Rehabilitation of Patients With Osteoporotic Fractures

Osteoporosis is a silent, asymptomatic disease until a fragility fracture is sustained. Fractures greatly affect the physical functioning and health-related quality of life and are associated with increased mortality and morbidity rates. Furthermore, once a fragility fracture occurs, the patient is more susceptible to sustain further fractures. Repeated falls are the main causes of fractures in patients with osteoporosis. The management of osteoporosis postfracture is a combination of medical treatment, nutritional interventions, and rehabilitation in order to improve activities of daily living to prevent falls and increase safety while reducing the loss of bone mass. In this article the principles of fracture prevention and physical rehabilitation of patients with osteoporosis postvertebral and hip fragility fractures will be discussed, as well as the rehabilitation management to prevent further falls and fractures.

The Effects of Home Exercise in Older Women With Vertebral Fractures: A Pilot Randomized Controlled Trial

BACKGROUND

Regular exercise is advocated in osteoporosis guidelines to prevent fractures. Few studies have evaluated the effect of exercise on functional performance, posture, and other outcomes that are important to patients after vertebral fractures.

OBJECTIVE

This pilot study will explore the effect of home exercise versus control on functional performance, posture, and patient-reported outcome measures.

DESIGN

This study was a parallel 2-arm pilot feasibility trial with 1:1 randomization to exercise or attentional control groups.

SETTING

This study took place in 5 Canadian and 2 Australian academic or community hospitals/centers.

PARTICIPANTS

This study included 141 women ≥65 years of age with radiographically confirmed vertebral fractures.

INTERVENTION

A physical therapist delivered exercise and behavioral counseling in 6 home visits over 8 months and monthly calls. Participants were to exercise ≥3 times weekly. Controls received equal attention.

MEASUREMENTS

Functional performance, posture, quality of life, pain, and behavior-change outcomes were assessed at baseline and after 6 (questionnaires only) and 12 months. Adherence to exercise was assessed by calendar diary. All t tests examined between-group mean differences (MD) in change from baseline in intention-to-treat and per-protocol analyses.

RESULTS

There was a small effect of exercise on 5 times sit-to-stand test versus control (MD = -1.58 [95% CI = -3.09 to -0.07], intention-to-treat; MD = -1.49 [95% CI = -3.12 to 0.16], per-protocol). There were no other major or statistically significant MDs for any other measured outcomes after follow-up. Adherence declined over time.

LIMITATIONS

Treatment effects on variables may have been underestimated due to multiple comparisons and underpowered analyses.

CONCLUSIONS

Our exploratory estimate of the effect of exercise on functional leg muscle strength was consistent in direction and magnitude with other trials in individuals with vertebral fractures. Declining adherence to home exercise suggests that strategies to enhance long-term adherence might be important in future confirmatory trials.

Decreased physical health-related quality of life-a persisting state for older women with clinical vertebral fracture

In a population-based study of older Swedish women, we investigated if clinical vertebral fracture was associated with lower health-related quality of life (HRQoL) and determined whether the association remained over time. Clinical vertebral fracture was associated with lower HRQoL and the effect persisted for up to 18.9 years.

INTRODUCTION

Vertebral fractures are often associated with back pain and reduced physical function, which might result in isolation and depression. As a result, women with vertebral fractures often have lower health-related quality of life (HRQoL), but during what time frame the decrease lingers is unclear. Therefore, the aim of this study was to investigate if clinical vertebral fracture and hip fracture were associated with lower HRQoL and to determine whether the associations remained over time.

METHODS

Vertebral fracture assessments (VFA) were performed using dual-energy X-ray absorptiometry. Data regarding prior fractures, medications, medical history, and physical activity was collected using a questionnaire. Self-rated physical HRQoL was assessed using the 12-Item Short-Form Health Survey (SF-12). Women with clinical vertebral fractures were divided into tertiles according to time since fracture onset and their HRQoL was compared with non-fractured women.

RESULTS

In a population-based cross-sectional study of 3028 women aged 77.8 ± 1.63 (mean ± SD), a total of 130 (4.3%) women reported at least one clinical vertebral fracture. Women with a clinical vertebral fracture, divided into tertiles (T1-T3) depending on time since the fracture occurred, had lower HRQoL (T1: 36.3 ± 10.8; T2: 41.0 ± 9.94; and T3:41.6 ± 11.4) than women without fracture (46.2 ± 10.6; p < 0.001). Using linear regression analysis, clinical vertebral fracture was associated with reduced physical HRQoL for up to 18.9 years, independently of covariates (age, height, weight, smoking, prior stroke, mental HRQoL, grip strength, and lumbar spine BMD).

CONCLUSIONS

Clinical vertebral fracture was associated with lower self-rated physical HRQoL, for up to 18.9 years after time of fracture.

Progression to ambulation following lower limb fractures in an individual with a spinal cord injury: a case report

Introduction

Patients with spinal cord injury (SCI) and concomitant lower limb fractures are a challenge to rehabilitate. Conventionally, postural orientation is an important milestone in the rehabilitative process. We propose an alternative strategy in achieving goals in individuals with an SCI with concomitant injuries that preclude weight bearing below the knee.

Case presentation

A 16-year-old girl sustained a burst fracture of L1 in conjunction with bilateral ankle fractures. During rehabilitation, the calcaneal fracture on the left and tibial plafond fracture on the right prevented her progression in conventional rehabilitation. An alternative strategy "K-ing" (Kneel Standing/Kneel Walking) was adopted to facilitate truncal activation without loading the ankle joints. This was found to be helpful in obtaining upright posture stability without hampering her recovery of associated ankle injuries.

Discussion

"K-ing" strategy can be useful and presents a simple alternative in the presence of associated ankle injuries. It also avoids complications associated with bedrest when there is delay in initiation of ambulation.

Impact of mild and moderate/severe vertebral fractures on physical activity: a prospective study of older women in the UK

Little is known about the long-term impact of vertebral fractures on physical activity. There is also uncertainty over the clinical significance of mild vertebral fracture. We showed that women with moderate/severe but not mild vertebral fracture do less walking duration and housework than those without fracture after 5.4 years of follow-up.

INTRODUCTION

Little is known about the long-term impact of vertebral fractures on physical activities. There is also uncertainty over the clinical significance of mild fracture. Therefore, the aim of this study was to evaluate the prospective association between vertebral fracture and future physical activity.

METHODS

This is a 5-year prospective study of a mixed community and secondary care cohort of women aged > 50 from the UK. Vertebral fractures were identified at baseline on radiographs or DXA-based Vertebral Fracture Assessment by a Quantitative Morphometric approach and defined as moderate/severe (≥ 25% height decrease) or mild (20-24.9% height decrease). Physical activity data were collected 5.4 years later by self-completion questionnaires. Multivariable logistic regression was used to determine the association between presence of fracture and various physical activities while adjusting for potential confounders.

RESULTS

Two hundred eighty-six women without, 58 with mild, and 69 with moderate/severe fracture were recruited. Those with mild and moderate/severe fracture were older than women without fracture and had more concomitant diseases at baseline. At 5.4 years follow-up, women with moderate/severe fracture self-reported shorter walking duration compared to those without fracture, even after adjusting for potential confounders (OR 2.96, 95%CI 1.11-7.88, P = 0.030). No independent association was seen between the presence of mild fractures and reduced physical activity at follow-up.

CONCLUSION

This is the first study of older women from the UK that explored the prospective association between vertebral fracture and physical activity duration. Moderate/severe fractures were associated with reduced walking duration. Mild fractures had no impact on future physical ability.

Effect of a resistance and balance exercise programme for women with osteoporosis and vertebral fracture: study protocol for a randomized controlled trial

BACKGROUND

Osteoporotic vertebral fractures are common, and are associated with reduced functioning and health related quality of life. The primary aims of this randomized controlled trial are to examine the immediate and long-term effects of a 12-weeks supervised group exercise programme on habitual walking speed in older women with osteoporosis and a history of vertebral fracture. The secondary aims are to examine the immediate and long-term effects of the exercise program on physical fitness, fear of falling and quality of life.

METHODS

The study is a single-blinded randomized controlled trial. Women aged 65 years or older with osteoporosis and a history of vertebral fracture are included. The intervention group receives a 12-week multicomponent exercise programme, including resistance training combined with balance training. The control group receives usual care. Adherence to the programme will be of importance for the internal validity of the study. Participants in the exercise group who don't attend will be followed up with motivational phone calls. The primary outcome is habitual walking speed over 10 m. Secondary outcomes are health related quality of life (Qualeffo-41, SF-36), physical activity (I-PAQ), Patient Specific Functional Scale, Fear of falling (FES-1) and physical fitness (Senior Fitness test, Functional reach test, 4 square step test, grip strength). Sample size, based on the primary outcome, is 150 participants randomized into the two arms on a 1:1 allocation, including an estimated 20% drop out. Descriptive data will be reported as mean (standard deviation), median (range) or count (percent) as appropriate. The data will be analysed following the intention-to-treat principle. Between group differences in primary and secondary outcomes at 3 months follow-up will be assessed using linear regression models with respective outcome at baseline as covariate and the randomised group as factor.

DISCUSSION

This trial will generate new knowledge on the effects of a multicomponent exercise programme among women over 65 years with osteoporosis and a history of vertebral fracture, knowledge that is of importance for clinicians, health managers and policy makers.

TRIAL REGISTRATION

ClincialTrials.gov Identifier: NCT02781974 . Registered 18.05.16. Retrospectively registered.

Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS

This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture.

METHODS

Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture.

RESULTS

Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types.

CONCLUSIONS

Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.

Vertebral fractures and their association with health-related quality of life, back pain and physical function in older women

Studies investigating prevalent vertebral fracture (VF) diagnosed using densitometry-based VF assessment (VFA) and associations with physical function, assessed by performance-based measures, are lacking. In this population-based study of 1027 older women, we found that prevalent VF, identified by VFA, was associated with inferior physical health, back pain and inferior physical function.

PURPOSE

Several studies have investigated the associations between health-related quality of life (HRQL) and back pain with prevalent VF, detected by spine radiographs, but just a few have been population-based and have used vertebral fracture assessment (VFA) for diagnosing VF. The aims of this study were to investigate associations between prevalent VF, detected by VFA, with HRQL, back pain and physical function, and investigate if also mild VFs were associated with these clinical parameters.

METHODS

One thousand twenty-seven women aged 75-80 years participated in this population-based cross-sectional study. VF was identified by VFA using dual-energy X-ray absorptiometry. HRQL was assessed by SF-12, back pain during the past 12 months using a questionnaire, and physical function was tested with one leg standing (OLS), Timed Up and Go (TUG), walking speed, 30-s chair stand test and maximum grip strength.

RESULTS

Physical health (Physical Component Summary, PCS), derived from SF-12, was worse (43.5 ± 11.3 vs. 46.2 ± 10.5, p < 0.001) and back pain more frequent in women with any VF than in women without (69.0 vs. 59.9%, p = 0.008). PCS and physical function (OLS, 30-s chair stand test), were significantly worse for mild VF compared to no VF (43.8 ± 10.9 vs. 46.2 ± 10.5, p < 0.001, 12.7 ± 9.9 vs. 15.3 ± 10.4 s, p = 0.038, 10.7 ± 3.2 vs. 11.4 ± 3.4 times, p = 0.021, respectively). In multivariable adjusted linear regression models, VF prevalence was associated with PCS (β = - 0.079, p = 0.007), TUG (β = 0.067, p = 0.021), walking speed (β = - 0.071, p = 0.009) and 30-s chair stand test (β = - 0.075, p = 0.012).

CONCLUSIONS

In conclusion, prevalent VF, diagnosed by VFA, was associated with inferior physical health, back pain and inferior physical function, indicating VFA is useful for diagnosing clinically relevant vertebral fractures. Also, mild VF was associated with inferior physical health and inferior physical function.

Health state utility values and patient-reported outcomes before and after vertebral and non-vertebral fractures in an osteoporosis clinical trial

We assessed the health state utility value (HSUV) reductions associated with vertebral fractures using data collected in the Japanese Osteoporosis Intervention Trial-03 (JOINT-03). Our analysis revealed that assessment of HSUVs after morphometric vertebral fracture is important to capture the burden of vertebral fractures.

INTRODUCTION

Evaluation of the HSUV after fracture is important to calculate the quality-adjusted life years (QALYs) of osteoporosis patients, which is essential information in the context of health economic evaluation.

METHODS

JOINT-03 study patients were aged ≥65 years and treated with risedronate and vitamin K₂ or risedronate alone. Radiographic information and patient-reported outcomes measured by EQ-5D and a visual analogue scale (VAS) were assessed at registration and followed up after 6, 12, and 24 months. According to differences among the dates of these assessments and the radiographic information, we classified the follow-up HSUVs calculated based on EQ-5D results into before or after fracture categories regardless of clinical symptoms.

RESULTS

Among 2922 follow-up HSUVs, 201 HSUVs were categorized as HSUVs that were observed after incident vertebral fractures on X-ray films. The median time from the detection of an incident vertebral fracture until the EQ-5D assessment was 53 days (25th percentile, 0 day; 75th percentile, 357 days). The impact of incident vertebral fractures on HSUVs was quantified as -0.03. Among the five health profile domains on the EQ-5D, an incident vertebral fracture had significant effects on anxiety/depression, self-care, and usual activities.

CONCLUSIONS

The results suggest that incident morphometric vertebral fracture was associated with impairment of the HSUV for patients with osteoporosis not only immediately but also several months after the fracture.

Direct C2 Pedicle Screw Fixation for Axis Body Fracture

BACKGROUND

Acute complex C2 vertebral body fracture specifically does not involve the odontoid process or C2 pars interarticularis. External stabilization can be effective but may prolong healing and increase morbidity. Many traditional surgical techniques can achieve internal stabilization at the expense of normal cervical motion. We describe direct surgical C2 pedicle screw fixation as an option for managing acute complex C2 vertebral body fracture.

CASE DESCRIPTION

Three patients were treated with direct pedicle screw fixation of acute traumatic complex C2 vertebral body fractures. All fractures were coronally oriented Benzel type 1. None of the patients sustained neurological injury. Stereotactic navigation with intraoperative computed tomography scanning was used for each procedure. Surgery provided immediate internal orthosis and stability, as judged by intraoperative dynamic fluoroscopy. Rigid cervical collar bracing was used for 1 month after surgery when the patients were out of bed. Initial radiographs showed acceptable screw placement and fracture alignment. Dynamic radiographs at 3 months showed structural stability at the fracture site and adjacent levels, and complete bony union was confirmed with late computed tomography scanning (>1 year) in each case. Each patient reported resolution of trauma-related and postsurgical pain at 30-day follow-up. Postoperative Neck Disability Index questionnaires for each patient suggested no significant disability at 1 year.

CONCLUSIONS

Direct pedicle screw fixation of acute complex C2 vertebral body fracture appeared to be safe and effective in our 3 patients. It may provide a more-efficient and less-morbid treatment than halo brace or cervical collar immobilization in some patients.

The Role of Trunk Musculature in Osteoporotic Vertebral Fractures: Implications for Prediction, Prevention, and Management

This review examines the current evidence for associations between vertebral fractures (VFx), the most common type of fracture in older adults, and trunk muscles, which are intimately tied to spinal loading and function. Individuals with prevalent VFxs have more fat infiltration in the trunk muscles, lower trunk extension strength, and altered muscle activation patterns. However, no longitudinal studies have examined whether assessment of trunk muscle can contribute to prediction of fracture risk. A few studies report that exercise interventions targeting the trunk muscles can reduce the risk of VFx, improve trunk strength and endurance in patients who have had a VFx, and reduce the risk of falling, a common cause of VFx, but the quality of evidence is low. Trunk muscles likely have an important role to play in prediction, prevention, and management of VFx, but additional longitudinal studies and randomized controlled trials are needed to clarify this role.

A painful, never ending story: older women's experiences of living with an osteoporotic vertebral compression fracture

Vertebral compression fractures (VCF) cause pain and decreased physical ability, with no known well-established treatment. The aim of this study was to illuminate the experience of living with a VCF. The results show that fear and concerns are a major part of daily life. The women's initial contact with health-care providers should focus on making them feel acknowledged by offering person-centered and tailored support.

INTRODUCTION

In the past decade, osteoporotic-related fractures have become an increasingly common and costly public health problem worldwide. Vertebral compression fracture (VCF) is the second most common osteoporotic fracture, and patients with VCF describe an abrupt descent into disability, with a subsequent desire to regain independence in everyday life; however, little is known of their situation. The aim of this study was to illuminate the lived experience of women with an osteoporotic VCF.

METHODS

Ten women were interviewed during 2012-2013, starting with an open-ended question: could you tell me what it is like to live with a vertebral compression fracture? The verbatim transcribed interviews were analyzed using a phenomenological hermeneutical approach.

RESULTS

The narrative provided descriptions of living in turmoil and chaos, unable to find stability in their life with little improvement regarding pain and physical function. Shifts from periods of constant pain to periods of fear of constant pain created a loss of confidence and an increased sense of confinement. The structural analysis revealed fear and concerns as the most prominent experience building on five themes: struggling to understand a deceiving body, breakthrough pain fueling fear, fearing a trajectory into isolation, concerns of dependency, and fearing an uncertain future.

CONCLUSIONS

Until researchers find a successful prevention or medical/surgical treatment for osteoporotic VCFs, health-care providers and society abandon these women to remain in a painful and never ending story.

Better life quality and sexual function in men and their female partners with short-segment posterior fixation in the treatment of thoracolumbar junction burst fractures

PURPOSE

Thoracolumbar junction burst fractures remain a challenging problem due to controversy over the treatment choice of short- or long-segment posterior fixation. The aim of the present study was to compare life quality and sexual function of patients after short- and long-segment posterior fixations in the treatment of thoracolumbar junction burst fractures.

METHODS

In this prospective, randomized study, 24 sexually active male patients diagnosed with thoracolumbar junction burst fractures were randomly assigned to either the short-segment posterior fixation (SSPF) group or the long-segment posterior fixation group (LLPF). The exclusion criteria were rheumatological disease and spinal surgery history. There were no significant differences in age, body mass index or smoking habits between the groups. The life quality score of EQ-5D and the International Index of erectile function (IIEF-5) score of male patients and the Female Sexual Function Index (FSFI) score of female partners were recorded preoperatively and 1 year after surgery.

RESULTS

The mean age of patients in the SSPF and LSPF groups was 44.58 and 42.92 years, respectively. There were no statistically significant differences between the groups in the preoperative EQ-5D and IIEF-5 scores of male patients and the FSFI score of their partners. Postoperatively, the EQ-5D scores (p = 0.011) and IIEF-5 scores (p = 0.000) of male patients and the FSFI score of their partners (p = 0.001) were better in the short-segment group.

CONCLUSIONS

Patients treated with SSPF have better sexual function and life quality with their partners compared to those treated with LSPF. The main clinical relevance of this study is that the impact of the choice of short or long-segment treatment on postoperative sexual function and life quality should be considered by surgeons when performing posterior fixation after thoracolumbar junction burst fractures.

[Hip Fracture--Epidemiology, Management and Liaison Service. Rehabilitation for the hip fracture]

In Japan, the number of patients with hip fracture has been increasing year by year with a drastic increase in the number of ages. Hip fractures are not only the more significant osteoporotic fracture, but make activity in daily life (ADL) , health outcome, and quality of life (QOL) more difficult. To rehabilitate patients with hip fracture through a multidisciplinary approach is important in the early phases of fracture incidents in order to keep their ADL and QOL at a high level.

Does an intraoperative finding of an intact dural sac help to prognosticate neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures? An analysis of 31 patients

OBJECTIVE

To evaluate the effect of integrity of dural sac in determining motor neurological recovery in patients with cauda equinal and epiconal injuries in vertebral fractures at thoracolumbar junction.

METHODS

Thirty-one patients with single-level vertebra fracture over T12-L2 with cauda equinal or epiconal injuries that underwent posterior spinal decompression and stabilization were evaluated in the period between 2006 and 2012. All patients included had motor incomplete ASIA C in neurology and were either Type B or C (AO/Magerl classification) of fracture morphology. Radiologist opinion to confirm the level of conus in MRI was done preoperatively. Intraoperative findings with respect to intactness of dura was noted. All MRI images were postoperatively evaluated by an independent, blinded radiologist for evidence of dural breach caused by the trauma. All participants provided basic demographic data, ambulatory status, and current neurology and received neurologic examination at intervals. The differences in neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cut-off value of lower extremities motor score (LEMS) in functional walkers and non-walkers. All patients were seen at a postoperative follow-up of minimum 18 months.

RESULTS

Data of the 31 patients were analyzed. Seventeen patients (55%) had epiconus and lumbar roots lesions and 14 (45%) had cauda equina lesions. The injury was at the T12 vertebra in 9 patients (29%), L1 in 12 (39%) and in L2 in 10 patients (32%). Mean LEMS for patients with T12, L1, and L2 fractures were calculated. Fourteen patients had intraoperative findings of intact dura as against 17 patients with dural breach. MRI images when revisited by an independent radiologist by keeping him blind about the intraoperative surgeons findings showed statistically very good interobserver agreement (κ = 0.618) with regard to integrity of the dural sac. Postoperative neurological assessment at minimum 18 months follow-up showed that four out of the 14 patients with intact dura were walkers (28%) whereas of the 17 patients with dural breach, 13 were walkers (82%).

CONCLUSION

Neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures is significantly less likely in an intact dural sac, probably because the dural breach prevents the roots to take as much impact as compared to an intact dural sac.

A systematic review and meta-analysis of utility-based quality of life for osteoporosis-related conditions

This study aimed to statistically combine multiple health state utility values (HSUVs) reported in the literature for patients with osteoporosis and osteoporotic fractures. Fracture events were associated with decrements in HSUVs which differed between fracture sites. We have provided summary values for use in future health economics analyses in osteoporosis. Osteoporotic fractures have high financial and health burden. Economic evaluations on osteoporotic fracture prevention have been frequently performed in past decades. One of the challenges in the economic evaluations was to identify consistent health state utility values (HSUVs) to use for osteoporotic fracture-related conditions. The objective of this study was to determine summary measures of multiple HSUVs reported in the literature for patients with osteoporosis and osteoporotic fractures. We performed a systematic review, meta-analysis and meta-regression of published literature that reported HSUVs for osteoporotic fracture-related conditions. There were 62 studies representing 142,477 patients included. In total, 362 HSUVs were identified: 106 for pre-fracture; 89 for post-hip fracture; 130 for post-vertebral fracture and 37 for post-wrist fracture. The pooled HSUVs, using a random-effects model were 0.76 (95% CI 0.75, 0.77, I (2) = 0.99) for pre-fracture; 0.57 (95% CI 0.52, 0.63, I (2) =1) for post-hip fracture; 0.59 (95% CI 0.55, 0.62, I (2) = 0.99) for post-vertebral facture and 0.72 (95% CI 0.67, 0.78, I (2) = 1) for post-wrist fracture. Heterogeneities were addressed through meta-regression. HSUVs immediately following hip, vertebral and wrist fractures were 0.31, 0.44 and 0.61, respectively. Patients' HSUVs improved over time following fracture events: HSUVs for the first year after hip, vertebral and wrist fractures were 0.59, 0.55 and 0.78, respectively; and 0.66, 0.66 and 0.81 for subsequent years. Fractures were associated with significant decrements in HSUVs. This study provides a standard set of HSUVs that can be used in health economic assessments in osteoporosis.

Fear of falling, fracture history, and comorbidities are associated with health-related quality of life among European and US women with osteoporosis in a large international study

We studied 7,897 women with postmenopausal osteoporosis to assess factors that influence health-related quality of life (HRQoL). An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL. Understanding the factors that affect HRQoL may improve management of these patients.

INTRODUCTION

HRQoL is impaired in women treated for postmenopausal osteoporosis (PMO). The objective of this study was to examine the relationship between clinical characteristics, comorbidities, medical history, patient demographics, and HRQoL in women with PMO.

METHODS

Baseline data were obtained and combined from two large and similar multinational observational studies: Prospective Observational Scientific Study Investigating Bone Loss Experience in Europe (POSSIBLE EU®) and in the US (POSSIBLE US™) including postmenopausal women in primary care settings initiating or switching bone loss treatment, or who had been on bone loss treatment for some time. HRQoL measured by health utility scores (EQ-5D™) were available for 7,897 women (94 % of study participants). The relationship between HRQoL and baseline clinical characteristics, medical history and patient demographics was assessed using parsimonious, multivariable, mixed-model analyses.

RESULTS

Median health utility score was 0.80 (interquartile range 0.69-1.00). In multivariable analyses, young age, low body mass index, previous vertebral fracture, increased number of comorbidities, high fear of falling, and depression were associated with reduced HRQoL. Regression-based model estimates showed that previous vertebral fracture was associated with lower health utility scores by 0.08 (10.3 %) and demonstrated the impact of multiple comorbidities and of fear of falling on HRQoL.

CONCLUSIONS

In this large observational study of women with PMO, there was substantial interindividual variability in HRQoL. An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL.

The impact of different health dimensions on overall quality of life related to kyphoplasty and non-surgical management

This study uses data from a previously published randomised trial where balloon kyphoplasty was compared to non-surgical management. Of the improved overall quality of life, 60 % was caused by decreased pain. However, ignoring other dimensions of quality of life would underestimate the procedure's effect.

INTRODUCTION

Acute back pain has been viewed as the most important factor lowering quality of life (QoL) for patients suffering vertebral fractures. The objective of this study was to quantify the impact of different health dimensions on overall QoL using patient-reported outcome measurements (PROMs) collected in Fracture Reduction Evaluation (FREE) trial.

METHODS

The analysis was based on patients included in the 2-year-long randomised controlled FREE trial studying the efficacy and safety of balloon kyphoplasty procedure (BKP) compared to non-surgical management (NSM). The PROMs included were EQ-5D, Short Form (SF)-36, visual analogue scale (VAS) pain and the Roland-Morris Disability Questionnaire (RMDQ). The health dimensional contribution to the overall QoL improvements was analysed by isolating the impact of each dimension on QoL in the SF-36 and EQ-5D, respectively. A correlation analysis of the QoL improvement was performed to investigate the relationships between the four instruments.

RESULTS

Changes in pain explained 60 % of the quality-adjusted life years (QALY) gained in BKP vs. NSM followed by self-care (17 %), mobility (16 %) and usual activities (10 %) (EQ-5D). Health dimensions capturing the mental state had little impact on the QALY gained. The SF-36 dimensional analysis showed similar results. The correlation analysis showed that the correlation between VAS pain, RMDQ and QALY improvement was fairly weak.

CONCLUSIONS

Changes in the pain dimension of health are the most important drivers for changes of overall QoL in patients treated with BKP or NSM. However, ignoring the impact of other dimensions would lead to an underestimation of the actual improvement in overall QoL.

Neurologic recovery according to the spinal fracture patterns by Denis classification

PURPOSE

Although Denis classification is considered as one of most clinically useful schemes for the evaluation of spinal fracture, there is little documentation on the relationship between fracture pattern and the neurologic recovery. The purpose is to evaluate the correlation between the fracture patterns according to Denis classification and neurologic recovery.

MATERIALS AND METHODS

The 38 patients (26 men and 12 women) in this series had an average follow-up of 47.1 months, and they were all managed surgically. Denis classification had been used prospectively to determine the fracture morphology. Frankel Scale and American Spinal Injury Association Spinal Cord Injury Assessment Form [American Spinal Injury Association (ASIA) score] were obtained before surgery, after surgery and at the final follow-up.

RESULTS

The common injuries making neurologic deterioration were burst fracture and fracture-dislocation. The degree of neurologic deficits seen first and at the final follow-up was more severe in fracture-dislocation than burst fracture. The neurologic recovery was not different between burst fracture and fracture-dislocation, assessed by Frankel grading and ASIA scoring system. The neurologic recovery evaluated by ASIA score was not different between the lumbar and thoracic spinal fracture. The neurologic recovery assessed by Frankel grade was greater in the lumbar spinal fractures in than the thoracic spinal fractures.

CONCLUSION

The severity of initial and the final follow-up neurologic deficits were correlated with the fracture patterns according to Denis classification, but the neurologic recovery was not correlated.

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)--quality of life during the first 4 months after fracture

The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS.

METHODS

ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire.

RESULTS

The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not.

CONCLUSIONS

The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.

Health-related quality of life in patients with osteoporosis in the absence of vertebral fracture: a systematic review

To review whether osteoporosis in the absence of vertebral fracture (VFX) affects health-related quality of life (HRQoL), a systematic search of the main literature databases for HRQoL in patients with osteoporosis without VFX was undertaken. This was undertaken. This identified 1,327 articles as potentially relevant to the review. After screening of abstracts and reviewing 168 articles in detail, 27 were considered relevant. HRQoL data were extracted and collated into tables and, where possible, were converted into normative scores and further analysed. Data relating to the associations between HRQoL and bone mineral density (BMD) were also collated. Of the 27 articles included, only 5 directly compared osteoporosis without VFX with a control group (BMD T-score > -1.0, without VFX). Extracted raw data from 21 articles demonstrated that patients with osteoporosis without VFX had clinically relevant reductions in role physical, general health, vitality, mental health domains and the mental component summary score, using SF36. Using Qualeffo-41, pain and physical function were worse in these patients. Also, HRQoL was related to upper femur, but not lumbar spine BMD. HRQoL data in patients with osteoporosis without VFX are limited and variable but suggest that HRQoL is adversely affected by osteoporosis in the absence of VFX. The association of lower BMD and worse HRQoL suggests that more attention should be paid to HRQoL in those without VFX. Future studies are needed to investigate HRQoL in patients with osteoporosis in the absence of fracture, controlling for co-morbidities and social and economic status.

Burden of non-hip, non-vertebral fractures on quality of life in postmenopausal women: the Global Longitudinal study of Osteoporosis in Women (GLOW)

Among 50,461 postmenopausal women, 1,822 fractures occurred (57% minor non-hip, non-vertebral [NHNV], 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D, followed by major NHNV and hip fractures. Decreases in physical function and health status were greatest for spine or hip fractures.

INTRODUCTION

There is growing evidence that NHNV fractures result in substantial morbidity and healthcare costs. The aim of this prospective study was to assess the effect of these NHNV fractures on quality of life.

METHODS

We analyzed the 1-year incidences of hip, spine, major NHNV (pelvis/leg, shoulder/arm) and minor NHNV (wrist/hand, ankle/foot, rib/clavicle) fractures among women from the Global Longitudinal study of Osteoporosis in Women (GLOW). Health-related quality of life (HRQL) was analyzed using the EuroQol EQ-5D tool and the SF-36 health survey.

RESULTS

Among 50,461 women analyzed, there were 1,822 fractures (57% minor NHNV, 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D summary scores, followed by major NHNV and hip fractures. The number of women with mobility problems increased most for those with major NHNV and spine fractures (both +8%); spine fractures were associated with the largest increases in problems with self care (+11%), activities (+14%), and pain/discomfort (+12%). Decreases in physical function and health status were greatest for those with spine or hip fractures. Multivariable modeling found that EQ-5D reduction was greatest for spine fractures, followed by hip and major/minor NHNV. Statistically significant reductions in SF-36 physical function were found for spine fractures, and were borderline significant for major NHNV fractures.

CONCLUSION

This prospective study shows that NHNV fractures have a detrimental effect on HRQL. Efforts to optimize the care of osteoporosis patients should include the prevention of NHNV fractures.

Impact of clinical fractures on health-related quality of life is dependent on time of assessment since fracture: results from the FREEDOM trial

In the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) study, women with incident clinical fractures reported significant declines in health-related quality of life (HRQoL). The largest declines were observed when the assessment was <3 months post fracture. The largest impact of incident clinical fractures was on physical function, and that of incident clinical vertebral fractures was on back pain.

INTRODUCTION

In the FREEDOM trial, denosumab significantly reduced the risk of new vertebral, hip, and nonvertebral fractures. We evaluated the effect of denosumab on HRQoL and the association between incident clinical fractures and HRQoL.

METHODS

The FREEDOM trial enrolled 7,868 women aged 60-90 years with a total hip and/or lumbar spine BMD T-score <-2.5 and not <-4.0 at either site. Women were randomized to receive denosumab 60 mg or placebo every 6 months, in addition to daily calcium and vitamin D. HRQoL was assessed with the Osteoporosis Assessment Questionnaire-Short Version (OPAQ-SV) at baseline and every 6 months for 36 months. The OPAQ-SV assesses physical function, emotional status, and back pain. Higher scores indicate better health status.

RESULTS

No statistically significant differences in mean change in HRQoL from baseline to end of study were found when comparing treatment groups. Compared with women without any incident fractures during the study, women with incident clinical fractures reported significant declines in physical function (-4.0 vs. -0.5) and emotional status (-5.0 vs. -0.8) at month 36 (P < 0.001 for both). Importantly, time-dependent covariate analyses demonstrated that the largest declines were observed when the assessment was <3 months post fracture. The largest impact of incident clinical fractures was on physical function, and that of incident clinical vertebral fractures was on back pain.

CONCLUSIONS

These findings not only demonstrate that incident clinical fractures impact HRQoL but also contribute new information regarding the impact of these fracture events on HRQoL over time.

Discharge disposition following vertebroplasty

BACKGROUND AND PURPOSE

A variety of factors, such as pain level at rest and with activity, have been used to assess outcome of the VP procedure. However, few studies have assessed discharge disposition as a reflection of VP efficacy in the inpatient population. The purpose of this study was to compare patient disposition status before and after VP and determine what relationship exists between the treatment and patient discharge status.

MATERIALS AND METHODS

We performed a retrospective review of inpatients who underwent consultation for consideration of spinal augmentation for treatment of painful vertebral compression fractures. We gathered data concerning patients' demographics, living arrangements before hospitalization, discharge disposition, quantitative and qualitative pain levels, and length of hospital stay before and following VP.

RESULTS

Ninety inpatients underwent VP, 73 (81%) of whom lived independently at home before hospitalization. Of these 73 patients, 31 (42%) returned home after discharge, 9 (12%) returned home with home health care assistance, and 32 (44%) were sent to skilled nursing facilities. Six (7%) of the 90 patients resided in assisted-living centers before hospitalization; all of these patients were discharged to assisted-living or skilled nursing facilities. Eight (9%) of the 90 patients resided at skilled nursing centers before hospitalization, and all returned to nursing centers after their hospital stay. Discharge disposition was not significantly associated with preoperative pain levels at rest or with activity (P = .76 and P = .23, respectively) or with postoperative pain levels at rest or with activity (P = .08 and P = .25, respectively).

CONCLUSIONS

This study demonstrates that patients undergoing VP as inpatients are often discharged to rehabilitation centers rather than home, irrespective of their status before hospitalization or their pre- and postoperative pain levels.

The burden of osteoporotic fractures beyond acute care: the Canadian Multicentre Osteoporosis Study (CaMos)

BACKGROUND

the burden associated with osteoporotic fractures has commonly been reported in terms of utilisation of acute care. However, individuals with fractures suffer lasting deficits in quality of life and the burden of care extends well beyond the initial acute care period. The burden of fractures related to post-acute heath care utilisation, and informal care giving, has not been sufficiently addressed. We examine the use of formal and informal post-acute care in men and women 50 years and older who sustained fractures.

METHODS

the study sample consisted of 1,116 men and women from the Canadian Multicentre Osteoporosis Study (CaMos) who sustained a fracture. We assessed utilisation of post-acute care including rehabilitative and home care services, as well as informal care in persons with a hip, vertebral, or non-hip-non-vertebral fractures.

RESULTS

use of rehabilitative and home care services was reported by 37.1% and 18.2% of men and women, respectively. Persons with hip fracture were more likely to report use of these services compared with persons with non-hip-non-vertebral fractures; those with vertebral fracture were less likely to report using these services. Use of informal care was reported by 47.2% of participants. Individuals with multiple fractures made more extensive use of post-acute resources compared with those with single fractures.

CONCLUSIONS

use of post-acute care in individuals with fracture is extensive and the contribution of use of these resources to the overall burden of fractures cannot be ignored. Our findings have implications for future economic analyses and policy-making related to care of osteoporotic fractures.

The effect of posterior instrumentation of the spine on canal dimensions and neurological recovery in thoracolumbar and lumbar burst fractures

A prospective study was designed to determine whether posterior instrumentation of the spine in thoracolumbar and lumbar burst fractures produces indirect decompression of the spinal canal leading to better remodeling and neurological recovery. The study was conducted in Kasturba Medical College Manipal, India. Sixty-eight consecutive cases of thoracolumbar and lumbar burst fractures were treated by posterior instrumentation, and approval from the hospital ethical committee was obtained. The degree of initial spinal canal compromise, indirect decompression, and remodeling were assessed from the computed tomography scans. The neurological status at the time of presentation and at final follow-up was assessed by the American Spinal Injury Association's modified Frankel's grading. The median canal compromise in patients with and without neurological deficit was 47.32 and 39.33%, respectively. The overall mean canal compromise at the time of admission, post-operative, and final follow-up were 47.37, 26.58 and 14.85%, respectively (P = <0.001). The median canal compromise in patients who recovered was 44.5% and in those with no neurological recovery was 55.85%. The median percentage of canal decompression achieved in patients who recovered was 22.15%, whereas it was 22% in those who did not recover. The median remodeling in recovered and non-recovered groups was 64.50 and 80%, respectively. None of these differences was statistically significant. This study shows that posterior instrumentation of the spine produces significant indirect decompression of the spinal canal and better remodeling. However, these factors may not improve the neurological recovery.

Effects of therapeutic exercise for persons with osteoporotic vertebral fractures: a systematic review

A systematic literature review was conducted and revealed nine studies investigating the effects of therapeutic exercise for persons with osteoporotic vertebral fractures. Although modest improvements were noted in strength and balance, results were inconsistent in supporting therapeutic exercise as effective in improving outcomes such as pain and quality of life (QOL).

INTRODUCTION

The purpose of this systematic review was to investigate the effects of therapeutic exercise as an intervention for patients over age 45 years with one or more osteoporotic vertebral fractures. The effects of the intervention on the following outcomes are summarized in this review: pain/analgesic use, QOL, function, strength, balance, range of motion, bone mineral density, and incidence of future fractures.

METHODS

A systematic literature review of therapeutic exercise as a treatment for persons with osteoporotic vertebral fractures was conducted. Studies were retrieved from six databases, screened for inclusion, and assessed for methodological quality. Results were analyzed qualitatively based on levels of evidence, methodological rigor, and consistency of findings across studies within each of the eight health-related outcomes.

RESULTS

Due to inconsistent results across the nine studies included in the review, there is only limited or inconsistent evidence for the effectiveness of therapeutic exercise on each of the outcomes investigated.

CONCLUSIONS

Due to lack of high-quality, consistent research on the effects of exercise for persons with vertebral fractures, no definitive conclusions can be drawn from this systematic review. Positive trends were identified with regard to improvements in strength and balance, with no increase in pain following exercise protocols. Future research is needed in this area.

The importance of carrying a backpack in the rehabilitation of osteoporotic patients (biomechanical analysis)

Based on a simple biomechanical analysis available to physicians, the article recommends carrying a backpack regularly as a part of the complex rehabilitation of osteoporotic patients. Carrying a backpack in front or on the back is recommended to patients with uncomplicated osteoporosis, while carrying a backpack on the back only is recommended to patients with osteporotic vertebral fractures. The importance of carrying a backpack is based upon removing the muscular dysbalance of the trunk muscles and upon increasing the bone strength by compressive force acting upon the vertebrae and proximal femur and activating osteoblasts to enhance the process of osteoformation. The backpack load is differentiated--patients with vertebral fractures put a weight up to 1 kg into their backpacks, patients without vertebral fractures increase the load up to 2 kg (Fig. 2, Ref. 12).

Comparison of 5766 vertebral compression fractures treated with or without kyphoplasty

BACKGROUND

The majority of the 700,000 osteoporotic vertebral compression fractures (VCFs) that occur annually in the United States affect women. The total treatment costs exceed $17 billion and approximate the total costs of breast cancer ($13 billion) and heart disease ($19 billion). Balloon-assisted percutaneous vertebral augmentation with bone cement (kyphoplasty) reportedly reduces VCF-related pain and accelerates return of independent functional mobility. Kyphoplasty may decrease overall cost of VCF treatment costs by reducing use of posttreatment medical resources.

QUESTIONS/PURPOSES

We evaluated complications, mortality, posthospital disposition, and treatment costs of kyphoplasty compared with nonoperative treatment using the Nationwide Inpatient Sample database.

METHODS

We identified 5766 VCFs (71% female) in patients 65 years of age or older with nonneoplastic VCF as the primary diagnosis in nonroutine hospital admissions; 15.3% underwent kyphoplasty. Demographic data, medical comorbidities, and fracture treatment type were recorded. Outcomes, including complications, mortality, posthospital disposition, and treatment costs, were compared for each treatment type.

RESULTS

Women were more likely to be treated with kyphoplasty than were men. Patients undergoing kyphoplasty had comorbidity indices equivalent to those treated nonoperatively. Kyphoplasty was associated with a greater likelihood of routine discharge to home (38.4% versus 21.0% for nonoperative treatment), a lower rate of discharge to skilled nursing (26.1% versus 34.8%) or other facilities (35.7% versus 47.1%), a complication rate equivalent to nonoperative treatment (1.7% versus 1.0%), and a lower rate of in-hospital mortality (0.3% versus 1.6%). Kyphoplasty was associated with higher cost of hospitalization (mean $37,231 versus $20,112).

CONCLUSIONS

Kyphoplasty for treatment of VCF in well-selected patients may accelerate the return of independent patient function as indicated by improved measures of hospital discharge. The initially higher cost of treatment may be offset by the reduced use of posthospital medical resources.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Biofeedback load technique in the rehabilitation of osteoporotic patients (biomechanical analysis)

Based on a simple biomechanical analysis, available to physicians, the article recommends carrying a backpack regularly as a part of the complex rehabilitation of osteoporotic patients. Carrying a backpack in front or on the back is recommended for patients with uncomplicated osteoporosis, carrying a backpack only on the back is recommended for patients with osteporotic vertebrae fractures. The importance of carrying a backpack is based upon remove the muscular dysbalance of the trunk muscles and upon increasing the bone strength by compressive force acting upon the vertebrae and proximal femur and activating osteoblasts to osteoformation. The backpack load magnitude is differentiated--patients with vertebrae fractures put a weight up to 1 kg into the backpack, patients without vertebrae fractures up to 2 kg.

Retrospective multicenter study of surgical treatments for osteoporotic vertebral fractures

BACKGROUND

Although many surgical procedures are available for treating osteoporotic vertebral fractures, there have been no comprehensive multicenter surveys in Japan focusing on surgical treatments for these fractures. This study aimed at (1) conducting a retrospective multicenter study to survey surgical treatments performed at referral center hospitals in various regions in Japan and (2) analyzing situations and problems related to the surgical treatments of osteoporotic vertebral fractures in Japanese hospitals.

METHODS

Among 738 patients who were hospitalized in 13 hospitals in various regions in Japan between 2005 and 2006 for osteoporotic vertebral fractures, 84 patients (11.4%) who underwent spinal surgery were enrolled. These patients were retrospectively analyzed regarding cause of injury, preoperative symptoms, preoperative neurological function, surgical procedures, periods of bed rest, length of hospital stay, and ambulatory status at discharge from hospital.

RESULTS

As to the cause of spinal fracture, 38 patients (45% of the surgical patients) could not identify a specific cause of their spinal fracture. Preoperative neurological motor weakness in legs was observed in 41 (49%). With regard to surgical treatment, posterior spinal reconstruction surgery was performed in 50 patients (60%), vertebroplasty in 26 (31%), anterior reconstruction surgery in 6 (7%), anterior and posterior combined reconstruction surgery in 1, and posterior decompression alone in 1 patient. In all, 70 patients (83.3%), whose periods of hospital stay averaged 52.8 days, could walk by themselves at the time of discharge; 14 (16.7%), whose periods of hospital stay averaged 44.7 days, could not walk by themselves at the time of discharge.

CONCLUSIONS

Even after a large variety of surgical procedures were tried to treat osteoporotic vertebral fractures and long hospital stays, about 17% of the patients were unable to walk by themselves at the time of discharge from hospital.

[Treatment of thoracolumbar fractures by rehabilitation exercise using knee pads on the orthopedic traction bed]

OBJECTIVE

To discuss the clinical effectiveness in treating thoracolumbar fractures adopting the rehabilitation exercise utilizing knee pads on the orthopedic traction bed.

METHODS

From June 1996 to June 2006, we studied the clinical effectiveness of thoracolumbar fractures utilizing knee pads on the orthopedic traction bed for rehabilitation exercise. The cases surveyed total 209, 163 of which had full data. There were 98 males and 65 females with the age from 17 to 74 years (mean, 14.5 years). Consulting time after injury from 30 min to 7 days. Fracture site in T11 had 8 cases, in T12 24 cases, in L1 73 cases, in L2 33 cases, in L3 8 cases, in L4 3 cases, in T12 and L1 14 cases. Compression degree of vertebral anterior border: full compression had 1 case,more than 4/5 had 23, more than 2/3 had 67, more than 1/2 had 40, in 1/3 had 46.

RESULTS

Among them, 8 cases with legs paresis no recovery in nerval function or stopping recovery changed methods, and underwent surgical treatment. Others 155 cases were followed up from 2 to 12 years with an average of 3 years and 4 months. The average height of vertebral anterior borders of the 169 injured compressed had increased from 1.55 cm before treatment to 2.70 cm after treatment with an average of 1.15 cm. The height of the injured vertebral anterior borders had recovered from 50.5% (1.55/3.07) before treatment to 89.4% (2.70/3.02) after treatment. Kyphosis angle of the injured vertebral bodies had recovered from 13.25 degrees to -1.6 degrees in average. Twenty-three cases associated with dislocation basic reduction.

CONCLUSION

Rehabilitation exercise using knee pads on the orthopedic traction bed can obtain satisfactory clinical effect in treating thoracolumbar fractures, the method is easy. At 3, 7, 10 days after treatment, the height of bed should be adjusted according X-ray.

[Medical training therapy with special consideration to osteoporosis of the spinal column]

Medical training therapy (MTT) plays a decisive role in maintenance and development of musculoskeletal health of humans in all phases of life. In childhood and adolescence it can contribute to the highest possible so-called peak bone mass and thus avoid or delay the appearance of osteoporosis for as long as possible, in view of increased life expectations. In young adults targeted MTT is well suited to improve performance and to maintain the maximum developed bone mass. The latter is also true for perimenopausal and postmenopausal women in whom MTT can compensate for the loss of bone mass due to hormone deficiency in comparison to those not in training. Elderly people who have possibly already suffered several fractures and who are in danger of becoming permanently dependent on external help due to increasing fragility can still improve muscle strength and mass by regular MTT even in advanced age. This will reduce or avoid the risk of falling and maintain the ability to be self-sufficient for as long as possible. In order to support this, rehabilitation measures even in-hospital, could be useful and should be especially promoted in line with the amendments to the social legislation effective from 1st April 2007 ("Rehabilitation before nursing").

Rehabilitation of the spine following sports injury

The spine plays an essential role in the contribution toward athletic performance. As the central pillar of the body, the structures of the spine are susceptible to injury related with sports participation. This article identifies many of the most commonly seen sports-related injuries to the spine, and discusses practical rehabilitative interventions to manage such injuries. Anatomic considerations, biomechanical movements, and tissue properties are explained to better understand the clinical expectations associated with each of the injuries described.

Cross-geographic region differences in quality of life in women with and without vertebral fracture

SUMMARY

Not much is known about cross-geographic region differences in quality of life (QoL) in women with and without prevalent vertebral fractures (VFX). QoL differed between continents, countries, and ethnicities. The observed differences in QoL mostly appeared larger than the difference in QoL between women with or without mild to moderate VFX.

INTRODUCTION

Quality of life (QoL) is an increasingly important outcome measure in randomized controlled trials and cost-utility studies. However, not much is known about cross-geographic region differences in QoL. The objective of this study was to describe the cross-geographic region differences in QoL in women with and without mild to moderate prevalent vertebral fractures (VFX).

METHODS

The study was performed using baseline data of the bazedoxifene study. The study was carried out in 25 countries in six continents (n = 7117). QoL was assessed using the index and Visual Analogue Scale (VAS) scores of the EQ-5D, Qualeffo-41, and Women's Health Questionnaire (WHQ). VFX were assessed using semi-quantitative and quantitative morphometric methods.

RESULTS

In general, all four instruments followed more or less the same pattern. In most analyses, the reported QoL was lowest in Asia and Europe and highest in North America and Oceania. To examine the influence of ethnicity, North and South America were stratified on race. In both continents, a lower QoL was observed in Hispanic people.

CONCLUSIONS

QoL differed between continents, countries, and ethnicities. The observed differences in QoL appeared larger between most continents and countries than the difference in QoL between women with or without mild to moderate VFX.

Postoperative bedrest improves the alignment of thoracolumbar burst fractures treated with the AO spinal fixator

BACKGROUND

A loss of reduction due to inadequate support of the anterior column when using short-segment instrumentation to treat burst fracture and novel methods for support of the anterior column through a posterior approach to augment posterior instrumentation have been reported in the literature. We hypothesized that if anterior column support is an important adjunct to posterior short-segment instrumentation, then avoidance of axial load until sufficient anterior column healing occurs, allowing load-sharing with the implant, would improve spinal alignment at follow-up.

METHODS

We conducted a retrospective cohort study in which consecutive patients who had instrumentation and fusion with the AO spinal fixator were immediately ambulated after surgery or had 4 weeks of bedrest. We measured kyphosis and wedge angles preoperatively, immediately postoperatively and at the time of final follow-up. We used radiologic measures to assess instrumentation and bone failure.

RESULTS

We found significant differences in the mean loss of wedge and kyphosis angle correction between patients immediately ambulated and those who had 4 weeks of bedrest (0.71 masculine v. - 4.73 masculine for wedge and 1.81 masculine v. - 6.55 masculine for kyphosis, respectively). There was significant correlation between instrumentation and bone failure in both the immediate ambulation and bedrest groups.

CONCLUSION

Bedrest improves the maintenance of intraoperative sagittal alignment correction, which is in agreement with the theory that inadequate support of the anterior spinal column is the mechanism for loss of reduction when using short-segment instrumentation to treat burst fractures. Therefore, addressing the anterior column directly through anterior surgery or by employing novel techniques in posterior surgery is recommended if one of the goals of treatment is to maintain the sagittal correction achieved at the time of surgery. Trying to achieve this goal by addressing posterior implant design or bone quality alone will not be successful because instrumentation and bone failure occur together.

Sequential change in quality of life for patients with incident clinical fractures: a prospective study

Health-related quality of life in elderly women with sustained incident fractures was assessed prospectively for 1 year, using the EuroQol standard. Loss of QOL was more severe in patients after hip or vertebral fractures than those with wrist fracture. QOL was not completely restored in patients suffering from hip fracture.

INTRODUCTION

Osteoporosis-related fractures decrease mobility, social interaction, and emotional well-being. All of these characteristics determine health-related quality of life (HR-QOL). In this study, we assessed HR-QOL in elderly women following incident clinical fractures.

METHODS

Thirty-seven patients with hip fractures (mean age 76.1 years), 35 with vertebral fractures (mean age 72.6 years), and 50 with wrist fractures (mean age 68.6 years) were enrolled. HR-QOL was prospectively measured using EuroQol (EQ-5D) before the fracture, 2 weeks, 3 months, 6 months, and 1 year after the fracture.

RESULTS

During the observation period, reduction of EQ-5D values was greatest in the hip fracture group. In the wrist fracture group, EQ-5D values at 6 months after the fracture showed recovery; however, in the hip and vertebral fracture groups, recovery was significantly lower than before the fracture. One year after the fracture, EQ-5D values were not significantly different from prefracture values in the vertebral and wrist fracture groups, but remained significantly lower in the hip fracture group.

CONCLUSIONS

Loss of QOL was more severe in patients after hip or vertebral fractures than in patients with wrist fracture. HR-QOL was not completely restored in patients suffering from hip fracture.

The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study

Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time.

INTRODUCTION

This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI.

METHODS

The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses.

RESULTS

Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores.

CONCLUSION

The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.

Rehabilitation after falls and fractures

Falls are one of the most common geriatric problems threatening the independence of older persons. Elderly patients tend to fall more often and have a greater tendency to fracture their bones. Fractures occur particularly in osteoporotic people due to increased bone fragility, resulting in considerable reduction of quality of life, morbidity, and mortality. This article provides information for the rehabilitation of osteoporotic fractures pertaining to the rehabilitation of the fractured patient, based on personal experience and literature. It also outlines a suggested effective and efficient clinical strategy approach for preventing falls in individual patients.

Back pain in osteoporotic vertebral fractures

This review article examines the epidemiology and pathogenesis of back pain and vertebral fractures in osteoporosis, reviewing the management of pain in patients with vertebral fractures and the direct and indirect effect of osteoporosis treatments on back pain.

INTRODUCTION

The management of patients with vertebral fractures has largely concentrated on the prevention of further fractures by the treatment of underlying osteoporosis, with drug treatment for acute and chronic back pain and the non-pharmacological management of vertebral fractures receiving less attention.

DISCUSSION

Emerging evidence suggests that, in addition to reducing the incidence of vertebral fractures, calcitonin, intravenous bisphosphonates and teriparatide may also have a direct effect on bone pain. Targeted analgesia, tailored to individual need is often required in both the acute and chronic phases following vertebral fracture. Vertebroplasty and kyphoplasty have also been approved for use in the management of vertebral fractures and may prove useful in selected patients unresponsive to conventional pain relief. There is some evidence to support the use of individualised tailored exercise programmes aimed at strengthening back muscles to maintain bone density and reduce further fracture incidence. In addition the use of specific orthoses may help to reduce kyphosis, improve mobility and reduce pain.

CONCLUSION

Chronic back pain associated with vertebral fracture provides a great challenge to health care professionals and the patient. This demands a combination of options, including not only therapeutic interventions, but also physiotherapy, psychological support and patient education.

Nordic walking--is it suitable for patients with fractured vertebra?

This article brings the biomechanical analysis of sport--Nordic walking--for patients with osteoporotic fractured vertebrae and shows that it is suitable for them. Based on the biomechanical model of skeletal load we have developed a method of walking movement for patients, different from the method of walking movement for healthy people. And so came into being the "first sport" for patients with osteoporotic fractures. They can go for regular walks in easy terrains outdoors with friends and family, and so be liberated from social isolation. It requires only one-off financial costs of buying the poles and special footwear (Tab. 7, Fig. 3, Ref. 14). Full Text (Free, PDF) www.bmj.sk.

[New conceptions in complex management of spine trauma patients including reconstructive microsurgery and succeeding rehabilitation]

This work is been based upon the experience of performing 100 reconstructive microsurgical operations with transplantation of combined vascular-neural autografts, in 24 cases--with introduction cellular material into zone of transplantation. The complex approach aimed to creating optimal conditions for the functional regeneration of the spinal cord (SC), including neurosurgical methods restoring anatomical integrity of the organ and also multicomponent and staging rehabilitation of patients has been developed. On the base of complex approach during a postoperative period there has been put synchronous multifactorial action, consisting of functional multichannel electrical pacing of muscles simultaneously participating in tumble. The patient concentrates all his attention on the trial to tumble with paralized extremities by himself. At that the series and the site of application of these electrical impulses forms the algorithm of this tumble. Synchronism of produced afferent and efferent impulses creates new possibilities in activating of regenerating processes in the damaged area of the spinal cord. As a result of treatment within the bounds of the developed program the authors get clinically and electrophysiologically proved certain improvement that they can not only predict but guarantee patients of this group. Presented here results of the complex treatment of patients with trauma of the spinal cord within the framework of research international program confidently testify advantages of the new approach to solving of this problem. For the first time in history of medicine there is created close cooperation and regular continuity between molecular biology, neurosurgery and rehabilitation. This scientific alliance permits in proper time to keep a close watch, quickly correct and improve every stage of treatment. The effect of implement of innovations is been summarized at the each next stage of proposed complex treatment and eventually significantly elevates an ultimate result of medical rehabilitation of invalids with trauma of the spinal cord.

Homocysteine and fracture risk in postmenopausal women: the OFELY study

Homocysteine has recently been described as an independent risk factor for osteoporotic fractures in the elderly. We prospectively followed 671 postmenopausal women belonging to the OFELY study, mean age 62 years, during a mean follow-up of 10 years. After adjustment for age, there was no significant relation between the plasma level of homocysteine and the subsequent risk of fracture.

INTRODUCTION

Plasma homocysteine increases with age. Recent studies have described homocysteine as an independent risk factor for osteoporotic fractures in elderly. We investigated the role of plasma homocysteine in the subsequent risk of fractures in healthy ambulatory postmenopausal women.

METHODS

Homocysteine was measured at baseline in 671 postmenopausal women from the OFELY cohort (mean age 62.2 +/- 9 years). Incident clinical fractures were recorded during annual follow-up and vertebral fractures were evaluated with radiographs every four years. A cox proportional hazards model based on time to first fracture was used to calculate hazard ratios for quartiles of homocysteine values.

RESULTS

Mean homocysteine was 10.6 +/- 3.4 mumol/l, increasing with age. After adjustment for age, homocysteine was significantly associated with physical activity, calcium intake, serum albumin and serum creatinine but not with bone turnover markers and bone mineral density. During a mean follow-up of 10 years, 183 fractures occurred among 134 women. After adjustment for age, the overall relative risk of fracture for each 1 SD increment of homocysteine was 1.03 (95%CI 0.87-1.31). Fracture risk was higher in women with homocysteine in the highest quartile without adjustment but no longer after adjustment for age.

CONCLUSIONS

Homocysteine is not an independent risk factor of osteoporotic fractures in healthy postmenopausal women from the OFELY cohort with a broad age range.

Nonoperative management of osteoporotic vertebral compression fractures

As the population ages, vertebral compression fractures are an increasing source of pain and dysfunction. The immobilisation that often occurs with fractures can lead to multiple medical complications and their management can be complex as care may require multiple treatment modalities. Each individual responds to pain differently and a treatment plan must be tailored to the individual's pain, functional limitations and goals. The likely first choice for managing stable osteoporotic vertebral compression fractures is conservative management. Treatment options usually involve a combination of medications, bracing and physical therapy. If radicular pain is a component of the pain syndrome, epidural steroid injections may be beneficial. In addition, some patients may benefit from vertebral augmentation. This paper reviews current recommendations for managing vertebral compression fractures. Treatment options including vertebral augmentation are reviewed, including indications and complications.

Pelvic trauma with displaced sacral fractures: functional outcome at one year

STUDY DESIGN

A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with displaced sacral fractures.

OBJECTIVE

To describe the medium term functional outcome in unstable sacral fractures.

SUMMARY OF BACKGROUND DATA

Displaced sacral fractures pose a special challenge in orthopedic surgery due to the high rate of associated injuries. Little information is available on the medium-term functional outcome of patients with injuries which include unstable sacral fractures.

METHODS

We examined 31 patients with displaced sacral fractures having 10 mm or more displacement, 1 year (mean, 1.4 years; range, 1.0-2.5 years) after injury. Data from a previous study were supplemented with functional outcome measures (work status, independence in ADL, and SF-36). An association between outcome and tested variables was sought.

RESULTS

Fifteen months after injury, 65% of the patients had regained their independence in functions pertaining to daily activities; 33% had returned to work. All dimensions of perceived health were affected. Polytrauma and impairments relative to voiding and sexual function had a detrimental effect on outcome. Fracture characteristics were not predictive of poor outcome.

CONCLUSIONS

Although the majority of patients achieved independent living, medium-term follow-up indicated significant residual disability. The complex nature of these fractures and the associated injuries should be considered in the rehabilitation of these patients.

Long-term outcome in patients with combined spinal and pelvic fractures

The outcome of 30 patients with combined spinal and pelvic fractures (C group) was retrospectively investigated and compared with matched group of similar number of isolated spinal fractures (S group) and isolated pelvic fractures (P Group), admitted to our institution between Jan 1998 and May 2002, following a high-energy trauma. After a mean follow-up of 57 months their outcomes were studied using EuroQol questionnaire and return to work status. The EQ-5D scores for patients in the S group were 0.71 (SD 0.29) compared to 0.60 (SD 0.14) for patients in the P group and 0.63 (SD 0.23) for patients in the C group. The EQ-VAS scores were similarly favourable towards patients in the S group. Seventy percent of patients in the S group returned to their previous level of employment after a mean duration of 5.3 months compared to 55% in the P group and 57% in the C group after a mean duration of 9.4 months and 12.8 months, respectively. Patients with isolated spinal fractures had an overall satisfactory outcome compared with patients in the other 2 groups. However, no difference was noted while analysing the outcomes in the later 2 groups (p<0.05), suggesting that the pelvic fracture contributes to the poor outcome, and the presence of a spinal fracture does not influence the long-term outcome. However, problems related to associated injuries and motor neurological deficits have profound confounding effect on the outcome in all 3 groups.

Sacral stress fracture in a marathon runner

Athletically caused sacral stress fractures represent an uncommon reason for low back pain. The clinician must consider this possible diagnosis when evaluating patients with nonradicular low back or buttock pain. Women distance runners are more commonly afflicted. Athletically caused sacral stress fractures are most often unilateral. This case report presents an illustrative case of bilateral sacral stress fracture occurring in a male runner.