Efficacy of a specific rehabilitation protocol in postural control of a young woman with multiple fragility vertebral fractures: a case report

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Efficacy of a specific rehabilitation protocol in postural control of a young woman with multiple fragility vertebral fractures: a case report

A 60-year-old woman was presented with two vertebral fractures (L1 and L4) after a fall. She was subjected to vertebroplasty on L1-L2-L3-L4. She had come to the multidisciplinary outpatient clinic for “diagnosis, therapy, rehabilitation of patients with vertebral fragility fracture” of Pisa University Hospital after 7 months from vertebroplasty. She still presented pain in particular in lumbar and sacral spine. She was affected by rheumatoid arthritis and was receiving corticosteroid therapy.

The most likely diagnosis of this presentation is:

  • Osteoporosis

  • Osteopenia

  • Osteoarthritis

Introduction

The fragility vertebral fractures are a significant public health problem1. In fact, they can have a considerable impact on an individual’s health-related quality of life due to pain, limitations in activity, social participation and altered mood2. Vertebral fractures are related to increased thoracic kyphosis and loss of lumbar lordosis that are linked to increased spinal loading and back extensor muscles weakness. This can lead to an increased risk of further fracture3. Physiotherapy interventions may have an important role in improving life quality, balancing and reducing the fracture risk in people with osteoporotic vertebral fractures. In literature, there are only few studies that examine exercise interventions in osteoporotic populations with vertebral fracture4-6 and few studies that examine the effects on balance with instrumental measurements. In the present case, we present the effect of a specific rehabilitation program in a woman with fragility vertebral fractures presented to the multidisciplinary surgery for “diagnosis, therapy, rehabilitation of patients with vertebral fragility fracture” of Pisa, using clinical evaluation and instrumental measurements.

Medical History

She had a positive family history for osteoporosis (mother with femoral fracture). She was in therapy with methylprednisolone, methotrexate, alendronate, cholecalciferol and calcium carbonate.

Examination

At physical examination, she showed pain on spinous processes L1 and L2. She has a limited spinal flexion, only slight limitation on hip internal rotation and ankle flexion. She was investigated for all this parameters: number of fallings in the last year (1 falling), walking test in 20m (26,1 second), Barthel index7 (score: 95), cumulative illness rating scale (CIRS)8 (CIRS severity: 1,3; CIRS comorbidities:1), geriatric depression scale short version (GDS)9 (score: 11), VAS scale (neck score 4, dorsal score 0, lumbar score 8). The health outcome was measured with EuroQol-5D (Eq-5D)10. She indicated some problems for all dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression and indicated a Global health of 40. Height and weight was measured for calculation of Body Mass Index (BMI) that was 26,9. About the sagittal alignment, the occipital to wall distance was 5 cm. The scapular plane was 2 cm anterior than gluteal plane. The distance of apex of cervical lordosis from a virtual vertical plumb line was 9 cm, of lumbar lordosis 2 cm. In frontal plane, patient had asymmetry of the shoulder than the pelvis. The patient had a scar among breasts. For the instrumental evaluation of the balance, static stabilometry was used, which evaluates the postural balance through the quantification of the postural sway in the orthostatic position on a force platform. The variables for analysis of the stabilometric test were: displacement and speed of displacement in the medial-lateral (ML) and anterior-posterior (AP) axes from the center of pressure (COP).

Management

Tapentadol 50 mg and paracetamol 1 g was prescribed for pain. The patient was confirmed for treatment with alendronate, cholecalciferol and calcium carbonate to decreased risk of new fractures that is present also in patients treated with percutaneous vertebroplasty11. The patient started a specific rehabilitation program for fragility vertebral fractures (10 daily sessions, each of 40 minutes). The protocol was composed of supine exercises with legs in unloading above the cube, exercises in sitting position and standing against the wall. The exercise concentrated on the back extensor and posterior trunk postural muscles in order to promote a neutral spinal posture were suggested. All exercises were of low intensity in order to minimize compression loads though already-weakened vertebrae. In each position were performed proprioceptive exercises of trunk and pelvis.

About health outcome, the patient has a significant improvement in all dimensions of Eq-5D (T0: 0,19; T1: 0,53) and also in the global health (T0: 40; T1: 80). After treatment, the patient had performed a new stabilometric test. The postural balance was improved after the protocol. The ellipse surface was 22,59 mm2 after treatment (T1) instead of 63,81 mm2 at T0. The COP resultant displacement (total path) was improved by 135,1 mm (T0) to 126,8 mm (T1); the COP resultant velocity was improved by 2,63 mm/sec (T0) to 2,47 mm/sec (T1). The COP’s anterior-posterior velocity was improved by 1,52 mm/sec (T0) to 1,42 mm/sec (T1).

Discussion

This report presented the case of a woman with fragility vertebral fractures (L1, L4) treated with vertebroplasty (L1, L2, L3, L4), subjected to a specific rehabilitation program. Based on the concept that back extensors weakness is associated with vertebral fractures and can be a key element in the pathophysiology of flexed posture, exercises for strengthening of back extensor muscles were included in the protocol. The exercises proposed were well tolerated and there were no adverse effects. Good results were achieved with the specific rehabilitation program. The lumbar VAS score was changed from 8 (T0) to 3 (T1), the walking test changed from 26,1 sec (T0) to 23,8 sec (T1). The health outcome was improved in all dimensions of Eq-5d (T0:0,19; T1:0,53) and also in the Global health (T0: 40; T1: 80). Scapular plan distance was changed from 2 cm (T0) to 1 cm (T1), the lumbar lordosis distance from 2 cm (T0) to 3 cm (T1). The height was changed from 162 cm to 163 cm. The fact that rises interest in this case was the stabilometric evaluation. In fact, even though she doesn’t have significant posture disorders, the COP’ displacement shows an impaired postural control.

There is evidence that patients with chronic low back pain have poorer postural control12. The patient had a VAS score of 8. The postural control is also influenced by reduced mobility13 and the fear of falling14, in fact the patient has a reduced mobility of spine and a GDS score of 11. After rehabilitation program, the COP’s displacement is improved with a reduction in COP mean velocity and COP anterior-posterior velocity.

Learning

In conclusion, the specific rehabilitation program proposed to this patient had showed good results about pain, health outcome, postural alignment and postural balance. In literature, there are no standardized protocols for the treatment of patients with fragility vertebral fractures. This is only a single case, but of a standardized protocol currently applied to all patients who belong to the multidisciplinary outpatient for “diagnosis, therapy, rehabilitation of patients with vertebral fragility fracture” of Pisa University Hospital. The mechanism underlying postural control are not clear yet. The instrumental evaluation of postural balance is important for an early and clear diagnosis of postural imbalance and to identify with more accuracy the patients that need rehabilitation.

References

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  12. Radebold A, Cholewicki J, Polzhofer GK, Green HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine (Phila Pa 1976). 2001 Apr 1;26(7):724-30.

  13. Briggs AM, Greig AM, Bennell KL, Hodges PW. Paraspinal muscle control in people with osteoporotic vertebral fracture. Eur Spine J. 2007:1137-44. 14. Carpenter MG, Frank JS, Silcher CP, Peysar GW. The influence of postural threat on the control of upright stance. Exp Brain Res. 2001 May;138(2):210-8.

  14. Carpenter MG, Frank JS, Silcher CP, Peysar GW. The influence of postural threat on the control of upright stance. Exp Brain Res. 2001 May;138(2):210-8.

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