Treatment before evaluation seems to go against standard practice. To understand how to treat a patient, we need to find out what it is that we need to treat. In the field of osteoporosis, however, treatment before evaluation is often the norm. Physicians often give medications before bone density testing. Even Medicare measures osteoporosis testing as “prescribed a bone protecting medication”. Until recently, the fragility of the osteoporosis patient has lead to therapists following procedures that limit physical function testing in these patients. The extreme concern about the fragility of the patient with osteoporosis is not unfounded. More than 30% of female patients over the age of 65 are not tested (via DXA) for bone loss and more than 79% of patients who have a fracture, never get a DXA…let alone get prescribed a bone protecting medication- how many of these patients do we as therapists work with? Do you always know that your patient has bone loss? This disease has been associated with fractures that have occurred under very low trauma conditions. In contrast, the method by which many of these fractures have been diagnosed has come under scrutiny.
From the first major osteoporosis medication trial (FIT trial), a large substudy (N=6,084) of patients was examined to see if vertebral fractures reported in the non-clinical event group were actually fractures by applying a strict use of a “20% deformity or 4mm loss” measure. This non-clinical event group consisted of patients in the original FIT study that did not associate pain with fracture or they never had pain and therefore never reported an event (i.e. fracture). In addition, this study was cross-sectional, including patients from both treatment groups – placebo or alendronate. So, results of this analysis can be generalized to pharmaceutically treated and not treated populations. The study found that only 1/4 of radiographic vertebral deformities identified were actually fractures according to the strict measure. It appears that many vertebral fractures that have been categorized as such really are not vertebral fractures. It is from this study, and those similar, that we gain our information regarding vertebral fracture prevalence. It can be easily argued that vertebral fracture prevalence is not as severe as we may have been lead to believe.
If a 65 year female with back pain came to your clinic, and an x-ray did not reveal osteoporosis or fracture, would you do some standard spine ROM and strength assessments. Would you look at her movement patterns to understand more about what she is doing to increase her back pain during her daily life? Would you ask her to bend over to see flexibility? Is this really safe? If we are going to determine that we should not ask a patient to bend over when we know they have bone loss, what do we do if we don’t know, what if we don’t even suspect bone loss? Would that change the way you test? It might. You may decide, however, that the benefits of testing to determine what is wrong far outweigh the very low risk of injury during testing. It can be argued that to avoid testing, and “assume the worst” could result in unnecessary treatment. What if you could assess physical performance in the patient with osteoporosis in a safer way and streamline treatment to just what the patient needs?
While physical performance testing is far from the rigors and risk of cardiac stress testing, it is a stress test of sorts. In fact, one may argue that the risk of injury while observing a patient’s natural activity patterns is far lower than the risk of injury during a cardiac stress test. By doing physical performance testing with a patient, we can observe how well their musculoskeletal system performs in the context of natural activities. We can also understand if the patient is engaging voluntarily in excessive loading conditions that can lead to fracture.
Moreover, impaired physical performance is associated with increased fracture prevalence. If physical performance is not observed, related fracture risk could be missed.
During the Bone Safety Evaluation (BSE), a physical performance test that is designed specifically to evaluate performance safety while protecting patients with bone loss during testing (hence the term “Bone Safety Evaluation”), the patient is not asked to do anything he/she would not normally, and naturally do on their own. In 10 years of use, there has not been one case of fracture, vertebral or other, during the physical performance testing conducted on patients with bone loss at UOC (over 1600 tests have been conducted). At UOC, fracture incidence has actually gone down with ongoing BSE testing (2007: 26%, 2008: 11%). And physical performance on the BSE is independently associated fracture prevalence.
As an occupational therapist, I find it is critical to observe a patient’s performance. If I don’t understand how the patient is moving naturally, I can’t work effectively to change their movement. Furthermore, if the patient does not understand how they are moving unsafely, they don’t effectively engage in changing that movement.
As therapists, we inherently want to treat without much testing. It’s in our nature to heal even before we have the whole picture. Would we refuse to treat a patient with obvious hemi paresis without an MRI to confirm a diagnosis of stroke? Of course we would not. Conversely, would we begin treatment of hemi paresis without knowing how the impairment is affecting our patient’s function? Again, we would probably not. Yet, if we understood from the MRI the severity, type and location of the stroke and we knew that our patient wanted to resume independence with self-care, we could apply our treatment more effectively; even be able to plan a better long term treatment plan because expected and desired outcomes are better understood. Is it fair to not offer the same expectations for the patient with bone loss? I believe all patients, regardless of disease state, deserve comprehensive assessment and care.
I think we all realize that every time we initiate treatment with a patient whether it is ultrasound, exercise, or anything else, there is an inherent risk of injury, however small. We temper those risks with knowledge, experience, and judgment. The knowledge part of the equation includes various tests and evaluations conducted before therapy. I don’t think it serves the patient to assume anything about their condition when there is a tool that can give us answers. Of course, it goes without saying that when we use the tool, whatever it is, we must use that tool wisely, carefully, and judiciously.
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