Osteoporosis: Orthoses Match Wits with the ‘Silent Thief’

"Persons with osteoporosis ...will expire prematurely if they cannot be managed for pain and lack of mobility. Currently there are few medical or surgical options for these people that will get them back on their feet. In my estimate, the population of these people in the United States that may benefit from proper orthotic management is about fifteen-fold the population that requires management for adolescent idiopathic scoliosis." —Thomas M. Gavin, CO Osteoporosis has been called a "silent thief" since it quietly steals away bone mass and strength over time. Its thievery often doesn't come to light until a crisis—such as when a bone suddenly breaks from a mild trauma or even a sneeze—and the culprit is revealed. Although postmenopausal women comprise the majority of sufferers, premenopausal women and even men and children can become victims of this quiet bandit. Osteoporosis is a major public health threat for an estimated 44 million Americans, or 55 percent of people aged 50 years and over, according to the National Osteoporosis Foundation (NOF). About 10 million persons—eight million women and two million men—are estimated to already have the disease, with another 34 million at risk. Osteoporosis is rare in children and adolescents and is most often secondary to an underlying medical disorder or to medications used to treat the disorder, although very rarely it may appear as a primary idiopathic condition, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National Institutes of Health (NIH). The World Health Organization (WHO) defines osteoporosis as a bone mineral density (BMD) value more than 2.5 standard deviations (SD) below the average value for a young, healthy woman. Osteopenia, or low bone mass—which can be a precursor to osteoporosis—is defined as -1.0 to -2.5 SD, or 10-30 percent below normal bone mass. Osteoporosis is costly. Projected costs for care of osteoporosis and low-energy fractures over the next two decades are $474 billion, according to the 2008 publication The Burden of Musculoskeletal Diseases in the United States, a joint project of the American Academy of Orthopaedic Surgeons (AAOS) and several other societies, academies, foundations, and other organizations during the National Bone and Joint Decade, which in turn is part of the international collaborative initiatives of the United Nations/WHO-sanctioned Bone and Joint Decade ( www.boneandjointburden.org ). "In addition to dollar cost, osteoporosis-related fractures bring a burden of pain and disability, resulting in time lost from work or the inability to perform activities of daily living," the authors note. "By 2020, if current trends continue and effective treatments are not found and widely implemented, it is estimated that more than 61 million persons will be at risk." Treatment modalities for osteoporosis and osteoporosis-caused conditions comprise pharmacologic; non-pharmacologic, including orthotic treatment; and surgery. Sharing Experience for Best Outcomes Spinal conditions take the lion's share of osteoporotic orthotic management, although hip and limb fractures may compose part of the caseload. "The most common condition I see is lumbar and thoracic vertebral compression fractures that are relative to osteopenia or osteoporosis; most patients are fit with a three-point hyperextension orthosis, such as Jewett, CASH, or ACE," says Roger Marzano, CPO, CPed, a clinician at Yanke Bionics, Akron, Ohio. The use of "soft" TLSOs has been indicated for those with chronic fractures or significant scoliosis or kyphosis, he adds, noting that he has also fit elastic posture supports and dorsolumbar corsets for patients with upper thoracic fractures. "Another common pathology we see is metatarsal stress fractures, commonly presenting with dorsal metatarsal swelling and pain with push-off activity," Marzano continues. For acute metatarsal stress fractures, he fits Aircast® S/P low-profile walking boots; for those suffering with chronic fractures, he fits custom foot orthoses with carbon fiber footplates. "Occasionally we fit a HKAFO for acute non-operative proximal femoral fractures," he adds. Becky Meyer, CO, of Mary Free Bed Orthotics & Prosthetics, Grand Rapids, Michigan, generally fits dorsolumbar or similar spinal braces but notes she sees very few osteoporosis patients. CASH Orthosis. Photograph courtesy of Roger Marzano, CPO, CPed . Tom Gavin, CO, president and director of clinical services at BioConcepts Orthotic Prosthetic Center Inc., Burr Ridge, Illinois, says, "Most specifically, we manage the loss of lordosis associated with the elongation of the erector spinae musculature that is secondary to thoracic vertebral compression fractures, or in other words, we get the person 'upright' on the sagittal plane." With orthotic management, Gavin expects the patient to become less dependent on assistive devices such as walkers and be able to ambulate with less pain for a longer period of time. "Frequently, the pain directly over these pathologic fractures is less debilitating than the pain from the spasms and fatigue in the over-stretched erector spinae," he adds. "In the laboratory, we see much erector-spinae muscle destruction in osteoporotic specimens [from patients] with spinal fractures and significant loss of lordosis. Balancing patients in the sagittal plane is significant insofar as increased ambulation reduces co-morbidities such as respiratory or circulatory maladies associated with sedentary lifestyles; pain reduction improves the quality of life. "We have frequently been called upon to manage these people with simple corsets or Jewett and CASH orthoses," he continues. Although these devices are excellent at providing three-point pressure mechanisms of action at the fracture site itself, Gavin notes, he contends that they do very little to address the loss of lordosis and erector spinae elongation. "In my experience, the latter of these two maladies is more debilitating in most cases. Whatever orthosis is chosen, it should restore sagittal balance so that one may dangle a plumb line from the acromium with the caudal end hanging at least two centimeters behind the greater trochanter. There are many orthotic methods to achieve this balance." Dorsolumbar orthosis. Photograph courtesy of Roger Marzano, CPO, CPed . Gavin points out that some physicians believe that the CASH and Jewett apply too much shear force and risk fracturing the patients' facet joints and no longer recommend orthotic management. "I no longer use the CASH, Jewett, or dorsolumbar corsets as the former two are risky and all three are suboptimal." When asked for his thoughts on orthotic management of osteoporosis-related conditions, Kevin Meade, PhD, directed attention to Chapter 11, "Orthoses for Osteoporosis," in the 2008 Atlas of Orthoses and Assistive Devices. Meade is a spinal-research specialist and university lecturer and has been instrumental in O&P education in Latin America, along with working at the Musculoskeletal Biomechanics Laboratory at the Department of Veterans Affairs (VA) Hospital in Hines, Illinois. Co-authored by Meade; Gavin; Bryan Malas, CO; and Avinash Patwardhan, PhD, the chapter is indeed a goldmine of information. Included is a section on "Best Practices": Direct the treatment plan toward relieving symptoms and improving function. Design the treatment plan with a multidisciplinary team approach since often there are co-morbidities such as chronic obstructive pulmonary disease (COPD), leg-length discrepancy, and pain, emphasizing the need for multidisciplinary involvement. Agree on clear goals of orthotic treatment. Patients may need to make significant changes in their environment and be willing to accept outside help for donning and doffing. This will be easier if the treatment goals and benefits are clear to patients. It is best to recommend the least invasive device that will accomplish the orthotic goals. Educate patients and caregivers on the proper fit and functioning of the orthosis. Compliance with treatment plan recommendations is crucial since patients are at high risk for further deterioration of their physical condition even over a short time. Agree upon the timing of follow-up visits and take steps to ensure patients follow it. Time is of the essence; major setbacks can occur quickly and greatly reduce the gains made over longer periods. Emphasize the importance of strengthening the paraspinal muscles. Many studies suggest that muscle strengthening is a key factor in improving function. A spinal orthosis should be seen as an aid to improving function by restoring posture and relieving pain rather than as an immobilization device. Do not use an orthosis intended to treat acute pain to treat chronic pain and vice versa. A common error is recommending an orthosis intended for acute pain management to manage chronic pain. In acute pain management, the orthosis is more immobilizing so the fracture can be stabilized. However, the same orthosis used in the same way to manage chronic pain may do more harm than good because immobilization over a long time is known to lead to further bone and muscle loss. Working closely with physical therapists in treatment also helps promote positive outcomes, note Gavin and Meyer. "Therapy is essential!" exclaims Gavin. He highly recommends physical therapists trained in the McKenzie Method of Mechanical Diagnosis and Therapy for spinal care, developed by Robin McKenzie and administered worldwide through the McKenzie Institute in New Zealand ( www.mckenziemdt.org ). At Mary Free Bed, Meyer feels she has the ideal setting for working with a physical therapist since they can attend the therapy session together. "I can see patients working with their physical therapist, and consequently, the therapist and I can discuss what we see happening and what may be the best form of action to take." Meyer firmly believes that it is best for the patient when the care team acts as a team and "bounces ideas off each other." She adds, "I have found the physical therapist's input extremely helpful and very valuable." Gavin also stresses the importance of patient education for good outcomes. "Many 25-year-olds cannot put a spinal orthosis on properly because of their spinal injury, so we cannot expect someone with a new osteoporosis orthosis to properly—key word 'properly'—don his or her orthosis." He adds, "An improperly donned spinal orthosis is worse than no orthosis at all! These need to be slowly donned and tightened while supine to allow the new sagittal geometry to be gently obtained." Gavin recommends that patients not use an orthosis before it is absolutely necessary and to arrange for help to don and doff the orthosis correctly. He notes that about 60 percent of patients fitted can eventually do this without assistance. "Education of the patient is key to your clinical success and crucial to your outcomes," Marzano concurs. Marzano advises orthotists to ask patients about their activities, lifestyles, employment, and associated pathologies to help determine which orthosis would best suit them. "Each patient is unique and needs a customized approach toward treatment," Meyer points out. Patients need to be compliant in following treatment recommendations by their doctors, therapists, and orthotists and take ownership of their treatment, she adds. "Many issues can come up when wearing an orthosis, such as skin problems, and the orthosis also must be maintained in good condition. Problems can occur if these things go unchecked." Orthotists should provide written instructions to patients as well. Concludes Marzano, "There will always be a role for orthotic treatment of osteoporosis and the associated pathologies involved. Orthotists and pedorthists should keep up-to-date on new orthosis designs and medical interventions." Miki Fairley is a contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at linkEmail('miki.fairley','gmail.com'); Osteoporosis: Risk, Prevention Although about 85-90 percent of adult bone mass is acquired by age 18 in girls and 20 in boys, bones are continuously being remodeled throughout life, with approximately 10 percent of bone mass being removed and replaced each year. The remodeling of bone requires the coordinated activity of two types of cells: osteoclasts, which demineralize bone; and osteoblasts, which secrete collagen and mineral to lay down new bone. Osteoporosis occurs when there is an imbalance between bone formation and resorption. Although men, children, and premenopausal women can develop osteoporosis, osteoporosis most often strikes postmenopausal women. Risk Factors According to the National Osteoporosis Foundation (NOF), risk factors for osteoporosis include the following: Age. People lose bone density as they age, and while not every older person develops osteoporosis, it does get more common with age. Gender. Osteoporosis is more common in women than in men. Family history of osteoporosis or fractures. Small, thin body build. Caucasian, Asian, or Hispanic/Latino race/ethnicity, although African Americans are also at risk. Amenorrhea, low sex hormones, or low estrogen levels in women and low levels of testosterone and estrogen in men. Certain medications, including steroids and some anticonvulsants, and certain diseases, such as anorexia nervosa, rheumatoid arthritis, and gastrointestinal diseases. The good news is that some risk factors, such as smoking, alcohol abuse, and lack of exercise, can be eliminated by lifestyle changes. Prevention The NOF recommends individuals follow these five steps to promote bone health and help prevent osteoporosis: Get the daily recommended amounts of calcium and vitamin D. Engage in regular weight-bearing and muscle-strengthening exercises. Avoid smoking and excessive alcohol. Talk to your healthcare provider about bone health. Have a bone-density test and take medication when appropriate. —Miki Fairley

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