This is a case study of a 66-yr-old woman with osteoporosis and thoracic kyphosis who had been receiving alendronate for 8 yrs. Her chief complaint was her stooped posture that was “getting worse.” She had had frequent chiropractic “adjustments” for occasional back pain but was pain-free at the time of her evaluation at our institution. Neurologic examination was within normal limits. Lumbar spine radiographs were negative for vertebral compression fractures. No thoracic spine radiographs had been obtained before her referral to the Rehabilitation of Osteoporosis Program–Exercise (ROPE), despite the location of her thoracic deformity.
Before the patient’s entry into the ROPE program, thoracic spine radiographs were obtained, and these showed a compression fracture of a midthoracic vertebral body and moderately severe thoracic hyperkyphosis (Fig. 1). A proper back exercise program for strengthening the back extensors, postural exercises, and a weighted kypho-orthosis were provided to the patient, along with instructions to avoid straining her spine. Pharmacotherapy including antiresorptive agents and proper intake of calcium and vitamin D were reviewed with the patient.
This case illustrates the need for a thorough evaluation with radiographs before initiation of an exercise program. Despite ongoing pharmacotherapy for osteoporosis and the lack of significant back pain, this patient had a compression fracture that, if left undiagnosed, could have progressed into a more serious condition during the course of her physical therapy or her chiropractic manipulations.
Vertebral compression fractures are common and can be insidious in the osteoporotic population. Although fractures generally are associated with pain, it is important to consider the possibility of vertebral involvement in this population, despite the absence of discomfort, particularly when there is obvious progression of kyphotic deformity. Patients with previous vertebral fractures are at risk for further vertebral fractures. They also have an increased risk of falls and mortality. Exercise is an integral part of the management of patients with osteoporosis and has been associated with improved physical ability, bone mineral density, and decreased pain.
Elizabeth Huntoon, MD
Mehrsheed Sinaki, MD, MS
From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
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