OSTEOPOROSIS: A REVIEW OF A COMMON

CONDITION AND PT IMPLICATIONS

Brandon Poen, SPTCadence Health & Fitness Center

Geneva, IL2/5/2015

Normal Bone Physiology 1, 2

Bone is constantly being broken down and replaced with new bone. Resorption (Osteoclasts) and Formation

(osteoblasts) Key age for laying done bone mass: 11-

16 in girls, 13-18 in boys Bone mass increases from birth and

reaches its peak in the early 30s. After age 30, bone removal begins

to exceed formation

Normal Bone Physiology Cont. 1, 2 Women

Menopause between 45-55, results in rapid lose in bone tissue due to estrogen loss.

Estrogen helps prevent bone loss by inhibiting osteoclasts (resorption)

Men Decrease in testosterone production can

occur which can lead to reduced bone mass.

After age 65, both men and women lose bone mass at the same time.

Pathophysiology 1,2

The trabeculae bone is more affected and the result leads to thin, hollow bones (Decreased spongy bone)

Problem occurs when creation of new bone is LESS than the removal of old bone

Prevalence3,4,5

Osteoporosis is estimated to affect 200 million women worldwide - approximately 10% of women aged 60, 20% of women aged 70, 40% of women aged 80 and 67% of women aged 903.

Worldwide, 1 in 3 women over age 50 will experience osteoporotic fractures, as will 1 in 5 men aged over 504.

By 2050, the worldwide incidence of hip fracture in men is projected to increase by 310% and 240% in women5.

Types of Osteoporosis

Primary Type I: Post-menopausal Type II: Age-related

Secondary Attributed to a systemic cause

Risk Factors 1,2,6

Medications (glucocorticoids, blood thinners, immuno-suppressives)

Endocrine disorders Reflex Sympathetic Dystrophy Inherited disorders (Osteogenesis

Imperfecta) Malignancy (myeloma, lymphoma) Spinal cord injury Multiple sclerosis Inflammatory disorders including arthritis,

asthma, and lupus (need glucocorticoids)

More Risk Factors1,2

Inactive lifestyle Early menopause Low calcium and vitamin D intake Low weight/ small build Caucasian Female Family History Scoliosis Easily Bruised Northwestern European background Hypermobility Poor teeth Smoking Alcohol

WHO Fracture Risk Assessment http://www.shef.ac.uk/FRAX/

Clinical Manifestations1,2,6

Loss of height Silent & progressive disease

Often long latency before symptoms develop Collapsed vertebra may initially be felt

or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis, or severely stooped posture.

Most common fracture sites: spine, wrist, and hip

Diagnosis1,2

BMD Calcaneal Ultrasonography

Bone Mineral Density Test2

Greater than 2.5 Standard deviations = Osteoporosis

1.1-2.4 = Osteopenia Less than 1 = Normal

Calcaneal Ultrasonography7

Effective at predicting fractures, cheaper, portable, no ionizing radiation.

Medications1,6

Nutritional Recommendations6

Vertebral Body Fractures1,8

Collapsed vertebra may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis, or severely stooped posture.

Tenderness of spinous processes An examination of chest radiographs taken on 934

women admitted to a hospital was performed by a study radiologist. Radiographic evidence of a vertebral fracture was found in 132 images. Only ½ of these fractures were noted in the original radiology report, and only 23 were noted in the medical record. Therefore, in this study, only 18% of women with a vertebral fracture received treatment for the fracture. 8

Surgical Procedures for VBF

Kyphoplasty https://

www.youtube.com/watch?v=HN0dUll1sBY

Vertebroplasty https://

www.youtube.com/watch?v=T_Ka8uhbL_o&x-yt-ts=1421914688&x-yt-cl=84503534

Be aware of Spinal cord involvement It’s possible that some of the cement can

travel into spinal cord (usually in posterior fracture of vertebral body)

Surgeries continued

Kyphoplasty

Vertebroplasty

Which surgery is better?

9,10

A systematic review of the available literature was performed to quantify the amount of pain reduction using the visual analog scale (VAS) between vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures. 9

No statistically significant difference between both procedures at both initial and follow up in terms of pain .

The two surgical procedures were both followed by significant pain relief, and the quality of life was similar regardless of the procedure used. Balloon kyphoplasty led to an ongoing reduction of freshly fractured vertebrae and was followed by a lower rate of cement leakage.

Another study characterized the cost to Medicare for treating VCF-diagnosed patients by nonsurgical management, vertebroplasty, or kyphoplasty. Kyphoplasty was found to be cost effective, and perhaps even cost

saving, compared with vertebroplasty. Utilized cost per life-year10.

PT Implications

General Considerations1

Spinal flexion (especially combined with rotation) is contraindicated

Strengthening of the back extensors is critical

Exercise must be enough to challenge the system

Exercise must be specific to anatomic site

Exercise must be varied so that system can continue to adapt

Outcome Measures

Osteoporosis Functional Disability Questionnaire

Women's Health Questionnaire Osteoporosis Quality of Life

Questionnaire Osteoporosis Assessment

Questionnaire

Examination

Vision Cognition Posture ROM Strength

Key muscles to test: trunk extensors, hip Abductors & extensors, gastroc, quadriceps, dorsiflexors, scapular retractors, and core stabilizers. Functional tests, such as the sit-to-stand, give an indication of lower extremity strength.

Requires trunk stabilization and small lever arm during MMTs! Flexibility Balance Gait Sensation

Exercises

Resistance exercises Weight bearing exercises Whole body vibration 11

Aerobic Exercises to avoid

SLR, KTC, sit ups, toe touches

Set Protocols

Walk Tall by Sarah Meeks

List of exercises(Meek’s Protocol)12

Supine Shoulder press – Press shoulders into table from neutral Chin tuck/ head press Glut sets Leg press = quad set + glut set Ankle pumps Elbow press- bring hands behind head, push elbows into

floor Thoracic lift-Shoulder press + thoracic extension Snow angels Arm press- Press shoulders into table (shoulders at 180) Bridging Shoulder flexion with wand PNF D2 pattern

Continued12

Sitting Scapular retraction Scapular retraction with depression

Standing Extension in standing Pushaway – push up on wall Weight shifts SLS

Continued12

Prone Hip extension Head lift Leg/arm lift Shoulder blade squeeze + thoracic and

head lift

Exercise1,13,14

WB exercise improves BMD, resistance training Frequency – At least 3x/ week Duration- 30 minutes Intensity- Moderate/High High impact weight bearing activities are found to be the

most effective at enhancing BMD at specific sites of impact. Resistance training is more effective at enhancing cortical bone than aerobic exercise alone and that muscle contraction can result in site-specific increases in BMD.

If do strength training, handheld weights are preferred as they allow for the most options for standing exercises with weight bearing through the extremities and trunk

Ideally, high load/low rep are the most effective at increasing BMD

More considerations13,14,15

Start out at a lower intensity. Higher-impact exercise is excellent at maintaining BMD;

however, the exercise should not put any sudden or excessive strain on bones, especially as there is an increased risk of stress fractures with high-intensity exercises.

Additionally continual cyclic loading during exercise may lead to fatigue degradation of bone and an increased risk of fracture. There needs to be a balance between intensity, impact, and mode of exercise in order to promote BMD without causing additional risk of fracture.

Not all patients can tolerate dry-land exercises and may benefit from aquatic therapy (resistance exercise from pool therapy can increase BMD).

Body Mechanics

Hip hinging and neutral spine during transfers and functional mobility tasks.

Group Fitness6

Dancing Tai Chi Aquatics

VBF Considerations1,6,13

Severe, constant pain often accompanies acute vertebral fracture

Complaints of severe pain with movement Normal healing time for VBF is 6 – 8 weeks, but

most result in loss of height Acute pain typically resolves within 6 – 8 weeks

Nothing will entirely get rid of pain (except Calcitonin)

Modalities and manual therapy do not control pain Can have continuing pain due to soft tissue

changes

Considerations continued1,6,13

Techniques typically used for LBP are usually ineffective in the patient with acute pain secondary to VBF

Treatment aimed at good alignment and moving from the hips, not the back

The patient needs to learn to move while avoid even subtle flexion and rotation of the spine

The most difficult mobility pattern to reach with good pain control is sit to sidelying and the reverse

Clinical Prediction Rules for VBF16

Roman, et al: Age > 52 years No presence of leg pain Body mass index < 22 Does not exercise regularly Female gender

Clinical Prediction Rules for VBF continued17

Henschke, et al.: Female sex Age > 70 years old Significant trauma (major in young

patients, minor in elderly patients) Prolonged use of corticosteroids

VBF Exercise1,6,13

Sit to stand Practice hip hinging Gentle isometric trunk extension Partial squats Activity and rest schedule Hourly walking Very limited erect supported sitting Lying in sidelying Progressive resistive exercise should not occur until

3 months after the fracture (Check with surgeon)

Exercises Including Weight Vests and a Patient Education Program for Women With Osteopenia:A Feasibility Study of the OsteoACTIVE Rehabilitation Program from JOSPT 201518 Purpose: describe the OsteoACTIVE

rehabilitation program and evaluate its feasibility in terms of progression, adherence, and adverse events in patients with low bone mineral density (BMD) and a healed forearm fracture. The secondary aim was to assess changes in measures of function and quality of life.

Methods

Inclusion Criteria: Low BMD (Less than 1.5 SDs) Postmenopausal women older than 55 Wrist fracture that occurred no more

than 2 years ago and was completely healed

Live in the Oslo region (Norway)

Exclusion Criteria: History of hip or vertebral fracture History of more than 3 fractures from

osteoporosis Medical problems precluding active

rehabilitation Already performing moderate to intense

physical activity for more than 4 hours per week.

Inability to understand written or spoken Norwegian.

Results

Thirty-five women (83%) completed the 6-month program and 31 women (74%) attended all the follow-up measurement sessions. All participants progressed during the rehabilitation program for both load and type of exercises. Furthermore, 87% of the participants met the a prior goal of 80% adherence, and no participants reported adverse events. Improvements in quadriceps strength and BMD of the femoral trochanter were noted at the end of the 6-month training period (P<.05). At 1-year follow-up, there were significant improvements in quadriceps strength and dynamic balance compared to baseline (P<.05).

Limitations

Small sample size Done in only one region in Norway Does not include individuals with

medical problems limiting rehabilitation or people with previous hip or spine fracture.

Implications

OsteoACTIVE rehabilitation program was feasible and achieved progression of training level, had high adherence, and had no adverse events. Positive improvements were established in lower extremity function and femoral trochanter BMD.

Other Resources

National Osteoporosis Foundation www.nof.org

Osteoporosis Education Project www.betterbones.com/bonehealthprofile/default.aspx

John Hopkins SCORE Screening Quiz http://www.hopkins-arthritis.org/arthritis-info/osteoporosis/diagnosis.html

Questions?

References 1. Magee D, Zachazewski J, Quillen W. Pathology and Intervention in Musculoskeletal Rehabilitation. St. Louis, MO:

Elsevier; 2009 2. Goodman C, Fuller K. Pathology: Implications for the Physical Therapist, 3rd Edition. St. Louis, MO: Saunders

(Elsevier), 2009. 3. Kanis JA (2007) WHO Technical Report, University of Sheffield, UK: 66. 4. Melton LJ, 3rd, Chrischilles EA, Cooper C, et al. (1992) Perspective. How many women have osteoporosis? J Bone

Miner Res 7:1005. 5. Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407.) 6. National Osteoporosis Foundation. Boning up on Osteoporosis: A guide to prevention and treatment. 7. Bouxsein M, Radloff S. Quantitative Ultrasound of the Calcaneus Reflects the Mechanical Properties of Calcaneal

Trabecular Bone. Journal of Bone and Mineral Research, Volume 12, Number 5, 1997 Blackwell Science, Inc. 8. .Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR. Recognition of vertebral fracture in a clinical

setting. Osteoporos Int J. 2000;11:577–82 9. Gill JB, Kuper M, Chin PC, Zhang Y, Schutt R., Jr Comparing pain reduction following kyphoplasty and vertebroplasty

for osteoporotic vertebral compression fractures. Pain Physician. 2007;10:583–90. 10. Edidin AA, Ong KL, Lau E, Schmier JK, Kemner JE, et al. (2012) Cost-effectiveness analysis of treatments for

vertebral compression fractures. Appl Health Econ Health Policy 10:273–284.) 11. Moushira Erfan Zaki. Effects of Whole Body Vibration and Resistance Training on Bone Mineral Density and

Anthropometry in Obese Postmenopausal Women. Journal of Osteoporosis. Volume 2014, Article ID 702589, Hindawi Publishing Corporation.

12. Meeks, Sara. Walk Tall: An exercise program for the prevention and treatment of osteoporosis. 1999. 1st edition. Triad Publishing Company

13. Blaschak, M.J. Osteoporosis presentation. November 16th, 2014. Northern Illinois University. 14. ACSM Guidelines for Exercise Testing and Prescription. Ninth edition. 2014. 15. Goodmann C,. Exercise Prescription for Medical Conditions (2011, FA Davis). 16. Roman M, Brown C, Richardson W, Isaacs R, Howes C, Cook CE. The development of a clinical decision making

algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity. Journal of Manual and Manipulative Therapy. 2010; 18(1): 44-49.

17. Henschke N, Maher CG, Refshauge KM. A systematic review identifies five “red flags” to screen for vertebral fracture in patients with low back pain. J Clin Epidemiol. 2008;61:110–118

18. Hakestad et all. Exercises Including Weight Vests and a Patient Education Program for Women With Osteopenia: A Feasibility Study of the OsteoACTIVE Rehabilitation Program. journal of orthopaedic & sports physical therapy | volume 45 | number 2 | february 2015.