Osteoporosis

General Information
Case no.	14.A Osteoporosis
Authors	Melissa Gilroy, DC, MSPAS, PA-C Sean Griech, PT, DPT, PhD, COMT, Board Certified Clinical Specialist in Orthopaedic Physical Therapy Julie M. Skrzat, PT, DPT, PhD, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy
Diagnosis	Acute Compression Fracture of T12 Due to Osteoporosis
Setting	Emergency Department
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	To understand the role of the physical therapist in the emergency department. To consider differential diagnoses for a patient presenting with back pain. To identify risk factors for vertebral compression fracture in the setting of osteoporosis.

Medical
Chief complaint	Mid-back pain × 2 days
History of present illness	The patient is a 72-year-old woman with a history of osteoporosis presenting to the emergency department with mid-back pain that began acutely following a fall onto her backside 2 days prior. She fell while using the bathroom in the middle of the night. She states she used minimal lights to avoid waking her husband. The patient denies loss of consciousness or head trauma. No other injuries were reported. She denies numbness or paresthesia in the extremities. She reports one episode of urinary incontinence since the fall. Pain is described as sharp and rated as 8/10 since injury. It is localized to mid-back without radiation. There is minimal improvement of pain with acetaminophen 500 mg every 4 hours. It is worst with movement, particularly forward spinal flexion. She is able to sleep supine with knees bent.
Past medical history	Hypertension: diagnosed in her 40s; hyperlipidemia: diagnosed in her 40s; osteoporosis: diagnosed age 65 years; dual-energy X-ray absorptiometry (DEXA) scan (spine/hip) performed 7 years ago with a T-score of –2.5 and Z-score of –2; history of tobacco use: half pack per day since age 20 years; abstinent for 5 years; alcohol use: one to two glasses of wine each week.
Past surgical history	Total abdominal hysterectomy: age 45 years; no complications
Allergies	None
Medications	Lisinopril, Atorvastatin, Multivitamin, No herbals/supplements
Precautions/orders	Bedrest until cleared by neurosurgery Activity as tolerated Ambulate with assist

Social history
Home setup	Lives in a multilevel home with her husband who continues to work full-time. Two steps without handrail to enter. No bathroom on the first floor. Bedroom and bathroom are located on the second floor. Flight of stairs + one handrail to the second floor.
Occupation	Elementary school teacher, retired 5 years ago.
Prior level of function	Independent with functional mobility and activities of daily living (ADLs). No regular exercise (+) driver
Recreational activities	Painting, sewing, scrapbooking Enjoys visiting family and grandchildren.

Vital signs	Hospital day 0: emergency department
Blood pressure (mmHg)	134/88
Heart rate (beats/min)	102
Respiratory rate (breaths/min)	22
Pulse oximetry on room air (SpO₂)	98%
Temperature (°F)	98.6 (oral)

Imaging/diagnostic test	Hospital day 0: emergency department
Thoracic and lumbar spinal X-ray anteroposterior/lateral	1. X-ray shows presence of a moderate-grade anterior wedge fracture of T12 with approximately 30% degree of deformity. Cortical breaking and impaction of trabeculae are consistent with acute compression fracture. No other acute findings noted.
Thoracic and lumbar spinal magnetic resonance imaging (MRI)	Fig. 14.1

Fig. 14.1 (a) Sagittal T1-weighted sequence of the thoracic spine demonstrates diffuse metastatic infiltration of the bone marrow by a rectal mucinous adenocarcinoma (T1-weighted signal of the marrow significantly lower than the disk). (b) Sagittal T2-weighted sequence. Arrows in (a) and (b) show a T12 pathologic vertebral compression fracture. (c) Fluoroscopic image demonstrates adequate polymethyl methacrylate (PMMA) fill of the vertebral body from pedicle to pedicle and from end plate to end plate. (Adapted from 18.2 Current Information Based on Recent Literature and State-of-the-Art Practice. In: Beall D, ed. Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty, and Implant Augmentation. 1st ed. Stuttgart: Thieme; 2020.)

Medical management	Hospital day 0: emergency department
Medications	1. Lisinopril 2. Morphine PRN 3. Acetaminophen PRN 4. Colace PRN 5. Polyethylene glycol PRN
Consults	1. Neurosurgery: evaluate and treat for T12 compression fracture; nonoperative management recommended; stable fracture and cleared for physical therapy evaluation. 2. Geriatrics: evaluate and treat medical conditions of hypertension and untreated osteoporosis. 3. Physical therapy: evaluate and treat, disposition planning

Medical management

Hospital day 0: emergency department

Medications

1. Lisinopril

2. Morphine PRN

3. Acetaminophen PRN

4. Colace PRN

5. Polyethylene glycol PRN

Consults

1. Neurosurgery: evaluate and treat for T12 compression fracture; nonoperative management recommended; stable fracture and cleared for physical therapy evaluation.

2. Geriatrics: evaluate and treat medical conditions of hypertension and untreated osteoporosis.

3. Physical therapy: evaluate and treat, disposition planning

Lab		Reference range	Hospital day 0: emergency department
Complete blood count	White blood cell	5.0–10.0 × 10⁹/L	8.7
	Hemoglobin	12.0–16.0 g/dL	12.2
	Hematocrit	35.5–44.9%	37
	Red blood cell	4.5–5.5 million/mm³	4.6
	Platelet	140,000–400,000/μL	250
Metabolic panel	Calcium	8.6–10.3 mg/dL	8.7
	Chloride	98–108 mEq/L	106
	Magnesium	1.2–1.9 mEq/L	1.2
	Phosphate	2.3–4.1 mg/dL	3.1
	Potassium	3.7–5.1 mEq/L	4.7
	Sodium	134–142 mEq/L	140
	Blood urea nitrogen	7–20 mg/dL	18
	Creatinine	0.7–1.3 mg/dL	1.02
	Anion gap	3–10 mEq/L	8
	CO₂	22–26 mEq/L	24

Pause points
Based on the above information, what are the priority: Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priority:

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Hospital Day 0, Emergency Department: Physical Therapy Examination
Subjective
“My back really hurts.”
Objective
Vital signs	Pre-treatment		Post-treatment
Blood pressure (mmHg)	132/88		136/90
Heart rate (beats/min)	101		102
Respiratory rate (breaths/min)	20		22
Pulse oximetry on room air (SpO₂)	98%		96%
Pain	8/10 low back		8/10 low back
General	Patient supine in bed. Well developed, well nourished, awake/alert, appears stated age, in mild to moderate distress secondary to back pain. Lines notable for peripheral intravenous (IV).
Head, ears, eyes, nose, and throat	Head normocephalic, atraumatic Extraocular motion intact, pupils equal, round, and reactive to light and accommodation
Cardiovascular and pulmonary	Normal sinus rate and rhythm, no murmurs, rubs, gallops S1 and S2 present, no S3 or S4 Point of maximal impulse (PMI) is nondisplaced.
Gastrointestinal	Soft, nontender, nondistended Positive bowel sound (BS) in all four quadrants. No organomegaly
Musculoskeletal	Range of motion	Bilateral upper extremity (BUE): grossly within functional range Bilateral lower extremity (BLE): grossly within functional range
Musculoskeletal	Strength	BUE: grossly 4/5 BLE: grossly 4/5 Facial grimacing and subjective reports of low back pain with resisted shoulder flexion and hip flexion.
Neurological	Balance	Static sitting, unsupported: supervision with BUE support Dynamic sitting, unsupported: supervision with BUE support Static standing, unsupported: minimal assistance Dynamic standing, unsupported: minimal to moderate assistance Dynamic standing, supported: minimal assistance with rolling walker
	Cognition	Alert and oriented × 4
	Coordination	Finger to nose: intact bilaterally
	Cranial nerves	II–XII: intact
	Reflexes	Patellar: 2 + bilaterally Achilles: 2 + bilaterally Babinski: negative bilaterally
	Sensation	Intact and symmetric to light touch and deep pressure in BLE.
	Tone	Normal throughout BUEs and BLEs
	Other	No clonus in BLE
Functional status
Bed mobility	Rolling either direction: supervision. Patient educated on log roll technique. Supine to/from sit: supervision with increased time, head of bed flat, no bedrails, used log roll technique Fig. 14.2a, b, c
Transfers	Sit to/from stand: contact guard assist Stand pivot transfer: minimal assistance with no assistive device
Ambulation	Ambulated × 10 feet with minimal to moderate assistance and no assistive device. Gait deviations notable for antalgic gait, flexed posture, decreased cadence, decreased bilateral (B/L) step length. Ambulated × 25 feet with minimal assistance and rolling walker. Gait deviations notable for above deficits, but to lesser degree. Patient reports that while she does not like using a rolling walker, she feels more secure.
Stairs	Attempted to ascend/descend one step, but unable to complete due to pain.

Fig. 14.2 (a-c) An example of the log roll technique to get in and out of bed.

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I want to get rid of this pain to go home.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☐ Physician’s ☑ Physical therapist’s ☐ Other’s	At this time, patient is not functioning at her baseline and, therefore, is not cleared to be discharged home. Patient would benefit from continued physical therapy to maximize functional mobility and safety.

Plan

☐ Physician’s

☑ Physical therapist’s

☐ Other’s

At this time, patient is not functioning at her baseline and, therefore, is not cleared to be discharged home. Patient would benefit from continued physical therapy to maximize functional mobility and safety.

Bloom’s Taxonomy Level	Case 14.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe. 4. Create a comprehensive home exercise program for this patient.
Evaluate	5. What are differential diagnoses for a patient presenting with back pain? How can they be ruled out?
Analyze	6. What components of the patient’s history are important to consider in the evaluation of cauda equina syndrome?
Apply	7. How should the DEXA score be interpreted?
Understand	8. What risk factors are implicated in the development of osteoporosis? 9. Why are the patient’s blood pressure, heart rate, and respiratory rate elevated?
Remember	10. What is the definition of osteoporosis? How does it differ from osteopenia?

Bloom’s Taxonomy Level	Case 14.A Answers
Create	1. The patient is a 72-year-old woman who presents to the emergency department status post fall with acute low back pain × 2 days. She was diagnosed with an acute compression fracture at T12 due to osteoporosis. Per neurosurgery, she is not a candidate for surgical interventions and, therefore, conservative management is recommended. She was previously independent with functional mobility and ADLs. Unfortunately, her primary limitation of pain warrants supervision—moderate assistance with/without an assistive device for functional mobility. Additionally, due to the pain, she is unable to successfully ascend/descend one step, impairing her ability to enter and exit her home and use bathroom, which is on the second floor. Finally, she has limited social support at home, since her husband continues to work full time. As a result of these, she is not safe to be discharged home. She would benefit from continued inpatient physical therapy for pain management and to maximize functional mobility and safety. Will continue to follow and progress as tolerated. 2. Short-term goals: Patient will independently perform bed mobility, utilizing logroll technique, within three visits to protect spine and promote independence. Patient will independently perform all transfers with least restrictive assistive device within three visits to promote independence. 3. Long-term goals: Patient will be modified independent to ambulate a minimum of 50 feet, using the least restrictive assistive device, within seven visits to promote independence at home. Patient will be modified independent to ascend/descend a flight of stairs, using one hand rail and a step-to pattern, within seven visits to be able to reach the second floor of home. Patient will independently verbalize three ways to reduce fall risk within her home within 7 visits to maximize safety. 4. The following is an example of a potential home exercise program for this patient. This exercise program should be prescribed to help prevent disease prevention. Only three to five exercises should be selected to ensure compliance. Strengthening: Frequency: 2 to 3 days a week Intensity: moderate, 60 to 80% 1 repetition maximum (RM) Time: 8 to 12 repetitions Type: mini-squats, standing hip abduction, bridges Aerobic training: Frequency: 3 to 5 days a week Intensity: moderate, 40 to < 60% heart rate reserve Time: 30 to 60 minutes a day Type: walking
Evaluate	5. The differential diagnoses for a patient with back pain can be broad, and many ruled out through an appropriate history and physical examination. Referred pain to the back from visceral complaints like pancreatitis (mid-back) or cholecystitis (right scapular) may be excluded in a patient who does not have associated abdominal pain, anorexia, and nausea/vomiting. Rupture of an abdominal aortic aneurysm may also cause referred back pain (mid to lower back). These patients may be identified by risk factors like older age, male sex, history of tobacco use, hypertension, hypercholesterolemia, known cardiovascular disease, etc. Any of these referred pain complaints can also be more definitively ruled out with appropriate imaging studies Other etiologies for consideration include malignancy or metastatic disease. The most common primary bone malignancy is multiple myeloma. Malignancies most likely to spread to the bone include prostate, thyroid, breast, lung, and renal cancers. These are typically identified on imaging studies but should be considered in patients with history of malignancy or based on other risk factors like advanced age, family history, hypercholesterolemia, and known cardiovascular disease. Various sources of infection like diskitis, osteomyelitis, or localized abscess may also present with back pain. These patients may have a history of immunosuppression, recent surgery or intervention, other infectious source (endocarditis, bacteremia), IV drug use, and may present with associated symptoms of fever and/or chills. A thorough history can help determine if an infectious etiology should be included on the differential and appropriate imaging can help identify the specific diagnosis Musculoskeletal considerations for back pain include herniated nucleus pulposus, spinal stenosis, muscular spasm/strain, spondylolisthesis, or bony fracture. A thorough history, physical examination, and appropriate imaging can be utilized to identify these conditions.
Analyze	6. Cauda equina syndrome is a condition in which the terminal nerve roots of the spinal cord are impinged, which can result in asymmetric multiradicular pain, leg weakness, and/or sensory loss in the lower extremities as well as bowel, bladder, or sexual dysfunction. Although not commonly caused by vertebral compression fractures, it is important to assess for these features in patients presenting with back pain. Failure to recognize and treat cauda equina syndrome in a timely fashion can result in permanent disability. This patient had one episode of urinary incontinence, which prompted the MRI evaluation to assess for integrity of the cord and nerve roots.
Apply	7. DEXA technology is used to measure bone mineral density (BMD), which is a reflection of bone strength. It is used to aid in the diagnosis of osteopenia and osteoporosis. The T-score is calculated by subtracting the mean BMD of a young adult reference population from the patient’s BMD, then dividing by the standard deviation (SD) of young adult population. The Z-score is used to compare the patient’s BMD to a population of peers. It is calculated by subtracting the mean BMD of an age, ethnicity, and sex-matched reference population from the patient’s BMD, then dividing by the SD of the reference population. There are some discrepancies between medical organizations regarding what sites of BMD should be used to make the diagnosis of osteoporosis. The World Health Organization recommends using the T-score measured by DEXA at the femoral neck as the international standard for diagnosing osteoporosis. In contrast, the National Osteoporosis Foundation and the International Society for Clinical Densitometry suggest using the lowest T-score from the lumbar spine (L1–L4), total proximal femur, or femoral neck as determined by DEXA scanning in making the diagnosis of osteoporosis.
Understand	8. Risk factors for the development of osteoporosis include advanced age, history of previous fracture, long-term glucocorticoid therapy, low body weight (< 127 lb), parental history of hip fracture, cigarette smoking, excess alcohol use, and race/ethnicity (Caucasian with the highest risk). Of these, the greatest predictors for the development of osteoporosis are advanced age and history of previous fracture. 9. The patient’s blood pressure, heart rate, and respiratory rate are likely elevated due to the patient’s reports of pain and anxiety.
Remember	10. Osteoporosis is a disease characterized by low bone mass. There are structural changes to the bone tissue, resulting in bone fragility. This puts an individual at risk of developing fractures, specifically at the hip, spine, and wrist. Osteoporosis, as defined by the World Health Organization, has a T-score less than –2.5. Osteopenia is a term used to describe a decrease in bone mineral density below normal reference values. Osteopenia, as defined by the World Health Organization, is a T-score between –1 and –2.5.

Key points
1. There is an increase in patients presenting at the emergency department with musculoskeletal complaints. Once acute pathology has been ruled out, physical therapists have the knowledge and abilities to implement therapeutic tests and measures to diagnosis and treat low back pain.
2. Physical therapists have the training and ability to integrate multiple date points to assist with disposition planning from the acute care setting.
3. Physical therapists can provide appropriate education on fall reduction techniques and proper body mechanics to assist in reducing incidence of vertebral compression fracture.