骨質疏鬆及脆性骨折 - CUHK Faculty of Medicine · 2016-07-18 · •The Osteoporosis...
Transcript of 骨質疏鬆及脆性骨折 - CUHK Faculty of Medicine · 2016-07-18 · •The Osteoporosis...
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骨質疏鬆及脆性骨折
麥建章醫生香港大學矯形及創傷外科學系臨床助理教授
香港大學深圳醫院顧問醫生
2016年4月9日香港中央圖書館
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目錄
•骨質疏鬆是甚麼?
•我們如何測量骨質疏鬆&為甚麼我們需要測量它
•骨質疏鬆與脆性骨折的關係?
•什麼是脆性(病理性)骨折?骨科醫生如何治療脆性骨折?
•我們如何治療和預防骨質疏鬆?
引文
我們每天從媒體看到和聽到的是甚麼?
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病理性骨折-部分誤解
•骨質疏鬆是不是會有症狀?
•是不是骨質疏鬆才會骨折?
•在香港,骨質疏鬆有年輕化嗎?
•患者只需要服用藥物就足夠了嗎?
•骨質改良了,就可以停藥嗎?
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甚麼是骨質疏鬆?
常見的問題和誤會
看圖識字:只有1/3的脊柱疏鬆骨折會求醫
正常脊椎骨質
疏鬆脊椎骨質
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這個世界不公平 -皮質骨 VS 鬆質骨
Singh index
鬆質:皮質
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世界衞生組織(WHO)
•骨量降低
•骨微結構破壞
•全身性、代謝性骨骼系統疾病
•骨脆性增加、骨強度下降
•骨折風險性增大
美國國立衞生研究院(NIH)
•2001,重新訂製
•骨強度減弱導致骨折機會增加
•骨強度 - 骨密度+骨質
•骨密度 - 克/面積或體積;骨峰值+流失量
•骨質 - 骨頭大小、微結構、骨轉換、礦化程度、微骨折
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骨質疏鬆的數字
•全球的形勢:
•人均壽命增加&人口老化
•2050,全球有6.26百萬髖關節骨折
•¾ 的人口在亞洲
•∴ ½ 的髖關節骨折
•大於45歲的女性因骨質疏鬆而需要住院的日子多於糖尿病、心肌梗塞、乳房癌的患者
•只有⅓的脊柱骨質會到醫生那裡求診!
髖關節骨折-香港的情況
醫管局數據
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導致骨質疏鬆的已知原因
•繼發性骨質疏鬆
•缺乏Vit D
•用藥 -類固醇、抗痙攣
•內分泌病(甲狀腺素或副
甲狀腺素過多、性激素)
•多發性脊髓瘤
•非疾病原因
•自然流失 - 年紀
•長期沒負重 - 太空
或臥床
•營養不良
骨質疏鬆風險因素
•女性
•老年
•過往骨脆性骨折
•<45 kg
•家庭史-骨質疏鬆、骨脆性骨折
•更年期過早(<45歲)
•低鈣
•無運動
•抽煙
•過量喝酒(每日≧3 標準飲品)
•少見陽光
•長期不動(e.g. 臥床)
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如何測量&為甚麼需要測量
殺雞的方法,但哪一種最好?
跟骨超聲波
它是如何測量骨密度?
它的局限性?
方便、便宜、無輻射不能直接衡量骨密度
沒有標準資料(大部分的臨床研究
用DEXA)
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DEXA(DUAL-ENERGY X-RAY ABSORPTIOMETRY)
雙能量X射線吸收測量法
•它是如何測量骨密度?
•它能測量其他嗎?
•哪個部位被測量?
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DEXA -人體結構分析
脂肪、肌肉、骨軀幹和手腳
骨質疏鬆與(脆性)骨折的關係?
有一點關係,否則就沒有這次講課的觀點了!?
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•T-score ≤ -2.5 (-2.5SD)
•每個SD增加1.5-3.0倍骨折機會
•Z-score - 排除繼發性骨質疏鬆
甚麼是脆性骨折?
名副其實,很脆!
骨科醫生如何治療脆性骨折?
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脊椎骨質疏鬆性骨折壓縮性骨折爆裂性骨折
椎體成形
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髖關節骨折
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腕關節骨折
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其他常見的老年骨折
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停不了的骨折
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我們如何治療和預防骨質疏鬆
循證醫學的證據是什麼?西方醫學的方式是什麼?
基本需求
•Vit D - 800IU/day,最高4000IU
•適量陽光 - 10-15分鐘臉、手、手臂
•鈣 - 1000mg成年男女,1200mg > 70歲
•中國人每天餐飲大概400mg
•50歲以上,不能超過2000mg/day
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骨質疏鬆藥物的歷史
選擇性雌激素受體調節劑
第一隻雙磷酸鹽藥物
(口服)
第二隻雙磷酸鹽藥物
(口服)
第三隻雙磷酸鹽藥物
(口服)
第四隻雙磷酸鹽藥物
(靜脈注射)
副甲狀腺荷爾蒙
鍶
仿「保骨素」骨鬆針
服藥的依從性
•香港大學+香港醫院藥劑師學會
•接近一半受訪者未能完全遵從用藥指示
•ALAFOS 研究
•在香港大學骨科進行中
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雙磷酸鹽藥物-“藥物假期”
•5 年看一看
•藥物留存在骨頭裡(t½很長)
重點
•開不開藥
•骨密度
•風險評估
•臨床
•FRAX - Fracture Risk Assessment Tool
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骨質的常規監測
•骨頭新陳代謝
• P1NP
•骨量
•DEXA
生活方式調整
•Adequate daily calcium intake
•Appropriate exercises (the following talk)
•Weight-bearing
•Strength-training – including back extensor
•Balance-training
•Improve standing & sitting postures
•Quit smoking
•Reduce drinking alcohol, caffeine & excessive tea, salty & preserved foods
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預防摔倒
•留意家居安全
•保持地方乾爽
•不要亂放雜物
•把常用的東西放到容易取的地方
結論
關鍵信息
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骨質疏鬆&脆性骨折
•骨量
•新骨vs 舊骨 (塑形中,微骨折)
•測量骨密度- DEXA vs 超聲波
•脆性骨折風險 - 椎骨最多、髖&腕,也有胳膊、肘關節和踝關節
•手術- 很大的進步,功能恢復好多
•骨折風險的調整
•預防-生活方式(運動尤其重要)
•治療-食物補充劑(鈣、維生素D和藥物)
參考文獻
•The Osteoporosis Society of Hong Kong (OSHK) 2013 OSHK
Guideline for Clinical Management of Post-menopausal
Osteoporosis in Hong Kong. Hong Kong Medical J 2013.
•The Asian Audit. Epidemiology, Costs and Burden of
Osteoporosis in Asia 2009. International Osteoporosis
Foundation 2009.
•Osteoporosis Prevention, Diagnosis, and Therepy. NIH
Consensus Statement 2000.
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謝謝!
麥建章醫生港大骨科脊柱外科瑪麗醫院
港大深圳醫院
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强筋健骼運動方少萌博士
香港大學運動及潛能發展研究所助理教授註冊物理治療師 (香港及英國)
1
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要點
• 人體骨骼結構
• 骨骼受力及生長
• 骨骼老化 - 骨質疏鬆
• 影像診斷檢查
• 預防骨質疏鬆症
• 強化骨骼運動
2
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骨骼 成人~206塊; 兒童~300塊
3
(Moore and Dalley 2005)
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骨骼的結構
•皮質骨•5‐30% 孔隙
•支狀骨/骨小樑•30‐90% 孔隙
4
(Moore and Dalley 2005)
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要點
• 人體骨骼結構
• 骨骼受力及生長
• 骨骼老化 - 骨質疏鬆
• 影像診斷檢查
• 預防骨質疏鬆症
• 強化骨骼運動
5
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兒童及青少年正常骨骼生長
骨骼受力才能刺激生長!骨骺融合
6
(Moore and Dalley 2005)
(Cech and Martin 2002)
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骨骼遇到的外力
• 壓力
• 牽引力
• 剪切力
• 扭力
• 彎曲力
7
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壓力
•如: 地心吸力
8
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壓力
• 渥爾氏定律 (Wolff's Law):• 壓力刺激骨骼的重造過程
• 重量負荷之增加,造成骨骼厚度和骨幹密度的增加
• 「骨抗壓强度指數」 = 骨横截面面積 × 骨密度2
9
(Cech and Martin 2002)
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牽引力
• 如: 肌肉收縮時,在骨骼附著點產生的牽引力
10
(Cech and Martin 2002)
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扭轉 / 彎曲力• 皮質骨承受的扭轉 / 彎曲力 <-> 轉動慣量(慣性
力矩)
11
(Nordin and Frankel 2001)
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要點
• 人體骨骼結構
• 骨骼受力及生長
• 骨骼老化 - 骨質疏鬆
• 影像診斷檢查
• 預防骨質疏鬆症
• 強化骨骼運動
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骨質疏鬆症
•老年人健康的大敵!
•無聲無息!
•女性
更年期後
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骨質疏鬆症
• 骨質流失的速度 > 重造
• 皮質骨變薄
• 支狀骨的骨小樑逐漸消失
• 孔隙 ↑
• 骨質密度及強度下降
皮質骨
支狀骨/骨小樑
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(Nordin and Frankel 2001)
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骨質疏鬆症
• 成因:• 年老 (通常>60歲)• 荷爾蒙的改變 (停經)• 遺傳因素• 過瘦• 鈣質不足• 缺乏運動• 過多咖啡因、酗洒、吸煙• 長期服用類固醇等
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骨質疏鬆症
•影響:
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要點
• 人體骨骼結構
• 骨骼受力及生長
• 骨骼老化 - 骨質疏鬆
• 影像診斷檢查
• 預防骨質疏鬆症
• 強化骨骼運動
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雙能量 X 光吸收測量 (DXA / DEXA)
•多部位、快速、準確的骨密度測量 (g/cm2)
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骨質礦物密度 (T-score)
Osteoporosis
骨質疏鬆症
Osteopenia
骨質減少
Normal
正常
1SD = 骨折機會↑2.5倍
雙能量 X 光吸收測量 (DXA / DEXA)
-2.5
世衛標準值
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外周骨定量電腦斷層掃描 (pQCT)
• 體積骨密度 (mg/cm3)
• 骨幾何結構
• 「骨抗壓强度指數」= 骨横截面面積 × 骨密度2
%長
度
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(Moore and Dalley 2005)
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超聲波骨質強度檢查
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要點
• 人體骨骼結構
• 骨骼受力及生長
• 骨骼老化 - 骨質疏鬆
• 影像診斷檢查
• 預防骨質疏鬆症
• 強化骨骼運動
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鞏固骨質,由細做起
年齡 骨骼成長
0-30歲 生長期,骨骼累積/儲存鈣質
18-20歲 巔峰骨量的90%
30歲 巔峰骨量 (骨本)
>35歲 骨中的鈣質逐漸流失(每年↓0.5-1%)、骨量逐年下降
停經後/ >55歲
流失>>儲存
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骨質的儲存
• 研究顯示:
• 「青春期」(約11‐14歲)時積極參與運動的青少年,其骨質密度較高。
• 「青春期」是儲存骨本的黃金時期,因青春期骨質發育最快, 而運動的效果亦最明顯 (為期約2年)。
• 在年少時期由運動產生的骨質增加,可持續至成年。
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骨骼發展/防治骨質疏鬆的3大要素
•良好的飲食習慣:•攝取鈣質 (1000-1500mg/day)•避免過量的咖啡因及酒精
•曬太陽-維他命D•經常運動
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要點
• 人體骨骼結構
• 骨骼受力及生長
• 骨骼老化 - 骨質疏鬆
• 影像診斷檢查
• 預防骨質疏鬆症
• 強化骨骼運動
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運動3部曲
• 熱身(如: 原地緩跑)及伸展運動 (5-10分鐘)
• 強化骨骼運動鍛練 (30-60分鐘)
• 緩和運動 (減低運動速度及伸展) (5-10分鐘)
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強化骨骼運動
• 每週做>3次
• 每天做>2 次
• 每次做30-60分鐘
• 持之以恆 (半年以上) !
• 配合飲食-鈣質!
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1. 「負重」運動陸上運動 - 下肢及脊椎承重運動 (每週5天、每天30分鐘)
局部效果
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2. 「撞擊性」的運動
• 高負荷、高頻率
• 循序漸進地增加骨骼的負荷/撞擊力• 刺激骨質的增長
• 如: 跑步、體操、跳舞、跳繩、跳高、跳遠、籃球、足球、排球、跆拳道等
• 長者應選擇較溫和的運動,避免過度重複的負荷力• 壓力性骨折、關節磨損、提早退化
跳躍時地面反作用力=6-8倍體重
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3. 力量訓練
• 有抗阻力 (resistance) 、中至高强度
• 負重漸增
• 最大强度<最大重複次數 (1RM) 的60%
• 保持呼吸暢順
• 如: 健身、舉重
壓力性骨折!
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3. 力量訓練
• 當肌肉的力量增加骨的質量也隨著增加
• 因運動時肌肉加壓在骨頭上促進骨質的形成
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4. 配合伸展運動
• 好處:• 鬆弛肌肉
• 保持肌腱的柔韌性
• 增加關節活動幅度
• 預防肌肉拉傷
• 有利運動表現…
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4. 配合伸展運動
• 靜態伸展:
• 慢、切勿突然用力/彈動
• 有拉緊感覺,保持10-30秒
• 慢慢放鬆
• 每組肌肉重複3-5次
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5. 配合姿勢矯正運動
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6. 配合平衡訓練
• 預防跌倒
單腳企
重心轉移
小步站立
向橫行
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7. 中國傳統武術 ‐太極拳
• 傳統中國武術
• 動作柔和連貫
• 呼吸深長自然
• 強調身心合一
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7. 中國傳統武術 ‐習太極拳的好處
• 研究發現,經常練習太極拳的長者:• 平衡能力↑、 信心 ↑ 、 ↓跌倒• 肌肉收縮反應↑ (Fong and Ng, 2006)
• 關節本體感覺↑• 肌肉力量↑• 柔韌度↑• 強化心肺功能 (預防心臟病)• 改善不良姿勢• 改善步態及步速• 骨質疏鬆較輕微• 調劑心情• 擴闊社交圈子…
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8. 中國傳統武術 ‐詠春拳
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8. 中國傳統武術 ‐習詠春拳的好處• 研究發現:
• 長期練習詠春拳的中老年人,他們橈骨的骨骼強度 較普通人 (對照組) 為佳(Fong et al., 2013)。
• 詠春拳練習者的手握力 (Fong et al., 2013) 及下肢肌肉力量 (Fong et al., 2014) 亦較一般人強。
• 詠春拳練習者能在不同的環境下保持站立平衡 ,表現較普通人 (對照組) 優勝(Fong et al., 2013 and 2014)。此外,練習詠春的老年人有較強的平衡自信心 (Fong et al., 2014 and
Lip et al., 2015)。
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總括: 運動的好處
增加骨質密度
增強心肺功能
增強抵抗力
增強肌肉力量及耐力
消耗體內脂肪
增加靈活性及平衡能力, 減少受傷機會
消除壓力
增加柔韌性
減少患病的機會
• 適量• 適當• 循序漸進• 持之以恆
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http://www.medic.hku.hk/endocrinology/osteocentre/exercise.html
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免費兒童骨質密度、 脂肪、肌肉、步態、姿勢和肌能評估與肌能系貼布治療
• 對象: 6至9歲
• 日期及時間:個別預約
• 地點:薄扶林沙宣道五號香港大學香港賽馬會跨學科研究大樓三樓運動及潛能發展研究所
• 有興趣參與檢查及評估的人士,請聯絡任先生 (WhatsApp 6234 4825 / [email protected])
(DXA)
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研究計劃
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謝謝!
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參考資料• Lip, R.W.T., Fong, S.S.M., Ng, S.S.M., Liu, K.P.Y., and Guo, X. (2015). Effects of Ving Tsun Chinese martial art
training on musculoskeletal health, balance performance, and self‐efficacy in community‐dwelling older adults. Journal of Physical Therapy Science, 27(3), 667‐672.
• Fong, S.S.M., Ng, S.S.M., Liu, K.P.Y., Pang, M.Y.C., Lee, H.W., Chung, J.W.Y., Lam, P.L., and Guo, X. (2014). Musculoskeletal strength, balance performance and self‐efficacy in elderly Ving Tsun Chinese martial art practitioners: Implications for fall prevention. Evidence‐Based Complementary and Alternative Medicine, Article ID 402314, 6 pages.
• Fong, S.S.M., Guo, X., Cheung, A.P.M., Jo, A.T.L., Lui, G.K.W., Mo, D.K.C., Ng, S.S.M., and Tsang, W.W.N. (2013). Elder Chinese martial art practitioners have higher radial bone strength, hand‐grip strength and better standing balance control. ISRN Rehabilitation, 1‐6. Article ID 185090.
• Fong, S.M., and Ng, G.Y.F. (2006). The effects on sensorimotor performance and balance with Tai Chi training. Archives of Physical Medicine and Rehabilitation, 87, 82‐87.
• Nordin, M., and Frankel, V.H. (2001). Basic Biomechanics of the Musculoskeletal System. 3rd ed., Lippincott Williams and Wilkins, USA.
• Moore, K.L., and Dalley, A.R. (2005). Clinically Oriented Anatomy. 5th ed., Lippincott Williams & Wilkins, USA.
• Cech, D.J., and Martin, S.T. (2002). Functional Movement Development Across the Lifespan. 2nd ed., W.B. Saunders Company, Philadelphia.
• http://www.medic.hku.hk/endocrinology/osteocentre/
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