Osteomalacia

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Clinically Relevant Anatomy

Osteomalacia is softening of the bones. This ineffective bone mineralization in children is referred to as Rickets. It is caused by impaired bone metabolism which in turn causes inadequate bone mineralization. Bone metabolism is impaired due to insufficient calcium, vitamin D or phosphate or calcium resorption[1].

Mechanism of Injury / Pathological Process

[2]

Osteomalacia is due to impaired bone mineralization. The deficiency may be from one of many causes including lack of sun exposure, poor nutritional intake, low levels of phosphate, abnormal vitamin D metabolism or drug induced bone mineralization[3]. Vitamin D deficiency in older adults is the most common cause of osteomalacia[4].

Clinical Presentation

Typically a person will present with only subtle indicators and diagnosis can easily be missed. The symptoms are typically diffuse bone pain, fatigue and proximal muscle pains. A waddling gait may be present due to muscle weakness and hip pain. A fracture may be the first presenting sign[4]. Bony deformity may be apparent in the long bones or the pelvis as the condition progresses.ADL may be affected due to weak and stiff muscles eg climbing stairs, sit to stand, carrying loads. Social activities may be curtailed due to limited mobility. They may initially be misdiagnosed as fibromyalgia of somatisation of depression[3].

Diagnostic Procedures

The diagnosis is made from biochemical findings in the blood serum. The main finding is low vitamin D in the serum. Other major finding are: low calcium in serum and urine; abnormalities in phosphate (low serum levels) and parathyroid levels (elevated due to low calcium in serum)[1].

Management / Interventions

The main treatment to address the bone mineralization issue is to increase vitamin D intake. This should be overseen by the consulting doctor to check vitamin D levels and check on progress.This may be through medication or ensuring sufficient nutritional intake of vitamin D and increasing exposure to the sun[3]. Fifteen minutes of sunshine a day may be adequate. Use of sunscreen lotions can be a factor in development of Osteomalacia in at risk populations. As a physiotherapist you may be educated in dietary advice or wish to refer person on to a dietician for more formal advice.

The Role of Physiotherapy in Osteomalacia

Physiotherapy plays an important role in a multidisciplinary approach to treatment.

Tailored exercise programs (by a physiotherapist ) are important to ensure strengthening of major muscle groups and improvement in ADL and social activities. Weight bearing exercises should be encouraged such as walking but not intensive or high impact exercises[3]. A similar approach can be taken as to exercise programs for osteoporosis.
[5]

Differential Diagnosis

Osteoporosis

Pagets disease

Fibromyalgia

Somatisation of depression

Red flags eg cancer or infection[3]

Resources

https://speciality.medicaldialogues.in/osteomalacia-standard-treatment-guidelines/

References

  1. 1.0 1.1 Wikipedia. Osteomalacia. Available from: https://en.wikipedia.org/wiki/Osteomalacia (last accessed 25.2.2019)
  2. Dr Arzoo Sadiqi . What is Rickets/Osteomalacia. Available from: https://www.youtube.com/watch?v=QHHnaPydYvw [last accessed 25.2.19]
  3. 3.0 3.1 3.2 3.3 3.4 Walker J. Pathogenesis, diagnosis and management of osteomalacia. Nursing older people. 2014 Jun 30;26(6). Available from: Walker J. Pathogenesis, diagnosis and management of osteomalacia. Nursing older people. 2014 Jun 30;26(6).(last accessed 26.2.2019)
  4. 4.0 4.1 John Hopkins Medicine. Chater 27 Osteoporosis and osteomalacia. Available at: https://www.hopkinsmedicine.org/geriatric_medicine_gerontology/_downloads/readings/section7.pdf (last accessed 25.2.2019)
  5. Physical Therapy Video. Top 3 exercises for osteoporosis or osteopenia 29.12.2014. Available from: https://www.youtube.com/watch?v=bKHj7Ec1MsI (last accessed 26.2.2019)