Osteoporose
De richtlijn Osteoporose van het Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF) dient als leidraad voor de fysiotherapeut bij de behandeling van patiënten met gezondheidsproblemen die samenhangen met osteoporose.
Algemene informatie
Alle aanbevelingen
Diagnostisch proces
(1) Rode vlaggen
Bij elke patiënt dient de fysiotherapeut na te gaan of er rode vlaggen aanwezig zijn. In geval van een of meerdere rode vlaggen moet de patiënt worden geïnformeerd en krijgt de patiënt het advies om contact op te nemen met de huisarts (in geval van Directe Toegankelijkheid Fysiotherapie, DTF) of verwijzend arts (niveau 4).
Kwaliteit van de gevonden artikelen: D.
(2) Anamnese
Bij het inventariseren van de gezondheidsproblemen van mensen met osteoporose moet de fysiotherapeut de gezondheidstoestand in kaart brengen door, volgens het ICF-model, gebruik te maken van de gezondheidsdomeinen: functies en anatomische eigenschappen, activiteiten, participatie, externe en persoonlijke factoren (niveau 4).
Kwaliteit van de gevonden artikelen: D.
Therapeutisch proces
(3) Bevorderen of in stand houden van de botmineraaldichtheid (niveau 1 t/m 4)
Oefeningen ter bevordering of instandhouding van de botmineraaldichtheid moeten langdurig worden volgehouden; het duurt ongeveer 1 jaar voordat een effect op de botdichtheid zichtbaar is. Het verdient aanbeveling om oefeningen ter behoud of bevordering van de botdichtheid dagelijks uit te voeren.
Oefeningen ter bevordering of instandhouding van de botmineraaldichtheid moeten bij voorkeur gewichtsdragend zijn, bijvoorbeeld gewichtsdragende oefeningen in de vorm van krachttraining of wandelen. De intensiteit van deze oefeningen moet voldoende zijn:
- krachtoefeningen moeten een intensiteit hebben van 70-90% van het 1RM;
- er moet worden gewandeld met een snelheid van meer dan 6 km/uur.
Indien veilig en mogelijk voor de patiënt, verdienen zogeheten high-impactoefeningen, zoals springen, de voorkeur boven low-impactoefeningen.
Ter bevordering van de botdichtheid van de pols worden krachtoefeningen van de armen aanbevolen, omdat in de pols van gewichtsdragende oefeningen geen effect wordt verwacht. Om het effect van krachttraining op de botdichtheid te optimaliseren, wordt aanbevolen om oefeningen met een snelle, meer explosieve krachtopbouw te kiezen.
Kwaliteit van de gevonden artikelen: A1 (Asikainen et al., 2004160; Bonaiuti et al., 2002138; De Kam et al., 2009140; Ernst et al., 1998243; Kelley et al., 2001241; Palombaro 2005171; Sheth et al., 1999162;Wolff et al., 1999172; Zehnacker et al., 2007165), A2 (Chillibeck et al., 2002177; Hourigan et al., 2008143; Korpelainen et al., 2006121; Liu-Ambrose et al., 2004131; Papaioannou et al., 2003146; Sinaki et al., 2002188; Uusi-Rasi et al., 2003190; Woo et al., 2007191), B (Borer et al., 2007173; Chan et al., 2004175; Cheng et al., 2002176; Englund et al., 2005180; Going et al., 2003182; Gusi et al., 2006183; Huuskonen et al., 2001244; Karinkanta et al., 2007184; Kontulainen et al., 2004245; Maddalozzo et al., 2007185; Milliken et al., 2003186; Rhodes et al., 2000187; Stengel et al., 2005119 en 2007120; Swanenburg et al., 2007148; Vainionpäa et al., 2005133; Wu et al., 2006117) en D.
(4) Val- en fractuurincidentie (niveau 1 t/m 3)
Ter verlaging van de val- en fractuurincidentie bij mensen met osteoporose worden functionele oefeningen voor kracht en balans aanbevolen.
A1 (Baker et al., 2007161; Gillespie et al. 2009113), A2 (Beyer et al., 2007197; Freiberger et al., 2007199; Korpelainen et al., 2006121; Lin et al., 2007200; Lord et al., 2005201; Luukinen et al., 2007126; Mahoney et al., 2007202; Means et al., 2005203; Voukelatos et al., 2007205en Woo et al., 2007191)en B (Faber et al., 2006198; Li et al., 2004127, 2005128; Sakamoto et al., 2006204 en Weerdesteyn et al., 2006206).
(5) Spierkracht (niveau 1 en 2)
Ter verbetering van de spierkracht wordt geadviseerd om 2-3 keer per week te trainen met 8-10 verschillende oefeningen voor de grote spiergroepen, en een intensiteit van minstens 50% van het 1RM. Ter versterking van de rugspieren worden extensieoefeningen van de rug met een lage intensiteit geadviseerd.
Kwaliteit van de gevonden artikelen: A1 (Asikainen et al., 2004160), A2 (Baker et al., 2007213;Beyer et al., 2007197; Chilibeck et al., 2002177; De Vreede et al. 2005217) en B (Beneka et al., 2005214; Chien et al., 2005154; Going et al., 2003182, Henwood et al., 2006221; Hongo et al., 2007155; Kalapotharakos et al., 2005222;Karinkanta et al., 2007184; Maddalozzo et al., 2007185; Orr et al., 2006227; Rhodes et al., 2008187 en Stewart et al., 2005189).
(6) Balans (niveau 1 t/m 3)
Ter verbetering van de balans worden functionele balansoefeningen geadviseerd in een frequentie van 3 keer per week. Daarnaast kan vibratietraining de balans helpen verbeteren.
Kwaliteit van de gevonden artikelen: A1 (de Kam et al., 2009140), A2 (Beyer et al., 2007197; De Bruin et al., 2007216; Freiberger et al., 2007199; Lin et al., 2007200; Means et al., 2005203; Voukelatos et al., 2007205 en Yang et al., 2007238), B (Bogaerts et al., 2007124; Bruyere et al., 2005234; Cheung et al., 2007235; Donat et al., 2007208; Gusi et al., 2006183; Karinkanta et al., 2007184; Li et al., 2004127 en 2005128, Rosendahl et al., 2006228; Weerdesteyn et al., 2006206 en Zhang et al., 2006210).
(7) Uithoudingsvermogen Iniveau 2)
Ter verbetering van het uithoudingsvermogen wordt een aerobe trainingsvorm geadviseerd in een frequentie van minstens 3 keer per week en een intensiteit die overeenkomt met minstens 50% van de VO2max of HRreserve of 12-13 op de BORG RPE-schaal.
Kwaliteit van de gevonden artikelen: B (Asikainen et al., 2006212; Chubak et al., 2006178; Kalapotharakos et al., 2006223; Marsh et al., 2006236 en Stewart et al., 2005189) en A2 (Evans et al., 2007181).
(8) Loopsnelheid (niveau 2)
Ter verbetering van de loopsnelheid wordt in elk geval geadviseerd om in het programma een aerobe training in de vorm van lopen op te nemen.
Kwaliteit van de gevonden artikelen: A1 (Baker et al., 2007161) en A2 (Baker et al., 2007213 en Freiberger et al., 2007199).
(9) adl-activiteiten (niveau 2)
Ter bevordering van de adl-activiteiten wordt geadviseerd om adl-gerichte oefenvormen te kiezen.
Kwaliteit van de gevonden artikelen: A2 (De Vreede et al., 2005217).
Leeswijzer
Fysiotherapeuten met weinig tot geen kennis op het gebied van osteoporose en de gevolgen ervan voor de patiënt kunnen de hele richtlijn doorlezen. Fysiotherapeuten met voldoende kennis op het gebied van osteoporose, maar met geringe ervaring in het behandelen van de gezondheidsgerelateerde klachten, kunnen beginnen bij paragraaf B.
Fysiotherapeuten met uitgebreide kennis op het gebied van osteoporose en de gevolgen ervan voor de patiënt en met ruime ervaring in het behandelen van patiënten van deze doelgroep, kunnen hun eigen handelen vergelijken met het handelen zoals beschreven in deze richtlijn en hun handelen op grond daarvan eventueel aanpassen.
Inleiding
De herziening van de ‘KNGF-richtlijn Osteoporose’ van het Koninklijk Genootschap voor Fysiotherapie (KNGF) dient als leidraad voor mensen met gezondheidsproblemen die samenhangen met osteoporose en de rol van de fysiotherapeut hierbij. In de richtlijn wordt het diagnostisch en therapeutisch proces beschreven conform het methodisch fysiotherapeutisch handelen. De Praktijkrichtlijn dient als leidraad voor het fysiotherapeutisch handelen; in de Verantwoording worden de in de Praktijkrichtlijn gemaakte keuzes toegelicht. Deze herziene richtlijn kan worden gezien als een beroepsspecifieke invulling van de multidisciplinaire ‘CBO-richtlijn Osteoporose en Fractuurpreventie’ die in 2011 is ontwikkeld door een multidisciplinaire werkgroep van onder andere medisch specialisten, huisartsen en fysiotherapeuten, onder auspiciën van het Kwaliteitsinstituut voor de Gezondheidszorg CBO. De inhoud van de richtlijn is op hoofdlijnen afgestemd op de aanbevelingen zoals beschreven in de ‘NHG-Standaard Osteoporose’ en genoemde multidisciplinaire richtlijn.
Hoewel de aandoening osteoporose op zichzelf geen verwijsindicatie voor fysiotherapie hoeft te zijn, kunnen de met osteoporose samenhangende problemen, bijvoorbeeld pijn, bewegingsangst, houdingsproblemen, verminderde spierkracht of een afgenomen balans, fysiotherapeutische behandeling behoeven. Ook kunnen fysiotherapeuten patiënten (voor een ander gezondheidsprobleem) behandelen, die mogelijk (ook) osteoporose hebben of kunnen ontwikkelen. In dat geval is case-finding van belang.
Deze richtlijn vervangt de oorspronkelijke richtlijn (2001) en de update ervan uit 2005.
De richtlijn beschrijft de rol van de fysiotherapeut vanuit een breed perspectief. De fysiotherapeut moet zelf de informatie selecteren die van belang is voor de individuele patiënt.
De ‘KNGF-richtlijn Osteoporose’ is een leidraad voor het fysiotherapeutisch handelen bij patiënten met osteoporose en met osteoporose samenhangende gezondheidsproblemen. In de richtlijn worden het diagnostisch en therapeutisch proces beschreven conform het methodisch fysiotherapeutisch handelen. Op dit moment zijn er in Nederland 2 andere richtlijnen over diagnostiek en behandeling bij osteoporose beschikbaar, namelijk de ‘NHG-standaard Osteoporose’1 en de multidisciplinaire ‘CBO-richtlijn Osteoporose en Fractuurpreventie’ (van het Kwaliteitsinstituut voor de gezondheidszorg CBO)2
De ‘KNGF-richtlijn Osteoporose’ is afgestemd op de multidisciplinaire richtlijn en vervangt de ‘KNGF-richtlijn Osteoporose’ van 2001 en de daaropvolgende update van 2005.
A.1 Doelstellingen en doelgroep
Doelstelling van deze richtlijn is fysiotherapeuten informeren over osteoporose en met osteoporose samenhangende klachten en de wijze waarop deze klachten zijn te beïnvloeden, zodat fysiotherapeuten aan de hand van de opgedane kennis een behandelplan op kunnen stellen.
De richtlijn is van toepassing bij patiënten met primaire en secundaire osteoporose.
Men spreekt van primaire osteoporose bij botverlies dat samen-hangt met het normale verouderingsproces, zonder verdere aanwijsbare oorzaak. Primaire osteoporose kan te wijten zijn aan een verhoging van de botafbraak, eerder dan aan een afname van de botaanmaak, of aan een abnormaliteit in het koppelingsmechanisme tussen botaanmaak en botafbraak. Primaire osteoporose wordt onderverdeeld in postmenopauzale en ouderdomsosteoporose.
- Postmenopauzale osteoporose komt voor bij vrouwen tussen de 51 en 61 jaar, bij wie sprake is van een duidelijk verhoogd verlies van trabeculair botweefsel. Dit verlies van botweefsel kan tot wervelfracturen leiden.
- Ouderdomsosteoporose komt voor bij zowel vrouwen als mannen ouder dan 65 jaar. De aandoening wordt gekenmerkt door een verlies van trabeculair en corticaal botweefsel, dat kan leiden tot heupfracturen en wervelinzakkingen.
Men spreekt van secundaire osteoporose als het botverlies een aanwijsbare oorzaak heeft. Voorbeelden van aandoeningen die het risico op osteoporose sterk vergroten zijn: inflammatoire darmziekten, coeliakie, osteogenesis imperfecta, anorexia nervosa, hypogonadisme, malabsorptiesyndroom, primaire hyperparathyreoïdie, maagresectie, syndroom van Cushing en chronische reumatoïde artritis. Ook corticosteroïden leiden vooral in het eerste jaar van gebruik tot omvangrijk botverlies. Andere medicamenten met risico op osteoporose of osteopenie zijn anti-epileptica, fenprocoumon (een anticoagulans) en gosereline (een middel dat remmend werkt op de aanmaak van hormonen in de hypothalamus).
Bij patiënten met secundaire osteoporose kan de primaire aandoening een adequate uitvoering van deze richtlijn in de weg staan en aanleiding zijn om af te wijken van het beleid zoals beschreven in deze richtlijn.
A.1.1 Doelstellingen
De doelstelling van deze richtlijn is het beschrijven van de ‘optimale’ fysiotherapeutische zorg, met betrekking tot doeltreffendheid, doelmatigheid en zorg op maat, voor patiënten met osteoporose en/of met osteoporose samenhangende gezondheidsproblemen, gebaseerd op de huidige wetenschappelijke inzichten, leidend tot opheffing of vermindering van klachten en het optimaliseren van het functioneren.
Naast de genoemde doelstellingen is de KNGF-richtlijn expliciet bedoeld om:
- de zorg in de gewenste richting te veranderen op basis van huidige wetenschappelijke inzichten, en de uniformiteit en de kwaliteit van de zorg te verhogen;
- de taken en verantwoordelijkheden van beroepsgroepen af te bakenen, inzichtelijk te maken en de onderlinge samenwerking te stimuleren;
- de fysiotherapeut te ondersteunen bij het nemen van beslissingen ten aanzien van wel of niet behandelen en het toepassen van diagnostische en therapeutische handelingen.
Om de richtlijn toe te kunnen passen, worden aanbevelingen geformuleerd in termen van deskundigheidseisen die noodzakelijk zijn om volgens de richtlijn te kunnen handelen.
A.1.2 Doelgroep
Deze richtlijn is bedoeld voor alle fysiotherapeuten (zowel algemene fysiotherapeuten als gespecialiseerde fysiotherapeuten) die mensen met gezondheidsproblemen ten gevolge van osteoporose behandelen, in zowel een eerste-, tweede- als derdelijns setting. Hoewel de aandoening osteoporose op zichzelf geen verwijsindicatie voor fysiotherapie hoeft te zijn, kunnen de met osteoporose samenhangende problemen, bijvoorbeeld pijn, bewegingsangst, houdingsproblemen, verminderde spierkracht of een afgenomen balans, fysiotherapeutische behandeling behoeven. Ook kunnen fysiotherapeuten patiënten behandelen (voor een ander gezondheidsprobleem), die mogelijk (ook) osteoporose hebben of kunnen ontwikkelen. In dat geval is case-finding van belang. Om mensen met osteoporose adequaat te kunnen behandelen, is het noodzakelijk dat de fysiotherapeut beschikt over specifieke kennis en vaardigheden (verkregen via opleiding, werkervaring en/of via bij- en nascholing).
De KNGF-richtlijn Osteoporose verschaft de fysiotherapeut specifieke kennis over het beloop van osteoporose en de bij osteoporose behorende pathofysiologische processen, de gevolgen van osteoporose die door de fysiotherapeut te beïnvloeden zijn, en informatie over het diagnostisch en therapeutisch proces, met daarbij de meest relevante klinisch-wetenschappelijke literatuur.
A.2 Afbakening en omvang van het probleem
Osteoporose is een aandoening van het skelet die wordt gekenmerkt door een lage botmineraaldichtheid (BMD) en een verstoring van de samenhang (microarchitectuur) van het bot, die het bot brozer maken en het fractuurrisico vergroten. De World Health Organization (WHO) onderscheidt verschillende gradaties van osteoporose op basis van een BMD-meting (dual energy X-ray absorptiometry, DEXA-meting) en het al dan niet optreden van osteoporotische fracturen:
- geen osteoporose: de BMD ligt op of boven de grens van 1 standaarddeviatie (SD) onder de gemiddelde botdichtheid (piekbotmassa) van jongvolwassenen (25-30 jaar);
- osteopenie: de BMD is verminderd en ligt 1-2,5 SD onder de gemiddelde botdichtheid (piekbotmassa) van jongvolwassenen, maar er is nog geen sprake van osteoporose;
- osteoporose: de BMD ligt meer dan 2,5 SD onder de gemiddelde botdichtheid (piekbotmassa) van jongvolwassenen;
- ernstige osteoporose: osteoporose die gepaard gaat met osteoporotische fracturen.
De WHO-definitie wordt in de klinische praktijk veel gebruikt. Voor mannen en vrouwen gelden verschillende piekbotmassa’s. De piekbotmassa wordt overwegend bepaald door genetische factoren. Daarnaast spelen voeding en leefwijze (lichaamsbeweging) een belangrijke rol. Na het veertigste levensjaar gaat de afbraak overheersen, wat resulteert in een geleidelijk botverlies van 0,3-0,5% per jaar. Mannen verliezen gedurende de rest van hun leven 20-30% van hun botmassa. Bij vrouwen verloopt het botverlies rond de menopauze gedurende enkele jaren versneld (3-5% per jaar). Bij sommige vrouwen loopt het totale verlies aan botmassa op tot 40-50%. Alleen voor postmenopauzale vrouwen is de klinische betekenis van osteoporose op basis van een BMD-meting gevalideerd, maar er bestaat nog veel onduidelijkheid over de referentiewaarden die gebruikt zouden moeten worden, niet alleen over de referentiewaarden bij vrouwen, maar vooral over die bij mannen. Op basis van huisartsenregistraties wordt de prevalentie van osteoporose geschat op 1,9 per 1000 mannen en 16,1 per 1000 vrouwen. Omdat osteoporose in veel gevallen niet gediagnosticeerd is, zal de werkelijke prevalentie hoger liggen. Karakteristieke locaties van osteoporotische fracturen zijn de (thoracale) wervelkolom, de heup en de pols. Per jaar breken ongeveer 17.900 mensen een heup, en van de 55-plussers breken er 15.970 een wervel en 12.114 een pols. Heupfracturen doen zich vooral voor bij vrouwen ouder dan 70 jaar en polsfracturen vooral bij vrouwen van 40-60 jaar oud.
De oorzaak van fracturen is bijna altijd een val, maar bij ernstige vormen van osteoporose kunnen fracturen ook spontaan ontstaan of het gevolg zijn van een gering trauma. Jaarlijks komt in Nederland ongeveer 1 op de 3 personen ouder dan 65 jaar ten val; bij minder dan 10% van de valincidenten treedt een fractuur op.
Osteoporose is een skeletaandoening die wordt gekarakteriseerd door een lage botmineraaldichtheid (BMD) en een verlies van de botstructuur, met als gevolg een grotere breekbaarheid van de botten.12 De WHO spreekt van osteoporose indien de BMD-waarde meer dan 2,5 keer de standaarddeviatie lager is dan het gemiddelde van jongvolwassenen (voor volwassen blanke vrouwen, gemeten in de lumbale wervelkolom en femurhals).13 Een normale botmassa is een BMD die maximaal 1 standaarddeviatie lager is dan het gemiddelde van jongvolwassenen. Het stadium tussen een normale botmassa en osteoporose heet osteopenie.
Osteoporose kan primair of secundair zijn. Bij secundaire osteoporose zijn condities aanwijsbaar die oorzakelijk of belastend zijn voor het ontstaan van osteoporose, zoals chronische obstructieve longaandoeningen of reumatoïde artritis. Bij primaire osteoporose zijn dergelijke oorzaken niet vast te stellen.
Maatschappelijke impact
Zowel nationaal als internationaal is er de laatste jaren grote belangstelling voor het ziektebeeld osteoporose. Medische richtlijnen met betrekking tot onderzoek en behandeling voor osteoporose zijn onder andere verschenen in Groot-Brittannië,14 Canada15 en Australië.16 In Engeland is een osteoporoserichtlijn voor fysiotherapeuten uitgebracht.17 Belangrijke Nederlandse producten zijn het recente rapport van de Gezondheidsraad,18 de NHG-Standaard Osteoporose1 (van het Nederlands Huisartsen Genootschap) en de ‘CBO-Richtlijn Osteoporose en Fractuurpreventie’ van het Kwaliteitsinstituut voor de gezondheidszorg CBO.2
Er bestaan discrepanties tussen de aanbevelingen van de Gezondheidsraad en die van het NHG. De Gezondheidsraad pleit voor actieve case-finding van personen met een verhoogd risico op fracturen en het voorschrijven van preventieve medicamenteuze therapie. Het standpunt van het NHG is dat uitgebreide case-finding vooralsnog geen navolging verdient, omdat aan de voorspellende waarde van diverse risicofactoren kan worden getwijfeld én omdat er nog weinig zicht is op de effectiviteit van medicamenteuze interventies bij mensen die nog geen fractuur hebben gehad.
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A.3 Epidemiologische gegevens
Niet alle mensen die osteoporose hebben, zijn hier ook mee gediagnosticeerd. Daarom geven de huisartsenregistraties een onderschatting van de prevalentie. De meeste fracturen komen voor bij vrouwen en het fractuurrisico neemt toe met de leeftijd.
A.3.1 Prevalentie en incidentie van osteoporose
Op basis van huisartsenregistraties werd het aantal mannen met osteoporose op 1 januari 2007 geschat op 15.200 (1,9/1000) en het aantal vrouwen op 133.000 (16,1/1000) (tabel 2). Omdat niet alle mensen die osteoporose hebben hier ook mee gediagnosticeerd zijn, geven de huisartsenregistraties een onderschatting van de prevalentie. De werkelijke prevalentie is waarschijnlijk 2-3 keer zo hoog.19 De puntprevalentie, de incidentie en de geschatte prevalentie van osteoporose staat in de volgende drie tabellen.
Puntprevalentie van osteoporose (absoluut en per 1000) op 1 januari 2007 naar leeftijd en geslacht.19,a,b
| Prevalentie per | 1000 | Prevalentie | absoluut | |
|---|---|---|---|---|
| leeftijd (in jaren) | mannen | vrouwen | mannen | vrouwen |
| 0-4 | 0,06 | 0,08 | 28 | 36 |
| 5-9 | 0,08 | 0,08 | 41 | 39 |
| 10-14 | 0,11 | 0,10 | 58 | 46 |
| 15-19 | 0,16 | 0,13 | 82 | 65 |
| 20-24 | 0,23 | 0,20 | 111 | 97 |
| 25-29 | 0,32 | 0,34 | 158 | 168 |
| 30-34 | 0,45 | 0,61 | 243 | 328 |
| 35-39 | 0,64 | 1,14 | 417 | 731 |
| 40-44 | 0,90 | 2,20 | 597 | 1.421 |
| 45-49 | 1,27 | 4,25 | 788 | 2.607 |
| 50-54 | 1,79 | 8,16 | 1.019 | 4.592 |
| 55-59 | 2,53 | 15,29 | 1.420 | 8.415 |
| 60-64 | 3,51 | 26,21 | 1.631 | 12.062 |
| 65-69 | 4,99 | 43,40 | 1.724 | 15.697 |
| 70-74 | 7,02 | 64,78 | 1.901 | 20.349 |
| 75-79 | 9,83 | 86,51 | 1.971 | 23.749 |
| 80-84 | 13,76 | 102,86 | 1.693 | 22.229 |
| 85+ | 18,71 | 108,05 | 1.343 | 20.518 |
| totaal | 1,88 | 16,10 | 15.200 | 133.000 |
| ondergrens 95%-BI | 1,12 | 10,88 | 9.000 | 90.000 |
| bovengrens 95%-BI | 3,19 | 23,78 | 25.800 | 197.000 |
Incidentie van osteoporose (absoluut en per 1000 per jaar) naar leeftijd en geslacht in 2007.19,a,b
| incidentie per | 1000 | incidentie | absoluut | |
|---|---|---|---|---|
| leeftijd (in jaren) | mannen | vrouwen | mannen | vrouwen |
| 0-4 | 0,01 | 0,00 | 4 | 0 |
| 5-9 | 0,01 | 0,00 | 6 | 0 |
| 10-14 | 0,02 | 0,00 | 9 | 0 |
| 15-19 | 0,02 | 0,00 | 13 | 2 |
| 20-24 | 0,04 | 0,01 | 18 | 6 |
| 25-29 | 0,05 | 0,04 | 26 | 20 |
| 30-34 | 0,08 | 0,13 | 41 | 67 |
| 35-39 | 0,11 | 0,34 | 73 | 214 |
| 40-44 | 0,17 | 0,80 | 109 | 514 |
| 45-49 | 0,24 | 1,67 | 150 | 1.030 |
| 50-54 | 0,35 | 3,12 | 200 | 1.764 |
| 55-59 | 0,51 | 5,20 | 285 | 2.838 |
| 60-64 | 0,74 | 7,54 | 354 | 3.603 |
| 65-69 | 1,08 | 9,93 | 380 | 3.629 |
| 70-74 | 1,58 | 11,50 | 430 | 3.614 |
| 75-79 | 2,29 | 11,81 | 465 | 3.265 |
| 80-84 | 3,32 | 10,78 | 413 | 2.330 |
| 85+ | 4,67 | 8,93 | 346 | 1.729 |
| totaal | 0,41 | 2,97 | 3.300 | 24.600 |
| ondergrens 95%-BI | 0,24 | 2,07 | 1.900 | 17.100 |
| bovengrens 95%-BI | 0,72 | 4,29 | 5.900 | 35.500 |
De incidentie van osteoporose werd in 2007 geschat op 3300 mannen en 24.600 vrouwen (tabel 3). Als gevolg van demografische ontwikkelingen, zoals vergrijzing, maar wellicht ook door een vermindering van lichamelijke activiteit, zal het aantal mensen met osteoporose tussen 2007 en 2025 stijgen met 38%.20
Geschatte prevalentie van heup-, wervel- en polsfracturen bij mannen en vrouwen vanaf 50 jaar.11
| vrouwen | mannen | |
|---|---|---|
| % (95%-BI) | % (95%-BI) | |
| heup | 17,5 (16,8-18,2) | 6,0 (5,6-6,5) |
| wervel (klinisch gediagnosticeerd) | 15,6 (14,8-16,3) | 5,0 (46-5,4) |
| pols | 16,0 (15,7-16,7) | 2,5 (2,2-3,1) |
| totaal | 39,7 (38,7-40,6 | 13,1 (12,4-13,7) |
A.3.2 Prevalentie fracturen
De meest voorkomende locaties zijn de heup, de pols en de wervelkolom (tabel 3). Osteoporose kan echter ook ten grondslag liggen aan het ontstaan van andere fracturen.1 Na iedere fractuur is het risico op een nieuwe fractuur ongeveer 2 keer zo groot.1
Wervelfracturen zijn niet altijd symptomatisch, waardoor het exacte aantal wervelfracturen lastig is te achterhalen. Omdat een wervelfractuur leidt tot een deformatie van de wervelkolom zijn onderzoeken naar deformatie van de wervelkolom indicatief voor het vóórkomen van wervelfracturen. Het CBO schatte in 2002 dat er jaarlijks 15.970 mensen van 55 jaar en ouder een wervelfractuur krijgen (12.686 vrouwen en 3284 mannen). Voor vrouwen komt dit neer op een incidentie van 7 per 1000 per jaar en bij mannen op 2 per 1000 per jaar.21 Na iedere wervelfractuur is het risico op een nieuwe fractuur ongeveer 4 keer zo groot.1
Heupfracturen komen voornamelijk voor bij personen ouder dan 55 jaar. Vanaf die leeftijd is er een flinke stijging in het aantal heupfracturen. Het verhoogde valrisico is de belangrijkste reden van de stijging van de incidentie van het aantal heupfracturen.1 De afname van de BMD heeft hier minder invloed op.22
In 2007 waren er 17.900 heupfracturen.23 Heupfracturen komen vaker voor bij vrouwen (75%) dan bij mannen (25%). Bijna alle heupfracturen (97%) zijn het gevolg van een val.24 Fracturen van de onderarm komen vooral voor bij personen van middelbare en oudere leeftijd. De incidentie van polsfracturen neemt bij vrouwen sterk toe na de menopauze om na ongeveer het 60e levensjaar weer af te vlakken.25 Het aantal nieuwe polsfracturen per jaar bij 55-plussers in Nederland is in 2002 geschat op 12.114 (11.022 bij vrouwen en 1092 bij mannen). Dit komt neer op 6 per 1000 polsfracturen per jaar bij vrouwen en minder dan 1 per 1000 bij mannen.21
A.3.3 Kosten
De gezondheidszorgkosten van osteoporose zijn in 2005 geschat op 120 miljoen euro per jaar. In het rapport zijn de kosten voor heupfracturen en fracturen van de bovenste extremiteit als aparte kostenpost opgenomen. Deze kosten bedroegen respectievelijk 392 miljoen en 109 miljoen euro per jaar.26 Echter, niet alle heupfracturen en fracturen van de bovenste extremiteit worden veroorzaakt door osteoporose.
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A.4 Risicofactoren voor ontstaan van osteoporose
Ouderdom en vrouwelijk geslacht zijn de voornaamste risicofactoren voor het ontstaan van osteoporose. Daarnaast zijn er nog tal van andere risicofactoren voor een lage BMD, zoals een laag lichaamsgewicht en osteoporose in de familie. Roken, weinig lichaamsbeweging en deficiënte voeding, in het bijzonder onvoldoende intake van calcium en, bij ouderen die weinig buiten komen, van vitamine D, zijn risicoverhogende leefgewoonten. Recent zijn er aanwijzingen gevonden dat ook een sterk verhoogde homocysteïnespiegel geassocieerd is met een verhoogd risico. Het is onvoldoende duidelijk of alcoholgebruik een risicofactor is.
A.4.1 Pathofysiologie en risicofactoren
Gezond bot wordt in stand gehouden door een normale botombouw. De geometrische eigenschappen van bot worden beïnvloed door de activiteit van osteoblasten en osteoclasten. De processen van botaanmaak en -afbraak zijn nauw met elkaar verbonden. Julius Wolff beschreef de relatie tussen aanpassing van bot aan belasting al in de 19e eeuw (Wolff’s law). Osteoclasten breken dagelijks bot af, terwijl mechanische belasting van bot voor de osteoblasten een belangrijke stimulus is voor de aanmaak van nieuw botweefsel.39 Vooral spongiosa in gewrichtsuiteinden reageert snel op mechanische belasting. Nieuw bot wordt voornamelijk aangelegd in de richting van inwerkende krachten.
De langst bestaande visie op botaanpassingen is dat wisselende drukkrachten op het skelet piëzo-elektrische stroompjes in bot genereren, waarop osteoblasten reageren met botaanmaak.40,41 Van deze werking is ook het aanbrengen van elektrodes met een potentiaalverschil bij slecht helende wonden afgeleid. Nieuw onderzoek toont aan dat osteocyten de activiteit van osteoblasten en osteoclasten mede regelen, doordat osteocyten gevoelig zijn voor vervorming.42-44 Osteocyten zijn door een wijdvertakt netwerk van vloeistofkanaaltjes (canaliculi) in bot met elkaar verbonden. Een belangrijke stimulus voor een osteocyt blijkt de vloeistofstroming te zijn in deze kanaaltjes bij mechanische botbelasting. De langsstromende weefselvloeistof veroorzaakt wrijving (shear stress) waardoor de osteocyten NO2-gas en prostaglandines afgeven. Dit geven ze door aan de osteoblasten aan het botoppervlak (paracriene regeling). Tevens zijn osteocyten via hechtverbonden uitlopers met elkaar in contact en communiceren ze direct met osteoblasten. Die vormen door deze stimuli nieuw botmateriaal.
Bot blijkt vooral gevoelig voor een snelle opbouw van spanning en spanningswisselingen en er bestaat minder verband tussen botopbouw en de absolute spanning in bot. Belastingen met hoge frequentie en kleine amplitude blijken een groter osteogeen effect te hebben dan belastingen met een lage frequentie en hoge amplitude. In dit kader zou dus dynamische belasting de botopbouw het beste stimuleren. Inwerking van spiercontracties, dynamische vormen van bewegen en hun impact op bot is effectiever dan constante druk. Als mechanische prikkels ontbreken, zoals bij immobiliteit, daalt de stimulerende werking van osteocyten. Osteoclasten die normaal worden geremd door actieve osteocyten, gaan over tot intensievere afbraak van botmineraal, wat leidt tot vermindering van de botmassa en een lagere belastbaarheid van het skelet.42,45
Bij mensen met osteoporose zijn zowel de botdichtheid verminderd als de kwaliteit van de microarchitectuur van het bot. Dit wordt veroorzaakt door inactiviteit (Wolff’s law) met als gevolg een verminderde botvormende prikkel door actieve osteocyten, en op hoge leeftijd tevens doordat de spiegels van de geslachtshormonen lager zijn geworden. Er zijn verschillen tussen mannen en vrouwen met osteoporose. Bij vrouwen gaan er hele trabekels van de spongiosa verloren, terwijl bij mannen de dikte van de trabekels afneemt. Uit onderzoek blijkt dat bot van mensen met osteoporose een lagere osteocytendichtheid heeft dan bot van gezonde controles.46 Dit is in overeenstemming met de onderzoeksbevinding dat in osteoporotisch bot de reactie op mechanische stimuli is verminderd.42
A.4.2 Risicofactoren voor een lage botmassa
Bij osteoporose is er sprake van een geringe botmassa (lage botdichtheid en een structuurverlies van het bot). Twee mechanismen staan aan de basis van een geringe botmassa: een lage piekbotmassa en versneld botverlies op volwassen leeftijd.47 De hoogte van de piekbotmassa wordt grotendeels erfelijk bepaald, maar ook factoren als lichamelijke activiteit tijdens de jeugd, voeding en hormonale factoren spelen een rol.47 Vrouwen bereiken een lagere piekbotmassa dan mannen en hebben hierdoor een groter risico op het ontwikkelen van osteoporose. Mannen en vrouwen verliezen botweefsel vanaf het 35e levensjaar met een snelheid van 0,5-1% per jaar.13 Bij vrouwen in de menopauze gaat de daling van de oestrogeenspiegels gepaard met een verhoogd botverlies van 3-5% per jaar. Deze daling houdt gemiddeld 10 jaar aan.13 Volgens Riggs en Melton kan een derde tot de helft van het botverlies bij vrouwen worden toegeschreven aan de menopauze en de hiermee gepaard gaande verlaging van de oestrogeenspiegel.48
Op hogere leeftijd (na circa het 70e levensjaar) doet zich zowel bij mannen als bij vrouwen een langzaam voortschrijdend botverlies voor. De achteruitgang in de functie van organen die zijn betrokken bij de regulering van de calciumhuishouding kan leiden tot een vergrote calciumbehoefte.31 Eenzijdige voeding en weinig zonlicht kunnen aanleiding geven tot calcium- en vitamine-D-tekort. Om het calciumgehalte in het bloed op peil te houden, kan er calcium aan het skelet worden onttrokken. Verder draagt vermindering van de lichamelijke activiteit op hogere leeftijd ook bij tot het achterblijven van de botaanmaak bij de botafbraak.
Er is een aantal risicofactoren voor het ontstaan van een lage BMD.13,18,31,49 Er kan onderscheid worden gemaakt tussen beïnvloedbare en niet-beïnvloedbare risicofactoren.
- niet-beïnvloedbare factoren:
- hogere leeftijd:
- vrouwelijk geslacht;
- eerdere osteoporotische fractuur;
- positieve familie-anamnese (heupfracturen moeder);
- erfelijke aanleg (vooral bij piekbotmassa);
- klein en tenger van gestalte;
- etnische origine (blank ras groter fractuurrisico);
- bij vrouwen: late menarche, langdurige periodes van amenorroe, vroege menopauze; (natuurlijk of door operatief ingrijpen);
- beïnvloedbare factoren:
- gebrek aan lichaamsbeweging;
- ondergewicht, snelle gewichtsafname;
- vitamine-D-tekort door onvoldoende expositie aan zonlicht en niet gebruiken van suppletie;
- voeding, namelijk een lage inname van calcium en een hoge inname van cafeïne, eiwit, vezels en zout;
- overmatig alcoholgebruik;
- overmatig roken van sigaretten.
De beïnvloedbare factoren verklaren slechts een deel van de variatie in BMD. De Gezondheidsraad stelt op basis van verschillende studies dat circa 60% van de variatie in de BMD door genetische factoren wordt verklaard.18 Dit overzicht is gebaseerd op 4 literatuuroverzichten.
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A.5 Risicofactoren voor fracturen
Vrouwen hebben een hoger fractuurrisico dan mannen. Bij ouderen is dit verhoogde risico ook aanwezig na correctie voor de BMD. Mensen die eerder een fractuur hebben gehad (vooral na de menopauze) hebben een verhoogd risico op nieuwe fracturen. Ook een laag lichaamsgewicht en geringe activiteit vormen risicofactoren voor fracturen. Ouderen hebben ook een verhoogd risico op fracturen vanwege hun hogere valrisico. Andere risicofactoren voor vallen hebben betrekking op de gezondheidstoestand (zoals balansstoornissen, verminderde spierkracht of mobiliteit van de gewrichten van de onderste extremiteiten, visusstoornissen en CVA) en het gebruik van medicijnen met een sedatieve werking (zoals antidepressiva of analgetica). Omgevingsfactoren (zoals slecht passende schoenen, slechte verlichting, losliggende vloerbedekking of een trap zonder leuning) kunnen het valrisico en dus het risico op fracturen vergroten. Regelmatige lichaamsbeweging en voldoende botbelasting, die in veilige omstandigheden plaatsvinden, zijn beschermende factoren voor vallen.
Fracturen tengevolge van osteoporose kunnen ontstaan na een val, maar bij ernstige vormen van osteoporose kunnen ze ook spontaan of tengevolge van een klein trauma ontstaan. Een wervelfractuur is de meest specifieke uiting van osteoporose, omdat bij het ontstaan ervan de invloed van een val beperkt betekenis heeft. In de wervelkolom kunnen fracturen optreden tijdens routineactiviteiten, zoals buigen, zich oprichten of opstaan vanuit de stoel of bij het uit bed komen.
Het risico op het krijgen van een fractuur hangt nauw samen met de BMD, maar ook met het valrisico.13,50 Alhoewel het risico op een fractuur toeneemt naarmate de BMD lager is, is deze relatie niet lineair. Verschillende prospectieve studies laten zien dat een daling van de BMD met 1 SD het risico op fracturen verhoogt met een factor 1,4-2,5.51-54 Een verschil van 2 SD’s is geassocieerd met een 4-6-voudig toegenomen fractuurrisico; een eerder doorgemaakt wervelfractuur is geassocieerd met een 5 keer hoger risico op een nieuwe wervelfractuur.55Andere risicofactoren voor fracturen zijn een verminderde spierkracht, balans en weinig fysieke activiteit.56,57
De volgende factoren verhogen het risico op heup- en wervelfracturen.
- leeftijd > 60 jaar;
- een fractuur na het 50e levensjaar (of aanwezige wervelfractuur);
- familiegeschiedenis: moeder had een heupfractuur;
- laag lichaamsgewicht (< 60 kg);
- gebruik van corticosteroïden (> 7,5 mg/dag) langer dan 3 maanden;
- visusstoornissen;
- ernstige immobiliteit.
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A.6 Gevolgen van fracturen
Fracturen, en de consequenties ervan, hebben een grote invloed op de kwaliteit van leven. Dit geldt vooral voor oudere mensen, omdat zij een langere hersteltijd nodig hebben, hierdoor relatief lang uit de roulatie zijn en mogelijk niet volledig herstellen.
Een wervelfractuur hoeft geen klachten te geven (circa 2 op de 3 wervelfracturen zijn asymptomatisch), hoewel ze ook gepaard kunnen gaan met een episode van hevige pijn. Deze pijn verdwijnt meestal na 1-3 maanden. Wervelfracturen kunnen leiden tot een vergroting van de thoracale kyfose, die in de loop van de tijd tot problemen aanleiding kunnen geven, zoals rib-crista-iliacawrijvingen, compressie op interne organen en chronische rugklachten. Daarnaast verandert een vergrote thoracale kyfose de lichaamshouding, waardoor iemand tijdens het uitvoeren van dagelijkse activiteiten sneller uit balans kan raken. Chronische pijn en beperkingen als gevolg van wervelfracturen worden vooral gezien bij patiënten met een ernstige deformatie van de wervelkolom.
Na een heupfractuur is opname in een ziekenhuis bijna altijd noodzakelijk. Op de lange termijn heeft een heupfractuur de meest ingrijpende gevolgen in vergelijking met de gevolgen van bijvoorbeeld een onderarmfractuur, zoals beperkingen in het zichzelf voortbewegen en soms verlies van zelfstandigheid en langdurige zorg in een verpleegtehuis.
Onderarmfracturen veroorzaken bij de meeste patiënten alleen een tijdelijk functieverlies van de desbetreffende arm.
Op den duur leidt de (tijdelijke) immobiliteit waarmee fracturen gepaard kunnen gaan, tot een afname van de BMD en een vermindering van functies van het houding- en bewegingsapparaat, zoals een afgenomen spierkracht en coördinatie, die op hun beurt weer leiden tot een groter risico op vallen en (nieuwe) fracturen. Bovendien vergroot de immobiliteit, vooral bij de oudere patiënt, het risico op sociaal isolement. Bij patiënten met osteoporose kunnen angst voor nieuwe fracturen en immobiliteit door angst om te vallen een rol spelen bij het ontstaan van psychosociale problemen.
De gevolgen van osteoporose betreffen voornamelijk de fracturen en de directe gevolgen daarvan, zoals pijn, verminderde mobiliteit van gewrichten en verlies van zelfstandigheid.
Wervelfracturen kunnen plaatsvinden zonder klachten (circa 2 op de 3 zijn asymptomatisch27,28), maar ze kunnen ook gepaard gaan met een episode van hevige pijn. Deze pijn verdwijnt meestal na 1-3 maanden.
Als gevolg van wigvormige deformaties en inzakkingen kan een versterkte thoracale kyfose ontstaan. De afstand tussen ribben en bekken wordt kleiner.29 Dit gaat vaak gepaard met een verminderde ribspreiding en een verminderd longvolume.30 Deze vervorming kan ook leiden tot druk op interne organen, waardoor bijvoorbeeld stoornissen in het maag-darmkanaal kunnen optreden. Deze stoornissen kunnen grote gevolgen hebben voor de activiteiten en participatie van de patiënt in het dagelijks leven.31 Lynn et al. hebben aangetoond dat patiënten met osteoporose, en dan vooral diegenen met een thoracale kyfose, andere balansstrategieën gebruiken en meer met hun romp slingeren dan gezonde mensen.32 Hierdoor dreigen patiënten met osteoporose makkelijker uit balans te raken tijdens alledaagse activiteiten.
Prospectieve studies tonen aan dat pijn en/of functionele beperkingen vooral optreden bij ernstige deformaties van de wervelkolom.33,34 Lyles et al. hebben aangetoond dat wervelfracturen het lichamelijke, functionele en psychosociale functioneren beïnvloeden zonder dat andere chronische aandoeningen daarbij een rol spelen.35
Heupfracturen gaan gepaard met een hoge morbiditeit en mortaliteit en leiden tot een verlies aan zelfstandigheid. De gevolgen van een heupfractuur kunnen zodanig zijn dat de patiënt moet verhuizen naar een aangepaste woonomgeving.13,18 In 1999 overleed na een heupfractuur 6,5% van de vrouwen en 11,1% van de mannen tijdens hun verblijf in het ziekenhuis.21 Uit onderzoek is gebleken dat de mortaliteit in het eerste jaar na een heupfractuur tussen de 25 en 33% ligt.24,36,37 Verder blijft 25% van de patiënten permanent invalide.24
Polsfracturen worden meestal veroorzaakt door een val op de gestrekte arm. Ze geven gedurende een of meer maanden een beperking in activiteiten waarbij de arm gebruikt wordt. Meestal wordt de arm gedurende 4-6 weken ingegipst.13 Daarna treedt gewoonlijk herstel op tot de normale uitgangssituatie. Procentueel gezien is de afname van kwaliteit van leven vanwege polsfracturen laag (3% bij vrouwen en 1% bij mannen) vergeleken met de kwaliteitsafname vanwege heupfracturen (63% bij vrouwen en 70% bij mannen) of vanwege wervelfracturen (17% bij vrouwen en 12% bij mannen).21
A.6.1 Osteoporose en kwaliteit van leven
Door het CBO werd in 2002 geschat dat er per jaar vanwege osteoporose tussen de 38.000 en 60.000 voor kwaliteit van leven gecorrigeerde levensjaren verloren gaan.21 In een review naar de kwaliteit van leven van vrouwen met osteoporose beschrijft Gold38 dat osteoporose lichamelijke en functionele, maar ook psychosociale consequenties heeft. In het beginstadium van osteoporose zijn patiënten vaak bang voor de mogelijkheid dat fracturen kunnen optreden en voor de lichamelijke deformiteit. Deze angst voor fracturen kan inactiviteit veroorzaken. Vooral bij personen met ziektegerelateerde problemen, zoals een heupfractuur of multipele wervelfracturen of pijn, kunnen problemen ontstaan bij het uitvoeren van activiteiten en het deelnemen aan sociale activiteiten. Dit kan leiden tot gevoelens van depressie en een sociaal isolement doordat iemand zijn sociale rol(len) niet meer kan vervullen. Hulpverleners kunnen het verlies aan zelfvertrouwen en depressie makkelijk onderschatten en toeschrijven aan de toenemende leeftijd en niet aan de fracturen.
A.6.2 Primaire preventie
Omdat osteoporose meestal asymptomatisch is totdat een fractuur optreedt, wordt binnen de gezondheidszorg gediscussieerd over het belang van primaire preventie: het voorkómen van osteoporose. Dit kan aan de ene kant door de piekbotmassa te verhogen door bijvoorbeeld de jeugd te stimuleren om veel te bewegen en gezond te eten en aan de andere kant door de botmassa zo veel mogelijk te onderhouden en te verbeteren. Onderdeel van primaire preventie is het vroegtijdig screenen van mensen op hun risico op osteoporose. Dit kan plaatsvinden door case-finding. Case-finding is het herkennen van personen met een verhoogd risico door medische behandelaars. Ook de fysiotherapeut moet alert zijn en patiënten met een hoog risico adviseren contact op te nemen met de huisarts. Bij deze patiëntengroep zouden dat bijvoorbeeld personen met een verhoogd fractuurrisico zijn.13 Binnen de gezondheidszorg is er nog geen eenduidigheid over het belang van case-finding bij osteoporose.
Primaire preventie past binnen het beleid van fysiotherapeuten, dat gericht is op het bevorderen van een actieve leefstijl. Omdat fysiotherapeuten regelmatig patiënten behandelen met een verhoogd risico op osteoporose of aan osteoporose gerelateerde fracturen, spelen fysiotherapeuten een rol bij case-finding en bij primaire preventie van osteoporose. Daarnaast geven fysiotherapeuten voorlichting en begeleiden ze patiënten naar een verantwoord beweeggedrag en een actieve leefstijl. De werkgroep is van mening dat de fysiotherapeut bij een verdenking op osteoporose de patiënt moet adviseren contact op te nemen met de huisarts.
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A.7 Risicofactoren voor vallen
Elk jaar komt bijna een derde van alle mensen van 65 jaar en ouder ten val. Dit risico neemt toe met de leeftijd en is veel hoger bij de verzorgingstehuispopulatie dan bij zelfstandig wonende ouderen.
Op basis van prospectieve studies beschrijft de Gezondheidsraad dat het jaarlijkse valrisico bij de laatste groep in de leeftijd van 60 jaar en ouder wordt geschat op 30%.18 In verpleeghuizen kan het valrisico oplopen tot 50% per jaar.
In hun review beschrijven Gillespie et al.58 dat ongeveer 20% van de valincidenten medische zorg vraagt en dat minder dan 10% resulteert in fracturen. Valincidenten leiden ook tot een vermindering van het zelfvertrouwen. Tot 25% van de personen die zijn gevallen, zijn beperkt hun dagelijkse activiteiten, vanwege opgelopen letsel, maar ook omdat ze bang zijn om weer te vallen.59,60
Ouderen die al eens eerder zijn gevallen en mensen die problemen hebben met hun balans en/of gangpatroon hebben een verhoogd valrisico.60-67 Ook stoornissen in het functioneren van de onderste extremiteiten (spierkracht of mobiliteit van gewrichten) verhogen het valrisico.60,68,69 Een speciale rol wordt toegekend aan de dorsaalflexoren van de voet: verzwakte dorsaalflexoren verhogen het valrisico.70 Lichamelijke inactiviteit is een onafhankelijke risicofactor voor fracturen: mensen die weinig bewegen hebben een groter risico op fracturen.54,71-75 Lichamelijke activiteit beschermt dus tegen fracturen. Opgemerkt moet worden dat de genoemde studies steeds andere maten voor lichamelijke activiteit hanteren. Cummings et al. definiëren actief zijn als meer dan 4 uren per dag ‘op de been’ zijn.54 Jaglal et al.,74 Paganini-Hill et al.71 en Tromp et al.72 maken een somscore van de frequentie en de duur van activiteiten, zoals zwaar huishoudelijk werk, tuinieren, wandelen, fietsen en sporten, terwijl Wickham et al.73 alleen spreken van activiteiten in de buitenlucht.
Andere factoren die het valrisico verhogen, hebben betrekking op:60,66,69,76
- de gezondheidstoestand: status na een beroerte, de ziekte van Parkinson, dementie, cognitieve stoornissen, depressie, duizeligheid, een slecht gezichtsvermogen, gebruik van medicatie die een (langdurige) sedatieve werking heeft of de reactiesnelheid beïnvloedt;
- omgevingsfactoren: schoeisel, losse matjes, meubilair dat in de weg staat, slecht licht, hulpmiddelen bij het lopen, drempels en trappen; Carter et al. vonden dat in woonhuizen de badkamer de gevaarlijkste ruimte was en dat in 80% van de huizen ten minste 1 gevaarlijke omgevingsfactor aanwezig was; een val bleek echter meestal veroorzaakt te worden door een combinatie van factoren.77
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A.8 Beïnvloeden van risicofactoren
Om botweefsel te versterken, moeten de botten worden belast. De belastingsintensiteit moet hoog genoeg zijn (‘ongewoon’ en afgestemd op het actuele belastingsniveau) en de belastingsvorm moet dynamisch (hoge snelheid, weinig herhalingen) van aard zijn. Zie voor een uitgebreide beschrijving van de invloed van calcium en vitamine D de Verantwoording en toelichting.
Een heupbeschermer is een kunststof schijf die in speciaal ondergoed over de heupkop wordt geplaatst. Bij een eventuele val vangt deze beschermer de krachten op die op de heupkop zouden komen en verdeelt deze over de omringende weefsels.
A.8.1 Calcium
Op basis van diverse studies beschrijft de Gezondheidsraad dat de aanbevolen hoeveelheid calcium voor ouderen (> 70 jaar) is vastgesteld op 1200 mg per dag.78 Voor mensen met osteoporose wordt eveneens 1200 mg per dag aanbevolen. De CBO-richtlijn Osteoporose en Fractuurpreventie stelt dat het wenselijk is dat patiënten met osteoporose een calciumsupplement van 500-1000 mg per dag gebruiken wanneer de inname van calcium met de voeding lager is dan 1200 mg per dag.2 Daarbij geldt de suppletiedosis van 1000 mg vooral wanneer de patiënt geen zuivelproducten gebruikt.19 Correctie van een te lage calciuminname (fysiologische toediening) heeft een gunstig effect op de BMD en kan het fractuurrisico verlagen. Er zijn geen bewijzen dat calciuminname boven de aanbevolen hoeveelheid de te bereiken piekbotmassa of de botafbraak na de menopauze of tijdens de ouderdom gunstig kan beïnvloeden.18 Volgens de voedselconsumptiepeilingen in Nederland gebruiken de mensen in de diverse leeftijdscategorieën ruim voldoende calcium De CBO-richtlijn formuleert hierover: ‘Calcium reduceert alleen in combinatie met vitamine D het optreden van heupfracturen’.2
A.8.2 Vitamine D
Op basis van diverse studies concludeert de Gezondheidsraad dat een tekort aan vitamine D gepaard gaat met een afname van de BMD en met spierzwakte.79 De huid maakt vitamine D aan onder invloed van zonlicht. Ook kan voeding een bron zijn van vitamine D. Het advies van de Gezondheidsraad luidt als volgt: ‘De commissie vindt het wenselijk dat:
dagelijks 10 microgram vitamine D extra wordt gebruikt door:
- kinderen tot 4 jaar;
- personen van 4-50 (vrouwen) of 70 (mannen) jaar die een donkere huidskleur hebben of onvoldoende buitenkomen;
- vrouwen tot 50 jaar die een sluier dragen;
- vrouwen die zwanger zijn of borstvoeding geven;
- personen vanaf 50 (vrouwen) of 70 (mannen) jaar die een lichte huidskleur hebben en voldoende buitenkomen.
dagelijks 20 microgram vitamine D extra wordt gebruikt door:
- personen die osteoporose hebben of in een verzorgings- of verpleeghuis wonen, personen vanaf 50 (vrouwen) of 70 (mannen) jaar die een donkere huidskleur hebben, onvoldoende buitenkomen en vrouwen vanaf 50 jaar die een sluier dragen.
Hierbij veronderstelt de commissie dat de inname van calcium voldoende is.’
De CBO-richtlijn stelt dat suppletie van vitamine D in combinatie met calcium leidt tot minder fracturen. Vitamine D is eveneens effectief bij het reduceren van valincidenten bij ouderen.2
A.8.3 Beweging
Het continue proces van botafbraak en -opbouw is een respons op druk- en trekkrachten op het bot. Hierdoor kan het lichaam de botmassa en de structuur van botten aanpassen aan de eisen die het lichaam aan het skelet stelt.
Opbouw van botweefsel vindt plaats door modelling en remodelling. Modelling is de som van de mechanismen die de sterkte van de botten vergroten en die de vorm van de botten aanpassen aan de mechanische belasting tijdens de groei. Remodelling is het vernieuwen van de botmassa. Bij elke vernieuwing gaat echter een beetje botweefsel verloren, waardoor remodelling gepaard gaat met een afname van botmassa.80 Om een toename van botweefsel te bewerkstelligen, is overschrijding van een bepaalde belastingsintensiteit nodig. Frost stelt dat een belasting die hoger is dan 1500-3000 microstrain (maat voor botdeformatie) het modellingproces in gang zet, terwijl een belasting die lager is dan 100-300 microstrain (bijvoorbeeld door lichamelijke inactiviteit of langdurige bedrust) het remodellingproces in gang zet.81 Oudere mensen of mensen die weinig bewegen, zouden de drempelwaarde voor modelling eerder bereiken, omdat de botten minder sterk zijn (geworden).
Dierexperimenteel onderzoek toont aan dat de osteogene respons positief is gerelateerd aan de hoogte van de belasting82 en aan de snelheid van de belasting83 en dat weinig herhalingen nodig zijn om een maximaal effect te bereiken.84 Ook blijkt het modellingproces afhankelijk te zijn van een ‘ongewone’ belasting (ongewoon in grootte of qua verdeling van de belasting).82De respons op een dynamische botbelasting is groter dan op een statische belasting.42,84
In overeenstemming met deze gegevens is bekend dat personen die regelmatig bewegen een hogere piekbotmassa bereiken in vergelijking met niet-sporters en dat personen met veel lichamelijke activiteiten een hogere botmassa hebben dan minder actieve personen.85,86
Samenvattend: om botweefsel te versterken, moeten de botten worden belast. De belastingsintensiteit moet hoog genoeg zijn (‘ongewoon’ en afgestemd op het actuele belastingsniveau) en de belastingsvorm moet dynamisch (hoge snelheid, weinig herhalingen) van aard zijn.
A.8.4 Heupbeschermers
De resultaten van 1 gecontroleerde studie87 en 3 observationele studies88-90 lijken veelbelovend. Een gerandomiseerde studie wijst echter uit dat heupbeschermers geen significant effect hebben op het aantal heupfracturen en dat de interventie niet kosteneffectief is.91,92 Er wordt namelijk een lage compliance gevonden voor het dragen van heupbeschermers.87,89,90 Ook worden de heupbeschermers vaak niet ’s nachts gedragen.93 De heupbeschermer zou vooral een optie zijn bij personen met een aanzienlijk en niet te reduceren valrisico, bijvoorbeeld patiënten met dementie.18
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A.9 Rol van de fysiotherapie
De rol van fysiotherapie bij patiënten met osteoporose is drieledig:
- verminderen van het risico op (nieuwe) fracturen door het verhogen van de BMD en het verlagen van het valrisico, met als aangrijpingspunten stoornissen (zoals een afgenomen spierkracht of balans) en beperkingen (zoals moeite hebben met lopen of met transfers);
- secundaire preventie van met osteoporose samenhangende klachten van het houding- en bewegingsapparaat, zoals pijn, een veranderde lichaamshouding (vergrote kyfose), verminderde spierkracht, verminderde balans, afgenomen mobiliteit van gewrichten of valangst;
- begeleiden van patiënten, onder meer in de vorm van het geven van informatie over osteoporose en de gevolgen hiervan, het adviseren van de patiënten in relatie tot een actieve leefstijl, en het instrueren ten aanzien van het gebruik van eventuele (loop)hulpmiddelen.
A.9.1 Samenwerking met andere disciplines
Samenwerking met andere disciplines verhoogt de doelmatigheid en de doeltreffendheid van de zorg. Het is belangrijk dat de verschillende zorgverleners inzicht hebben in elkaars deskundigheid en werkwijze en dat zij de informatieverstrekking aan de patiënt op elkaar afstemmen.
Het beleid van arts en fysiotherapeut bij patiënten met osteoporose is gericht op de preventie van (nieuwe) fracturen, het verminderen van bewegingsangst en het bevorderen van participatie. Bij ouderen is er aandacht voor het behoud van mobiliteit, het onderhouden van een actieve leefstijl en voor valpreventie.
Redenen voor (zelf)verwijzing van patiënten met osteoporose naar een fysiotherapeut zijn:
- stoornissen en beperkingen op het gebied van het houding- en bewegingsapparaat en immobiliteit;
- een fractuur in de subacute fase als de patiënt de klachten op grond van het advies van de arts onvoldoende zelfstandig kan oplossen en meer begeleiding is aangewezen.
Een belangrijk onderdeel in de samenwerking met de verschillende behandelaars is het elkaar over en weer informeren over patiënten bij signalering van een ernstig toegenomen risico op osteoporose of fracturen (valrisico). De fysiotherapeut informeert de medebehandelaars/verwijzers over de gezondheidstoestand van de patiënt en let daarbij op tekenen van osteoporose. De fysiotherapeut schat onder andere in wanneer het voor een individuele patiënt niet meer vertrouwd is om zelfstandig te lopen of om zelfstandig transfers uit te voeren. Indien een fysiotherapeut behandeling van een andere discipline wenselijk vindt, wordt met deze discipline contact opgenomen. In geval van secundaire osteoporose moet samenwerking plaatsvinden met de betrokken specialisten.
A.10 Probleemgebieden
Afhankelijk van de hulpvraag en de wijze van functioneren van de patiënt staan verschillende probleemgebieden (alleen of in combinatie met elkaar) centraal. De volgende probleemgebieden zijn te onderscheiden:
- (Dreigende) immobiliteit. Immobiliteit leidt op den duur tot een afname van de BMD, stoornissen en beperkingen. Hierdoor ontstaat een verhoogd fractuurrisico. Val- of bewegingsangst kan een rol spelen bij het in stand houden van de immobiliteit.
- Een verhoogd valrisico. Een verhoogd valrisico kan ontstaan door stoornissen en beperkingen, zoals een verminderde spierkracht, een verminderde mobiliteit van gewrichten of een verminderde balans bij algemene dagelijkse levensverrichtingen (adl).
- Status na een fractuur. Afhankelijk van de lokalisatie van de fractuur kunnen specifieke stoornissen, beperkingen en participatieproblemen optreden. Bij wervelfracturen staan bijvoorbeeld de houding en balans centraal, bij een heupfractuur kunnen dat bijvoorbeeld het gangpatroon en transfers zijn. In alle gevallen is het van belang om functies en activiteiten aan te leren die nodig zijn voor het dagelijks functioneren. Aanbevelingen in de richtlijn zijn gericht op de subacute fase na een (wervel)fractuur.