb 500 mg/ingestion so spread the doses
- Females > 50 y.o. take 1500 mg/day
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#1 complaint ages 25-60
Low back pain
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Acute low back pain
Less than three months of pain
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Chronic low back pain
Greater than 3 months
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What causes low back pain?
- Osteoporosis/arthritis
- spinal stenosis
- Nerve impingement
- Trauma, sprain, strain
- Muscle contracture
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Sciatica
- Pain and impingement caused by impingement in the lumbosacral area
- Often due to weak core
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Normal spinal curvature
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis
- Sacral kyphosis
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Sprain
Ligament damage/tear
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Strain
Muscle damage/tear
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Muscles causing posterior tilt
- Abdominals
- hamstrings
- gluteals
- illiacus, quads, sartorius, TFL
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Muscles causing anterior pelvic tilt
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Tight iliopsoas
Lumbar lordosis
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Weak abdomen
anterior pelvic tilt
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Normal posture
- ASIS line up with pubic symphysis
- Femoral head should line up with lumbar L5
- Ears and ASIS
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Anterior tilt
- Hip flexors tight
- Abdominals weak
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How should you sit in a chair?
On your ischeal tuberosity, with knees at 90˚
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How should you lift objects?
Close to your body to decrease the lever length
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Diabetes insipidous
- Kidneys unable to hold water (lack of ADH)
- Glucose in urine
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Gestational diabetes
Occurs during the third trimester
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Type I diabetes
Hypoinsulinemia
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Type II diabetes
Hyperinsulinemia
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Phaeochromocytoma
- Cancer in the adrenal medulla
- Prevents release of insulin
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Roles of insulin
- Increase glucose uptake, oxidation, and storage in cells
- Increase TAG storage
- Decrease TAG breakdown
- Increase aa uptake and protein synthesis
- Inhibit action and release of anti-insulin hormones
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Insulin insufficiency
- Increased adipocyte lypolysis
- Increased blood glucose
- Increased FFA (increased LDL, VLDL)
- Increased ketone production
- acetone form ketone production causes fruity breath
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Symptoms of diabetes
- Glycosuria
- Polyuria
- Polydipsia (thirsty)
- Polyphagia (hungry)
- Lethargic/fatigue
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Glycosylated hemoglobin
- Eventually, glucose binds to hemoglobin. Since this process takes a while it gives a bit of history to how long you have been hyperglycemic
- Normal < 6.5% of Hb
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Blood insulin
7-20 uU/ml is normal
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C-peptide
0.5 - 3.0 is normal
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Kussmaul respiration
- Deep, labored, gasping
- caused by ketoacidosis
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Diabetic ketoacidosis (diabetic coma)
pH dropped too far
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Arteriosclerosis
Calcification of fatty plaque causing artery to be stiff and hard
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Microvascular disease
- Retinopathy
- Nephropathy (40%-50% will have renal disease) 2/3 of these will have kidney faiure and need a transplant
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Diabetic neuropathy
16-58% will eventually develop gangreen
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Diabetic management of diabetes
- Decrease total kcals if obese (300-500 kcals/day to lose 1-2 lbs)
- 55-70% CHO's
- Cholesterol <300 mg
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IDDM feeding schedule
3 meals + 3 snacks
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Insulin like effect of exercise
- Muscle contractions stimulate glucose to go from blood to muscle
- May last up to 48 hours
- Prolonged exercise can increase HDL by 50% and drop triglycerides by 50%
- Increase insulin receptors and glut-4 carriers in cell
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