Low-Back Orthoses

The Efficacy of Fentanyl Transdermal Patch as the First-Line Medicine for the Conservative Treatment of Osteoporotic Compression Fracture

Objective

There are no strong guidelines on how long or how we should undertake conservative treatment during the acute period of an osteoporotic vertebral compression fracture (VCF).

Methods

We treated 202 patients with conservative treatment on VCF from March 2012 to August 2015. On inclusion criteria, 75 patients (22 males and 53 females) were included in the final analysis. After admission, a transdermal fentanyl patch with low dose (12.5 µg) application was attempted in all patients. In an unresponsive patient, the fentanyl patch was increased by 25 µg. After identifying the tolerable toilet ambulation of the patient without any assistance, hospital discharge was recommended. We classified two patient groups into one favorable group and one unfavorable group and compared several clinical and radiological factors.

Results

Among 75 patients, the clinical outcome of 57 patients (76%) was favorable, but that of 18 patients (24%) was unfavorable. In clinical outcomes, the numeric rating scale at 6 and 12 months and Odom's criteria at 12 months was significantly different between the favorable and the unfavorable groups. The dose of the patches used showed statistically significant differences between the two groups (p=0.001).

Conclusion

The only statistically significant affecting factor for an unfavorable outcome was the use of a higher dose fentanyl patch. Our data inferred that the unresponsiveness to a low-dose fentanyl patch could be helpful to select patients necessary for percutaneous vertebroplasty or kyphoplasty.

Osteoporotic vertebral fractures: current concepts of conservative care

INTRODUCTION

Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966-2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures.

AREAS OF AGREEMENT

Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing.

AREAS OF CONTROVERSY

A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials.

GROWING POINTS

Randomized controlled trials are being performed worldwide on vertebral augmentation techniques.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Conservative management of patients with an osteoporotic vertebral fracture

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Nonoperative management of osteoporotic vertebral compression fractures

As the population ages, vertebral compression fractures are an increasing source of pain and dysfunction. The immobilisation that often occurs with fractures can lead to multiple medical complications and their management can be complex as care may require multiple treatment modalities. Each individual responds to pain differently and a treatment plan must be tailored to the individual's pain, functional limitations and goals. The likely first choice for managing stable osteoporotic vertebral compression fractures is conservative management. Treatment options usually involve a combination of medications, bracing and physical therapy. If radicular pain is a component of the pain syndrome, epidural steroid injections may be beneficial. In addition, some patients may benefit from vertebral augmentation. This paper reviews current recommendations for managing vertebral compression fractures. Treatment options including vertebral augmentation are reviewed, including indications and complications.

Conservative Care for Patients with Osteoporotic Vertebral Compression Fractures

As the aging population grows, vertebral compression fractures are becoming an important source of pain and dysfunction. Management can be complex, because care may require multiple treatment modalities and the treatment plan must be tailored to the individual's pain, functional limitations, and goals. Treatment options usually involve a combination of medications, bracing, and physical therapy. This article reviews current recommendations for managing vertebral compression fractures. Indications, complications, and treatment options, including vertebral augmentation, are discussed.

Current medical, rehabilitation, and surgical management of vertebral compression fractures

Approximately 25% of women over the age of 50 in the United States will suffer one or more vertebral compression fractures (VCFs) related to osteoporosis. VCFs are the most common of all osteoporotic fractures, with an incidence of approximately 700,000 annually. Such a fracture may cause significant pain, disability, and loss of general health and mobility and may lead to a progressive decline in quality of life. This is a review of the clinical literature on VCFs, including patient presentation, methods of diagnosis, and current rehabilitation and medical management. Much of the pain and disability that follow a VCF may be minimized by addressing the psychological impact of such a fracture, using current medications to help limit bone loss and preserve bone mass, adhering to a well-planned rehabilitation program, and consideration of vertebroplasty or kyphoplasty in appropriate patients. A multifaceted approach will help to optimize recovery from a VCF related to osteoporosis.

Bony pathology in the cancer patient

Bony pathology in the cancer patient represents a significant source of morbidity and mortality. Complications include insufficiency and pathological fractures resulting from either medical treatments or bony metastases that can cause significant functional limitations. Additional complications include spinal cord compression, hypercalcemia, and bone marrow failure. Rehabilitation management of such conditions is reviewed, with an emphasis on diagnostic and therapeutic management. Bracing and focused rehabilitation programs facilitate maximal participation and functional outcomes, which can result in an enhanced quality of life. Specific rehabilitation goals and strategies are discussed, with an emphasis on tailoring these according to the functional staging of the patient.

The effects of a lumbar support on repositioning error in subjects with low back pain

OBJECTIVE

To determine whether a lumbar support improves trunk repositioning error (RE), an aspect of proprioception.

DESIGN

RE was measured with and without a lumbar support.

SETTING

Outpatient clinic.

PARTICIPANTS

Twenty subjects with chronic low back pain (LBP) and 20 control subjects.

INTERVENTIONS

Subjects wore the lumbar support for 2 hours and then testing was repeated.

MAIN OUTCOME MEASURES

Standing with legs and pelvis immobilized, subjects moved to a predetermined target position and then attempted to replicate the position. The 3-dimensional position of the trunk was measured with a 3Space Tracker. RE was calculated as the absolute difference between the actual target position and the subject-perceived target position. Testing was performed with and without a lumbar support both before and after wearing the support for 2 hours.

RESULTS

In subjects with LBP, RE was significantly lower with a support in flexion, extension, and right lateral bending. In control subjects, RE was significantly lower when wearing the support in left bending only, and RE was significantly higher in control subjects after wearing the support for 2 hours.

CONCLUSION

A lumbar support improves trunk RE. In subjects with LBP, this result was significant in the sagittal plane and in right lateral bending, whereas in control subjects, it was significant only in left lateral bending.