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A 60-year-old woman was presented with two vertebral
fractures (L1 and L4) after a fall. She was subjected to vertebroplasty on
L1-L2-L3-L4. She had come to the multidisciplinary outpatient clinic for
“diagnosis, therapy, rehabilitation of patients with vertebral fragility
fracture” of Pisa University Hospital after 7 months from vertebroplasty. She
still presented pain in particular in lumbar and sacral spine. She was affected
by rheumatoid arthritis and was receiving corticosteroid therapy.
The most likely
diagnosis of this presentation is:
The fragility vertebral fractures are a significant public
health problem. In fact, they can have a considerable impact on an individual’s
health-related quality of life due to pain, limitations in activity, social
participation and altered mood. Vertebral fractures are related to increased
thoracic kyphosis and loss of lumbar lordosis that are linked to increased
spinal loading and back extensor muscles weakness. This can lead to an
increased risk of further fracture. Physiotherapy interventions may have an
important role in improving life quality, balancing and reducing the fracture
risk in people with osteoporotic vertebral fractures. In literature, there are
only few studies that examine exercise interventions in osteoporotic
populations with vertebral fracture and few studies that examine the effects on
balance with instrumental measurements. In the present case, we present the
effect of a specific rehabilitation program in a woman with fragility vertebral
fractures presented to the multidisciplinary surgery for “diagnosis, therapy,
rehabilitation of patients with vertebral fragility fracture” of Pisa, using
clinical evaluation and instrumental measurements.
Patient with secondary osteoporosis was presented with
fragility vertebral fractures. Specific rehabilitation program improved pain,
health-related outcomes and postural alignment of the patient.
She had a positive family history for osteoporosis (mother
with femoral fracture). She was in therapy with methylprednisolone, methotrexate,
alendronate, cholecalciferol and calcium carbonate.
At physical examination, she showed pain on spinous processes L1 and L2. She has a limited spinal flexion, only slight limitation on hip internal rotation and ankle flexion. She was investigated for all this parameters: number of fallings in the last year (1 falling), walking test in 20m (26,1 second), Barthel index (score: 95), cumulative illness rating scale (CIRS) (CIRS severity: 1,3; CIRS comorbidities:1), geriatric depression scale short version (GDS) (score: 11), VAS scale (neck score 4, dorsal score 0, lumbar score 8). The health outcome was measured with EuroQol-5D (Eq-5D). She indicated some problems for all dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression and indicated a Global health of 40. Height and weight was measured for calculation of Body Mass Index (BMI) that was 26,9. About the sagittal alignment, the occipital to wall distance was 5 cm. The scapular plane was 2 cm anterior than gluteal plane. The distance of apex of cervical lordosis from a virtual vertical plumb line was 9 cm, of lumbar lordosis 2 cm. In frontal plane, patient had asymmetry of the shoulder than the pelvis. The patient had a scar among breasts. For the instrumental evaluation of the balance, static stabilometry was used, which evaluates the postural balance through the quantification of the postural sway in the orthostatic position on a force platform. The variables for analysis of the stabilometric test were: displacement and speed of displacement in the medial-lateral (ML) and anterior-posterior (AP) axes from the center of pressure (COP).
Tapentadol 50 mg and paracetamol 1 g was prescribed for pain. The patient was confirmed for treatment with alendronate, cholecalciferol and calcium carbonate to decreased risk of new fractures that is present also in patients treated with percutaneous vertebroplasty. The patient started a specific rehabilitation program for fragility vertebral fractures (10 daily sessions, each of 40 minutes). The protocol was composed of supine exercises with legs in unloading above the cube, exercises in sitting position and standing against the wall. The exercise concentrated on the back extensor and posterior trunk postural muscles in order to promote a neutral spinal posture were suggested. All exercises were of low intensity in order to minimize compression loads though already-weakened vertebrae. In each position were performed proprioceptive exercises of trunk and pelvis.
Table 1 - Results of clinical parameters at T0 and T1.
|
Clinical parameters |
T0 |
T1 |
|
VAS scale neck |
4 |
2 |
|
VAS scale dorsal |
0 |
0 |
|
VAS scale lumbar |
8 |
3 |
|
Height (cm) |
162 |
163 |
|
Occipital to wall distance
(cm) |
5 |
5 |
|
Apex of cervical lordosis
distance (cm) |
9 |
9 |
|
Scapular plane distance
(cm) |
2 |
1 |
|
Lumbar lordosis distance
(cm) |
2 |
3 |
|
Gluteal plan distance (cm) |
0 |
0 |
|
Walking test in 20m (sec) |
26,1 |
23,8 |
This report presented the case of a woman with fragility vertebral fractures (L1, L4) treated with vertebroplasty (L1, L2, L3, L4), subjected to a specific rehabilitation program. Based on the concept that back extensors weakness is associated with vertebral fractures and can be a key element in the pathophysiology of flexed posture, exercises for strengthening of back extensor muscles were included in the protocol. The exercises proposed were well tolerated and there were no adverse effects. Good results were achieved with the specific rehabilitation program. The lumbar VAS score was changed from 8 (T0) to 3 (T1), the walking test changed from 26,1 sec (T0) to 23,8 sec (T1). The health outcome was improved in all dimensions of Eq-5d (T0:0,19; T1:0,53) and also in the Global health (T0: 40; T1: 80). Scapular plan distance was changed from 2 cm (T0) to 1 cm (T1), the lumbar lordosis distance from 2 cm (T0) to 3 cm (T1). The height was changed from 162 cm to 163 cm. The fact that rises interest in this case was the stabilometric evaluation. In fact, even though she doesn’t have significant posture disorders, the COP’ displacement shows an impaired postural control.
There is evidence that
patients with chronic low back pain have poorer postural control. The patient
had a VAS score of 8. The postural control is also influenced by reduced
mobility and the fear of falling, in fact the patient has a reduced mobility of
spine and a GDS score of 11. After rehabilitation program, the COP’s
displacement is improved with a reduction in COP mean velocity and COP
anterior-posterior velocity.
In conclusion, the specific rehabilitation program proposed
to this patient had showed good results about pain, health outcome, postural
alignment and postural balance. In literature, there are no standardized
protocols for the treatment of patients with fragility vertebral fractures.
This is only a single case, but of a standardized protocol currently applied to
all patients who belong to the multidisciplinary outpatient for “diagnosis,
therapy, rehabilitation of patients with vertebral fragility fracture” of Pisa
University Hospital. The mechanism underlying postural control is not clear
yet. The instrumental evaluation of postural balance is important for an early and
clear diagnosis of postural imbalance and to identify with more accuracy the
patients that need rehabilitation.
Clin Cases Miner Bone Metab. 2016 Jan-Apr;13(1):67-70
Efficacy of a specific rehabilitation protocol in postural control of a young woman with multiple fragility vertebral fractures: a case report
Gloria Raffaetà et al.
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