858   n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• Suicide rate is 7.5 times higher than normal population.•...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                          859FIGURE 11–10 Calcium cycle. (From Ka...
860    n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• First clinical presentation is usually a fracture.• Majo...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                           861Skeletal Mass ComponentsCortical bo...
862   n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION3. Failure to achieve adequate peak bone mass (PBM) at skel...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                           863• Excess thyrosine• Lithium• Loop d...
864     n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATIONDiagnostic EvaluationDual x-ray absorpiometry (DXA) scan,...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                          865Radiographic StudiesDual X-Ray Absor...
866   n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• This technique is unique that it provides for true 3-D im...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                               8673. Estrogen• Mechanism of actio...
868   n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• Intravenous side effects: flu-like symptoms, fever, muscl...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                             869Activities associated with increa...
870    n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATIONFacet Joint Disease• Most prominent abnormality at vertebr...
872   n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• Bleeding/hematoma• Cement extravasation into spinal canal...
ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n                               873Other:• Postural training suppo...
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  1. 1. 858 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• Suicide rate is 7.5 times higher than normal population.• Decreased short-term memory, decreased reasoning, slow processing• Depression is a common finding and should be addressed by rehab psychology.OUTCOME IN MS• In general, 85% of patients with MS will have a normal life expectancy. However, the unpredictable outcome of the disease and variable nature of its impairment make predict- ing it difficult.• Seldom fatal• 1/3 require ambulatory assistance within 10 years of diagnosis; 2/3 do not.Minimal Record of Disability (MRD)• This consists of different types of rating scales that profile the main dysfunctions of MS.• The most common scale used is the Kurtzke Expanded Disability Status Scale (EDSS). – A 10-level rating scale used in MS examining 8 different neurologic systems. – Rating scale: 0 = normal 4 = severe disability, but still ambulatory without aid 8 = bedbound 10 = death – Areas tested: pyramidal, cerebellar, brainstem, sensory, bowel and bladder, vision, men- tal status, and general• Other outcome scales used in MS include: – Kurtzke Functional Systems (FS) – Incapacity Status Scale (ISS) – Environmental Status Scale (ESS)MRD = EDSS, ISS, and EESFIM: Functional Independence Measure—assesses disability and the need for assistance.Does not assess vision (Kurtzke, 1983) (see Figure 8–4). n OSTEOPOROSISOsteoporosis is a disease characterized by bone mass reduction and a deterioration of thebony microarchitecture. It is caused by an imbalance between bone formation and boneresorption, ultimately leading to osteopenia. Living bone is never metabolically at rest, as itis constantly remodeling and reappropriating its bony matrix and mineral stores along linesof mechanical stress. The factors that control bone formation and resorption are not wellunderstood, but in the normal adult skeleton, the 2 processes are coupled so that net boneformation equals net bone resorption (Figure 11–10).FACTS ABOUT OSTEOPOROSIS• Most common metabolic bone disease• Normal ratio of organic and mineral components but decreased bone tissue density• Differs from osteomalacia, which has normal or increased bone tissue density, but a reduced mineral content to organic component ratio).
  2. 2. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 859FIGURE 11–10 Calcium cycle. (From Kaplan FS. Prevention and Management of Osteoporosis.Clinical Symposia 1995; 47(1) Copyright Ciba-Geigy, with permission.)
  3. 3. 860 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• First clinical presentation is usually a fracture.• Major underlying cause of long bone fractures in the elderly is osteoporosis.• However, the diagnosis is not dependent on the patient suffering a fracture.EPIDEMIOLOGY• There are > 1.2 million fractures/year in the United States related to osteoporosis.• ~ 70% of fractures in people > 45 years old are related to osteoporosis.• 1/3 of females > 65 years old will have vertebral fractures.• ~ 50% of the population > 75 years old is affected, males and females equally.• Hip fracture is a significant cause of morbidity and mortality in Caucasian women aged 50 years and above, and to a lesser extent Caucasian men of similar age. – 17.5% of these women will sustain a hip fracture compared to 6% of men. – Fractures usually result in temporary disability, but approx. 50% of females with hip fractures admitted to nursing home, 14% of these patients in nursing home after 1 year. – Morbidity: 50% of patients with hip fracture require assistance ADLs, 15–25% long-term placement. – Mortality: 10–20% of patients die due to complications.• The National Osteoporosis Foundation (NOF) uses the quality adjusted life year (QALY) of fractures to determine the impact of osteoporotic fractures on a person’s life (Matkovic, 1996).RISK FACTORS FOR OSTEOPOROSISIncreased Risk• Caucasian or Asian• Female• Advanced age• Thin habitus• Smoking• Excess alcohol• Excess caffeine intake• Inactivity/immobilization• Diminished peak bone mass (PBM) at skeletal maturity• History of fracture as adult• Positive family history• Loss of ovarian function/estrogen depletion, testosterone deficiency• Exercise-induced amenorrhea• Low body mass index (BMI), typically < 20Decreased Risk• ObesityPHYSIOLOGYCellular Components of Bone Remodeling• Osteoblasts: bone forming cells that produce organic matrix which is mineralized to form normal lamellar bone• Osteoclasts: bone resorption cells• Osteocytes: osteoblasts incorporated in new bone matrix
  4. 4. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 861Skeletal Mass ComponentsCortical bone (compact)• Dense outer shell of bone• Concentric lamellae, Haversian systems• 80% of skeleton, most in shafts (diaphysis) long bones• Accounts for majority of skeletal mechanical strength.Trabecular bone (cancellous, spongy)• Found in central medullary canal; encloses marrow space.• Irregular branching plates, circumferential lamellae• 20% of total skeleton, found in vertebrae and flat bones (axial skeleton), ends of long bones• Vertebral bodies 42%, whole vertebrae 25%• More metabolically active than cortical bone.• Preferentially altered in osteoporosis type IMinerals, Hormones, Vitamins• Calcium phosphate (in the form of hydroxyapatite) – Major component of bone – Regulated by parathyroid hormone (PTH), calcitonin, and vitamin D; 99% of body’s calcium is in bone.• PTH—regulated by Ca+ concentration• Effects: – In bone: activates osteoclasts. – In intestine: stimulates formation of vitamin D in kidneys (inactive form of vitamin D to active form vitamin D), which results in increases Ca+ uptake. – In kidneys: increased phosphate excretion increases calcium reabsorption.• Calcitonin – Synthesized by C cells in thyroid glands. – Decreases serum Ca+ levels by inhibiting osteoclasts and increasing Ca+ incorporation into bone.• Vitamin D (1,25—Dihydroxyvitamin D3) – In the intestines: enhances Ca+ and phosphorus absorption. – In the kidneys: increases reabsorption of Ca+, phosphorus.MAIN DETERMINANTS OF OSTEPOROSISThe pathogenesis of osteoporosis is multifactorial. Causes include genetic and environmen-tal factors.1. Increased rate of bone loss • After PBM is achieved, bone loss occurs gradually thereafter, with the most rapid bone loss occurring in early postmenopausal period in females. • Rate of age related bone loss is approximately 0.25–1.0% per year in males and females. • Immediate postmenopausal period: 3–5% bone loss per year in females for approxi- mately 5–7 years after onset of menopause • Lifetime bone loss: 20–30% in males, 45–50% in females • Greatest contributor to bone loss in mature adults is loss of gonadal function.2. Quality of bone microstructures • Decreased trabecular bone (trabecular perforation)
  5. 5. 862 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION3. Failure to achieve adequate peak bone mass (PBM) at skeletal maturity • High risk groups include persons, such as female athletes (“female triad”= anorexia, amenorrhea, osteoporosis), anorexics, persons with decreased mobility, persons with nutritional deficiencies.CLASSIFICATION1. Generalized—Affects Different Parts of Whole SkeletonPrimary Osteoporosis (Involutional)–Most CommonBasic etiology is unknown.• Postmenopausal osteoporosis (also known as Type I) – Typically during the 15–20 years following menopause – Affects females 50–65 years old. – Trabecular > cortical bone loss – Most fractures in spine, hip, and wrist (Colles fracture) ie, axial skeleton• Senile- or age-associated osteoporosis (also known as Type II) – > 70 years old – 2:1 female:male ratio – Trabecular ≈ cortical bone loss – Fractures: hip, spine, pelvis, humerus• Juvenile: children and adolescents; self-limited• Idiopathic: premenopausal females, middle-aged malesSecondary Osteoporosis (Also Known as Type III)—Acquired or Inherited Diseases/Medication-Induced)Diseases:• Hyperparathyroidism• Hyperthyroidism• Cushing’s disease• Hypophosphatasia• Hypogonadism• Hypoestrogenism (anorexia, exercise induced amenorrhea)• Renal disease• Chronic obstructive pulmonary disease (COPD)• Systemic mastocytosis• Rheumatoid arthritis• Diabetes mellitus• Idiopathic hypercalciuria• Gastrointestinal disease (malabsorption syndromes, liver disease, partial gastrectomy)• Alcoholism• Nutrition (vitamin deficiency, calcium deficiency; high sodium, protein, phosphate, and caffeine intakes)• Malignancy (multiple myeloma, lymphoma, leukemia)• Immobility (tetraplegia/paraplegia/hemiplegia, prolonged bedrest)• Loss of ovarian function estrogen depletion, testosterone deficiencyMedication-induced:• Corticosteroids: most common cause of secondary osteoporosis; predominantly inhibits bone formation ( osteoblasts); mainly trabecular bone loss, leading to compression defor- mities of the vertebrae and pelvis• Heparin• Anticonvulsants
  6. 6. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 863• Excess thyrosine• Lithium• Loop diuretics2. Localized—Discrete Regions of Reduced Bone MassPrimary• Transient regional: rare, migratory; predominantly involves hip; usually self-limited.• Reflex sympathetic dystrophy (RSD, also known as CRPS Type I): radiographic changes may occur in first 3–4 weeks, showing patchy demineralization of affected area.Secondary• Immobilization, inflammation, tumors, necrosisDe nition from the World Health Organization (WHO)The diagnosis of osteoporosis is made by measuring a patient’s bone mineral density (BMD)and comparing it to the mean BMD of a young adult reference population. One methodcalled DXA scan (see Diagnosis section) is utilized to quantify BMD and is considered thegold standard for evaluating BMD. Results from a DXA scan are reported as T-scores andZ-scores. Diagnosis of osteopenia or osteoporosis is based on T-scores.1. The mean young adult bone mineral density (BMD) is the expected normal value of a patient’s peak BMD at about age 20 compared to others of the same sex and ethnicity.2. A T-score is the number of standard deviations (SD) away from the mean of a reference population. In this situation, the reference would be the young adult population as men- tioned above.3. Normal Bone Density: defined as T-score is between -1 SD and + 1 SD (-1 SD ≤ normal T-score ≤ +1 SD).4. Osteopenia: T-score is between –1 and –2.5, including –2.5.5. Osteoporosis: T-score is < –2.5.6. A Z-score represents the number of SDs the patient’s bone density is compared to adults of the same age and gender.7. Peak Bone Mass (PBM): the highest level of bone mass achieved as a result of normal growth generally occurs between adolescence and age 30, with variation at specific skel- etal sites. T-score: –2.5 –1 0 1 2.5 Osteoporosis Osteopenia Within Normal RangeDIAGNOSISHistory/Physical ExamEvaluate for presence of risk factors or predisposing medical conditions. The first clinical indication is usually a fracture:• Fracture of proximal femur, distal forearm – Usually associated with minimal trauma – Pain usually present.• Vertebral body fracture – Usually associated with minimal trauma – May be painful or asymptomatic.
  7. 7. 864 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATIONDiagnostic EvaluationDual x-ray absorpiometry (DXA) scan, CBC, comprehensive metabolic panel including LFTs,serum Ca+, phosphorus, total alkaline phosphataseAdditional Diagnostic Studies:• Ionized Ca+, ESR, vitamin D, protein electrophoresis, thyroid function tests, parathyroid hormone, follicle stimulating hormone, estradiol, testosterone, serum and urine markers, urine Ca+/creatinine ratio• Iliac crest bone biopsy with tetracycline labeling (osteoporosis shows thin cortices and decreased number of trabeculae)• Markers of Bone Resorption• Elevated levels of calcium/creatinine ratio in fasting urine, hydroxyproline/creatinine ratio in fasting urine, collagen cross links (pyridinolines, telopeptides), TRAP (tartrate resistant acid phosphatase)• Markers for Bone Formation• Serum osteocalcin y-carboxyglutamic acid (GLA) protein• Serum total and bone specific alkaline phosphatase• Procollagen propeptideIndications for Bone Mineral Density Measurement (National OsteoporosisFoundation)• Women age 65 and older and men age 70 and older, regardless of clinical risk factors• Younger postmenopausal women and men age 50 –70 of concern based on their clinical risk factor profile• Women in the menopausal transition if there is a specific risk factor associated with increased fracture risk, such as low body weight, prior low-trauma fracture, or high risk medication• Adults who have a fracture after age 50• Adults with a condition (eg, rheumatoid arthritis) or taking a medication (eg,glucocorticoids, ≥5 mg/day for ≥3 months) associated with low bone mass or bone loss• Anyone being considered for pharmacologic therapy for osteoporosis• Anyone being treated for osteoporosis to monitor treatment effect• Anyone not receiving therapy in whom evidence of bone loss would lead to treatment• Postmenopausal women discontinuing estrogen should be considered for bone density testing• Estrogen deficient women at clinical risk for osteoporosis• Individuals with vertebral abnormalities• Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy ≥5 mg/d of prednisone or an equivalent dose for ≥3 months• Individuals with primary hyperparathyroidism• Individuals being monitored to assess the response or efficacy of an approved osteoporo- sis drug therapyOther Indications1. If risk factors present for fractures in perimenopausal and postmenopausal women2. Screen for bone loss in conditions in which osteopenia is a manifestation.3. Following response to treatment4. Testosterone deficient men5. Research—epidemiologic studies, clinical therapy trials
  8. 8. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 865Radiographic StudiesDual X-Ray Absorptiometry (DXA, Formerly DEXA)• Gold standard for bone mineral density measurement testing• Accurate, precise, fast• Low radiation exposure (scan times are shorter than with DPA and radiation dose is very low).• Uses x-ray source instead of an isotope source.• There is suspicion because the radiation source does not decay and the energy stays con- stant over time.• Allows assessment axial or peripheral skeleton or entire skeleton.• Sites measured: spine, hip radius• Proximal femur density measurement useful for predicting hip fractures.• Lumbar spine density measurement useful for monitoring response to therapy.• Spinal osteophytes and aortic calcifications may contribute to false high readings.X-Ray• Not sensitive in assessing bone mass• 30–35% bone mass loss must occur before demineralization can be detected.• Findings: – Cortical thinning – Trabecular pattern coarsened due to loss of small trabeculae• Findings in the spine: – Increased radiolucency – Increased prominence of endplates – Increased concavity of endplates if nucleus pulposus has not degenerated (codfish vertebrae) – Anterior wedging and vertebral body height loss due to vertebral body compression fracturesSingle Photon Absorptiometry (SPA)/Single X-Ray Absorptiometry (SXA)• Inexpensive• Low radiation dose• Requires water bath or gel immersion.• Uses I125 (SPA, a radioactive isotope) or x-ray source (SXA).• Site measured: radius, calcaneus• Limited to bone measurement of peripheral skeleton; unable to measure bone density of hip or spine.Dual Photon Absorptiometry (DPA)• No water bath or immersion needed.• Uses AGD153 source, a radioactive isotope.• Less accurate and precise than dual energy x-ray absorptiometry (DXA)• Increased scan time.• Sites measured: proximal femur, lumbar spineQuantitative Computed Tomography (QCT)• Allows measurement of trabecular bone alone of spine, apart from cortical bone.• High-dose radiation• Expensive• Sites measured: spine, hip radius• Accuracy compromised by increased fat content of bone marrow in elderly.
  9. 9. 866 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• This technique is unique that it provides for true 3-D imaging and reports bone density measurement as true volume density measurements.• The advantage of QCT is its ability to isolate an area of interest from surrounding tissue.Ultrasonography• Inexpensive• No radiation• Not as precise as DXA• Sites measured: calcaneus, tibia, patella, fingersTREATMENTPharmacologic• Medications that preserve or improve bone mass• Medications that decrease bone resorption1. Calcium• Mainstay for prevention and treatment of osteoporosis• Optimal calcium requirements recommended by the National Institutes of Health (NIH) Consensus Panel (Table 11–11).TABLE 11–11 Calcium Requirements as Recommended by NIH Optimal Intake of Age Group Calcium (mg) Birth–6 mo 400 6 mo–1 yr 600 1–5 yr 800 6–10 yr 800–1200 11–24 yr 1200–1500 Men: 25–65 yr 1000 Women: 25–50 yr 1000 Postmenopausal women on estrogen: 50–65 yr 1000 Postmenopausal women not on estrogen: 50–65 yr 1500 Men and women: >65 yr 1500 Pregnant and nursing women 1200–1500• Immobilization + excess calcium intake predisposes patient to kidney stones; maintain urinary calcium excretion < 250 mg/24 h in those without kidney stones.2. Vitamin D• Increases Ca+ absorption in gut. – Recommended doses:• 400–800 IU daily
  10. 10. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 8673. Estrogen• Mechanism of action: – Suppresses interleukin 6 secretion with inhibition osteoclast recruitment. – Decreases bone resorption. – Increases calcium absorption in the gut.• Dosing regimens: – 0.625 mg/day –1.25 mg/day conjugated estrogen cycled or continuous with progester- one 2.5–10 mg – Transdermal estradiol: 0.05–0.10 mg weekly• Maintain therapy 10–20 years after onset of postmenopausal symptoms.• Intact uterus: use progesterone to decrease buildup of endometrium.• If patient has had a hysterectomy, she may use estrogen only.• Benefits: – Preserves bone mass at multiple skeletal sites. – Decreased incidence of fracture: n ~ 50% risk reduction of spine fracture n ~ 60% incidence reduction of hip/wrist fracture – Prevents vasomotor symptoms.• Side effects: – Endometrial cancer risk increased if estrogen is given without progesterone. – Breast cancer if prolonged use after menopause – Thromboembolic disease – Cardiac risks/benefits with use of estrogen remain controversial• Absolute contraindications: breast cancer, estrogen dependent neoplasia, thromboembolic disorder, hypercoagulable states, unexplained vaginal bleeding.• Relative contraindications: uterine leiomyomas or cancer, familial hypertriglyceridemia, migraine, strong family history breast cancer, endometriosis, chronic hepatic dysfunction, gallbladder disease4. Calcitonin (Derived From Salmon)• Directly inhibits osteoclastic activity.• Benefits: – Decreases pain in acute compression fractures through stimulation of beta endorphins. – Preserves bone mass. – ~ 36% incidence reduction of spine fractures• Recommended doses: – Nasal spray (Miacalcin, Fortical®) 1 spray 200 International units/d, alternate nostrils – Parenteral injection subcutaneously or intramuscularly (Calcimar®): prevention 100 IU QOD, treatment 100 IU QD – Must have adequate concurrent intake of calcium and vitamin D.• Side effects: nasal irritation, facial/hand flushing, local skin irritation, nausea; allergic reaction with injection form5. BisphosphonatesBisphosphonate have been shown to increase bone mass and reduce the incidence of spinefractures. They are taken 1/2 hour before food/drink/meds in morning in an upright posi-tion to avoid esophageal irritation.• Oral side effects: abdominal pain, nausea, dyspepsia, difficulty swallowing, inflammation esophagus, and risk of ulceration, osteonecrosis of jaw, visual disturbances, musculoskel- etal pain
  11. 11. 868 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• Intravenous side effects: flu-like symptoms, fever, muscle and joint pain, headache, osteonecrosis of jaw, visual disturbances• Alendronate (Fosamax) – Recommended dosing: prevention – 5 mg/day; treatment – 10 mg daily n ~ 49% risk reduction of spine fractures n ~ 56% risk reduction of hip fractures• Risedronate (Actonel) – Dosing prevention and treatment: 5 mg daily or 35 mg weekly or 75 mg twice monthly – Risk reduction of new spinal fractures up to 65%• Ibandronate (Boniva) – Dosing prevention and treatment: oral – 2.5 mg daily or 150 mg monthly – Intravenous – 3 mg q 3months – Comparable to Fosamax and Actonel in reduction of vertebral fracture• Zoledronic acid (Reclast) – Dosing: intravenous – 5 mg yearly; to be infused in no less than 15 minutes – Reduces vertebral fracture by 70% and nonvertebral by 25%. – Reduces hip fracture by 41%.6. Teriparatide (Forteo)• Injectable form of recombinant human parathyroid hormone• Stimulates new bone formation in spine and hip.• For treatment of osteoporosis in postmenopausal women and men at high risk for fracture• Recommended dosing: 20 mcg SC daily; approved for use up to 24 months.• Side effects: nausea, dizziness, leg cramps, cough7. Selective Estrogen Receptor Modulators (SERMs)• For prevention and treatment of osteoporosis in postmenopausal women unable to take estrogen due to side effects or risk of breast cancer• Raloxifene (Evista®) – Dosing: 60 mg daily – Side effects: hot flashes, increased risk of DVT8. Increase Bone Formation (Positive Bone Formers)These medications are not FDA approved for the treatment of osteoporosis.1. Sodium fluoride: stimulates osteoblast formation; high dosage may increase risk of non- spinal fracture, bone fragility.2. Anabolic steroids: may have beneficial effect on bone mass but side effects prohibit their use; side effects: nausea, GI bleeding, joint pain.3. Testosterone: may benefit men with hypogonadism.MANAGEMENTPreventative ExerciseActivities involving weight bearing (axial loading) and pull of functioning muscle preservesor increases bone mass. They reduce the risk of osteoporosis by maximizing bone mass inyoung adults, maintaining bone mass in mature adults and lessening bone loss in postmeno-pausal women.
  12. 12. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 869Activities associated with increase bone mass:• Jogging or running• Weight training• Aerobics• Stair climbing• Racquet, field, and court sports• DancingTherapeutic ExerciseThe goals are to mitigate bone loss, increase strength and balance, prevent falls, and avoidfractures. Exercise regiments should be tailored to fitness levels and anticipated propensityto fracture or current fractures.Goals of Therapeutic Exercise• Short term: education of proper posture, body mechanics, increasing strength and aerobic capacity• Long term: prevention of falls and fractures: proper nutrition, strength, aerobic capacity with adequate spine support, pain management, psychological supportExercise Principles• Weight-bearing exercises improve bone density.• Avoid spine flexion exercises in spinal osteoporosis, which may predispose to vertebral compression fracture.• Posture correction: avoid kyphotic posture.• Pectoral stretching• Strengthening: back extension, isometric exercises to strengthen the abdomen, upper and lower extremities.• Deep breathing exercises• Balance and transfer training• Proper lifting techniques and body mechanicsTYPES OF FRACTURESVertebral Fractures• Evaluation: history/physical exam, x-rays of spine, bone scan• Acute vertebral fractures—may follow minor injury or physical activity.• Most common osteoporotic fractures: vertebrae > hip > wrist• Vertebral compression fracture is most common type of fracture seen in osteoporosis. – Most common site: lower thoracic, upper lumbar areas – Typically involve anterior part of the vertebral body and result in anterior wedging. – Treatment: restrict flexion based activities and exercises, which load anterior vertebral body.Microfractures–Trabeculae• Pain in the absence of fracture visible on x-ray. May be seen on bone scan.Multiple Spine Fractures• Multiple collapsed/anteriorly wedged vertebrae kyphosis (Dowager’s hump)• Loss of height• Abdominal proturbance, GI discomfort• Pulmonary insufficiency• Costal iliac impingement syndrome
  13. 13. 870 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATIONFacet Joint Disease• Most prominent abnormality at vertebral collapse level with smaller lesions above and below levelRetropulsed Fragments• Can cause back pain with neurologic symptoms with fragments in the spinal canal.Costal Iliac Impingement Syndrome• Lower ribs impinge on iliac crest causing pain.• Increased pain with lateral rotation and bending.Treatment• Relief with soft wide belt which sinks into pelvic cavity avoiding rib contact with iliac crest.• Injection of sclerosing material into margins of iliac and lower ribs• Resection of lower ribsLimb FracturesHip fractures: multifactorial causes with 2 major risk factors: osteoporosis and falls.Muscle forces acting on hip are greater than the mechanical ability of femur to withstandthese forces.• Direction of fall is a major risk factor for fracture. – Falls to the side result in forces greater than muscle strength. – Elderly tend to fall sideways or drop in place.Wrist fractures: most common fracture in females > 75 years old.FALLSRisk Factors for Falling• Impaired vision (decreased vision, poor depth perception)• Cognitive impairment• Balance/gait abnormalities• Weakness (ie, inability to rise form a chair without using one’s arms)• LE disability/foot problems• Peripheral neuropathy• Sedative use• Polypharmacy• Environmental (inadequate lighting, rugs, lack of railings)Fall Prevention Program• General conditioning exercises• Improve balance• Assistive devices: canes, walkers, grab bars, tub benches• Adequate shoe-wear, avoid high heels• Modification of meds• Environmental modification: adequate lighting, removal of throw rugs, handrails for stairs, ramps
  14. 14. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 871TREATMENT OF VERTEBRAL BODY FRACTURESManagement of vertebral body fractures varies with acuity, location of fracture, and pain.Conservative approaches include bracing and physical therapy. Management can alsoinclude kyphoplasty or vertebroplasty.Acute Vertebral Body Fracture• Usually severe, most intense at fracture level• Sharp pain increased with movement and alleviated with bedrest• Severe pain lasting 2–3 weeks with decreased severity for 6–8 weeks• May be asymptomatic.Treatment:• Bedrest initially less than 1 week, graduating to bedside activities and progressive ambulation• Immobilization of fracture site with soft orthosis (corset). Rigid orthotic avoided to prevent disuse osteoporosis• Physical modalities: local heat or cold• Analgesics: initially give around the clock, opiates initially, then within 1–2 weeks, transi- tion to NSAIDs and acetaminophen.• Avoid constipation.• Avoid exertional exercises.Chronic Vertebral Body Fracture• Pain less intense than in an acute fracture• Mid-thoracic is most common location.• Mechanical deformity, paraspinal muscle spasm• Radiates laterally, associated with exertionTreatment:• Periods of bedrest 20–30 minutes BID• Analgesics: nonnarcotic agents, Calcitonin• Orthosis• Assess ADLs, use of devices to avoid aggravation of pain.• PT: core muscle strengthening, balance and flexibility, body mechanics• Avoid flexion-based activities increase vertebral compression forces.• Physical modalities: heat or cold, TENS, acupuncture• Behavioral modifications: biofeedback, hypnosis, counselingKyphoplastyA minimally invasive procedure to treat painful, progressive vertebral compression frac-tures typically caused by osteoporosis with the goal of re-establishing vertebral body heightand reducing pain.Technique: fluoroscopic guidance is used to place a hollow-bore needle into a vertebral body.A balloon tamp is inserted into needle and inflated to restore bone height. Cement is theninjected into vertebral cavity. The needle is then removed; cement hardens in ~ 15 minutes.Pain usually improves within days.Risks:• Risks associated with local or general anesthesia• Infection
  15. 15. 872 n ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION• Bleeding/hematoma• Cement extravasation into spinal canal SCI or nerve root damage• Cement embolism to lungsVertebroplastyA minimally invasive procedure similar to kyphoplasty. However, no balloon tamp isutilized to restore the vertebral body height. Instead, cement is injected directly into thevertebral body at higher pressures. Vertebroplasty is associated with the same risks askyphoplasty.BACK SUPPORTS/BRACINGOrthosesIndications for Using Bracing for Vertebral Fractures• Pain relief: for acute fractures, spinal immobilization decreases paraspinal muscle spasm and overuse• Stabilize spine• Prevent further fracture• Prevent soft tissue shortening• Decrease flexion• Compensate for weak erector spinal musclesContraindications to Back Bracing• Hiatal hernia• Inguinal hernia• Orthopnea secondary to COPD• Obesity• KyphoscoliosisRisks of Prolonged Use of Orthosis• Weakening/atrophy of trunk muscles• Reduced spinal mobility• Increased fracture risk due to disuse osteoporosisTypes of Orthoses (See Also Chapter 6: Prosthetics and Orthotics)1. Nonrigid Brace—Used in Stable Fractures for Pain Management• Abdominal corset (elastic binder) Decrease pain: increase intra-abdominal pressure placing anteriorly directed force on vertebral bodies; also serves as a reminder to restrict motion2. Rigid—(TL, TLSO, Jewett, CASH)—Used in Acute TL Fractures• Thoracolumbar support—assist spine extension via shoulder straps and paraspinal bars; increases intraabdominal pressure• TLSO (thoracolumbosacral orthosis) – Fixation from pelvis to shoulders – Greatest immobility – Increased noncompliance• Jewett brace – Forces act to extend thoracolumbar region• CASH (cruciform anterior sternal hyperextension)Note: Orthotics that cause excessive hyperextension forces on the spine may induce posteriorelement type fractures in the osteoporotic patient. This therefore should be a considerationin this patient population.
  16. 16. ASSOCIATED TOPICS IN PHYSICAL MEDICINE & REHABILITATION n 873Other:• Postural training supports consist of a brace suspended by loops from the shoulders with small pouches containing weights up to 2 lb. The weights are positioned just below the inferior angle of the scapula to counteract the tendency to bend forward and may be worn for 1-hour twice/day. n REHABILITATION OF BURN INJURIESBURNSGeneral• A burn is the body’s response to a soft tissue insult from an external agent, such as heat, cold, chemicals, electricity, and radiation.• 85–90% of burns are caused by heat.• 10–15% of burns are from frostbite, chemical, and electrical damage.• 1.5–2.0 million people sustain burns each year in the U.S.• 60,000–80,000 burn victims need hospitalization.• 5,000 people die each year from burns.• 35,000–50,000 people have temporary or permanent disability secondary to burns.• Burns are: – #1 cause of accidental deaths in children under 2. The majority of burns in this age group occur as a result of abuse. – #2 cause of accidental deaths in children under 4 – #3 cause of accidental deaths in children under 19Pathophysiology• Normal skin figure (Table 11–12)Cellular Response to Burns• Local reactions to burns include: a) Exposed collagen causes platelet activation. b) Intense vasoconstriction secondary to epinephrine, prostaglandins, serotonin, and leukotrienes. c) Within a few hours, histamine release causes vasodilatation and increased capillary permeability, allowing protein and albumin into the extravascular space. This is fol- lowed by fluid extravasation, which causes severe edema. d) Late capillary permeability secondary to leukotrienes. e) Swelling and rupture of damaged cells. f) Platelet and leukocyte aggregation with clot formation from tissue thromboplastin, endotoxin, interleukin-1, and Hageman factor. g) Establishment of a hypermetabolic state.Systemic Response to Burns• Loss of fluid into extravascular compartment resulting in hypovolemia and shock• Hyperventilation with increased oxygen demand• Inhalational injury causing decreased oxygenation and ARDS• Initial decrease followed in several days by a significant increase in cardiac output