2.5 Bone Health, Osteoporosis & Metabolic Bone Disease

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

2.5 Bone Health, Osteoporosis & Metabolic Bone Disease

Key Takeaways Explain This Topic AI

Osteoporosis is defined by a T-score <= -2.5 (DEXA at femoral neck/total hip/lumbar spine); osteopenia is T-score between -1.0 and -2.5, and a T-score <= -2.5 plus a fragility fracture denotes severe (established) osteoporosis.

The FRAX tool estimates 10-year probability of major osteoporotic and hip fracture and guides when to initiate pharmacotherapy; glucocorticoid use, rheumatoid arthritis, and immobility are key secondary risk factors relevant to rehab patients.

First-line pharmacotherapy comprises oral or IV bisphosphonates (alendronate, zoledronate); denosumab (RANKL inhibitor), teriparatide (anabolic PTH analog), and romosozumab (sclerostin inhibitor) are reserved for very high fracture risk.

Rehabilitation reduces bone loss through weight-bearing exercise and site-specific loading; prolonged immobility, SCI, and stroke hemiplegia accelerate bone resorption and fracture risk.

Last updated: July 2026

Bone Health, Osteoporosis & Metabolic Bone Disease

Bone health is a high-yield Domain D topic because rehabilitation patients are disproportionately affected by metabolic bone disease. Immobility, neurologic injury, glucocorticoid therapy, and inflammatory arthritis all accelerate bone loss and elevate fragility fracture risk. The physiatrist must interpret bone densitometry, stratify fracture risk, prescribe or coordinate pharmacotherapy, and design loading exercise that stimulates bone without exceeding fragility thresholds.

DEXA Interpretation & Diagnostic Thresholds

Dual-energy X-ray absorptiometry (DEXA) reports bone mineral density (BMD) as a T-score (comparison to a healthy young adult reference) and Z-score (age-matched comparison). Diagnostic categories apply to postmenopausal women and men >= 50 years:

Diagnostic Category T-Score (DEXA) Clinical Note

Normal >= -1.0 BMD within 1 SD of young-adult mean.

Osteopenia (low bone mass) -1.0 to -2.5 Counsel on calcium/vitamin D, weight-bearing exercise, recheck.

Osteoporosis <= -2.5 Pharmacotherapy indicated; fall-prevention program.

Severe (established) osteoporosis <= -2.5 plus fragility fracture High risk; anabolic therapy often first-line.

Z-scores <= -2.0 in younger patients suggest secondary osteoporosis and warrant workup for hyperparathyroidism, hypogonadism, celiac disease, or chronic glucocorticoid exposure.

FRAX Fracture Risk Stratification

The WHO FRAX tool integrates clinical risk factors (age, sex, BMI, prior fracture, parental hip fracture, smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol) with or without femoral-neck BMD to estimate the 10-year probability of a major osteoporotic fracture and of hip fracture. Pharmacologic treatment is generally recommended when the 10-year hip fracture probability reaches >= 3% or major-osteoporotic-fracture probability >= 20%. Glucocorticoid-induced osteoporosis uses adjusted FRAX thresholds.

Pharmacotherapy

Bisphosphonates (alendronate, risedronate, zoledronic acid): inhibit osteoclast-mediated resorption; first-line for most patients. Dental clearance is prudent given osteonecrosis of the jaw risk, and drug holidays after 3-5 years reduce atypical femoral fracture risk.

Denosumab : monoclonal antibody against RANKL; subcutaneous every 6 months; reversible on discontinuation ("rebound" vertebral fracture risk necessitates follow-on antiresorptive therapy).

Anabolic agents (teriparatide, abaloparatide, romosozumab): stimulate bone formation; reserved for very high fracture risk or multiple fractures; followed by an antiresorptive to consolidate gains.

Calcium (1000-1200 mg/day) and vitamin D (800-1000 IU/day) : foundational supplementation; monitor 25-hydroxyvitamin D levels in deficient patients.

Rehabilitation Relevance Immobility / SCI / Hemiplegia ──► ↑Bone Resorption ──► ↓BMD ──► Fragility Fracture Risk

│ │
└── Weight-bearing & Site-Specific Loading Exercise ◄─── Reverses Trend

Weight-bearing and high-load, low-repetition activity (resistance training, impact loading where safe) osteogenically stimulates bone remodeling. In SCI, standing frames and electrical-stimulation cycling slow but do not fully prevent distal-femur/proximal-tibia demineralization. Fall-prevention programs (balance training, home hazard reduction, vision/medication review) are essential adjuncts because most osteoporotic fractures result from falls.

Secondary & Glucocorticoid-Induced Osteoporosis

Chronic glucocorticoid therapy (>= 5 mg prednisone for >= 3 months) rapidly impairs osteoblast function and increases resorption; the FRAX glucocorticoid correction factor should be applied. Other secondary causes—hyperthyroidism, hyperparathyroidism, hypogonadism, chronic kidney disease, and malabsorption—must be identified and treated.

Falls, Fragility Fractures & Rehabilitation After Vertebral Compression

Fragility fractures most commonly occur at the spine (vertebral compression fractures), hip, distal forearm (Colles), proximal humerus, and pelvis. Vertebral compression fractures present with acute mid-back pain, often after minimal trauma or activities of daily living, and may cause progressive kyphosis with loss of height, restrictive lung impairment, and reduced abdominal space (early satiety, reflux). Most are managed conservatively with a brief period of relative rest, analgesia, early mobilization in a TLSO as needed, and bone-specific pharmacotherapy; vertebroplasty/kyphoplasty are reserved for selected refractory cases.

Hip fragility fractures carry high one-year mortality and disability. Rehabilitation emphasizes early mobilization, weight-bearing per fixation (germ and intertrochanteric fractures fixed with arthroplasty or sliding hip screw often permit early protected weight-bearing), delirium and pressure-injury prevention, VTE prophylaxis, and discharge to inpatient rehab when impairment warrants. Post-fracture, every patient should trigger an osteoporosis workup and treatment to prevent the next fracture.

Site Typical Mechanism Rehab Priorities
Thoracic/lumbar spine Bending/lifting, minimal trauma Brief rest, early mobilization, TLSO, treat osteoporosis
Hip Sideways fall Early WB per fixation, delirium/VTE/pressure prevention
Distal forearm FOOSH Immobilization, then hand therapy, AROM
Proximal humerus FOOSH Sling, early pendulums, progressive ROM
Pharmacologic Side Effects Relevant to Rehab

Bisphosphonates: esophageal irritation (take upright, with water, remain upright 30 min), rare osteonecrosis of the jaw and atypical subtrochanteric femoral fractures (prodromal thigh pain → image). Denosumab: must not be stopped without follow-on therapy due to rebound vertebral fracture risk. Teriparatide: transient orthostatic hypotension, hypercalcemia monitoring, limited to 2 years followed by antiresorptive. Candidates should recognize the prodrome of atypical femoral fracture (dull thigh pain) and the importance of drug holidays after 3-5 years of bisphosphonate therapy.

Integration With the Rehab Team

Bone health management is interdisciplinary: physiatrist (loading prescription, fall prevention, coordination), endocrinology/rheumatology/primary care (pharmacotherapy), dietitian (calcium/vitamin D, protein), therapy (balance, resistance, posture), and social work (home safety). The physiatrist's unique contribution is converting the osteoporosis diagnosis into a safe loading program that builds bone while preventing falls—the two levers that most reduce fracture events.