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As a physical therapist I see, assess and treat a wide variety of conditions, osteoporosis illnesses, and injuries. Frequently, I see patients who have recently fallen and have broken a bone or bones. In many cases, the patient has been immobilized (casted) following the fracture, usually for 4-6 weeks. The patient comes with a referral from a physician requesting assessment and treatment to increase mobility and strengthening of the muscles in the affected area. While assessing the patient, I often find out that the fracture was as the result of a slip or fall. Often the fall occurred from standing height or less.
As a physical therapist seeing a patient post fracture, there are a number of issues I must consider. The obvious area of concern is how much movement (range of motion) is available at the affected area? How much movement should there be? How strong are the muscles supporting the affected area? How is the injury affecting the patient’s normal activities of daily living? Other less obvious questions or concerns that often go uninvestigated include:
Why did the patient break a bone from a standing height or less?
Why did they fall in the first place?
What is the patient’s risk of falling and potentially fracturing again?
As a physical therapist, I am trained to help regain joint mobility lost due to immobilization with various manual therapy techniques and exercises. I can help manage and reduce the pain associated with the bone and soft tissue injuries, but should I not also be investigating and addressing the other less obvious questions as well? When asked, very rarely does the patient indicate that they have had a recent bone mineral density test. Osteoporosis Canada indicates that often a broken bone is the first sign of osteoporosis. In fact, after the age of 50, 80% of all broken bones are related to osteoporosis. It is reported that only 2 of 10 patients who have sustained a fracture are subsequently investigated for osteoporosis. 80% are treated for their fracture then sent home without any further investigation or treatment for osteoporosis.
What Are Osteoporosis and Fragility Fractures?
Osteoporosis is a condition that causes bones to become weak and brittle, so brittle that a fall or something as simple as bending over or coughing can cause a broken bone. Osteoporosis related fractures most commonly occur in the hip, wrist, shoulder, or spine. A fragility fracture is defined as a fracture caused by an injury that would not break a normal bone. A more practical definition is a fracture that occurs due to a fall from standing height of less.
The Numbers
The numbers associated with osteoporosis are staggering. At least 1 in 3 women and 1 in 5 men will suffer an osteoporosis related fracture in their lifetime. 1 in 3 hip fracture patients re-fracture at 1 year; 37% of men and 28% of women who suffer a hip fracture will die within the following year; 20% of those who have a spine fracture risk suffering a second fracture within the year following the first; the risk of a spine fracture is increased by 5 times after the first, 12 times after the second, and 75 times after the second, and in the presence of low bone mass. The health care cost associated with treating osteoporosis and fractures is 2.3 billion/year.
What Can Be Done?
Literally an ounce of prevention is worth a pound of cure. I often compare it to investing probably because of my wife’s influence as she is an investment adviser. I tell patients it’s like putting money away for retirement the more money or in this case bone you have saved up the longer you can go before you run out. The better your bone health at a young age, the longer your bones go before becoming fragile if they do at all, because we all lose bone density as we age. Bone density is dependent upon a number of factors, including diet and physical activity. So eating a healthy diet and being physically active throughout your life are keys to putting bone in the bone bank and investing in your future.
Exercise is Medicine
Physical therapists are in a great position to offer assistance following a fracture to help regain joint mobility and strength, and to help manage pain. The physical therapist can also assess factors that may have contributed to the fall in the first place, such as reduced mobility at certain joints such as the ankles or knees, muscular weaknesses, and posture and balance problems that often occur as we age. Even in the absence of a fracture, someone with osteoporosis and at high risk of fracture should avoid certain exercises or activities that will increase their risk of breaking a bone. The therapist may also be able to provide advice on how to make your home safer, thus reducing your risk of falling. An individualized rehabilitation program made up of exercises of appropriate design, intensity, and progression should be developed with patients post fracture or patients with osteoporosis without a history of fragility fracture. More often than not, due to fear of injury of hurting themselves, people with osteoporosis or post fracture reduce their exercise/activities too much and programs are not as intense or demanding as they could be to help preserve bone density and bone quality.
In general, exercise programs for individuals with osteoporosis should incorporate weight bearing (i.e. walking, resistance training and balance and posture training), and should take into account the individual’s fracture risk. A balanced diet including fresh fruits, vegetables, and adequate amounts of protein and calcium is recommended. Patients with osteoporosis are recommended to ensure they are getting sufficient amounts of calcium, as well as daily supplementation of Vitamin D is recommended.
Along with their appropriately designed exercise/activity program, patients with osteoporosis are recommended to ensure they are getting sufficient amounts of calcium and vitamin D through consultation with their doctors and or a registered dietician. In some cases your doctor may prescribe medications to help maintain bone density and prevent fracture. So, in short, invest in your bones as much as you can, as early as you can and as often as you can through activity and diet. Use it or lose it. It is a lot easier to lose bone strength than it is to get it back. If you have concerns regarding osteoporosis and fractures, speak with your family doctor and a trained fitness who can help guide you in efforts to improve your bone health. Community resources are available to help and include Osteoporosis Canada (www.osteoporosis.ca) and the Canadian Osteoporosis Patient Network (www.osteoporosis.ca/copn). For general information about exercise recommendations and precautions for people living with osteoporosis, order your copy of Too fit to Fracture: Managing Osteoporosis through Exercise by calling Osteoporosis Canada at 1-800-463-6842.