Latest / MSKMag OutLoud / Osteoporotic Vertebral Fractures: are we doing enough?

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Osteoporotic Vertebral Fractures: are we doing enough? · MSKMag OutLoud

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  SPEAKER_00: Osteoporotic vertebral fractures.
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  SPEAKER_00: Are we doing enough?
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  SPEAKER_00: Written by Jenny Dooley.
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  SPEAKER_00: Sponsored by Rehab My Patient, the Physio Matters team choice of exercise prescription software.
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  SPEAKER_00: Vertebral fractures are one of the most common osteoporotic fractures,
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  SPEAKER_00: yet they are the one that we miss most often.
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  SPEAKER_00: Case study.
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  SPEAKER_00: A 58 year old woman presents with mid slash lower back pain.
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  SPEAKER_00: She was lifting shopping bags out of her car boot and felt a twinge in her back.
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  SPEAKER_00: The pain progressively got worse over the next few days.
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  SPEAKER_00: It felt like a bad back spasm,
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  SPEAKER_00: similar to the one she'd had before and the pain wrapped around to her ribs.
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  SPEAKER_00: She was seen by a GP, had one chiro and four physio sessions.
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  SPEAKER_00: Her pain was improving, but she felt progress was too slow and her exercises were not helping.
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  SPEAKER_00: She had a lot of discomfort,
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  SPEAKER_00: washing the dishes,
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  SPEAKER_00: sitting for prolonged periods and was unable to go for her usual long walk.
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  SPEAKER_00: Her pain was eased by lying down.
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  SPEAKER_00: At her first appointment I asked her what her height she was and she said 5 foot 5.
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  SPEAKER_00: I measured her and she was just over 5 foot 3.
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  SPEAKER_00: Her imaging showed a vertebral fracture at T12 and evidence of an older fracture at T6.
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  SPEAKER_00: I see some version of this patient most weeks.
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  SPEAKER_00: If you work in MSK you have almost certainly seen a similar case too.
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  SPEAKER_00: With the above history would a vertebral fracture have been your working diagnosis?
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  SPEAKER_00: Would you have asked her height or measured her in clinic?
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  SPEAKER_00: The silent fracture.
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  SPEAKER_00: Vertible fractures are among the most common fragility fractures caused
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  SPEAKER_00: by osteoporosis, but they are also the least likely to be diagnosed.
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  SPEAKER_00: One vertebral fracture occurs every 22 seconds worldwide,
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  SPEAKER_00: yet only 33% of vertebral fractures come to clinical attention,
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  SPEAKER_00: with nearly 70% going undiagnosed.
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  SPEAKER_00: There are a few reasons vertebral fractures go under diagnosed.
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  SPEAKER_00: 65 to 75% of vertebral fractures have little to no symptoms.
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  SPEAKER_00: They often show up years later as height loss or increased kyphosis,
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  SPEAKER_00: which gets put down to old age.
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  SPEAKER_00: For symptomatic fractures,
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  SPEAKER_00: many present like the typical non-specific back pain we treat every day,
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  SPEAKER_00: and they have similar healing timeframes with most of the acute pain resolving
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  SPEAKER_00: within the first six to 12 weeks.
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  SPEAKER_00: Even when imaging does happen, they are frequently missed.
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  SPEAKER_00: This is because sometimes they are not being looked for.
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  SPEAKER_00: Referral letters have low back pain written on them instead of suspected vertebral fracture.
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  SPEAKER_00: M-plate changes can be subtle and easily missed.
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  SPEAKER_00: And even if they are noticed,
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  SPEAKER_00: they are instead reported as wedging, loss of height or compression.
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  SPEAKER_00: Most of us could recite the red flags to screen for Corderoquina syndrome or spinal malignancy.
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  SPEAKER_00: But are we confident when it comes to identifying signs of an osteoporotic vertebral fracture?
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  SPEAKER_00: Why one fracture matters.
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  SPEAKER_00: Vertical fracture is rarely a one-off event.
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  SPEAKER_00: It is usually the beginning of a steady decline.
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  SPEAKER_00: Vertical fractures can have a devastating impact on people's lives.
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  SPEAKER_00: One in five women who have a vertebral fracture will have another one within a year.
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  SPEAKER_00: Over 55% of older women with a hip fracture are taking osteoporosis medication at
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  SPEAKER_00: the time of the fracture.
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  SPEAKER_00: If we improved our diagnosis of vertebral fractures and addressed it much earlier,
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  SPEAKER_00: could we prevent future hip fractures?
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  SPEAKER_00: We all know the statistic that up to 20% of people will die
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  SPEAKER_00: within one year following a hip fracture,
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  SPEAKER_00: but a less known fact is up to 15% of men will die within one year following
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  SPEAKER_00: an osteoporotic vertebral fracture.
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  SPEAKER_00: Medication can reduce the risk of vertebral fractures by 30 to 70%.
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  SPEAKER_00: If you see someone with an osteoporotic vertebral fracture,
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  SPEAKER_00: make sure they have been referred to their GP or specialist
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  SPEAKER_00: for osteoporotic treatment.
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  SPEAKER_00: What should make you think vertebral fracture?
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  SPEAKER_00: Back pain is the most common presentation we see and people
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  SPEAKER_00: with osteoporosis also get back pain.
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  SPEAKER_00: That is not a vertebral fracture.
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  SPEAKER_00: We can send every patient into a blind panic that they might have a fracture.
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  SPEAKER_00: So when should we consider that back pain might be something more?
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  SPEAKER_00: Risk factors in clinical history.
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  SPEAKER_00: Has the person had a previous fragility fracture,
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  SPEAKER_00: taken corticosteroids for more than three months,
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  SPEAKER_00: or been diagnosed with rheumatoid arthritis?
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  SPEAKER_00: Height Loss.
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  SPEAKER_00: A historic height loss of over 4 cm or more than 2 cm in a recorded period
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  SPEAKER_00: of time should prompt further assessment.
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  SPEAKER_00: Don't just ask how tall people are, measure them in clinic.
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  SPEAKER_00: Sudden back pain after minimal or no trauma.
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  SPEAKER_00: Lifting,
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  SPEAKER_00: shopping,
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  SPEAKER_00: bending to the dishwasher or coughing can all cause vertebral fractures in people
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  SPEAKER_00: with osteoporosis.
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  SPEAKER_00: New or worsening kyphosis.
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  SPEAKER_00: Alongside assessing their spinal curve, measure wall occiput and rib pelvis distance.
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  SPEAKER_00: A wall occiput distance of greater than zero centimetres or a rib pelvis distance
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  SPEAKER_00: of less than two finger widths can be suggestive of a vertebral fracture.
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  SPEAKER_00: Pain that behaves differently.
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  SPEAKER_00: Pain from a vertebral fracture is often worse with standing,
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  SPEAKER_00: washing the dishes,
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  SPEAKER_00: sitting for long periods and is eased by lying flat on their back.
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  SPEAKER_00: Many people experience pain that wraps around their ribs like a vice grip.
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  SPEAKER_00: If someone isn't responding as usual and their symptoms don't fit
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  SPEAKER_00: the typical pattern,
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  SPEAKER_00: consider their risk factors and whether it could be a vertebral fracture.
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  SPEAKER_00: Stopping or missing a dose of denosumab.
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  SPEAKER_00: Stopping denosumab medication is associated with rebound bone turnover,
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  SPEAKER_00: loss of bone mineral density, BMD, and an increased rate of vertebral fractures.
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  SPEAKER_00: A case study showed a cumulative 50 vertebral fractures between nine women
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  SPEAKER_00: after stopping denosumab.
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  SPEAKER_00: Stopping denosumab should always be done alongside a specialist with
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  SPEAKER_00: a clear treatment and monitoring plan.
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  SPEAKER_00: If your patient is taking denosumab,
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  SPEAKER_00: make sure they haven't missed a dose or have stopped taking it themselves.
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  SPEAKER_00: Pregnancy and lactation associated osteoporosis.
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  SPEAKER_00: PAO, PLO is uncommon,
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  SPEAKER_00: but if someone presents with severe back pain,
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  SPEAKER_00: especially if combined with height loss in pregnancy or while breastfeeding,
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  SPEAKER_00: consider vertebral fractures.
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  SPEAKER_00: Low bone mineral density is Recognize the most robust risk factor
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  SPEAKER_00: for fragility fractures,
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  SPEAKER_00: but 55 to 70% of fractures occur in people without an osteoporosis diagnosis
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  SPEAKER_00: on their DEXA scan.
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  SPEAKER_00: Don't just rely on DEXA as a result to rule out a fracture.
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  SPEAKER_00: Combine it with clinical history, risk factors, and fracture risk.
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  SPEAKER_00: Why do we panic when we know it's a vertebral fracture?
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  SPEAKER_00: If we miss a vertebral fracture,
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  SPEAKER_00: or someone has a silent fracture,
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  SPEAKER_00: we rehab that patient like any other back pain patient.
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  SPEAKER_00: We load them,
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  SPEAKER_00: progress them,
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  SPEAKER_00: and get them back to their life, but this changes once we hear vertebral fracture.
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  SPEAKER_00: People with osteoporosis are told to be careful.
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  SPEAKER_00: No bending, no twisting, no lifting, and this often creates a lot of fear.
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  SPEAKER_00: Yes, exercise modifications are important and needed,
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  SPEAKER_00: but fear of sustaining another fracture is the thing I hear most often in clinic.
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  SPEAKER_00: By the time people reach me,
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  SPEAKER_00: they've stopped going to the gym,
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  SPEAKER_00: significantly reduced their activity levels,
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  SPEAKER_00: stopped gardening or picking up their grandkids.
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  SPEAKER_00: They are deconditioned and therefore at higher fall or fracture risk.
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  SPEAKER_00: But the fear doesn't stop with patients.
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  SPEAKER_00: Fear has crept into our own clinical practice and we are underloading the people
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  SPEAKER_00: who need to be loaded the most.
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  SPEAKER_00: How should we approach exercise?
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  SPEAKER_00: The Royal Osteoporosis Society's consensus statement,
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  SPEAKER_00: Strong Steady Straight,
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  SPEAKER_00: advises that exercise is safe and beneficial for people with osteoporosis,
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  SPEAKER_00: including after a vertebral fracture.
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  SPEAKER_00: It recommends progressive resistance training,
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  SPEAKER_00: balance training,
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  SPEAKER_00: and exercise to support spinal posture and impact at an appropriate level.
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  SPEAKER_00: In a study looking at women aged 65 or over who had a vertebral fracture,
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  SPEAKER_00: a 12-week supervised resistance and balance program improved their strength
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  SPEAKER_00: and balance and reduced their fear of falling.
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  SPEAKER_00: In the first...
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  SPEAKER_00: 12 weeks after an acute fracture,
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  SPEAKER_00: the priority is pain management and light activity as tolerated.
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  SPEAKER_00: It's important to understand the location and fracture type
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  SPEAKER_00: so you can modify necessary movements.
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  SPEAKER_00: I educate people on spine-safe movements and how to modify day-to-day activities
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  SPEAKER_00: to allow for fracture healing.
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  SPEAKER_00: As the pain eases,
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  SPEAKER_00: introduce walking,
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  SPEAKER_00: breathing and posture work and maintain as much strength as possible even
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  SPEAKER_00: with exercise like heel raise.
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  SPEAKER_00: Once the fracture is healed, I aim to get people back to being as active as possible.
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  SPEAKER_00: Progressive resistance training twice a week,
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  SPEAKER_00: covering squat, hinge, push, pull, press and carry.
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  SPEAKER_00: Being mindful of modifications but still making the exercises challenging.
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  SPEAKER_00: Balance training three times a week.
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  SPEAKER_00: Back extends to strengthening, focused on endurance to support and improve posture and pain.
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  SPEAKER_00: Walking 20 minutes daily.
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  SPEAKER_00: If the patient's goal is to improve bone mineral density,
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  SPEAKER_00: I build in low-level impact work at a later stage,
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  SPEAKER_00: progressing to moderate impact if appropriate.
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  SPEAKER_00: With movement modifications,
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  SPEAKER_00: the main caution is for repeated sudden sustained end of range spinal flexion
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  SPEAKER_00: and rotation, particularly under load.
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  SPEAKER_00: Good practice is teaching hip hinge technique, particularly when lifting.
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  SPEAKER_00: We should teach people how to adapt to the activities they want to return to.
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  SPEAKER_00: If the person loves golf, can we modify their swing if necessary?
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  SPEAKER_00: Can we make them stronger so they can tolerate the load or activity they want to return to?
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  SPEAKER_00: The most important thing is that we empower our patients with what they can do,
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  SPEAKER_00: not instill fear with what they can't.
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  SPEAKER_00: Next time someone presents with back pain,
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  SPEAKER_00: make sure vertebral fractures enter the differential diagnosis,
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  SPEAKER_00: especially if they have risk factors.
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  SPEAKER_00: And if it is a fracture,
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  SPEAKER_00: make sure to empower that person and support them to be as strong and active
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  SPEAKER_00: as possible going forward.
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  SPEAKER_00: The patient in front of you today could be the hip fracture admission in
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  SPEAKER_00: a few years, and we have the chance to change that.
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  SPEAKER_00: Why I Built Building Bones.
• 9:22
  SPEAKER_00: Working in osteoporosis, I keep seeing the same issues over and over again.
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  SPEAKER_00: People with low bone density receive very little support
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  SPEAKER_00: on why exercise they should do and how they should do it and what was safe.
• 9:32
  SPEAKER_00: And as a result, they stopped exercising or lost confidence in what they were doing.
• 9:36
  SPEAKER_00: Building Bones is a digital health platform
• 9:38
  SPEAKER_00: that builds personalized exercise programs based on people's own bone health history
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  SPEAKER_00: and exercise ability.
• 9:44
  SPEAKER_00: Each program is reviewed by a chartered physiotherapist before reaching the patient.
• 9:48
  SPEAKER_00: Building Bones supports users across three months of strength, balance and impact exercise.
• 9:52
  SPEAKER_00: It also includes education, tracking and community support.
• 9:55
  SPEAKER_00: If you want to learn more, please reach out to see us or our website.