Sam Dyer, PA-C, MHS, is a NCCPA-certified physician assistant with more than 20 years of practice experience in orthopedics. He also holds a Certificate of Added Qualifications in Orthopaedic Surgery from the NCCPA. He practices at Emerge Orthopedics in Chapel Hill, North Carolina, and Durham, North Carolina. He is the current president of the PAOS, and writes an orthopedic blog on the PAOS website titled the OrthoPA-C. He has also authored an onboarding manual for PAs new to orthopedics, which can currently be read by PAOS members on the PAOS website, and plans to publish the work in the future. He has written numerous forum posts for the PAOS website and PAOS newsletter. He enjoys seeing a variety of patients and conditions in his practice. He also has developed a charity advocacy program for the PAOS titled PAOS CARES, where he teaches primary care providers at community health centers and rural health clinics MSK injection techniques.

 

BLOG: Treatment modalities for patients with osteoporosis, osteoporotic fractures

by Daniel J. Acevedo, PA-C

What are some treatment modalities we can comfortably recommend to patients with osteoporosis and patients with osteoporotic fractures? Supplementation with vitamin D3 is certainly something that we can prescribe to all patients with osteoporosis, low bone mass or patients who have sustained an osteoporotic fracture. Vitamin D deficiency has been shown in 70% to 90% of those with hip fractures, and sufficient levels of vitamin D increases bone strength and mineralization, lower extremity muscle strength, gait speed and performance and balance in patients older than 65 years of age.

It has also been associated with a reduction in falls. The Institute of Medicine (IOM), International Osteoporosis Foundation (IOF), National Osteoporosis Foundation (NOF), and the American Geriatric Society (AGS) all recommend vitamin D supplementation. These organizations generally recommend around 1000 international units daily of vitamin D3 daily. The Institute of Medicine’s safe upper limit recommendation is 4000 international units daily. Once yearly vitamin D in the form of 500,000 international units once per year is not recommended.

Calcium citrate or calcium carbonate can also be prescribed. Total calcium intake recommendations from the IOM, the NOF and the Endocrine Society are 1,000 mg to 1,200 mg per day in the form of diet plus supplementation; the dosages may be higher in certain populations. The safe upper limit recommended by the IOM is 2,000 mg total per day. Caution should be taken with those with a history of kidney stones. There, also, has been some recent concern about increased cardiovascular risk with calcium supplementation. The NOF and the American Society for Preventative Cardiology 2016 position statement on calcium supplementation recommends calcium supplement and states that it is safe from a cardiovascular standpoint.

We can also comfortably recommend regular weight-bearing activity and muscle strengthening activities, such as walking, yoga and Tai Chi. Clinicians should have a low threshold to refer their patients with osteoporosis to outpatient physical therapy or to an athletic trainer or personal trainer with expertise in geriatric populations. Fall prevention strategies are also recommended. Most hip fractures are associated with a fall, and those who have fallen once tend to have an increased risk of future falls. In fact, a history of falls increases future fall likelihood nearly three times. I routinely urge patients to use assistive devices, such as walkers and canes, and counsel patients on proper type of carpeting for their homes to reduce falls, among other strategies. Certain modifiable activities, such as excess alcohol consumption, should also be discussed as this can increase the likelihood of falls and has a detrimental effect on bone quality.

The treatment of osteoporosis is difficult, especially for the orthopedic provider. However, it is our duty to treat those with osteoporosis or who have already sustained an osteoporotic fracture. There is much that can be done that is both safe and effective. Treatment can range from counseling of activities to vitamin and mineral supplementation recommendation to drug therapy. All require knowledge that is free and readily available. I urge all providers of orthopedic care to learn more about osteoporosis to better serve this vulnerable population. Best of luck to all those who treat osteoporosis and low bone mass in orthopedic practice. It is challenging but the future is bright.