The Core Issue: Orthotic Management of Osteoporosis

As baby boomers age and the U.S. senior citizen population grows, experts speculate that orthotists will see an increase in the number of patients who have a disease that coincides with aging: osteoporosis. Osteoporosis is a disease in which the body loses too much bone, makes too little bone, or both. As a result, the bones become weak and may break from just a minor fall. The disease can also cause the vertebrae to break or collapse, which can impact posture and result in hunching, or kyphosis. In light of this, it is essential for orthotists to learn effective treatment options, experts say. "These patients are very underserved by the medical community as a whole," says Thomas M. Gavin, CO/L, national orthotic specialist in charge of the spine, with the national orthotic program for Hanger Clinic, headquartered in Austin, Texas. "We shouldn't be focusing so much on scoliosis but instead should focus more on osteoporosis because that will soon be 17 times the demographic [of those with scoliosis]." Currently, according to the National Osteoporosis Foundation, osteoporosis and low bone mass, which places individuals at increased risk for osteoporosis, impact an estimated 54 million U.S. women and men age 50 and older. By 2020, that number is expected to grow to 64.4 million, and by 2030, it is expected to grow to 71.2 million-a 32 percent increase from 2010, according to the International Osteoporosis Foundation. The good news is that there are treatment options for these patients that include pharmaceuticals, physical therapy, and surgery in some cases. Orthotists who work with this population say they've also found ways to improve the quality of life for their patients in conjunction with other treatments. "Given certain clinical presentations, I've seen patients who were able to discontinue the pain medications or limit the use of an assistive device with proper orthotic management," says Bryan Malas, CO, director of the Orthotics-Prosthetics Department at the Ann & Robert H. Lurie Children's Hospital of Chicago. "To discontinue those medicines, that's a big deal." A Debilitating Disease and a Challenging Patient Population The disease tends to impact women four times more frequently than men because women can lose bone density during menopause, says Michael Mangino, CPO, CPed, co-owner of Bay Orthopedic & Rehabilitation Supply, Huntington Station, New York. In many cases, the disease isn't detected until it's already serious. "The problem with most patients is that they don't realize they have the condition-because it's usually painless-until they suffer a fracture," Mangino says. "In many cases osteoporosis can occur unevenly in the vertebrae, leading to wedging of the vertebrae, which can lead to adult onset scoliosis and kyphosis." Osteoporosis can also increase mortality in patients. A 2004 study showed that there are higher mortality rates associated with the severity of kyphosis. 1 A 1999 study also shows that women who had the most severe forms of kyphosis were more likely to die of pulmonary causes. 2 Along with the seriousness of osteoporosis, orthotists also have the challenge of trying to treat a patient whose condition is constantly changing because of the progressiveness of the disease, Malas says. "Their presentation is a moving target. So frequent discussions with the physical therapist, physician, family, and patient are important for establishing proper expectations." Another challenge of treatment is that patients with osteoporosis tend to have other ailments. "The patient is not necessarily easy to manage," Gavin says. "They have other issues associated with aging. [T]he issue of osteoporosis might just be one of several issues they are dealing with." While the process can be challenging, Gavin says, when the treatment he provides is successful, patients are less reliant on pain medication, have improved mobility, and in general, have a better quality of life. "The advantage is that they no longer need a walker, and they increase their ability to be vertical by four- to five-fold throughout the day." Finding Solutions When treating patients with osteoporosis, orthotists need to work in conjunction with the patient's physician and physical therapist, the experts say, and often the best solution is a combination of treatments. "There are a number of prescription medications and vitamin supplements that have been used to slow down the resorption process and treat menopause," Mangino says. "Physical therapy and exercise programs have also [been] shown to strengthen the human body and delay the effects of osteoporosis. I think a regimen of both modalities is the best way to thwart the effects of osteoporosis." Orthotic solutions, though, can help patients become more mobile and develop the strength necessary for a better quality of life, and the experts say treatments that use biomechanics to dynamically change the spine are superior to traditional braces that can restrict movement and cause atrophy. Malas says orthotists should not be treating patients with acute and chronic osteoporosis in the same way. In acute osteoporosis, a recent vertebral compression fracture requires stabilization around that site; however, if the patient has a chronic presentation secondary to osteoporosis, then the solution often depends on the severity of the case, he says. For the least severe cases of osteoporosis, postural training support has been found to be effective to help strengthen muscles and eventually lead to better mobility and posture, he says. The posture training support, also called a spinal weighted kyphoorthosis (WKO), resembles a backpack with a strap around the waist. Weights are added to the pack incrementally, and after at least a month, Malas says, the weights help shift the patient's center of gravity to reposition the spine and improve the patient's posture and resting alignment of the erector spinae. "If you can improve posture, there is a better chance of restoring proper muscle alignment," Malas says. Studies show that postural training support can also help patients with hyperkyphosis become steadier on their feet and less susceptible to falls. A 2005 study by the Mayo Clinic reports that patients with osteoporosis who used a WKO in addition to exercise showed improved balance and gait and a decreased risk of falls after four weeks. 3 Another possible solution for patients, especially those with acute osteoporosis, is medi USA's SpinoMed®, Malas says. The SpinoMed consists of an abdominal pad, paraspinal bars, a back pad, and a system of straps and Velcro® closures. This can be a solution for patients with acute osteoporosis when the back needs to be stabilized, or during the chronic phase when postural realignment is required. For patients with severe osteoporosis with kyphosis, orthotists have found solutions that can be helpful, though they tend to require the patience and motivation of the patient to work as they should. Gavin and his colleagues have spent years working to perfect a posterior shell thoracic-lumbarsacral orthosis (TLSO). This solution is similar to the SpinoMed, with a soft corset and shoulder straps to help correct posture. Once fitted, the straps are steadily tightened to improve posture gradually. He recommends that patients wear it full time for four months and then, as posture improves, patients can lessen their wear schedules. This TLSO is difficult to don and doff and patients will need assistance, he says. It's worth the effort when patients are able to stop using their walkers, though, he says. "[Using this TLSO] is under the premise that we might be able to better manage these patients' quality of life if we can just get them upright," Gavin says. "I've had people coming back to me ten years later just for some maintenance and I ask them if they are still wearing it. They look at me like I am crazy and say they couldn't get through the day without it." Mangino says he has had success with a lightweight design. He uses a semirigid TLSO with a two-part casting technique, which involves casting the patient while he or she is initially lying supine, and then gently rolling onto her or his stomach with the anterior portion of the cast still in place. He also employs techniques that use both laser and white light scanners to make the casting easier on the patient. "This is particularly effective in adult scoliotic or kyphotic patients because it improves the respiratory process by increasing the amount of air capable of being inhaled. The brace also removes the pain caused by the rib cage resting on the pelvis," Mangino says. Have Patience Part of the challenge of treating patients with osteoporosis is that they must be willing to be a bit uncomfortable and stay that way for at least a month before they see any noticeable results, Gavin says. "It's a major routine every day, and it's going to limit some of the motions of daily living," he says. He has this issue with many patients, including his mother. "She was skeptical for probably the first three months," he says. "Each time she tried to sneak out of it, she gave 101 excuses." Now, he says, his mom has noticeably improved and only needs to wear her brace five hours a week. Malas says that the process of improving posture through orthotic devices must be done gradually. Whether it is during the casting technique or fitting of the orthosis, the orthotist has to be careful not to force alignment or the orthosis will be too uncomfortable or can cause injury. In short, alignment should be progressive over the course of several months, which will change the look and feel of the device. "Patients and families need to understand that the initial fit of the orthosis will look different than the fit during subsequent visits. It is important that this expectation be made clear to the patient and family from the outset." When providing orthotic management for this population, it is important for the orthotist to step back and look at the patient's entire clinical presentation. If, for example, the patient has rheumatoid arthritis, it may be difficult for her or him to properly don the orthosis. Under these circumstances, regardless of the appropriateness of the orthotic design, the treatment will be ineffective if the patient is unable to don the orthosis. "You may have an orthosis that fits well, but if the patient can't properly don the orthosis, an alternative solution may be required. This could be a different design altogether or require the assistance of a caretaker...," Malas says. Patients and orthotists should not look to just one brace or treatment as a solution, Mangino says. Patients should not be expected to wear their braces all day long and should also look to other solutions, especially physical therapy, he says. "The one thing I would like to emphasize is that we don't expect our braces to be used more than six hours a day," he says. "I believe the physical therapy program, such as Schroth therapy, should be practiced at home so that a dependency does not occur. We like to see the brace used as a tool to allow the patient to shop, visit friends, and reduce pain. But they should maintain as active a lifestyle as possible and keep on developing their muscles and their strength." The Schroth Method, developed in the 1920s by Katharina Schroth, focuses on halting the progression of the spinal curve by using stretching, strengthening, and breathing techniques that are designed to counteract the rotation of the spinal curvature. It is most often used for scoliosis patients, but Mangino says it has promise to work well with osteoporosis patients. Looking Forward The future of treating osteoporosis patients should be based on science and studies of best outcomes, the experts say. Unfortunately, there still need to be more studies to determine which solutions are best for which patients. Gavin says, "We need to have more research to see why one device may be more effective than another, as well as what dosage is most beneficial for the patient. The question is, 'to what degree do certain variables take us to one direction versus another?'" Orthotists also need to help physicians see the benefits of their treatments, Gavin says. The best way to do that is to have peer-reviewed, evidence-based studies that show how the orthotic devices compare to other treatments, including surgery and physical therapy. Gavin is currently conducting research at the Musculoskeletal Biomechanics Laboratory at the Edward Hines Jr. VA Hospital, Hines, Illinois, to try to answer some of those questions. Mangino says he hopes to see a brace that will fulfill patients' changing needs, right when they need it. "In a perfect world, a brace design would allow the patient to have a fairly rigid device when necessary and soft support at other times so they can develop their own muscles," Mangino says. "I can foresee a brace design that could easily be created to be rigid one moment and flexible the next. I can see this happening by a patient controlling the rigidity of the orthosis by activating and deactivating a magnetic field on the brace with a valve or a switch, or for that matter using a pneumatic or hydraulic column that can be switched on or off in a fraction of a second...." For the moment, Gavin says, orthotists will have to work with the solutions they have. They have their jobs cut out for them, he says. "To walk in the room and see someone with such a forward posture and to get them upright seems like a daunting task," Gavin says. "It's every bit as intimidating as walking into an intensive care unit." Maria St. Louis-Sanchez can be reached at msantray@yahoo.com . References Kado, D. M., M. H. Huang, A. S. Karlamangla, E. Barrett-Connor, and G. A. Greendale. 2004. Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. Journal of American Geriatric Society 52 (10):1662-7. Kado, D. M., W.S. Browner, L. Palermo, M. C. Nevitt, H. K. Genant, and S. R. Cummings. 1999. Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Archives of Internal Medicine 159 (11):1215-1220. Sinaki, M., R. H. Brey, C. A. Hughes, D. R. Larson, and K. R. Kaufman. 2005. Significant reduction in risk of falls and back pain in osteoporotic-kyphotic women through a spinal proprioceptive extension exercise dynamic (SPEED) program. Mayo Clinic Proceedings 80 (7):849-55.

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