Episode 1624 - Fall prevention & management: what's missing?

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the importance of fracture risk screening & osteoporosis management, including utilizing the FRAX tool & DEXA scans to better help assess & manage fall risk with patients.

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.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I'm a member of the Older Adult Division. Excited to be talking to you all this morning all about the big critical piece that is missing from our fall prevention and management frameworks. The big critical piece that is missing from our fall prevention and management framework. So before we get into the goods, I want to let you all know about our courses that are coming up in January because we are hitting the new year just right out the gate. We are absolutely slammed. So our L1 and L2 online courses kick off January 11th and January 12th. And then we will be on the road all throughout the month. So we will be in Columbus, Ohio, We will be in Santa Rosa, California, Clearwater, Florida, and Kearney, Missouri. So we would love to see you in our online courses or out on the road starting the year off strong with us. FRAMEWORKS FOR ASSESSING FALL RISK Okay, let's dive in. I want you all to think of your typical frameworks for your fall risk assessment and your management plan. I want you to think about it. So I want you to think that 70 year old Betty is coming into your clinic or you're going to see her at her home or in her hospital room. She's been referred for strength and balance deficits. She's had a fall in the past. I want you to think about kind of that long list of assessment pieces that come into your head. You know, what you're probably going to evaluate or be thinking about. So when I think about that long list, here are some of the things that come to my mind that are probably coming to your mind. You may do some evaluations and assessments like the short physical performance battery. You may run a tug. You may look at strength. You're probably going to do a gait speed. Maybe you want to do a mini best and check Betty's vision, check her cognition, talk to her about her environment. Maybe you do a medication review or you check her shoe wear. Maybe you're going to check her vitals, right? This list could go on and on. It's definitely not all inclusive, but I would bet that a large percentage of you that for a large percentage of you, the piece that didn't make that list was fracture risk screening and osteoporosis management. FRACTURE RISK SCREENING & OSTEOPOROSIS MANAGEMENT This is our critical missing piece, fracture risk screening and osteoporosis management. So we are going to start by setting the foundation and talk about why that piece is commonly missed. We are going to talk about why as fitness forward rehab professionals, fracture risk screening and osteoporosis management has to be on our radar, especially given the fact that we have the goal, especially in this crew, we have the goal of identifying, seeking out, and absolutely destroying one ret max living in order to make our older adults as robust as possible. And in this specific case, helping to make their bones as robust as possible. And then I will give you guys a few clear, easy to implement actionables that you can start getting after this week that are going to be able to give you a very comprehensive clinical picture of your patient's skeletal health. Okay. So first and foremost, we need to think about why is this not on our radar? You know, why for many of us was fracture risk screening and osteoporosis management not something that came to our minds. And if you're like me, I didn't really learn about that in school. It wasn't emphasized. I definitely didn't learn it out on clinical. And I really didn't address it in my clinical practice. If someone, one of my patients had osteoporosis, I kind of just assumed that it was going to be managed by their PCP or the medical team. And I didn't really have a big role to play, right? And we also have to realize that we understand that falls and fractures are important, right? Like falls and fractures, especially in working with older adults, this is on our mind a lot. And we know that as our older adults age, falls and fractures are going to increase. And we know that This results in years and years and years of disability that our older adults have to live with. So we know that it's important. So we have to start thinking like, why isn't this on our radar? So I want you all to start getting really curious about your patient's skeletal health. And when we look to the literature, we further see that this is an undertreated and an underdiagnosed condition. In the literature, it'll be deemed as the silent disease. And there are so many retrospective cohort studies that show that individuals who sustain a fracture after a fall, a very alarming high percentage of them were never scanned. They never had a DEXA scan. They were not on osteoporosis medication. And a very high percentage of them will go on to have another fracture in a few years. So this is a massive, massive problem that we are seeing and we have to realize that we have a role here and we can be the individuals to help screen and identify this as a problem and interrupt that cycle. So when we start to get curious about our patient's skeletal health, I want you all to think about Betty, right? About 75-year-old Betty who's coming in to see you. And we're really good at looking at Betty and assessing Betty and thinking, like, Betty's got a lot of muscular weakness on board. So if we know that Betty is weak muscularly, we have to remember that it's called the musculoskeletal system, and that those bones also may be very weak as well. So as soon as you identify muscular weakness in Betty, I want you all to be thinking, okay, I need to start thinking, hmm, are those bones weak as well? The other side of this, though, is that Betty may blow that, you know, 30 seconds to stand out of the water. Her gait speed may be great. Like she's really kind of crushing it on her on these outcome measures that we're running. And we may think like, oh, she's thriving. However, we can't automatically assume that those bones are thriving as well because there are so many factors that go into bone health that are not visible to the eye. So don't make the assumption that her skeletal system is absolutely crushing it. You want to continue to be curious and you have to start thinking there's so much more that goes into this. I need to do some assessments and do some screening to really get a clinical picture of what Betty's skeletal health is actually like, right? And we need to start thinking about this in terms of urgency. In the older adult division, the urgent situation is identifying someone who is at one rep max living, and then triaging our fitness forward approach, because that individual needs our fitness forward approach the most. So if you think about it, and Betty is coming in, and you're running assessments on her, and she's at risk for falls, and you haven't even looked at her skeletal health yet, Well, you're going to say, whew, Betty's at risk for falls. I definitely need to really triage a fitness board approach for her. But then if you also assess her skeletal health and you realize that she has weak bones and she's at risk for falls, my God, that is an incredibly, incredibly urgent situation. That individual needs our fitness forward approach the most, but we're not going to be able to know how to intervene, how to appropriately intervene if we don't even know the problem exists. So we have to be able to identify that this is a problem. We are the providers that can make this silent, invisible disease very visible. So how do we do that? Let's talk about some actionables here that you guys can start doing immediately that are going to be able to give you really critical data in order to gain a comprehensive picture of her skeletal health. Number one, it is the lowest hanging fruit. It's the easiest place to start. SCREENING FOR FRACTURE RISK: THE FRAX TOOL You can screen for fracture risk and you can do that by using the FRAX tool. The FRAX tool is so easy, so quick to implement. I will link it here for you. It takes two minutes, but the algorithm gives the 10-year probability of a fracture. So it's gonna give the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture, so of the spine, forearm, hip, or shoulder. In the questionnaire for the FRAX, ask some questions that start giving you an idea of things that affect bone health. So really easy, they're going to be asking just age and height and weight, right? These things you can get from EMRs or your patient. really quickly and then they're going to be asking some questions like have they had a previous fracture? Did one of their parents fracture a hip? Are they smoking? Are they on medications like glucocorticoids? Do they have an inflammatory disease like rheumatoid arthritis? Do they drink excessive alcohol? All of these factors that can really affect our bone health negatively. It will also ask for their bone mineral density. And you do not have to have Betty's bone mineral density in order to fill this out and for it to be to give you a validated probability. The frax has been validated without a bone mineral density value. However, Betty may have her bone mineral density. She may have a DEXA scan, and you can use that value, but only for the femoral neck. It is only validated for the bone mineral density of the femoral neck. So that's the caveat there, right? So really quick and dirty, you can do the FRAX tool. It's going to shoot out a probability. What happens next? This is going to start to give you an idea, like, whew, there's a lot going on here that I didn't realize with Betty. Her skeletal health isn't really thriving. And let's assume that Betty has not had a bone mineral density scan. And you're really thinking, well, I mean, gosh, she smokes, she's been on glucocorticoids, she drinks alcohol, she has had a previous fracture, like, she should probably get a DEXA scan. and you're thinking like, but you know, what are some, like, should I suggest that? The great news is that there are guidelines that tell us if we should suggest that Betty get a bone marrow density scan. I will link the clinician's guide to prevention and treatment of osteoporosis as well for you all to look at, but it just gives some general guidelines. A lot of the things that you have just heard about from the FRAX tool. So, it will tell us that we should consider BMD testing if with individuals based on age, based on the clinical risk factors such as taking glucocorticoids or having an inflammatory disease, individuals who have had a fracture. So we have guidelines to tell us this. TESTING FOR OSTEOPOROSIS So You've run the FRAX tool, you've looked at the guidelines, you are sure, you're like, Betty needs to go get a DEXA scan. So you're gonna communicate this to Betty. But what you're gonna do next is not, hey Betty, I really want you to go get those bones looked at. So schedule that with your doctor. I'll see you next week. That's not what we're gonna do. you're gonna help Betty set that appointment up or call a doctor, right? You are going to help her advocate for herself. You're not just gonna give that piece of education and then peace out, Betty. So what can you do? You can get the doctor on speakerphone during your session with Betty. and you can guide the conversation while she asks to set up an appointment to get a DEXA scan done. You can make sure Betty knows how to get into her MyChart so she can send a message to her doctor and you can help guide her on how she should formulate that message so she's communicating effectively. Make sure that you are a guide during that process and that you're not just throwing an educational piece at her and expecting her to take care of it. Help her through the process. Okay, so let's say we got a DEXA scan scheduled for Betty and she goes and has her appointment. She gets her DEXA scan. She has her results. This is where you can have a major role, not only in helping to deal hope to Betty once we are looking at those results, but it's also gonna be your guide when you start to implement your interventions. And it gives you very critical information, okay? So if you all have not seen a DEXA scan in the wild and what that looks like, I'm gonna tell ya, it's not patient friendly. I have seen one after my mom had to get one before she had a lumbar fusion surgery. It is chock full of scary words like osteopenia, fracture, osteoporosis. There's a lot of negative values, right? Like her T-scores all over the place and there's these negative numbers. It'll say increased risk for fracture. It is not easy to comprehend. and it deals a lot of fear. So this is an opportunity to help Betty interpret what this means. And you can really offer a lot of hope here. So with the DEXA scan, right, and with this data, you can be looking at it, and it's gonna give you that T-score, right? Betty may be looking at this and be like, oh my gosh, this number is so low, this is awful, right? I'm so scared. you can deal hope because you know, based on the law of initial values, those lower T-scores are going to respond to bone loading the best. They're gonna have the best result from starting to load those bones up. That's an amazing thing. You can share that news. So even if that T-score is really low, you can say, Betty, that's all right. That low score, those bones, you're gonna respond the best. And together, we're gonna help get those bones stronger. So right away, you can start dealing some hope. It's also going to tell you where those low T-scores are. The location of where the osteopenia or osteoporosis is is incredibly critical. How many of you have had patients come into your clinic and say, I can't lift that because I have weak bones? And you know, Betty, if it was Betty, she may assume that her weak bones are all over the place. However, that DEXA scan could tell you that the only place where she has weak bones is in her radius. Okay, well, all those squats and the jumping and things that Betty's like, absolutely not, I can't do, they're kind of irrelevant because it's in her radius and not in the legs, right? So to help Betty alleviate some of that fear, you could reassure her where those weak bones are. And that could really work in your favor when you're trying to get her to buy in to do exercise. However, you are also thinking, I need to know where and where is important because you know that bones are going to adapt specifically to where load is put on them. So let's say the low T score is in Betty's hip. You know that you have to load that hip up in order for that bone mineral density to increase. However, you also are taking this information and being cautious to say where it is so that Betty knows, yes, it's weak here. She may be a little apprehensive to load that area. So you know that you can give her the hope of, hey, it's weak here, but your bones are strong in these other places. So we can start loading where those strong bones are. So you can gradually expose her and mitigate some of the fear she may have. The other piece of information that is really important from the DEXA scan that you get as a provider is that it just gives you the severity, right? How low is low in that T-score? Because that is going to determine your rate of loading progression. So you have to know, hey, maybe this is someone where we are not going to start with impact exercises, we're going to start with just resistance exercises. And maybe I'm going to modify where I place that weight based on where that low T-score is. And maybe if we do start impact, or when we start impact, it's going to be upper extremity assisted versus just having Betty do jumping right away. So it's incredibly important so you know where the entry point is of appropriate and safe loading. So the bone mineral density scan, helping Betty interpret that information and you using it as a guide, sets you up to be able to appropriately intervene and start loading those bones up. All right. That is it, that is what I got for you all. I want you to start getting really curious about your patient's skeletal health, and then get after these two easy actionables. Run the FRAX tool, advocate for a bone mineral density test. Once you get the DEXA scan and you get that information, interpret that with Betty, use that as your guide, use it to deliver hope to Betty. After that, it is off to the races with your loading interventions. this framework of how to manage osteoporosis. This is one small piece. We expand on this so much greater in our L2 course. We talk about medical management. We talk about further into guidelines and how to load and what's appropriate to load. And we dig into the research. We would love to see you in that L2 course so that you all can really get a comprehensive really get comprehensive knowledge of how to manage this condition. In our live course, we have an entire lab focused on impact training, so it gives you all the ideas, all the ideas. You get to try them out of how to initiate bone loading for your athletes who are seated and they are non-ambulatory, they're in wheelchairs, all the way up to a very high, highly active older adult. That's what I got for you guys. I would love to hear if you all run the Fractual this week or interpret your patient's DEXA scan with them. I would love to hear how that goes. Have a wonderful rest of your Wednesday.

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