Nonpharmacologic management of osteoporosis to minimize fracture risk.

The traditional management of osteoporosis has focused on the pharmacologic aspects of treatment. Nonpharmacologic approaches, such as the use of orthoses, exercise programs, calcium and vitamin D supplementation, fall prevention, and kyphoplasty have largely been overlooked. Evidence for an essential contribution of nonpharmacologic treatments in the management of osteoporotic patients is increasing, particularly for patients who cannot, or will not, comply with medication regimens. This Review highlights the most important aspects of nonpharmacologic management of osteoporosis.

Clinical outcomes of ultrasound-guided aspiration and lavage in calcific tendinosis of the shoulder.

OBJECTIVE: To determine the effectiveness of ultrasound-guided aspiration and lavage in the treatment of patients with calcific tendinosis of the shoulder. MATERIALS AND METHODS: Retrospective chart review resulted in 44 patients who were identified as having received ultrasound-guided aspiration of calcific tendinosis of the shoulder between 2000 and 2003. Of these, 36 patients were interviewed by telephone for pre- and posttreatment assessment of pain, shoulder function, prior shoulder surgery, injury, and prescribed treatment modalities with a follow-up time of 8 months to 3.1 years (mean = 22.5 months). L'Insalata score, numeric rating scale (NRS), and patient satisfaction score served as outcome measures. RESULTS: Our criteria for a successful outcome included (1) 12-point or greater improvement in the L'Insalata shoulder rating questionnaire, (2) 2-point or greater improvement in the NRS, (3) patient satisfaction rating of "good", "very good", or "excellent", (4) patients' willingness to undergo the procedure again if they experienced recurrent symptoms, and (5) 1 month or less of analgesic medication use after the aspiration procedure. We determined that ultrasound-guided aspiration of calcific tendinosis of the shoulder resulted in a successful outcome for 75% (27/36) of patients with a mean 20.2-point improvement in the L'Insalata shoulder rating questionnaire score and a mean 6.4-point improvement in the NRS (p < 0.01). CONCLUSION: This retrospective study suggests that ultrasound-guided aspiration and lavage of calcific shoulder deposits appears to be an efficacious therapeutic modality for treatment of calcific tendinosis. Further studies involving prospective randomized controlled trials would be helpful to further assess the long-term efficacy of this procedure as a minimally invasive treatment for calcific tendinosis of the shoulder.

Rehabilitation of the older adult with an osteoporosis-related fracture.

Osteoporosis is the most common metabolic bone disease and is clinically silent until it manifests in the form of fracture. When this occurs, significant deformity and disability can result. Appropriate rehabilitation of fracture includes antiosteoporotic medication; exercise programs; fall prevention; orthoses, such as bracing and hip protectors; and the minimally invasive procedures vertebroplasty and kyphoplasty.

Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial.

BACKGROUND: Treatment of osteoporosis following a hip fracture has been notoriously poor. Many efforts have been made to improve treatment rates. The purpose of this study was to determine whether a perioperative inpatient intervention program, involving patient education and providing a list of questions for the primary care physician, increased the percentage of patients in whom osteoporosis was addressed following a hip fracture. METHODS: A prospective, randomized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted. During their hospitalization, the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures, the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment, and the importance of medical follow-up for osteoporosis management. These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician, and they were reminded about the questions during a follow-up telephone call six weeks later. The patients in the control group received a brochure describing methods for preventing falls. Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed. Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy. RESULTS: The average age in each group was eighty-two years, and 78% of the patients were female. Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial. Fifteen (42%) of the thirty-six patients who had been randomized to the study group, compared with only seven (19%) of the thirty-six patients in the control group, had their osteoporosis addressed by their primary physician. This difference between the groups was significant (p = 0.036). CONCLUSIONS: Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions. Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management.

Falls in the elderly population.

Falls among elderly persons remain a difficult problem with few easy solutions. Falls are symptomatic of underlying clinical deficits, and a multidisciplinary approach is essential in identifying the risk factors and appropriate treatments for these patients. Patients with chronic medical conditions, such as spinal cord injury, traumatic brain injury, and amputations, possess additional unique risk factors that must be addressed. Interventions include treatment of potentially reversible medical conditions such as B12 and vitamin D deficiencies and home modifications,balance and exercise training programs, medication modification, hip protectors, and monitoring devices. Physicians, patients, family members, and caretakers should be reminded that minimizing falls risk requires persistence, patience, and dedication. Progress may not be noted overnight, but adherence to recommendations correcting intrinsic and extrinsic factors can help to minimize falls and their potentially devastating complications.

Osteoporosis: a review.

Osteoporosis is the most common metabolic bone disorder and remains an increasingly significant problem, affecting 200 million individuals worldwide. Osteoporosis often is undertreated and underrecognized, in part because it is a clinically silent disease until it manifests in the form of fracture. Sufficient recognition of the disease and its appropriate medical and nonmedical treatment are essential. Treatments including calcium and vitamin D, the bisphosphonates, estrogen, selective estrogen receptor modulators, calcitonin, parathyroid hormone, balance and exercise training programs, and the minimally invasive spine procedures vertebroplasty and kyphoplasty comprise a comprehensive multidisciplinary approach in the treatment of osteoporosis. The data suggest that medical treatment of osteoporosis is increasing each year as physician awareness is heightened. Nonmedical treatment of osteoporosis complements the appropriate pharmacologic treatment, and these treatments should be used together to maximize outcomes for patients with osteoporosis. Fracture data for the intravenous biphosphonates and the long-term effects of the minimally-invasive spine procedures vertebroplasty and kyphoplasty have yet to be reported in the literature, but the effects on bone mineral density, and short-term results of these procedures, respectively, have been promising.

Postpartum sacral fracture presenting as lumbar radiculopathy: a case report.

Although rare, sacral stress fractures may occur in pregnant women, and osteoporosis of pregnancy is a poorly understood entity. We present the case of a young, postpartum, recreational runner who developed low back pain (LBP) and radicular symptoms suggestive of L5 radiculopathy found to be secondary to sacral stress fracture. The patient had a good clinical outcome after several months and was able to resume her normal activities. This case illustrates that clinicians should have a high index of suspicion for sacral stress fracture in athletic pregnant or postpartum women presenting with LBP and/or lumbar radiculopathy. Also included are a brief review of osteoporosis in pregnancy and guidelines on the diagnosis and management of sacral stress fractures.

Prevention of hip fractures: medical and nonmedical management.

Hip fractures can have a significant detrimental effect on morbidity and mortality. Medical and nonmedical management approaches both may be used to help decrease the risk of hip fracture. Medical management includes the use of antiresorptive agents such as the bisphosphonates, calcium and vitamin D, selective estrogen receptor modulators, and anabolic agents such as parathyroid hormone, which strengthen bone. Nonmedical management includes fall prevention programs and hip protectors. Physicians caring for patients at risk for hip fracture should be cognizant of these management approaches to most effectively minimize fracture risk.

Sacral stress fractures.

Stress fractures result from skeletal failure resulting from submaximal repetitive forces over time. Sacral stress fractures may represent an underdiagnosed cause of low back and buttock pain. They occur primarily in two populations, young active persons and elderly osteoporotic women, usually corresponding to fatigue and insufficiency-type fractures, respectively. The clinical presentation of these fractures is similar, but the medical and rehabilitation management of these patient populations differs and is tailored to the specific underlying etiology. In both types of fractures, appropriate conservative measures generally result in good functional outcomes. This paper provides an overview of the anatomical considerations, risk factors, clinical presentations, diagnostic imaging findings, appropriate laboratory studies, medical management, and rehabilitation management of patients with sacral stress fractures.

De Quervain's tenosynovitis in patients with lymphedema: a report of 2 cases with management approach.

De Quervain's tenosynovitis is a tendonitis of the abductor pollicis longus and extensor pollicis brevis tendons. It commonly occurs as a result of overuse and is often seen in patients who perform repetitive activities. The occurrence of de Quervain's tenosynovitis in lymphedema has not been reported, nor has the management of de Quervain's tenosynovitis been discussed in the literature for patients whose lymphedema results from cancer or other disorders. Musculoskeletal conditions in lymphedema patients often require special considerations because these patients are more susceptible to infections and other complications. We describe the rehabilitation management of de Quervain's tenosynovitis in 2 patients with lymphedema secondary to breast carcinoma. Both patients responded to conservative management with a good clinical outcome. We conclude that a conservative initial management approach consisting of the continued wear of a compression garment, the fabrication of a custom-made thumb spica, occupational therapy with an emphasis on tendon gliding exercises, and prescription of a nonsteroidal anti-inflammatory drug is effective and safe.

The aging spine: new technologies and therapeutics for the osteoporotic spine.

Osteoporosis results in low-energy fractures of the spine. The load necessary to cause a vertebral fracture is determined by the characteristics related to the vertebral body structure, mineral content, and quality of bone. Radiographic techniques centered on dual X-ray absorptiometry (DXA) permit a determination of bone mass and fracture risk. Current medical therapies principally using bisphosphonate and pulsatile PTH profoundly decrease the risk of fracture (50+%). Fall prevention strategies can further decrease the possibility of fracture. A comprehensive approach to osteoporosis can favorably alter the disease.

Thromboembolic events in the cancer patient.

Thromboembolic events are a major cause of morbidity in cancer patients and may be harbingers of occult malignancy. Trousseau's syndrome (TS) is probably the best known thromboembolic syndrome in the cancer patient, encompassing a variety of paraneoplastic thromboembolic disorders. These include spontaneous recurrent or migratory venous thromboses and arterial emboli caused by nonbacterial thrombotic endocarditis in a patient with malignancy. Although linked to almost all cancers, venous thromboembolism (VTE) is a terminal event in many cancers occurring in women, such as breast, uterine, and lung cancers (Monreal et al. Thrombosis and Haemostasis 1997;78:1316). Appropriate recognition of the syndrome is paramount because TS often requires careful medical surveillance and management. Significant complications of thromboembolic events in the cancer patient include limb ischemia and deep venous thrombosis/pulmonary embolism, which can cause devastating and permanent consequences. The rehabilitation management of these complications is reviewed, with an emphasis on diagnostic and therapeutic approaches in this patient population.

Use of surface scanning for creation of transparent facial orthoses. A report of two cases.

OBJECTIVE: To introduce the advantages of surface scanning over conventional burn mask construction to produce better fitting transparent facial orthoses (TFO). DESIGN: Two case reports. SETTING: Regional burn center. PARTICIPANTS: Two burn survivors who sustained 25% and 82% total body surface area second and third degree flame burns, respectively. DESCRIPTION: A 50-year-old male who sustained 4.5% second and third degree facial burns and a 41-year-old female who sustained 6% second and third degree facial burns during the World Trade Center were fitted with a digitally produced TFO approximately 4 months after injury. After the patients were scanned, the images were edited to smooth existing scars and replicated as a mold through which the healing process was observed. RESULTS/DISCUSSION: Facial burns represent many psychological and rehabilitation challenges. We recommend the use of a digitally produced device in patients with severe facial burns who require constant pressure to minimize hypertrophic scarring and to improve cosmesis. Scar management studies have shown that surface scanning results in a better fitting mask than conventional fabrication, without the labor-intensive, time-consuming, and imprecise process, which may delay treatment effects. The conventional process is slow and anxiety-provoking, especially for children, who often require anesthesia. In contrast, the head scanner rotates 360 degrees around the pateint's head, painlessly and accurately capturing the profile and contour of the face in 7s. Since the procurement of this scanner, our two patients, as well as many other burn victims, have greatly benefited from the creation of face masks utilizing this equipment. We believe that all rehabilitation professionals caring for burn patients should be aware of this new technology.

Evaluation of occult cervical spine fractures on radiographs and CT.

The aim of this study was to evaluate occult cervical spine fractures on radiographs and CT. We reviewed radiographs of 68 patients with cervical spine fractures at a level 1 trauma center. Twenty-six patients showed occult fractures on initial radiographs. Of seven odontoid fractures, two were diagnosed only after thinner repeat CT reconstructions. Five facet fractures were best seen on CT reconstructions. Three occult hangman's fractures were seen by CT. A C1 fracture was diagnosed on CT only. Two fractures through the C2 body were seen only by CT. Eight fractures were obscured by patient's shoulders, including five clay shoveler's fractures, a C6 facet fracture, a bilateral C6 pedicle fracture, and a C7-T1 fracture-dislocation. Odontoid, facet, and lower cervical spine fractures are most commonly occult on radiographs. CT, especially high-quality CT reconstructions for odontoid and facet fractures, can improve the diagnosis of cervical spine fracture.

Nonmedical management of osteoporosis.

Nonmedical therapies are playing an increasing role in the management of osteoporosis and its complications. They serve as useful adjuncts to medical treatment. Several areas of nonmedical options for the management of osteoporosis include bracing, exercise, and vertebroplasty and kyphoplasty.

Low back pain and myalgias in acute and relapsed mast cell leukemia: a case report.

Mast cell leukemia is a rare, severe disease that may manifest through an array of clinical presentations, including vasomotor flushing and hypotension. Leukemic infiltrate of muscle and bone may rarely occur, resulting in nonspecific myalgias, bony pain, and neuropathic pain secondary to compression of nerves by bone. Mast cell leukemia as a clinical entity has not been well described. We present the case of a 25-year-old man with a remote medical history of germ cell tumor who was initially diagnosed with mast cell leukemia after presenting with low back pain. One and a half years later, the patient presented with a chief complaint of back pain and myalgias and was found to have relapsed mast cell leukemia. Medical management and, specifically, rehabilitation of these patients can be extremely difficult. This report shows the complex management of patients with mast cell leukemia.

Lambert-eaton myasthenic syndrome: a case report and review of the literature.

Lambert-Eaton myasthenic syndrome (LEMS) is a type of paraneoplastic syndrome that may initially manifest with weakness and gait abnormalities. These symptoms may precede the diagnosis of malignancy by months or years, and morbidity and mortality may be significantly affected by early detection of the malignancy. A case report and review of the diagnosis, management, and treatment of these syndromes are presented, with particular emphasis on the rehabilitation management of these patients, often overlooked in medical treatment.

Bony pathology in the cancer patient.

Bony pathology in the cancer patient represents a significant source of morbidity and mortality. Complications include insufficiency and pathological fractures resulting from either medical treatments or bony metastases that can cause significant functional limitations. Additional complications include spinal cord compression, hypercalcemia, and bone marrow failure. Rehabilitation management of such conditions is reviewed, with an emphasis on diagnostic and therapeutic management. Bracing and focused rehabilitation programs facilitate maximal participation and functional outcomes, which can result in an enhanced quality of life. Specific rehabilitation goals and strategies are discussed, with an emphasis on tailoring these according to the functional staging of the patient.