Episode 1791 - 3 steps for fragility fracture management

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the 3 steps to consider when helping folks with a fragility fracture

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

DUSTIN JONES Hi, good morning folks. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. We're live on Instagram, we're live on YouTube. Thank you podcast listeners for tuning in. Today, we are going to talk about the three main steps you want to focus on to manage fragility fractures. all about fragility fracture management. This comes from an ICE student question that I really appreciate. I want to take the opportunity to address kind of our whole crew because we're all dealing with individuals that have had that fragility fracture. What in the world do we do after that insult has happened? So I'm going to read this question verbatim and then we're going to get into the goods. So Melissa McNulty, PT out in Oregon. It says, ICE provides some great guidance regarding what to look for, how to screen for vertebral fracture in those with osteoporosis. Can you please tell me, will you still work on strengthening with those with known fragility fractures in the spine? If so, how will you modify? Also, what about the history of a fragility fracture and how far out slash what evidence slash degree of healing do you need to see before you feel comfortable loading that area? I love this question, Melissa. These are all questions I think All of us have asked ourselves, right, when we have gotten that referral, we've evaled that individual with a nice, fresh fracture, maybe it's been a fragility fracture of the vertebra, maybe it's been, you know, femur, maybe it's been, you know, radius or ulna, for example. We all have these things, these doubts. I don't wanna do more harm, but I know this person needs to move. How can I do this in a safe manner? So I wanna start off with defining what a fragility fracture is, right? Because I feel like this gets thrown around a lot, but the definition of a fragility fracture is when you have a fracture that's a result from a fall at a standing height or less. So if someone has a fracture related to a fall, if they were standing high or less, that's considered a fragility fracture. This could be in multiple areas, right? So we often hear fragility fractures associated with fractures of the spine or vertebra, but it could be of the femur as well. So we need to be clear on what that means. So this person has had a fall. more than likely some type of balance deficit, right? They got in some type of dicey scenario, they weren't able to maintain their balance, they weren't able to land in a manner that distributed force and lowered the impact forces, and so they've had a fracture. I think there's three main steps that we want to focus on. What's unfortunate about this is this is a very difficult thing to study. in terms of what are some of the best interventions, what are safe interventions for individuals after they've had a fracture. So, the evidence is very limited compared to before they've had a fracture, right? We've got tons of evidence to support exercise and balance training, functional training and, you know, a lot of kind of that falls prevention. side of things. We have a lot of evidence there, but post fall there's not as much evidence of how to support these people well, which that is growing. There's a lot of people in the kind of osteoporosis fall space that are doing a lot of really good work, but the evidence is relatively limited. One thing we can be confident to say is that we need to get these people moving. I think that is our first step. STEP 1: DEFINE THE ENEMY What I like to think about is in that first step is what we really want to do is we want to define the enemy. As a clinician, it's easy to get someone and to see their chart and see they've, you know, maybe you've may seen some scans, some images you may, you know, have kind of this picture of like, man, they've got this very unstable, unstable situation, unstable fracture, for example, and you focus so much on that particular area. And I think that is where we can go wrong. What is the biggest harm to this person? is not the actual injury, it's the effects of the injury. And especially when we're talking about older adults, when we're talking about working with these individuals, the biggest threat to their independence and their quality of life is their decreased physical activity and their increased sedentary behavior. Their lives completely change after they have a fragility fracture. So we need to be aware of that. And when we have increased sedentary behavior, we're not doing a lot of things maybe out in the community that we once were doing. They give us a lot of purpose. There's a lot of deconditioning that can happen. There's a lot of mental health issues that can happen as well. So we want to combat that. That is the enemy. And so our goal is to try and get that person moving as much as possible so they can continue to do the things that are meaningful to them. It is a very, very delicate scenario. I experienced this, and I don't think I introduced myself. Sorry, my name is Dustin Jones. I'm one of the lead faculty within the older adult division, but I've spent a lot of time in home health, and I would see this in home health where these folks live these vibrant, kind of community-based lives, going out, doing this, yada, yada, yada, and then they had that fracture, and they may have still had some ability to participate in some of those things, but they didn't. And their sedentary behavior went up through the roof, physical activity went down, and over a stretch of weeks, deconditioning really set in that has massive implications for this person in terms of their quality of life and health outcomes. So I want to define the enemy. I don't think it's that particular injury. I think it's the effects of the injury, and we need to be very aware of that and combat that as much as we can. This is where, when we're working with Betty, for example, that we're saying, Betty, I need to get you as fit as possible. Yes, I know you've had that vertebral fracture and it's painful, but we're going to be able to work around that. So you're not going to experience as much pain. We're going to get you as strong and fit as possible in all the areas out around that area, which is ultimately going to help that area heal as well. Betty, how fit will you let me get you? All right. So one, we need to define the enemy. Beth Lee, she's tuned in on Instagram, she asked the question, does it include any environment like a fall on ice? That's a great question. In the literature that I've read that is defining a fragility fracture, it doesn't necessarily say anything about environmental factors. It just says fall, which is an invert and landing in a lower surface. or the ground, right, from a certain height, standing height or less. So, Beth, I'm going to assume that you can go ahead and throw in an environmental factor like ice. It basically indicating that this person likely has, you know, some bone marrow density issues. There's, you know, some type of balance deficit or scenario that led to them losing their balance. So, I think it's safe to say you can throw that in there. Good question, Beth. So one, we define the enemy, it's not the injury, it's the effects of the injury. STEP 2: PLAY OFFENSE Number two, then we play offense. In this scenario, we do want to protect the fracture, right? I don't want you all to walk away and think that we're just doing, you know, 80% 1RM deadlifts, you know, three days out from a vertebral fracture. I don't think that's a good idea. That's probably harmful for that individual. We want to protect that area and give that bone the space to do its job and heal and don't want to continue to pick the hypothetical scab, if you will. But we attack the deficits that are present. So we're often going to find strength deficits in other areas that we know can contribute to someone's risk of falling. We know we're going to more than likely going to find different balance deficits. Maybe they have difficulty with their reactive postural control and their different stepping strategies in different scenarios. We want to be able to attack that. Maybe they have an endurance-based deficit that when they do go on that long walk, relatively long walk to go get their mail, for example, that they start to have a decrease in their balance performance. Or, man, their balance and their stability really crashes when we add maybe a motor dual task component or a cognitive dual task component. We still want to assess them for those deficits and attack them. And so we can have a well-rounded program where we're building up their physical capacity, their balance capacity, their endurance capacity, while we're allowing that particular area to heal. And obviously this is going to look different for different injuries and kind of the level of injury, but we need to think about protecting the area but attacking the deficits that are present. If we can attack the deficits without, you know, causing more harm to the area, man, you're gonna do that person a huge service. And so for me, like in the context of home health, it was a lot of that. Like vertebral fractures, we would avoid kind of the end range, you know, flexion, twisting. We would kind of avoid those scenarios, but man, we would hit it hard on their endurance. I would try and get them as strong as possible in these other areas while respecting, you know, that particular fracture. What's really important I think particularly about this phase when we're kind of trying to attack deficits is that we're able to get accurate feedback on are we doing damage to that area and this is where pain management is really important for a lot of folks that typically they will have some type of pain medication prescribed on board which you know, for many of us, right, that gives us the ability to do a lot of activities because it's lowered their pain levels. But medication timing can be important here because I do want to be able to get some type of feedback that, oh man, that really hurts in that particular area. So I don't want them to take, you know, their meds, you know, an hour before so they're, the meds are in full swing and really masking a lot of that pain signal that can be helpful. I may have them take it 20 minutes before, for example, or if it's a relatively low pain level, let's take it at the end of the session. To get that feedback can be really helpful for your exercise selection and your dosage as well, all right? So step one, we define the enemy. It is not the injury, it's the effects of the injury. Number two, we play offense. Meaning, we're still going to protect the fracture, but we're going to attack deficits. STEP 3: PREPARE FOR THE NEXT FALL And number three, we want to prepare them for the next fall. We often talk about falls prevention, right? And in reality, falls prevention is usually in practice trying to prevent the next fall. I really want you to shift your thought to preparing them for the next fall. A lot of people fall. you've probably fallen within the past year. I don't want to say falling is a normal part of aging per se, but if we can prepare people for the next fall, that may actually prevent a fall or prevent an injurious fall. Now, when we typically talk about falls preparedness on this podcast in our courses, we're talking about fall landing techniques, we're talking about floor transfers, getting up from the ground, so on and so forth. And I think that's very appropriate for fragility fractures once they are healed and stable. So for some, this may be 12, 14, 16 weeks out. For some individuals, it may be a whole year, right? Like it definitely varies, but we can scale and modify fall landing techniques to a very safe and short range of motion to allow them to practice some of these principles to lower the impact forces that they experience if and when they do have a fall. So I think that's important. I'd be very conservative there. Make sure the fracture is very stable, it is healed. That's probably at the end of a plan of care. But along with false preparedness is preparing the bones for the future onset, right? And that is going to be getting those bones as strong as possible. And so, once those bones are healed, then this is anecdotally, right? There is not a lot of evidence really to show the effectiveness of a post-fragility fracture progressive loading, which that's growing. But for now, a very slow progressive loading of those particular areas I think is warranted once that fracture is healed. What can be really helpful for individuals is just showing them how to use their body in a manner, particularly with the vertebral fracture, related to Melissa's question, is like, for example, teaching them a hip hinge versus a rounding of the spine to pick something up. Like, that's something we probably want to be teaching that relatively early on in the rehab process, but I think we can really start to load that later on once that fracture has healed. And so we wanna think about preparing for the next fall. That's fall landing techniques, that's floor transfers, but it's also progressive loading too, that's fine. It's impact training. It's doing some of these things that we'll go over in detail in our MOA live course and then our level two course as well. The dosage is very tricky and the progression is very tricky, right? Because we're dealing with a somewhat delicate situation, so we need to be very respectful, but it can be done. And that's what I think we need to do for these folks that have had this fragility fracture. They've had a fall, a lot of fear on board. It changes their lives in so many ways. I think first we need to define the enemy. It's not the injury, it's the effects of the injury. We're trying to get this person as fit as possible, get them moving as much as they can so they can continue to do the things that they love. As they do that, we want to play offense. We want to protect the fracture but attack some of these other deficits as we're allowing that area to heal. So, it may be a lot of balance training, you know, strength training of other areas, but there's typically a lot that we can work on. And then, as things become more stable, as that fracture is healed, which it may be 12 weeks out, it may be 52 weeks out, right, depending on that individual and their rate of healing. We're starting to, you know, think more about preparing for the next fall. We're preparing the bones by progressive loading. We are showing them how to fall so they can distribute their load, lower their impact force to prevent that injury, showing them how to get up from the ground, so on and so forth. I think if we follow those three things, we can improve someone's confidence and hopefully get them back to where they were before the fracture and maybe even better, right? So, let me know your take on this. Evidence is relatively limited in this post-fracture category. I know Laura Gray and Gorio is doing some really awesome work, really pushing forward on developing some research studies and speaking to building the evidence post-fracture. And so, I'd love your all's take. What's your experience? What have you found? Just go throw comments on the Instagram video for those that are watching YouTube or listening on the podcast. SUMMARY Before I go, I do want to mention some of our Modern Management of the Older Adult courses that are coming up. All three of our courses, we have two online courses and a live course, those three culminate in the ICE Certified Specialist in the Older Adult. So that's a certification for those badass clinicians that are able to handle basically whatever kind of walks in through the doors or whatever they walk into in the home. Our level one online course, the next cohort is starting today, so Wednesday, August 14th at 8 p.m. So we have a few seats left, so hop in there if you've been wanting to do that. The next one won't be until later this year. Our level two is going to be in October, and then our live course, we've got several coming up. This upcoming weekend, if you're in Alaska and want to have a good time, Jeff Musgrave on set up, you're going to be in Anchorage, Alaska, August 17th to 18th. Then September 7th through 8th, we got a doubleheader, one in Mobile, Alabama, and then Minneapolis, Minnesota. And the following weekend, September 14th and 15th, we have another doubleheader in Bend, Oregon, and then Casper, Wyoming. We'd love to see you all. Love to practice some of these techniques, these fall landing techniques, progressive overloading, so we can help serve these folks that have had these fragility fractures. All right, you all have a lovely rest of your Wednesday. I'll talk to you soon.

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