The treatment of advanced osteoporosis is difficult and the real key to the management of this disease is prevention. It is therefore extremely important to identify, sooner rather than later, those individuals who are at risk. Osteoporosis is a silent disease with no symptoms until a fracture occurs- to wait for symptoms is therefore too late. What can be done to predict future fractures?
1. Clinical risk factor assessment
Those risk factors which may predispose to the development have already been discussed and we mention the more important ones again:
- Advanced age
- Premature menopause (before 45 years)
- Other causes of low sex hormone levels in men and women
- Long-term cortisone use
- Previous fracture after minimal trauma
- Alcohol or tobacco abuse
- Certain hormonal, intestinal or malignant diseases
- Excessive leanness
- A strong family history of osteoporosis
- Malnutrition, poor calcium intake and eating disorder (e.g. anorexia, bulimia)
Although the predictive value of a clinical risk factor is not accurate (i.e. individuals without risk factors may develop osteoporosis), it provides clear indications for further investigations (e.g. bone mass measurement).
2. Bone mass measurement
A low bone mass is strongly associated with the development of fractures and bone mass measurement is currently the best predictor of fractures. Bone mass measurements should always form part of a comprehensive programme of medical management, preferably done by a knowledgeable physician.
Routine screening of bone mass without any indication is cost- ineffective and not recommended.
Indications for Bone Mass Measurement:
- (i)Presence of disorders known to be bad for your bones; early menopause; other causes of low sex hormones; Hormonal, gut malignant, nutritional/eating disorders; bone-toxic drugs
- (ii) X-ray evidence of low bone mass or fracture
- (iii) History of non-traumatic fractures
- (iv) When there needs to be decided whether to start/continue with hormone replacement therapy or not
- (v)Presence of strong historic factors e.g.
- Family history of osteoporosis
- Excessive leanness
- Alcohol abuse
- Heavy smoking
Techniques available to measure bone mass and fractures include:
- Dual-energy X-ray Absorptiometry (DEXA): X-ray energy is passed through the spine, hip other part of the skeleton. It is precise, accurate and painless.
- Computerised tomography: The so-called CT accurately measures spinal bones mass. To date it cannot measure hip bone mass. Compared to DEXA, the radiation dose is higher and the measurement less reproducible.
- X-rays: Although essential to detect fractures and deformities, it is not accurate enough to detect bone loss. Up to 40% of bone loss needs to occur before it is detected on X-rays. The converse also happens where falsely positive findings for osteoporosis occur in about 25% of cases.
- Single photon absorptiometry (SPA): Measures bone in the wrist and forearm; this is useful but does not always provide accurate information about bone density in other sites.
- Ultrasound: Measurements of the heel bone or shin have much potential, but at present the technique is not recommended to confirm a diagnosis of osteoporosis or to follow up response to therapy.
3. Biochemical assessment
Biochemical tests done on blood and urine samples to assess bone turnover (the chewing away as well as the forming of new bone), are available to identify those at risk of rapid bone loss or fracture. They are also used to assess the response to therapy.
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