Osteoporosis is a condition characterized by a decrease in the density of bone, decreasing its strength and resulting in fragile bones.

Osteoporosis literally leads to abnormally porous bone that is compressible, like a sponge. This disorder of the skeleton weakens the bone and results in frequent fractures (breaks) in the bones. Osteopenia is a condition of bone that is slightly less dense than normal bone but not to the degree of bone in osteoporosis. Normal bone is composed of protein, collagen, and calcium, all of which give bone its strength. Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone to fracture. The fracture can be either in the form of cracking (as in a hip fracture) or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, ribs, and wrists are common areas of bone fractures from osteoporosis although osteoporosis-related fractures can occur in almost any skeletal bone. What are osteoporosis symptoms and signs? Osteoporosis can be present without any symptoms for decades because osteoporosis doesn't cause symptoms until bone fractures. Moreover, some osteoporotic fractures may escape detection for years when they do not cause symptoms. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. The symptom associated with osteoporotic fractures usually is pain; the location of the pain depends on the location of the fracture. The symptoms of osteoporosis in men are similar to the symptoms of osteoporosis in women. Fractures of the spine (vertebra) can cause severe "band-like" pain that radiates from the back to the sides of the body. Over the years, repeated spinal fractures can lead to chronic lower back pain as well as loss of height and/or curving of the spine due to collapse of the vertebrae. The collapse gives individuals a hunched-back appearance of the upper back, often called a "dowager hump" because it commonly is seen in elderly women. A fracture that occurs during the course of normal activity is called a minimal trauma, or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb. Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures also may heal slowly or poorly after surgical repair because of poor healing of the bone. causes? The following are factors that will increase the risk of developing osteoporosis:

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Female gender Caucasian or Asian race Thin and small body frame Family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture) Personal history of fracture as an adult Cigarette smoking Excessive alcohol consumption Lack of exercise Diet low in calciu Poor nutrition and poor general health Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as celiac sprue Low estrogenn levels in women (such as occur in menopause or with early surgical removal of both ovaries) Low testosterne levels in men (hypogonadism) Chemotherapy that can cause early menopause due to its toxic effects on the ovaries Amenorrhea (loss of the menstrual period) in young women associated with low estrogen and osteoporosis; amenorrhea can occur in women who undergo extremely vigorous exercise training and in women with very low body fat, for example, women with anorexia nervosa Chronic inflammation, du to chronic diseases such as rheumatoid arthritis or liver diseases Immobility, such as after a stroke, or from any condition that interferes with walking Hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is ingested as thyroid hormone medication Hyperparathyroidism is a disease wherein there is excessive parathyroid hormone production by the parathyroid gland, a small gland located near or within the thyroid gland. Normally, parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium from the diet to prevent osteoporosis. Vitamin D deficiencycan result from lack of intestinal absorption of the vitamin such as occurs in celiac sprue and primary biliary cirrhosis.

Certain medications can causeosteoporosis. These include long-term use of heparin (a blood thinner), antiseizure medications such asphenytoin (Dilantin) and phenobarbital, and long-term use of oral corticosteroids (such as prednisone). osteoporosis diagnosed? A routine X-ray can reveal osteoporosis of the bone because the bones appear much thinner and lighter than normal bones. Unfortunately, by the time X-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, X-rays are not accurate indicators of bone density. Thus, the appearance of the bone on X-ray often is affected by variations in the degree of exposure of the X-ray film. The National Osteoporosis Foundation, the American Medical Association, and other major medical organizations recommend a dual-energy X-ray absorptiometry scan (DXA, formerly known as DEXA) for diagnosing osteoporosis. DXA measures bone density in the hip and the spine. The test takes only five to 15 minutes to perform, exposes patients to very little radiation (less than one-tenth to one-hundredth of the amount used on a standard chest X-ray), and is quite precise. The bone density of the patient is compared to the average peak bone density of young adults of the same sex and race. This score is called the "T score," and it expresses the bone density in terms of the number of standard deviations (SD) below peak young adult bone mass.

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Osteoporosis is defined as a bone density T score of -2.5 or below. Osteopenia (between normal and osteoporosis) is defined as bone density T score between -1 and -2.5.

It is important to note that while osteopenia is considered a lesser degree of bone loss than osteoporosis, it nevertheless can be of concern when it is associated with other risk factors (such as smoking, cortisone steroid usage, rheumatoidarthritis, family history of osteoporosis, etc.) that can increase the chances for developing vertebral, hip, and other fractures. In this setting, osteopenia may require medication as part of the treatment program. Ma n a g eme n t The principles of management are : 1. Prevention and control of risk factors. 2. Management of menopause. 3. Drug therapy Antiresorptive and formation stimulation agents. 4. Musc ul os keletal and ps ychologic al rehabilitation. Prevention and control of risk factors A. Safety and all fall prevention The aim is to prevent fall and reduce fracture rate and it can be achieved by adopting simple measures. 1. Precautions and care during routine activities: To i l e ts a n d b a t h r o o m s s h o u l d b e k e p t uncongested and dry to avoid slipping on wet floor. Floor should be smooth but non-slippery and without any obstruction. Staircase should have railing on both sides. Clothes and shoes should be comfortable and well fitting. Rooms, toilets, and corridors should be well lit. 2. Avoid use of sedatives, hypnotics, and antihypertensives causing postural hypotension. 3. Encourage to join a regular active exercise programme. Nursing Osteoporosis Focus on careful positioning, ambulation, and prescribed exercises. Administer analgesics and heat to relieve pain as ordered. Include the patient and his family in all phases of care. Encourage the patient to perform as much self-care as her immobility and pain allow. Provide the patient activities that involve mild exercise. Check the patients skin daily for redness, warmth, and new painsites. Monitor the patients pain level, and assess her response to analgesics, heat therapy, and diversional activities. Explain all treatments, tests, and procedure to the patient.

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9. Make sure the patient and her family clearly understand the prescribed drug regiman. 10. Tell the patient to report any new pain sites immediately, especially after trauma. 11. Provide emotional support and reassurance to help the patient cope with limited mobility. carpal tunnel syndrome? Carpus is a word derived from the Greek word karpos, which means "wrist." The wrist is surrounded by a band of fibrous tissue that normally functions as a support for the joint. The tight space between this fibrous band and the wrist bone is called the carpal tunnel. The median nerve passes through the carpal tunnel to receive sensations from the thumb, index, and middle fingers of the hand. Any condition that causes swelling or a change in position of the tissue within the carpal tunnel can squeeze and irritate the median nerve. Irritation of the median nerve in this manner causes tingling and numbness of the thumb, index, and the middle fingers -- a condition known as "carpal tunnel syndrome." What is tarsal tunnel syndrome? Anatomy similar to that of the wrist and hand exists in the ankle and foot. Tarsal is a word derived from the Latin word for "ankle." When the sensory nerve that passes through the tarsal tunnel is irritated by pressure in the tunnel, numbness and tingling of the foot and toes can be felt. This condition is referred to as "tarsal tunnel syndrome." Tarsal tunnel syndrome is analogous to, but far less common, than carpal tunnel syndrome. It is treated similarly. What conditions and diseases cause carpal tunnel syndrome? For most patients, the cause of their carpal tunnel syndrome is unknown. Any condition that exerts pressure on the median nerve at the wrist can cause carpal tunnel syndrome. Common conditions that can lead to carpal tunnel syndrome include obesity, pregnancy, hypothyroidism, arthritis,diabetes, and trauma. Tendon inflammation resulting from repetitive work, such as uninterrupted typing, can also cause carpal tunnel symptoms. Carpal tunnel syndrome from repetitive maneuvers has been referred to as one of the repetitive stress injuries. Some rare diseases can cause deposition of abnormal substances in and around the carpal tunnel, leading to nerve irritation. These diseases include amyloidosis, sarcoidosis, multiple myeloma, and leukemia. What are carpal tunnel syndrome symptoms? People with carpal tunnel syndrome initially feel numbness and tingling of the hand in the distribution of the median nerve (the thumb, index, middle, and part of the fourth fingers). These sensations are often more pronounced at night and can awaken people from sleep. The reason symptoms are worse at night may be related to the flexed-wrist sleeping position and/or fluid accumulating around the wrist and hand while lying flat. Carpal tunnel syndrome may be a temporary condition that completely resolves or it can persist and progress.

Picture of carpal tunnel syndrome

As the disease progresses, patients can develop a burning sensation, and/or cramping and weakness of the hand. Decreased grip strength can lead to frequent dropping of objects from the hand. Occasionally, sharp shooting pains can be felt in the forearm. Chronic carpal tunnel syndrome can also lead to wasting (atrophy) of the hand muscles, particularly those near the base of the thumb in the palm of the hand. How is carpal tunnel syndrome diagnosed? The diagnosis of carpal tunnel syndrome is suspected based on the symptoms and the distribution of the hand numbness. Examination of the neck, shoulder, elbow, pulses, and reflexes can be performed to exclude other conditions that can mimic carpal tunnel syndrome. The wrist can be examined for swelling, warmth, tenderness, deformity, and discoloration. Sometimes tapping the front of the wrist can reproduce tingling of the hand, and is referred to as Tinel's sign of carpal tunnel syndrome. Symptoms can also at times be reproduced by the examiner by bending the wrist forward (referred to as Phalen's maneuver). The diagnosis is strongly suggested when anerve conduction velocity test is abnormal. This test involves measuring the rate of speed of electrical impulses as they travel down a nerve. In carpal tunnel syndrome, the impulse slows as it crosses through the carpal tunnel. A test of muscles of the extremity, electromyogram (EMG), is sometimes performed to exclude or detect other conditions that might mimic carpal tunnel syndrome.

Blood tests may be performed to identify medical conditions associated with carpal tunnel syndrome. These tests include thyroid hormone levels, complete blood counts, and blood sugar and protein analysis. X-ray tests of the wrist and hand might also be helpful to identify abnormalities of the bones and joints of the wrist. What is the treatment for carpal tunnel syndrome? Can carpal tunnel syndrome be prevented? The choice of treatment for carpal tunnel syndrome depends on the severity of the symptoms and any underlying disease that might be causing the symptoms. Initial treatment usually includes rest, immobilization of the wrist in a splint, and occasionally ice application. Those whose occupations are aggravating the symptoms should modify their activities. For example, computer keyboards and chair height may need to be adjusted to optimize comfort. These measures, as well as periodic resting and range of motion stretchingexercise of the wrists can actually prevent the symptoms of carpal tunnel syndrome that are caused by repetitive overuse. Underlying conditions or diseases are treated individually. Fractures can require orthopedic management. Obese individuals will be advised regarding weight reduction. Rheumatoid disease is treated with measures directed against the underlying arthritis. Wrist swelling that can be associated with pregnancy resolves in time after delivery of the baby. Several types of medications have been used in the treatment of carpal tunnel syndrome. Vitamin B6 (pyridoxine) has been reported to relieve some symptoms of carpal tunnel syndrome, although it is not known how this medication works. Nonsteroidal anti-inflammatory drugs can also be helpful in decreasing inflammation and reducing pain. Side effects include gastrointestinal upset and even ulceration of the stomach. These medications should be taken with food, and abdominal symptoms should be reported to the doctor. Corticosteroids can be given by mouth or injected directly into the involved wrist joint. They can bring rapid relief of the persistent symptoms of carpal tunnel syndrome. Side effects of these medications, when given in short courses, for carpal tunnel syndrome are minimal. However, corticosteroids can aggravate diabetes and should be avoided in the presence of infections. Most patients with carpal tunnel syndrome improve with conservative measures and medications. Occasionally, chronic pressure on the median nerve can result in persistent numbness and weakness. In order to avoid serious and permanent nerve and muscle consequences of carpal tunnel syndrome, surgical treatment is considered. Surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. This surgical procedure is called "carpal tunnel release." It can now be performed with a small diameter viewing tube, called an arthroscope, or by open wrist procedure. After carpal tunnel release, patients often undergo exercise rehabilitation. Though it is uncommon, symptoms can recur. Carpal Tunnel Syndrome and Tarsal Tunnel Syndrome At A Glance

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Carpal tunnel syndrome is caused by irritation of the median nerve at the wrist. Any condition that exerts pressure on the median nerve can cause carpal tunnel syndrome. Symptoms of carpal tunnel syndrome include numbness and tingling of the hand. Diagnosis of carpal tunnel syndrome is suspected based on symptoms, supported by physical examination signs, and confirmed by nerve conduction testing. Treatment of carpal tunnel syndrome depends on the severity of symptoms and the underlying cause.

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What Is Osteoporosis? Osteoporosis is a disease characterized by low bone mass and loss of bone tissue that may lead to weak and fragile bones. If you have osteoporosis, you have an increased risk for fractured bones (broken bones).

Normal bone is composed of protein, collagen, and calcium, all of which give bone its strength. Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone to fracture. The osteoporosis condition can be present without any symptoms for decades. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. Symptoms depend on the location of the fracture Osteoporosis Symptoms: Fractures of the Spine Fractures of the spine (vertebra) can cause severe "band-like" pain that radiates around from the back to the side of the body. Over the years, repeated spine fractures can cause chronic lower back pain as well as loss of height or curving of the spine, which gives the individual a hunched-back appearance of the upper back, referred to as a "dowager hump. What Factors Determine Bone Strength? Bone mass (bone density) is the amount of bone present in the skeletal structure. Generally, the higher the bone density, the stronger the bones. Bone density is greatly influenced by genetic factors and can be affected by environmental factors and medications. For example, men have a higher bone density than women. African Americans have a higher bone density than Caucasian or Asian Americans. Normally, bone density accumulates during childhood and reaches a peak by around 25 years of age. Bone density is then maintained for about 10 years. After age 35, both men and women will normally lose 0.3%-0.5% of their bone density per year as part of the aging process. Menopause, Estrogen, and Osteoporosis Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause, bone loss accelerates. During the first five to 10 years after menopause, women can suffer up to 2%-4% loss of bone density per year! This can result in the loss of up to 25%-30% of their bone density during that time period. Accelerated bone loss after menopause is a major cause of osteoporosis in women. What Are the Risk Factors for Developing Osteoporosis? female gender Caucasian or Asian race thin and small body frames family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture) personal history of fracture as an adult cigarette smoking

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excessive alcohol consumption lack of exercise diet low in calcium poor nutrition and poor general healthWhat Are the Risk Factors for Developing Osteoporosis? (continued) malabsorption (nutrients in the bowels are not properly absorbed) low estrogen levels chemotherapy loss of the menstrual period (amenorrhea) chronic inflammation immobility, such as after a stroke or any condition that interferes with walking vitamin D deficiency (vitamin D helps the body absorb calcium) certain medications can cause osteoporosis such as long-term use of heparin (a blood thinner), antiseizure medications phenytoin (Dilantin) and phenobarbital, and long-term use of oral corticosteroids (such as prednisone)

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How Is Osteoporosis Diagnosed? A routine X-ray can suggest osteoporosis of the bone, which appears much thinner and lighter than normal bones. Unfortunately, by the time X-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, X-rays are not accurate indicators of bone density. The appearance of the bone on the X-ray is often affected by variations in the degree of exposure of the X-ray film How Is Osteoporosis Treated and Prevented? The goal of osteoporosis treatment is the prevention of bone fractures by stopping bone loss and by increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment. We'll take a look at some of the prevention and treatment options on the following slides Prevention and Treatment: Exercise Exercise has a wide variety of beneficial health effects. However, exercise does not bring about substantial increases in bone density. The benefit of exercise for osteoporosis has mostly to do with decreasing the risk of falls, probably because balance is improved and/or muscle strength is increased. Research has not yet precisely determined what type or duration of exercise is best for osteoporosis. Nevertheless, most doctors recommend weight-bearing exercise, such as walking, preferably daily. Prevention and Treatment: Quit Smoking and Curtail Alcohol Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5%-10% of bone mass. Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause. Smoking cigarettes can also lead to earlier menopause. Data on the effect of regular consumption of alcohol and caffeine on osteoporosis is not as clear as with exercise and cigarettes. In fact, research regarding alcohol and caffeine as risk factors for osteoporosis shows widely varying results and is controversial. Certainly, these effects are not as powerful as other factors. Nonetheless, moderation of both alcohol and caffeine is prudent. Prevention and Treatment: Calcium Supplements Building strong and healthy bones requires an adequate dietary intake of calcium and exercise beginning in childhood and adolescence for both sexes. Importantly, once osteoporosis is present, a high dietary calcium intake or taking calcium supplements alone is not sufficient in treating osteoporosis and should not be viewed as an alternative to or substituted for more potent prescription osteoporosis medications. In the first several years after menopause, rapid bone loss can occur even if calcium supplements are taken. Unfortunately, surveys have shown that the average woman in the United States consumes less than 500 milligrams of calcium per day in her diet, less than the recommended amounts. Additional calcium can be obtained by drinking more milk and eating more yogurt or cottage cheese or by taking calcium supplement tablets as well from calcium-fortified foods, such as orange juice Prevention and Treatment: Calcium-Fortified Foods Excluding dairy products, the average American diet contains approximately 250 mg of calcium. As mentioned on the previous slide, here are some examples of calcium-fortified foods and their respective calcium intake. Prevention and Treatment: Menopausal Hormone Therapy Menopausal hormone therapy (previously referred to as hormone replacement therapy or HRT) has been shown to prevent bone loss, increase bone density, and prevent bone fractures. Estrogen is available orally (Premarin, Estrace, Estratest, and others) or as a skin patch (Estraderm, Vivelle, and others). Estrogen is also available in combination with progesterone as pills and patches. Progesterone is routinely given along with estrogen to prevent uterine cancer that might result from estrogen use alone. Women who have had a hysterectomy (surgical removal of the uterus) may take estrogen alone. Due to adverse effects of menopausal hormone therapy, such as increased risks of heart attack, stroke, blood clots in the veins, and breast cancer; menopausal hormone therapy is no longer recommended for long-term use but rather short-term use to relieve menopausal hot flashes. Every woman should have an individualized discussion regarding estrogen replacement with her doctor. Prevention and Treatment: Medications Currently, the most effective medications for osteoporosis that are approved by the FDA are anti-resorptive agents, which prevent bone breakdown. Antiresorptive medications inhibit bone removal (resorption), thus tipping the balance in favor of bone rebuilding and increasing bone density. Menopausal estrogen hormone therapy is one example of an antiresorptive agent. Others include alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast). Selective estrogen receptor modulators (SERMs) are a class of drugs that work like estrogen in some tissues. The SERMs are developed to reap the benefits of estrogen while avoiding the potential side effects of estrogen. Examples include tamoxifen and Raloxifene (Evista).