Ptp&M013 Npte 5

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M013 NPTE-5/5 Revision: 02 Page: 1 of 110
NATIONAL PHYSIOTHERAPY EXAM PREP GUIDE
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Medicine: it’s a noble profession, It serves humanity
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PASSAGE TO THE USA, VIA CAPE OF NPTE.
NATIONAL PHYSIOTHERAPY EXAMINATION-PART-5
SPEC. BY: Abdulrehman S. Mulla
DATE: 03/21/2009
REVISION HISTORY
REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT0013 ASM 04/25/2009

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TABLE OF CONTENTS PAGE
7.0 OSTEOPOROSIS UPDATE INCLUDING WORLD HEALTH ORGANIZATION CRITERIA, BONE MINERAL DENSITY AND
INTERVENTION: ....................................................................................................................................................................................................... 6
7.1 DIAGNOSING OSTEOPOROSIS:............................................................................................................................................................. 7
7.1.1 BMD TEST: ............................................................................................................................................................................... 8
7.1.2 RECIEPIENTS OF THE BMD Test: .......................................................................................................................................... 8
7.1.3 TYPES OF BONE DENSITY TESTS: ....................................................................................................................................... 9
7.1.4 OTHER TYPES OF TESTS: ................................................................................................................................................... 10
7.1.5 HOW OFTEN TO REPEAT A BMD TEST: ............................................................................................................................. 11
A. TESTS TO FIND BROKEN BONES:....................................................................................................................................... 11
7.1.6 UNDERSTANDING BMD TEST RESULTS: ........................................................................................................................... 11
7.1.7 WHAT YOUR T-SCORE MEANS: .......................................................................................................................................... 12
7.1.8 TREATMENT CONSIDERATIONS:........................................................................................................................................ 12
7.2 PHYSIOTHERAPY INTERVENTIONS:................................................................................................................................................... 14
7.2.1 RISK FACTORS:..................................................................................................................................................................... 14
7.2.2 TARGET CLIENT GROUPS FOR TREATMENT BY PHYSIOTHERAPISTS:........................................................................ 14
7.2.3 PHYSIOTHERAPY ASSESSMENT: ....................................................................................................................................... 15
7.2.4 ANTHROPOMETRIC AND SPINAL MOBILITY ASSESSMENT: ........................................................................................... 16
A. HEIGHT:.................................................................................................................................................................................. 16
B. WEIGHT: ................................................................................................................................................................................. 16
C. CHEST EXPANSION MEASURED AT XIPHISTERNUM:...................................................................................................... 16
D. CERVICAL/THORACIC DEFORMITY (TRAGUS TO WALL): ................................................................................................ 16
E. SHOULDER ELEVATION: ...................................................................................................................................................... 16
F. LUMBAR SPINE RANGE OF MOVEMENT (SCHOBER EXTENSION):................................................................................ 16
7.2.5 STRENGTH/ENDURANCE ASSESSMENT: .......................................................................................................................... 16
7.2.6 AEROBIC CAPACITY ASSESSMENT:................................................................................................................................... 17
7.2.7 BALANCE ASSESSMENT:..................................................................................................................................................... 17
7.2.8 FUNCTIONAL ASSESSMENT:............................................................................................................................................... 17
7.2.9 PAIN ASSESSMENT: ............................................................................................................................................................. 18
7.2.10 ANALYSIS OF ASSESSMENT AND OUTCOMES:................................................................................................................ 18
7.3 PHYSIOTHERAPY MANAGEMENT: ...................................................................................................................................................... 18
7.3.1 MANAGEMENT FOR THE OSTEOPENIC AND PREVENTION GROUP:............................................................................. 18
7.3.2 EXERCISE MANAGEMENT FOR BONE HEALTH: ............................................................................................................... 19
7.3.3 PRECAUTIONS: ..................................................................................................................................................................... 21
7.3.4 THE OSTEOPOROTIC GROUP WHO HAVE NOT SUSTAINED FRACTURES: .................................................................. 21
A. EXERCISE MANAGEMENT FOR BONE HEALTH: ............................................................................................................... 21
B. PRECAUTIONS ...................................................................................................................................................................... 22
7.3.5 FRAILER GROUP WITH SEVERE CHANGES WHO HAVE OFTEN SUSTAINED FRACTURES:....................................... 22
A. EXERCISE MANAGEMENT: .................................................................................................................................................. 22
B. PRECAUTIONS: ..................................................................................................................................................................... 23
C. PAIN MANAGEMENT: ............................................................................................................................................................ 23
I. HYDROTHERAPY: ......................................................................................................................................................... 23
II. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS):.......................................................................... 23
III. INTERFERENTIAL THERAPY:....................................................................................................................................... 23
IV. HEAT: ........................................................................................................................................................................ 23
V. RELAXATION:................................................................................................................................................................. 24
VI. COMPLEMENTARY THERAPIES: ................................................................................................................................. 24
7.3.6 BALANCE AND FALLS MANAGEMENT: ............................................................................................................................... 24
7.3.7 POSTURE AND FLEXIBILITY: ............................................................................................................................................... 25
7.3.8 EXERCISE PRESCRIPTION: ................................................................................................................................................. 25
7.3.9 PSYCHOLOGY OF EXERCISE:............................................................................................................................................. 26
A. ADHERENCE:......................................................................................................................................................................... 26
B. PROMOTING HABITUAL EXERCISE: ................................................................................................................................... 26
7.4 POTENTIAL HARMS AND RISKS: ......................................................................................................................................................... 27
7.5 EDUCATION: .......................................................................................................................................................................................... 27
7.5.1 PATIENT EDUCATION: .......................................................................................................................................................... 27
7.5.2 HEALTH EDUCATION: ........................................................................................................................................................... 27
8.0 MUSCULOSKELETAL DIFFERENTIAL DIAGNOSIS; KINEMATIC CHAIN TABLES: ........................................................................... 28
8.1 GENERAL PRINCIPLES:........................................................................................................................................................................ 28
8.1.1 DIFFERENTIAL DIAGNOSIS IN ORDER OF PREVALENCE:............................................................................................... 29

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8.1.2 DIFFERENTIAL DIAGNOSIS OF JAUNDICE:........................................................................................................................ 30
8.2 ARTHRITIS:............................................................................................................................................................................................. 31
8.2.1 APPENDICULAR ARTHRITIS: ............................................................................................................................................... 31
A SUTTON'S LAW:..................................................................................................................................................................... 31
B RADIOGRAPHIC HALLMARKS:............................................................................................................................................. 31
C PATTERN APPROACH: ......................................................................................................................................................... 35
D DEMOGRAPHICS:.................................................................................................................................................................. 36
E THE LAW OF PARSIMONY:................................................................................................................................................... 37
F. CONCLUSION: ....................................................................................................................................................................... 37
8.2.2 AXIAL ARTHRITIS: ................................................................................................................................................................. 38
A. DEGENERATIVE DISORDERS:............................................................................................................................................. 38
I. OSTEOARTHRITIS:........................................................................................................................................................ 38
II. DEGENERATIVE NUCLEAR DISEASE: ........................................................................................................................ 39
III. DEGENERATIVE ANNULAR DISEASE: ........................................................................................................................ 39
IV. DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH)....................................................................................... 40
V. INFLAMMATORY SPONDYLOARTHROPATHIES: ....................................................................................................... 40
1. RHEUMATOID ARTHRITIS:................................................................................................................................... 40
2. ANKYLOSING SPONDYLITIS:............................................................................................................................... 40
VI. CRYSTALLINE ARTHRITIS:........................................................................................................................................... 41
1. GOUT:..................................................................................................................................................................... 41
2. CALCIUM PYROPHOSPHATE CRYSTAL DEPOSITION DISEASE: .................................................................... 41
VII. PSORIATIC ARTHRITIS:................................................................................................................................................ 41
VIII. PSORIATIC ARTHRITIS:................................................................................................................................................ 41
IX. REITER'S SYNDROME: ................................................................................................................................................. 41
X. ENTEROPATHIC ARTHROPATHY:............................................................................................................................... 42
B. RADIOGRAPHIC HALLMARKS:............................................................................................................................................. 42
I. OSTEOPHYTES: ............................................................................................................................................................ 42
II. SYNDESMOPHYTES: .................................................................................................................................................... 43
III. DISC SPACE NARROWING:.......................................................................................................................................... 43
IV. BONY PROLIFERATION: ............................................................................................................................................... 43
V. EROSIONS: .................................................................................................................................................................... 44
VI. CRYSTAL DEPOSITION:................................................................................................................................................ 44
VII. SCLEROSIS:................................................................................................................................................................... 44
VIII. ANKYLOSIS:................................................................................................................................................................... 44
IX. SUBLUXATION:.............................................................................................................................................................. 44
C. PATTERN APPROACH: ......................................................................................................................................................... 44
I. OSTEOARTHRITIS:........................................................................................................................................................ 44
II. DEGENERATIVE DISC DISEASE:................................................................................................................................. 45
III. DISH: ........................................................................................................................................................................ 46
IV. ANKYLOSING SPONDYLITIS: ....................................................................................................................................... 47
V. RHEUMATOID ARTHRITIS: ........................................................................................................................................... 48
VI. CPPD CRYSTAL DEPOSITION DISEASE:.................................................................................................................... 48
VII. GOUT: ........................................................................................................................................................................ 49
VIII. HYDROXYAPATITE CRYSTAL DEPOSITION DISEASE:............................................................................................. 49
IX. PSORIATIC ARTHRITIS:................................................................................................................................................ 49
X. REITER'S SYNDROME: ................................................................................................................................................. 50
XI. ENTEROPATHIC ARTHROPATHY:............................................................................................................................... 50
D. DEMOGRAPHICS:.................................................................................................................................................................. 51
I. ARTHROPATHIES WITH MALE PREDOMINANCE: ..................................................................................................... 51
II. ARTHROPATHIES WITH FEMALE PREDOMINANCE:................................................................................................. 51
E. THE LAW OF PARSIMONY:................................................................................................................................................... 51
8.3 LUCENT LESIONS OF BONE: ............................................................................................................................................................... 52
8.3.1 DIFFERENTIAL DIAGNOSIS OF SOLITARY LUCENT BONE LESIONS:............................................................................. 52
A. AGE:........................................................................................................................................................................................ 53
B. AGE VS. MALIGNANT TUMOR TYPE ................................................................................................................................... 53
C. SIZE: ....................................................................................................................................................................................... 53
D. MARGINS:............................................................................................................................................................................... 53
E. MATRIX:.................................................................................................................................................................................. 54
F. LOCATION: ............................................................................................................................................................................. 54
G. EPIPHYSIS: ............................................................................................................................................................................ 55
H. METAPHYSIS: ........................................................................................................................................................................ 55

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I. DIAPHYSIS: ............................................................................................................................................................................ 55
J. PERIOSTEAL REACTION: ..................................................................................................................................................... 55
K. MULTIPLICITY: ....................................................................................................................................................................... 56
8.3.2 DIFFERENTIAL DIAGNOSIS OF MULTIPLE LUCENT BONE LESIONS:............................................................................. 56
A. WISE SAYINGS ABOUT SOLITARY LUCENT LESIONS:..................................................................................................... 56
8.4 SCLEROTIC LESIONS OF BONE: ......................................................................................................................................................... 58
8.4.1 GENERIC DIFFERENTIAL DIAGNOSIS OF SCLEROTIC BONE LESIONS:........................................................................ 58
8.4.2 DIFFERENTIAL DIAGNOSIS OF FOCAL OR MULTIFOCAL SCLEROTIC BONE LESIONS: .............................................. 59
8.4.3 DIFFERENTIAL DIAGNOSIS OF DIFFUSE SCLEROTIC BONE LESIONS:......................................................................... 59
8.4.4 THINGS TO REMEMBER ABOUT SCLEROTIC LESIONS: .................................................................................................. 60
8.5 PERIOSTEAL REACTION: ..................................................................................................................................................................... 60
8.5.1 CAUSES OF SOLID PERIOSTEAL REACTION:.................................................................................................................... 62
8.6 SOFT TISSUE CALCIFICATIONS: ......................................................................................................................................................... 62
8.6.1 GENERIC DIFFERENTIAL DIAGNOSIS OF DYSTROPHIC SOFT TISSUE CALCIFICATIONS: ......................................... 63
8.6 FRACTURES WITHOUT SIGNIFICANT TRAUMA:................................................................................................................................ 66
8.7 FACIAL AND MANDIBULAR FRACTURES:........................................................................................................................................... 68
8.7.1 FACIAL FRACTURES:............................................................................................................................................................ 68
8.7.2 RADIOGRAPHIC SIGNS OF FACIAL FRACTURES:............................................................................................................. 69
A. WISE SAYINGS ABOUT FACIAL FRACTURES: ................................................................................................................... 72
8.7.3 MANDIBULAR FRACTURES:................................................................................................................................................. 72
A. THINGS TO REMEMBER ABOUT MANDIBULAR FRACTURES:......................................................................................... 74
8.8 THE PAINFUL JOINT PROSTHESIS:..................................................................................................................................................... 75
8.9 SCOLIOSIS: ............................................................................................................................................................................................ 77
8.9.1 CLASSIFICATION OF SCOLIOSIS: ....................................................................................................................................... 79
8.9.2 RADIOGRAPHIC ASSESSMENT OF THE SCOLIOSIS PATIENT: ....................................................................................... 79
9.0 UPDATES ON BASIC LIFE SUPPORT AND CPR: ................................................................................................................................ 82
9.1 ADULT BASIC LIFE SUPPORT: ............................................................................................................................................................. 82
9.1.1 MAIN CHANGES IN ADULT BASIC LIFE SUPPORT (FIGURE 1). ....................................................................................... 84
9.1.2 MAIN CHANGES IN AUTOMATED EXTERNAL DEFIBRILLATION (AED). .......................................................................... 84
9.1.3 MAIN CHANGES IN ADULT ADVANCED LIFE SUPPORT (FIGURE 2). ............................................................................. 85
A. CPR BEFORE DEFIBRILLATION:.......................................................................................................................................... 85
B. DEFIBRILLATION STRATEGY:.............................................................................................................................................. 85
C. FINE VF:.................................................................................................................................................................................. 86
D. ADRENALINE: ........................................................................................................................................................................ 86
E. ANTI-ARRHYTHMIC DRUGS:................................................................................................................................................ 86
F. THROMBOLYTIC THERAPY FOR CARDIAC ARREST: ....................................................................................................... 86
G. POST RESUSCITATION CARE - THERAPEUTIC HYPOTHERMIA: .................................................................................... 86
A. ADULT BLS SEQUENCE:....................................................................................................................................................... 87
9.1.4 EXPLANATORY NOTES: ....................................................................................................................................................... 89
A. RISK TO THE RESCUER: ...................................................................................................................................................... 89
B. JAW THRUST: ........................................................................................................................................................................ 89
C. AGONAL GASPS:................................................................................................................................................................... 89
D. MOUTH-TO-NOSE VENTILATION:........................................................................................................................................ 89
E. MOUTH-TO-TRACHEOSTOMY VENTILATION:.................................................................................................................... 89
F. BAG-MASK VENTILATION:.................................................................................................................................................... 89
G. CHEST COMPRESSION: ....................................................................................................................................................... 90
H. COMPRESSION-ONLY CPR:................................................................................................................................................. 90
I. OVER-THE-HEAD CPR: ......................................................................................................................................................... 90
J. RECOVERY POSITION: ......................................................................................................................................................... 90
9.1.5 CHOKING:............................................................................................................................................................................... 91
A. RECOGNITION: ...................................................................................................................................................................... 91
B. ADULT CHOKING SEQUENCE:............................................................................................................................................. 91
9.1.6 EXPLANATORY NOTES: ....................................................................................................................................................... 92
A. RESUSCITATION OF CHILDREN AND VICTIMS OF DROWNING: ..................................................................................... 92
9.2 ADULT ADVANCED LIFE SUPPORT:.................................................................................................................................................... 93
9.2.1 CPR BEFORE DEFIBRILLATION:.......................................................................................................................................... 93
A. DEFIBRILLATION STRATEGY:.............................................................................................................................................. 93
B. FINE VF:.................................................................................................................................................................................. 94
C. VF/VT: ..................................................................................................................................................................................... 94
D. PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE:............................................................................................................ 94
E. ALS TREATMENT ALGORITHM: ........................................................................................................................................... 94

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I. SHOCKABLE RHYTHMS (VF/VT):................................................................................................................................. 94
a. Sequence of actions................................................................................................................................................ 94
F. PRECORDIAL THUMP: .......................................................................................................................................................... 95
G. EXPLANATION FOR THE CHANGES IN THE TREATMENT OF VF/VT:.............................................................................. 95
I. CPR BEFORE DEFIBRILLATION:.................................................................................................................................. 95
II. DEFIBRILLATION STRATEGY:...................................................................................................................................... 95
H. FINE VF:.................................................................................................................................................................................. 96
I. ADRENALINE: ........................................................................................................................................................................ 97
J. VASOPRESSIN:...................................................................................................................................................................... 97
K. ANTI-ARRHYTHMIC DRUGS:................................................................................................................................................ 98
I. NON-SHOCKABLE RHYTHMS (PEA AND ASYSTOLE)............................................................................................... 98
L. ASYSTOLE: ............................................................................................................................................................................ 99
M. DURING CPR:......................................................................................................................................................................... 99
N. POTENTIALLY REVERSIBLE CAUSES:................................................................................................................................ 99
O. THE FOUR ‘HS’: ..................................................................................................................................................................... 99
P. THE FOUR ‘TS’:.................................................................................................................................................................... 100
Q. INTRAVENOUS FLUIDS:...................................................................................................................................................... 100
R. OPEN-CHEST CARDIAC COMPRESSION:......................................................................................................................... 100
S. SIGNS OF LIFE:.................................................................................................................................................................... 100
9.2.2 DEFIBRILLATION: ................................................................................................................................................................ 100
A. STRATEGIES BEFORE DEFIBRILLATION:......................................................................................................................... 100
I. SAFE USE OF OXYGEN: ............................................................................................................................................. 100
II. CHEST HAIR:................................................................................................................................................................ 101
III. PADDLE FORCE: ......................................................................................................................................................... 101
IV. ELECTRODE POSITION: ............................................................................................................................................. 101
V. PADS VERSUS PADDLES:.......................................................................................................................................... 101
B. AIRWAY MANAGEMENT AND VENTILATION: ................................................................................................................... 101
I. BASIC AIRWAY MANOEUVRES AND AIRWAY ADJUNCTS:..................................................................................... 101
C. VENTILATION:...................................................................................................................................................................... 102
D. ALTERNATIVE AIRWAY DEVICES:..................................................................................................................................... 102
I. LARYNGEAL MASK AIRWAY (LMA):........................................................................................................................... 102
II. THE COMBITUBE:........................................................................................................................................................ 102
III. TRACHEAL INTUBATION: ........................................................................................................................................... 102
IV. CONFIRMATION OF CORRECT PLACEMENT OF THE TRACHEAL TUBE:............................................................. 103
E. CRICOTHYROIDOTOMY: .................................................................................................................................................... 103
F. ASSISTING THE CIRCULATION:......................................................................................................................................... 104
I. INTRAVENOUS ACCESS:............................................................................................................................................ 104
G. POST-RESUSCITATION CARE: .......................................................................................................................................... 105
I. AIRWAY AND BREATHING:......................................................................................................................................... 105
II. CIRCULATION:............................................................................................................................................................. 105
H. DISABILITY (OPTIMISING NEUROLOGICAL RECOVERY):............................................................................................... 105
I. SEDATION:................................................................................................................................................................... 105
II. CONTROL OF SEIZURES:........................................................................................................................................... 105
III. TEMPERATURE CONTROL:........................................................................................................................................ 105
10.0 DISASTER RESPONSE AND PLANNING INCLUDING PT ROLE: ..................................................................................................... 107
10.1 DISASTER PLANNING/PREPAREDNESS:.......................................................................................................................................... 107
10.1.1 DISASTER RECOVERY: ...................................................................................................................................................... 109
10.1.2 EVALUATING THE PLAN ANNUALLY. DISASTER RESPONSE........................................................................................ 109
10.2 PRINCIPLES OF HOSPITAL DISASTER PLANNING:......................................................................................................................... 110
TOPICS COVERED:
• Osteoporosis update including World Health Organization criteria, bone mineral density and
intervention
• Musculoskeletal differential diagnosis; kinematic chain tables
• Updates on basic life support and CPR
• Disaster response and planning including PT role

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7.0 OSTEOPOROSIS UPDATE INCLUDING WORLD HEALTH ORGANIZATION
CRITERIA, BONE MINERAL DENSITY AND INTERVENTION:
Osteoporosis is characterized by reduced bone strength, diminished bone density, and altered
macrogeometry and microscopic architecture of bone. Although both men and women can have
osteoporosis, the risk in men is often unrecognized and remains undiagnosed for years. The resultant
morbidity, mortality, and healthcare costs could all be avoided with timely intervention. No clear-cut
guidelines are available for the management of osteoporosis in men. A silent disease until the catastrophic
end result, osteoporosis is underdiagnosed and undertreated in men and women but is even less managed
in men. With appropriate therapy, the disease can be arrested before any fracture occurs.
Osteoporosis is generally considered a women’s health issue, as evidenced by a substantial body of
literature on this topic. However, according to the National Osteoporosis Foundation, approximately one
fifth of patients with symptomatic osteoporosis are men. Even though osteoporosis is more common in
women, the associated morbidity and mortality are greater in men. This is because osteoporosis is
unrecognized in men and therefore the resulting fractures in men are associated with more complications. It
is high time that primary care physicians evaluate all men starting at age 70 or those at high risk.
• About one fifth of all patients with symptomatic osteoporosis are men.
• The morbidity and mortality associated with osteoporosis is greater in men than in women.
• In men older than 70, osteoporosis results from decreases in calcium intake/ absorption, vitamin D
activation, sex hormone concentration, and declining functioning of osteoblasts.
• Evaluate all men older than 70 regularly for osteoporosis using dual-energy x-ray absorptiometry
testing.
• Treatment options for primary disease include bisphosphonates, parathyroid hormone, androgens, and
nonpharmacologic interventions, including diet and calcium and vitamin D supplementation.

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7.1 DIAGNOSING OSTEOPOROSIS:
There is no method of determining the actual structure of bones without actually removing a
piece during a biopsy (which is not practical or necessary). Instead, the diagnosis of osteoporosis is
based on special x-ray methods called densitometry. Densitometry will give accurate and precise
measurements of the amount of bone (not their actual quality). This measurement is termed "bone
mineral density" or BMD.
The World Health Organization "WHO" has established criteria for making the diagnosis of
osteoporosis, as well as determining levels which predict higher chances of fractures. These
criteria are based on comparing bone mineral density (BMD) in a particular patient with those of a
25 year old female. BMD values which fall well below the average for the 25 year old female (stated
statistically as 2.5 standard deviations below the average) are diagnosed as "osteoporotic". If a
patient has a BMD value less than the normal 25 year old female, but not 2.5 standard deviations
below the average, the bone is said to be "osteopenic" (osteopenic means decreased bone mineral
density, but not as sever as osteoporosis). Interestingly, although these criteria are widely used,
they were devised in a Caucasian female so there will be some differences when these levels are
applied to non Caucasian females or to males in general. Despite this flaw, measurement of BMD
is used daily and has proven to be very helpful in all groups. Some men will be subject to increased
fracture rates when they have significantly less BMD than the predicted fracture level for women.
In other words, some men will be at increased risk for fracture even when they have osteopenia.
Osteoporosis is different from most other diseases or common illnesses in that there is no one
single cause. The overall health of a person's bones is a function of many things ranging from how
well the bones were formed as a youth, to the level of exercise the bones have seen over the
years. During the first 20 years of life, the formation of bone is the most important factor, but after
that point it is the prevention of bone loss which becomes most important. Anything which leads to
decreased formation of bone early in life, or loss of bone structure later in life will lead to
osteoporosis and fragile bones which are subject to fracture.

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7.1.1 BMD TEST:
A BMD test is the only way to detect low bone density and diagnose osteoporosis. The
lower a person’s bone mineral density, the greater the risk of having a fracture. A BMD test
is used to:
• Detect low bone density before a person breaks a bone
• Predict a person’s chances of breaking a bone in the future
• Confirm a diagnosis of osteoporosis when a person has already broken a bone
• Determine whether a person’s bone density is increasing, decreasing or remaining
stable (the same)
• Monitor a person’s response to treatment
7.1.2 RECIEPIENTS OF THE BMD Test:
There are some reasons (called risk factors) that increase your likelihood of developing
osteoporosis. The more risk factors you have, the more likely you are to get osteoporosis
and broken bones. Some examples are being small and thin, older age, being female, a
diet low in calcium, lack of enough vitamin D, smoking and drinking too much alcohol.
Your healthcare provider may recommend a BMD test if you are:
• A postmenopausal woman under age 65 with one or more risk factors for osteoporosis
• A man age 50-70 with one or more risk factors for osteoporosis
• A woman age 65 or older, even without any risk factors
• A man age 70 or older, even without any risk factors
• A woman or man after age 50 who has broken a bone
• A woman going through menopause with certain risk factors
• A postmenopausal woman who has stopped taking estrogen therapy (ET) or hormone
therapy (HT)
Some other reasons your healthcare provider may recommend a BMD test:

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• Long-term use of certain medications including steroids (for example, prednisone and
cortisone), some anti-seizure medications, Depo-Provera and aromatase inhibitors (for
example, anastrozole, brand name Arimidex)
• A man receiving certain treatments for prostate cancer
• A woman receiving certain treatments for breast cancer
• Overactive thyroid gland (hyperthyroidism) or taking high doses of thyroid hormone
medication
• Overactive parathyroid gland (hyperparathyroidism)
• X-ray of the spine showing a fracture or bone loss
• Back pain with a possible fracture
• Significant loss of height
• Loss of sex hormones at an early age, including early menopause
• Having a disease or condition that can cause bone loss (such as rheumatoid arthritis or
anorexia nervosa)
7.1.3 TYPES OF BONE DENSITY TESTS:
Central DXA: The National Osteoporosis Foundation (NOF) recommends a BMD test
of the hip and spine by a central DXA machine to diagnose osteoporosis. DXA stands for
dual energy x-ray absorptiometry. When testing can’t be done on the hip and spine, NOF
suggests a central DXA test of the radius bone in the forearm. In some cases, the type of
bone density testing equipment used depends on what is available in your community.
Healthcare providers measure BMD in the hip and spine for several reasons. First,
people with osteoporosis have a greater chance of fracturing these bones. Second, these
fractures can cause more serious problems, including longer recovery time, greater pain
and even disability. BMD test results in the hip and spine can predict the likelihood of future
fractures in other bones.
With most types of BMD tests, a person remains fully dressed, and the test usually
takes less than 15 minutes. BMD tests are non-invasive, meaning that no needles or
instruments are placed through the skin or body. When repeating a BMD test, it is best to
use the same testing equipment and have it done at the same place. This provides a more
accurate comparison with your last test result.
Although it is not always possible to have your BMD test at the same place, it is still
important to compare your current BMD test to your last one.
pDXA

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7.1.4 OTHER TYPES OF TESTS:
In addition to central DXA, there are other methods to measure bone density that can
predict the risk of breaking a bone. However, the results from these other methods are not
equivalent to the results from a central DXA machine. Below are other BMD testing
methods:
• pDXA (peripheral dual energy x-ray absorptiometry)
• QUS (quantitative ultrasound)
• QCT (quantitative computed tomography)
• pQCT (peripheral quantitative computed tomography)
The QUS method of BMD testing uses sound waves to measure bone density. The other
types of equipment listed above use radiation. Except for QCT, the amount of radiation is
very small. For comparison, you are exposed to 10–15 times more radiation flying in a
plane round trip between New York and San Francisco.
Healthcare providers do not routinely use standard x-rays for BMD testing. While x-
rays can identify broken bones, they are not sensi-tive enough to detect osteoporosis until
25 to 40 percent of bone density has been lost. By this time the disease is well advanced.
pQCT
QUS
QCT

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7.1.5 HOW OFTEN TO REPEAT A BMD TEST:
People taking an osteoporosis medication should repeat their BMD test by central DXA
every two years, according to the National Osteoporosis Foundation (NOF). Some
healthcare providers may have certain patients repeat their BMD test after one year. The
peripheral tests (pDXA, QUS and pQCT) are not appropriate for monitoring response to
treatment at this time.
A. TESTS TO FIND BROKEN BONES:
• If you have a loss of height, posture changes or back pain, your healthcare
provider may order an x-ray to look for fractures in your spine. An x-ray is the most
common way to tell if you have a broken bone in your spine or other bones. In
some people, spine fractures don’t cause any pain.
• Once you have a fracture in the spine, you are at greater risk for more spine
fractures in the future. If you have this type of fracture, that’s why you need to
speak with your healthcare provider about steps to protect your spine. You should
also consider treatment with an osteoporosis medication. When you have a
fracture in the spine, you still need to have a BMD test if you haven’t had one.
• Another way to find fractures in the spine is with a vertebral fracture assessment
(VFA) by a DXA machine. This method uses less radiation than a standard x-ray.
VFAs can show breaks in the spine and can also show the difference between
broken bones and abnormally shaped bones.
7.1.6 UNDERSTANDING BMD TEST RESULTS:
When you have a bone mineral density test,
• It compares your bone density to a “young normal” healthy 30-year-old adult with peak
bone density (also called peak bone mass). Peak bone density is the point at which a
person has the greatest amount of bone that she or he will ever have.
• You will get the result of your BMD test in a special number called a T-score. It stands
for “standard deviations” or “SD.” It indicates how much your bone density is above or
below normal.
• Healthcare providers use the T-score to diagnose osteoporosis. If more than one bone
is tested, they use the lowest T-score to make a diagnosis of osteoporosis. The World
Health Organization (WHO) has defined the T-scores and what they mean.

12
7.1.7 WHAT YOUR T-SCORE MEANS:
• A T-score between +1 and -1 is normal bone density. Examples are 0.8, 0.2 and -0.5.
• A T-score between -1 and -2.5 indicates low bone density or osteopenia. Examples are
T-scores of -1.2, -1.6 and -2.1.
• A T-score of -2.5 or lower is a diagnosis of osteoporosis. Examples are T-scores of -
2.8, -3.3 and -3.9.
• The lower a person’s T-score, the lower the bone density. A T-score of -1.0 is lower
than a T-score of 0.5; a T-score of -2.0 is lower than a T-score of -1.5; and a T-score of
-3.5 is lower than a T-score of -3.0.
• For most BMD tests, 1 SD difference in a T-score equals a 10-15 percent decrease in
bone density. For example, a person with a T-score of -2.5 has a 10-15 percent lower
BMD than a person with a T-score of -1.5.
Your BMD test result also includes a Z-score that compares your bone density to what
is normal in someone your age and body size. Healthcare providers do not use Z-scores to
diagnose osteoporosis in postmenopausal women and men age 50 or older. Among older
adults low bone mineral density is common, so Z-scores can be misleading. An older
person might have a “normal” Z-score but still be at high risk for breaking a bone.
Most experts recommend using Z-scores rather than T-scores for younger men,
premenopausal women and children. However, healthcare providers often use
T-scores for perimenopausal women. A Z-score above -2.0 is normal according to the
International Society for Clinical Densitometry (ISCD). A diagnosis of osteoporosis in
younger men, premenopausal women and children should not be based on a BMD test
result alone. NOF does not recommend routine BMD testing in children, adolescents,
healthy young men or premenopausal women.
7.1.8 TREATMENT CONSIDERATIONS:
The results of the BMD test help your healthcare provider make recommendations
about either prevention or treatment of osteoporosis. When making a decision about
treatment with an osteoporosis medication, your healthcare provider will also consider your
risk factors for osteoporosis, your likelihood of having future fractures, your medical history
and your current health.
Below are treatment guidelines for postmenopausal women and men age 50 or
older:
• Most people with T-scores of -1 and above (normal bone density) do not need to take
an osteoporosis medication.
• People with T-scores between -1 and -2.5 (osteopenia) should consider taking an
osteoporosis medication when they have certain risk factors.
• All people with T-scores of -2.5 and below (osteoporosis) should consider taking an
osteoporosis medication.
WORLD HEALTH ORGANIZATION DEFINITIONS OF OSTEOPOROSIS
BASED ON BONE DENSITY
T-Scores BMD Category
Examples Range
1-1 & aboveNormal BMD
0.5
0
osteopenia

13
-0.5
-1
-1.5 Between Low BMD (Osteopenia)
-2 -1 and -2.5
-2.5 -2.5 and Osteoporosis
-3 below
-3.5
-4
A new method called absolute fracture risk helps healthcare providers and their
patients age 40 and older make better decisions about when to take an osteoporosis
medication. Absolute fracture risk estimates a person’s chance of breaking a bone over a
period of 10 years. Postmenopausal women and older men with osteoporosis are at
greatest risk of breaking a bone.
In the past, healthcare providers knew to treat people with osteoporosis, but were
sometimes uncertain about when to treat patients with osteopenia. The absolute fracture
risk method makes it easier for healthcare providers and their patients with osteopenia to
decide when an osteoporosis medication is necessary. This method helps make sure that
people with the greatest chance of breaking a bone get treated.
Healthcare providers can get a patient’s absolute fracture risk by using a special web-
based tool on a computer in their office. The healthcare provider enters a patient’s hip T-
score and certain risk factors for osteoporosis. The tool predicts the patient’s absolute
fracture risk. Soon, some central DXA machines will be able to provide this information.
Osteoporosis medications either slow or stop bone loss or rebuild bone. They also
reduce the chances of having a broken bone. NOF encourages you to discuss your
treatment options with your healthcare provider. Always look at both the risks and benefits
of taking a medication, including potential side effects.
For an osteoporosis medication to work, a person still needs to get enough calcium
and vitamin D and to exercise. According to NOF recommendations, adults under age 50
need 1,000 mg of calcium and 400-800 IU of vitamin D daily. Adults 50 and over need
1,200 mg of calcium and 800-1,000 IU of vitamin D daily. There are two types of vitamin D
supplements. They are vitamin D3 and vitamin D2. Previous research suggested that
vitamin D3 was a better choice than vitamin D2. However, more recent studies show that
vitamin D3 and vitamin D2 are equally good for bone health. Vitamin D3 is also called
cholecalciferol. Vitamin D2 is also called ergocalciferol.

14
7.2 PHYSIOTHERAPY INTERVENTIONS:
7.2.1 RISK FACTORS:
Physiotherapists need to be aware of the major risk factors for osteoporosis so that they
can effectively participate in all aspects of the prevention and management of this
condition. The two major risk factors are being female and elderly. In addition, there are a
number of other well established risk factors listed below6:
• Early menopause (age <45)
• Hypogonadism
• Physical inactivity
• Thin body type
• Major gynaecological surgery e.g. hysterectomy
• Amenorrhea
• Anorexia
• Heredity
• Rheumatological conditions e.g. rheumatoid arthritis, ankylosing spondylitis
• Smoking
• High alcohol
• High caffeine intake
• Insufficient dietary calcium and Vitamin D.
• Secondary osteoporosis accounts for 20% of cases in women and 40% of cases in
men and may occur as a result of 11:
• Endocrine disorders (including thyrotoxicosis, primary hyperparathyroidism, Cushing’s
• Syndrome).
• Rheumatological conditions
• Gastro-intestinal disorders (malabsorption, partial gastrectomy, liver disease)
• Malignancy (multiple myeloma, metatastic carcinoma)
• Certain drugs (corticosteroids, heparin).
7.2.2 TARGET CLIENT GROUPS FOR TREATMENT BY PHYSIOTHERAPISTS:
For the purpose of these guidelines a pragmatic decision was made to separate the target
client groups into 3 broad categories:
Amenorrhea
Endocrine
disorders

15
1. Those with normal bone mass concerned with reducing the risk together with people
with mild bone changes (osteopenia).
2. People with a clinical diagnosis of osteoporosis without any history of fracture (#).
3. A frailer group with advanced bone changes usually having sustained fractures (#).
All categories can include both men and women of all ages. However the frailer group
do tend to be older. Physiotherapists must use all available clinical information to
ensure that clients are correctly categorised. If in doubt a definitive diagnosis should be
obtained from the referring specialist.
The following symbols denote each group and are used throughout the recommendations
to assist in the correct choice of assessment techniques and effective interventions for
each category.
• Men and women who have been diagnosed with mild bone changes (i.e. BMD
more than 1 SD below young average) (osteopenia) and those concerned with
reducing the risk (prevention).
• Men and women who have been diagnosed with osteoporosis (i.e. BMD 2.5 SD
below young adult mean) but have not yet sustained any fractures.
• A much frailer group with more severe osteoporotic changes (i.e. BMD more than
2.5 SD). This group mainly but not always comprises a more elderly population
(both men and women). These patients may or may not have sustained one or
more fractures.
These symbols are printed at the foot of each page as a reminder to the reader.
7.2.3 PHYSIOTHERAPY ASSESSMENT:
Once patients with a diagnosis of osteoporosis have been referred for physiotherapy, they
should be correctly categorised and a detailed, standard physiotherapy assessment carried
out. This will help to ensure that important issues are not inadvertently omitted. Accurate
assessment of all aspects of impairment, disability and handicap, using reliable and
appropriate measuring tools, is the key to delivering successful and appropriate
management programmes, and assessing effectiveness. Listed below are assessment
procedures applicable to osteoporosis patients, which are reliable and considered good
practice by the Guideline Developers. Most of the testing procedures do not require
sophisticated equipment and can therefore be used by most physiotherapists. They should
be used selectively, according to the disease severity at the time of referral. Measurement
of cervical /thoracic deformity, balance, lumbar spine endurance, flexibility and effect on life
style should always be carried out when assessing any osteoporotic patient.

16
7.2.4 ANTHROPOMETRIC AND SPINAL MOBILITY ASSESSMENT:
These measures should always be assessed and recorded.
A. HEIGHT:
Measured in centimetres (cm), patient standing with back against the wall without shoes.
B. WEIGHT:
In kilograms (kg) using calibrated scales.
C. CHEST EXPANSION MEASURED AT XIPHISTERNUM:
Record chest excursion with the patient standing with their hands on their head. Maximal
inhalation is followed by exhalation. Total change is measured as the value at maximal
inhalation minus the value at maximal exhalation. The measuring tape is placed around the
xiphisternum. One measure is taken to the nearest cm. A modified technique may have to
be used for those osteoporotic patients who do not have sufficient range of movement to
stand with their hands on their head.
D. CERVICAL/THORACIC DEFORMITY (TRAGUS TO WALL):
Heels and buttocks touching the wall, the knees straight, pushing head back while still
keeping the chin in neutral position. The distance between the tragus (mastoid process)
and the wall is measured to the nearest 0.1 of a cm using an tape measure.
E. SHOULDER ELEVATION:
Measurement is taken with the patient standing with their back against the wall. A
goniometer is placed over the greater tuberosity. The patient is instructed to elevate their
shoulder into flexion. Again modifications may have to be made to the starting position for
those patients with kyphotic changes.
F. LUMBAR SPINE RANGE OF MOVEMENT (SCHOBER EXTENSION):
Patient standing with knees straight and feet slightly apart. Three skin marks are made:
the first at the lumbosacral junction, the second and third 5cm below and 10cm above
this mark. The patient is then asked to extend their back. The approximation is
measured and subtracted from 15cm. One measurement should be taken.
7.2.5 STRENGTH/ENDURANCE ASSESSMENT:
Some measure of strength/endurance should be assessed and recorded.
Various methods of strength measurement are available:
• The trunk extension endurance measurement is a simple method of measuring the trunk
extensors. The procedure is as follows: the patient lies prone and holds their sternum off
the floor.
• A small pillow is placed under the abdomen to decrease lumbar lordosis and the patient is
asked to maintain cervical flexion and to demonstrate this position15. This assessment
should not be maintained for longer than 20 seconds. It is contra-indicated for patients with
a history of heart complaints as blood pressure may become elevated. Patients with a
marked kyphosis must also be excluded.
• These client groups can use various modalities of other strength testing equipment, e.g.
isometric, isotonic, using the 1 Repetition Maximum (1RM) method or more sophisticated
equipment, such as isokinetics.

17
• Measurement of 1RM can also be used in this group, but care should be taken to avoid
using weights at the end of long levers.
7.2.6 AEROBIC CAPACITY ASSESSMENT:
Some measure of aerobic capacity should be assessed and recorded.
Various methods of aerobic tolerance testing can be used, specific to the target group.
• A submaximal progressive exercise test using either a treadmill or cycle ergometer
can be used to estimate aerobic capacity.
• Where testing equipment is not available, the Adapted Shuttle Walking Test is a
useful test and very easy to carry out. This test can safely be used on patients with
moderate osteoporotic changes depending on their level of disability.
The procedure is as follows:
The patient is asked to walk up and down a 10m course. The speed is dictated by
an audio signal played on a tape. The patient walks at the stated pace and aims to
turn around when they hear the signal. The patient is asked to continue the test
until they are unable to maintain the required speed, or a pre-determined endpoint
is met e.g. 60% of age-adjusted predicted maximum heart rate. This is worked out
by using the simple equation 220 minus the age of the patient. This gives predicted
maximum heart rate. This figure is the multiplied by 0.60 to give the 60%
maximum.
• Other walking tests may be appropriate for patients with more severe changes or those
tested at home, for example, the Elderly Mobility Scale (EMS) and the ‘Timed Up and
Go Test’ (TUAG).
• The Guideline Developers consider these two tests appropriate for this patient group.
The EMS is a 20 point scale measuring functional abilities such as transfers, balance
and walking speed. For the TUAG test the subject is asked to stand up from a standard
height chair walk 3 metres, turn around, walk back and sit down. The whole process is
timed from initiation of standing to the sitting position.
7.2.7 BALANCE ASSESSMENT:
This should always be assessed and recorded.
• Assessment of balance is an important measurement, as one of the main aims of a
physiotherapy exercise programme is to reduce falls. A very simple test is the ‘one
legged stand’. For this, the patient is asked to stand between a set of parallel bars on
one leg without holding onto the bars.
• The subject is given a practice attempt and this is followed by a timed attempt. Testing
can be carried out on both legs and can also be carried out with eyes closed. This
should always be tested between parallel bars for safety.
7.2.8 FUNCTIONAL ASSESSMENT:
• Assessment of functional ability in the community should always be made. This will
help to ensure the appropriate intervention for each individual.
• It is important to establish the extent of disability and handicap. This will help in the
setting of treatment goals, plans for intervention, and so take the physiotherapy
management effective for the patient; to reduce the chances of falling in the
community. For an in-depth pain and activity record the Osteoporosis Functional
Disability Questionnaire (OFDQ) is very useful.

18
• An appropriate functional test for this group should be used e.g. ‘timed sit to stand’,
grip strength, stair climbing or 20 metre timed walk.
7.2.9 PAIN ASSESSMENT:
• There are various measurement tools applicable for these patient groups. For example:
visual analogue scales, the McGill pain questionnaire, and the monitoring of daily
analgesic intake.
• The QFDQ can also be used as a measurement of pain.
7.2.10 ANALYSIS OF ASSESSMENT AND OUTCOMES:
• It is not enough to merely record a standard assessment and use standardised
outcome measures.
• The findings of the assessment and the results of the outcome measures should be
routinely analysed by individual clinicians and the Service as a whole. This will help
clinicians to consider the effects of intervention and attribute the reasons for changes
appropriately.
7.3 PHYSIOTHERAPY MANAGEMENT:
The management section deals firstly with the unique exercise and lifestyle requirements for
enhancing bone health and functional independence in each of the three target groups. This is
followed by more general sections about balance, posture, education, psychological well-being and
potential harms and risks which affect all three groups.
7.3.1 MANAGEMENT FOR THE OSTEOPENIC AND PREVENTION GROUP:
Aims
• Increase the peak bone mass in the at risk/preventative group
• Maintain or increase BMD in the osteopenic group and reduce the early rapid bone
loss after menopause
• Improve muscle strength, balance, cardiovascular fitness
• Improve posture
• Improve psychological well-being
• Provide education.

19
7.3.2 EXERCISE MANAGEMENT FOR BONE HEALTH:
• Exercise therapy in the form of weight bearing aerobic training activity and or strength
training activity is now recognised as a valid and important intervention in the
management of bone health. It is thought that the mechanical stresses that are put
through bone during exercise can affect bone density. Weight bearing activity
stimulates bone remodelling. It has been hypothesised that bone hypertrophy occurs in
response to microfractures at the level of the osteon. Microscopic damage occurs
where the tendon attaches to the bone when the stress applied is in excess of the
normal levels, e.g., during weight bearing physical activity.
• There is evidence that high impact exercise has the greatest potential to affect bone
density in pre-menopausal women.
• High impact exercise is suitable for those who regularly exercise. A lower impact
programme of exercise is also appropriate especially for those not used to exercise. To
be effective all exercise programmes need to be progressive in terms of impact and
intensity as fitness and strength levels improve. However it is essential that all
programmes begin at a low level that is comfortable for the patient. The assessment
will give the physiotherapist a reference point from which to start the exercise
programme. Reference should be made to the ACSM on progression of exercise
programmes. However it is generally accepted that microfracture is needed for an
osteogenic response.

20
Many well-designed randomised controlled trials have investigated the effects of exercise
on bone health in the postmenopausal osteopenic group. The aim of exercise in this group
is to reduce the early rapid loss of bone density following the menopause and also maintain
and sometimes increase bone mass.
• High impact exercise, e.g. skipping and jogging, has the greatest potential to improve
BMD in premenopausal group.
Grade A Level Ib
• Low to medium impact exercise, such as step aerobics, intermittent jogging is more
appropriate for those not used to exercising and those over 50 years of age 30.
Grade A Level 1b
• Integrate high impact with medium and or low impact activities for a well-designed and
safe programme. People should be instructed in the use of rebound techniques, i.e.
give or bend in the knees on take off and landing.
• Strength training is useful in sedentary young individuals provided it is of a high enough
intensity i.e. 70–80% 1RM. It not only improves strength, but also is accompanied by
improvements in BMD.
Grade A Level 1b
• All exercise programmes should start at an easy level and be progressive in terms of
intensity and impact.
Grade C, Level III

21
7.3.3 PRECAUTIONS:
Although high impact exercise is recommended for improvements in bone health,
prolonged periods of high impact exercise are not necessary and can cause soft tissue
injuries and pelvic floor stress. Optimum benefits will only be achieved by ensuring safe
design of programmes and correct performance that incorporates a balance of high/low
impact exercise. All high impact exercise is inappropriate and unsafe if:
• People suffer from joint conditions
• People cannot perform exercise with correct technique i.e. unable to rebound
effectively
• People with pelvic floor problems
• The design of the programme is unsafe, e.g. all of the exercise occurs on the spot, and
if the programme does not incorporate medium and low impact exercise.
7.3.4 THE OSTEOPOROTIC GROUP WHO HAVE NOT SUSTAINED FRACTURES:
Aims
• Maintain bone strength
• Prevent fractures
• Improve muscle strength, balance, cardiovascular fitness
• Improve posture
• Improve psychological well-being
• Provide education
• Aim to reduce falls
A. EXERCISE MANAGEMENT FOR BONE HEALTH:
• The evidence of the effects of exercise on the skeleton is not as conclusive for
those with an actual diagnosis of osteoporosis. Most of the studies have been
carried out on postmenopausal sedentary women who are not actually
osteoporotic. The conclusions from these studies are that exercise regimes are
beneficial in promoting bone health. It has been inferred from these studies and
others that these regimes could be used effectively for those with osteoporosis.
• One study, which has investigated those patients with an actual diagnosis of
osteoporosis, found improvements in bone mineral density of the distal forearm
following high rates of dynamic loading. This reinforces the hypothesis that
exercise training is required to be site specific.
• One study carried out concluded that post-menopausal bone mass can be
significantly increased by a strength regimen that uses high load, low repetitions
but not by an endurance regimen that uses low load, high repetitions. This
suggests that peak load is more important than the number of loading cycles in
increasing bone mass in early post-menopausal women.
• Some of the principles also apply to the postmenopausal osteopenic group and in
these cases the symbol will also be shown.
• It is advised that the overload principle is applied through a high load and low
repetitions regime.
• Any form of strength training does require to be site specific i.e. targeting areas
such as the muscle groups around the hip, quadriceps, dorsi/plantar flexors,
rhomboids, wrist extensors and back extensors. Grade A, Level 1b

22
• Weight bearing exercises should be targeted to loading bone sites predominantly
affected by osteoporotic change i.e. hip, vertebrae and wrist. Grade B, Level 2a
• The most recent meta-analysis concluded that exercise (aerobic and strength)
helps to slow the rate of post-menopausal bone loss in postmenopausal women.
• Exercise should be used in combination with both adequate calcium intake and
some type of hormone replacement therapy for maintaining and/or increasing bone
mineral density in postmenopausal women at risk from osteoporosis 38. Grade A,
Level 1a
• All exercise programmes should start at an easy level and be progressive in terms
of intensity and impact.
B. PRECAUTIONS
The following activities should be avoided:
• High impact exercise
• Trunk flexion
• Trunk rotational torsion movements with any loading
• Lifting
• The pelvic floor precautions listed in the 7.3.3 section also apply.
7.3.5 FRAILER GROUP WITH SEVERE CHANGES WHO HAVE OFTEN SUSTAINED
FRACTURES:
Aims
• Falls reduction
• Prevention of further fractures
• Balance/co-ordination
• Improvements in muscle strength, flexibility, aerobic capacity, posture
• Gait re-education
• Psychological well-being and increased confidence
• Reduce/control pain
A. EXERCISE MANAGEMENT:
• The aim of exercise therapy in this frailer group is predominantly to minimise the
risk of falling and thereby risk of fracture, as opposed to affecting bone density.
However, studies of this generally elderly group have found that improvements in
muscle strength can be achieved.
• The exercise tolerance of this group may be poor. Therefore any form of training
must start with a very low intensity.
• Exercise training must start at a very low intensity using low impact exercises.
• For strength training initially use very short levers or body resistance.
• Exercises in warm water (hydrotherapy) are assisted by the physical properties of
water, namely buoyancy and temperature. The weight relieving property of water
immersion allows easier movement with less pain. There is no evidence to suggest
that hydrotherapy has any effect on bone mineral density. However, there is
evidence that other physiological parameters can be affected, such as muscle
strength, aerobic capacity and pain control. There may also be an increase in
psychological well being.

23
• Exercises that patients find difficult on dry land may be more easily carried out in
water. For example, trunk extension will be impossible for some of these patients
on dry land but can be achieved in water and resistance can gradually be
increased.
• All exercise programmes should be progressive in terms of intensity and impact. A
very gentle low impact programme using gravity and body resistance exercise is
recommended. Grade C, Level III
B. PRECAUTIONS:
• No high intensity exercise
• All the precautions listed in the previous sections apply to this frail group.
C. PAIN MANAGEMENT:
Pain management in this group is a major part of the therapeutic intervention. These
patients are often referred for physiotherapy following painful vertebral compression
fractures. Pain management therefore becomes a priority before the patient can be
introduced to any exercise programme. However, it should be noted that only 50% of
patients with a vertebral fracture complain of pain 45. Other causes of pain can be
abnormal stress on joints and soft tissues due to postural changes, resulting in muscle
spasms and imbalances. Another complaint is pain arising from the lower ribs pressing
down onto the pelvis, due to reduction in height and kyphotic changes.
The following modalities may be effective for osteoporosis and apply to all those with
associated pain in any of the target groups.
I. HYDROTHERAPY:
Hydrotherapy should be considered as a treatment modality where the patient has
pain from recent vertebral fractures, and/or postural and balance problems.
Hydrotherapy is also a very useful modality to build confidence in very disabled
people and those afraid of further falls.
II. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS):
• TENS has been shown to be effective in some patients with chronic pain
conditions. The rationale for use is based on the activation of the pain gate
mechanism.
• TENS should be considered as a modality for the osteoporotic patient with
intractable pain, especially those with chronic back pain and recent vertebral
fractures. Grade A, Level Ib
III. INTERFERENTIAL THERAPY:
The mechanism for pain relief is the same as for TENS.
IV. HEAT:
• Applied heat has several possible physiological benefits, such as reducing
muscle spasm, increasing local blood flow and stimulating an analgesic effect.
• Patients should be instructed on how to use heat therapy safely at home to
relieve pain symptoms

24
V. RELAXATION:
Relaxation has long been advocated for reducing muscle tension and anxiety 49.
The two most widely accepted methods are the Jacobsen progressive relaxation
and the Mitchell simple physiological technique.
The use of relaxation should be discussed with/offered to osteoporotic patients
with intractable pain.
VI. COMPLEMENTARY THERAPIES:
Recently other forms of pain management such as reflex therapy; aromatherapy
and acupuncture have become more popular as alternative ways of managing pain
by physiotherapists. For more detailed information reference should be made to
the specific literature and the appropriate CSP Clinical Interest Group.
7.3.6 BALANCE AND FALLS MANAGEMENT:
• Exercise for all age groups has the potential to improve dynamic stability and co-
ordination and therefore could have a protective role in preventing falls in later life. The
activity needs to be weight bearing.
• A study carried out on pre-menopausal women found that high impact loading exercise
carried out once a week improved both balance and co-ordination.
• The diagnosis of osteoporosis becomes of clinical importance following fractures,
which are generally the result of trauma from falls. Causes of falls are known to be
multi-factorial. They include deficiencies in eyesight, footwear, balance, co-ordination,
strength, home environment and general health, including diet and medication.
• Tai Chi is an ancient exercise and martial art that has been practised in China for
centuries by all age groups. There are various forms of Tai Chi. One particular form of
Tai Chi is Chuan, which is especially useful for older people. It includes slow, controlled
dimensional movements and has been shown to improve balance, muscle strength and
to reduce significantly the fear of falling.
• It is important particularly with the fragile groups to aim for a sensible balance between
providing people with protective means, i.e. walking frames, hip protection pads, and
enough exercise to obtain potential improvements in bone health, strength and
balance. Physiotherapists, through their training, experience of exercise with other
vulnerable groups, and skills in observation, are well placed to facilitate progress in
these groups and should be encouraged to do so.
• A thorough falls risk assessment should be made and risk factors eliminated as far as
possible.
• Some elements of Tai Chi could be incorporated into any exercise class but are
especially effective for those elderly people where balance is a problem.
• Any activity that promotes co-ordination and balance appropriate to the severity of the
disease should be encouraged, i.e. simple balance exercises such as supported one
leg stands can be effective.
• The use of hydrotherapy is frequently indicated to reduce pain, and to provide a safe
environment for balance exercises.

25
7.3.7 POSTURE AND FLEXIBILITY:
• Thoracic kyphosis, due to vertebral fractures, is often a clinical sign of osteoporosis
and is often associated with pain. Postural education and awareness are important in
preventing/minimising respiratory problems, neck pain and balance disorders.
• Severe kyphotic changes may be a problem for subjects in this group, possibly limiting
their ability to exercise due to a compromised respiratory system and causing pain. It is
especially important for those with postural deformities to maintain maximum range of
movement of the shoulder girdle, spine and hips and prevent further postural changes.
Stretching exercises should focus on the thoracic and cervical spine for these patients.
• Back extension exercises are very important for this group55. Kyphosis can often be
improved as it is not totally dictated by the shape of the bones but also by muscle
weakness and/or pain. Grade B, Level IIa
• Back extension exercises can also be taught in the seated position for those unable to
lie on their front.
• Exercises should concentrate on encouraging chest excursion, rhomboid exercises
and balance.
• Gait re-education and appropriate walking aids may also be necessary.
• Stretching to improve flexibility should be part of every exercise programme for all of
the client groups. Stretching of all the major upper and lower limb muscle groups
should be carried out.
• Stretching should always be carried out following a warm-up period.
• Ballistic stretching should always be avoided.
7.3.8 EXERCISE PRESCRIPTION:
• It is important to consider the roles of Frequency/Intensity and Duration of Exercise
Prescription in maximising the positive effects on bone health.
• Studies have shown that weight-bearing exercise, with progressive increases in
intensity, needs to be continued for more than nine months in order to achieve positive
effects on bone density. Once exercise programmes are discontinued the positive
effects will be reversed.
• There is now evidence of a dose response relationship between exercise and bone
mineral accretion following a study by Korht et al. She found a significant relationship
between increases of whole body BMD and the net increase in energy expenditure (i.e.
physical activity). She indicated that vigorous exercise training can induce significant
increases in BMD in older postmenopausal women. However, more work needs to be
done to determine whether single parameters of the amount of exercise, such as
frequency, duration and intensity, can be predictive of changes in BMD.
• In the absence of other specific literature on intensity of exercise needed to impact
directly on bone health, it is suggested that the recommendations from the American
College of Sports
• Medicine on dosage in connection with cardiovascular health might be applied. In 1990
it recommended a weekly minimum of at least three x 20-minute sessions of vigorous
intensity exercise. However, in 1993 the Centre for Disease Control in conjunction with
the American
• College of Sports Medicine recommended a general more active living approach with
more frequent bouts of moderate intensity exercise 17. Five x 30 minutes per week of
moderate exercise is a general guideline.

Ptp&M013 Npte 5

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