28/03/2017. Content. Non-Pharmacological Treatments for Osteoporosis. Managing Pain from A Vertebral Fracture. Traditional Conservative Approach

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1 Content Non-Pharmacological Treatments for Osteoporosis T.Masud Nottingham University Hospitals NHS Trust University of Nottingham University of Derby University of Southern Denmark Back Pain Back Supports / Bracing Vertebroplasty / Kyphoplasty Hip Protectors Exercise Whole Body Vibration Not Covered: Falls Vitamin D Nutrition Flooring type Post hip fracture Ultrasound Mud Therapy Managing Pain from A Vertebral Fracture Traditional Conservative Approach Bed Rest Analgesics Bracing Physiotherapy Systematic Review: Longo et al; J Bone Joint Surg 2012 To date the best management of acute painful vertebral Crush Fractures has not been defined and few level 1 studies are available for review Calcitonin for treating acute pain of osteoporotic VFs : A systematic review of RCTs Knopp et al, Osteoporos Int (2005) 16: RCTs Calcitonin versus Placaebo, n=246 2 IM, 2 IN, 1 Rectal Visual Analogue Scale Intravenous pamidronate for pain relief in recent osteoporotic vertebral compression fracture: a double-blind RCT Armingeat et al, Osteoporos Int (2006) 17: placaebo, 16 pamidronate 30mg IV 3 consecutive days; M+F, mean age 75 (SD 5) IM route best Shortened time to mobilisation Day 7 MD 23 mm (p 0.018), Day 30 MD 26 mm (p 0.03) Day 7 placaebo 4/16 50% responders; pamidronate 12/16 50% responders 1

2 Journal of Pain 2009 Bracing Goal- stabilise spine and limit progression of deformity Reduction in bed rest period - earlier mobilisation L2 dorsal root ganglion may innervate the L3 and L4 vertebral bodies in humans. L2 spinal nerve block for acute L3 or L4 osteoporotic vertebral body fracture was effective for 2 weeks, but it had no long term effects on pain and social function. May be a useful strategy to treat acute low back pain. Use is largely opinion based rather than evidence based Good results in acute non-osteoporotic VFs {24 RCTs} ( burst fractures ) Examples are: 3 pt pressure system holds spine in hyperextension eg. Jewett orthosis CASH orthosis (cruciform anterior spinal hyperextension) Taylor brace, Knight-Taylor corset Spinomed and Spinomed Active Effects of Two Newly Developed Spinal Orthoses on Trunk Muscle Strength, Posture, and Quality-of-Life in Women with Postmenopausal Osteoporosis: an RCT Vertebroplasty Pfeifer et al Am J Phys Med Rehabil 2011 Back Extensor Strength 72% Abdo Flexor Strength 44% Angle of Kyphosis 11% Body Sway 23% Vital Capacity 19% Average Pain 41% Well Being 18% Limitations in Daily Living 49% Acrylic bone cement Drop out rate 7% To relieve pain from a vertebral fracture and to stabilise the vertebra 2

3 Balloon Kyphoplasty A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures Kallmes et al, NEJM INVEST Used for - relief of refractory pain caused by vertebral fractures - to increase vertebral strength - to restore vertebral height / reduce kyphotic angle A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures Buchbinder et al NEJM 2009 Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Klazen et al. Lancet 2010 n 202 n 78 Comparing effects of kyphoplasty, vertebroplasty, and nonsurgical management in a systematic review of randomized and non-randomized controlled studies Papanastassiou et al; Eur Spine J; 2012 Systematic Review; Papanastassiou et al; 2012 Pa 3

4 PAIN CHANGES Meta-regression: Fracture age versus pain change BKP NSM VP Papanastassiou et al Papanastassiou et al 2012 Quality of Life Changes: BKP versus VP NICE TA 279 April 2013 NICE recommends vertebroplasty or kyphoplasty (without stenting) as possible treatment options for some people with spinal compression fractures caused by osteoporosis: with severe on going pain after a recent unhealed fracture of the spine despite treatment for pain pain is confirmed to where the fracture is Papanastassiou et al Biopsychosocial Model of Chronic Pain FRACTURE PREVENTION TRIANGLE Vitamin D Exercise Whole Body Vibration FRAGILITY HIP FRACTURE Drugs / Lifestyle FALLS FORCE Hip Protectors Francis et al Osteopor Int 2008 Adapted from Spanswick and Main 2000 Fall Prevention Measures 4

5 Hip Protectors; P. Kannus et al NEJM % non compliance in active group. 50 % drop out during study 1801 ambulatory but frail elderly adults (1409 women and 392 men; mean age, 82 years), randomly assigned in a 1:2 ratio, either to a group that wore a hip protector or to a control group. 13 subjects in the hip-protector group had a hip fracture, as compared with 67 subjects in the control group. In the hip-protector group, four subjects had a hip fracture (among 1034 falls) while wearing the protector, and nine subjects had a hip fracture (among 370 falls) while not wearing the protector (relative hazard, 0.2; 95 percent confidence interval, 0.05 to 0.5; P=0.002). Hip Protectors in Care Homes: Systematic Review. Hip Protectors in Care Homes: Cochrane Review Parker M J et al. BMJ 2006;332: BMJ Parker et al l Hip Protectors in Community Dwellers: Systematic Review. Hip Protectors in Community Dwellers: Cochrane Review 2014 Hip Protectors may increase Pelvic Fractures 2006 BMJ Parker et al Santesso et al 5

6 When to Consider Hip Protectors? EXERCISE Care Home Residents Cognitively impaired Recurrent fallers Severely osteoporotic individuals Main advantages: 1. Low cost 2. Immediate Benefit Mechanostat Theory- Harold Frost The Muscle-Bone Unit MES - Minimal Effective Strain for bone modelling and remodelling BONE STRAIN Strain < MES Lazy Zone Strain > MES Cochrane Review on Falls (Community Dwellers, 2012) Pooled Analysis of 6 exercise trials showed that exercise intervention can reduce fractures by 66% (RR 0.34; CI ) Bone Loss No bone accrual or loss Bone Gain Type of Exercise on Spine Fame reduced falls Fame and Otago did not increase BMD Type of Exercise Reoccurrence of Fracture Back extension 16% Flexion (abd. curls) 89% Combined 53% No exercise 67% Sinaki & Mickelson

7 Yoga and Vertebral Fractures Whole Body Vibration What is the Mechanism? Muscle Activation Increased O 2 Uptake Increased Blood Flow Hormones Stem cell differentiation into osteoblasts rather than adipocytes Sinaki Pain Practice 2012 Types of Vibration POWERPLATE GALILEO Balance and Mobility Training Effect Muscular Strength and Power Vibration Bosco et al. 1998, Eur J Appl Physiol 79(4) Vibration with Exercise Torvinen et al. 2002, Med Sci Sp Ex 34(9) Delecluse et al. 2003, Med Sci Sp Ex 35(6) Vibration during Weight Training Issurin et al. 1994, Jnl Sp Sci 12(6) Berchin et al. 2003, Leistungssport 33(4) No Change in Sway Torvinen et al. 2002, Med Sci Sp Ex 34(9) Reduced Sway Verschueren et al. 2004, JBMR 19(3) Reduced Get Up and Go Time Bautman et al. 2005, BMC Geriatrics 5(17), p6 Bruyere et al. 2005, Arch Phys Med Rehabil 86, p

8 WBV - effects on BMD Increased bone mineral density Effects of Vertical and Side-alternating Vibration training on Fall risk factors and Bone Turnover in older people at risk of Falls 49 Patients Rubin et al Ward et al (disabled children); Rittweger 2004 (bed rest) 17 Vertical Vibration (Powerplate) 16 Tilting Vibration (Galileo) 16 Placebo (Sham vibration) Verschueren 2004 (PMW, hip BMD) Gilsanz et al No change Torvinen et al INTERVENTION 3/week for 12 weeks 1x30 sec to 6x1min (1min recovery) 30Hz Russo 2003 Rubin 2004 Corrie, Brooke-Wavell, Mansfield, Cowley, Morris, Masud Age Ageing 2015 USUAL CARE Falls prevention strategy based on the Otago programme Conclusion on WBV Increased muscular strength and power Balance? Mobility? Bone health? Falls?? Fractures?? Vibration Training Protocol? Combination with Osteoporosis Treatments? PAVOS study in Denmark- results awaited Summary Back Pain Back Supports / Bracing Vertebroplasty / Kyphoplasty Hip Protectors Exercise Introduction Whole Body Vibration Thank You Any Questions? 8