Peterson, Melissa L. PT, PhD, GCS; Bertram, Stacie PT, PhD; McCarthy, Shyla DPT; Saathoff, Emily DPT
Osteoporosis is a common disorder among older women, but other groups can also be affected as well. Nearly 10 million people in the United States have osteoporosis.1 One out of every 2 women and 1 in 4 men older than 50 years of age will have an osteoporosis-related fracture in their lifetime.2 Although numerous resources involving osteoporosis and its treatment are available,3–18 little information exists regarding physical therapists' knowledge of osteoporosis, how they screen for it, and how they actually manage patients with osteoporosis. One recently published study surveyed osteoporosis knowledge and learning needs in health care professionals caring for patients who have experienced or are at risk for fracture. More than 70% of the respondents understood that fragility fractures are a risk factor for future fractures, loss of height may be an indicator of osteoporosis, and that prednisone increases osteoporosis risk. There were, however, gaps in osteoporosis knowledge among nurses and other health care professionals working with individuals who are at risk of osteoporotic fractures or have had a fracture, especially about prevalence of osteoporosis and nutritional needs of those with osteoporosis.19
The lack of information regarding what physical therapists know about osteoporosis is of concern because therapists provide care for many persons at risk for or not yet diagnosed with the disease. Because certain medical conditions contribute to increased risk for osteoporosis, physical therapists must be able to identify these risk factors.3,20 Considering the prevalence of osteoporosis, it is clinically relevant for physical therapists to be able to identify the patient at risk so that an earlier diagnosis can be made and safer interventions can be employed.
Although osteoporosis may be a concern for individuals across sex, racial, and age groups, certain groups are at greater risk. Conditions and events in a woman's life affecting peak bone mineral density and rate of bone loss increase the risk for osteoporosis. These conditions include a high body mass index during adolescence and early adulthood, decreased calcium intake, poor diet and nutrition, pregnancy, breast feeding, early menstruation, physical inactivity, alcoholism, cigarette smoking, depression, use of corticosteroids, and bariatric surgery.1,4 Ethnicity also plays a role in developing osteoporosis, because bone mass correlates positively with skin pigmentation. European American and Asian American women aged 50 year and older have the highest risk for osteoporosis with an estimated 20% of each group affected.21 In contrast, African American women have a lower risk at an estimated 5% of individuals affected. The more risk factors that are present, the more likely the disorder will occur.
Despite the awareness of known risk factors, likelihood that osteoporosis may be present is commonly overlooked. In many cases, osteoporosis is not recognized until a patient has fallen and sustained a fracture; by this time, preventative treatment may no longer be an effective option.5,22,23 One retrospective study of 125 patients admitted for hip fracture revealed that only 4% received any evaluative tests for osteoporosis, such as bone densitometry or urinalysis, while hospitalized.24 Bellantonio et al25 reported only 13% of the women hospitalized with a recent hip fracture were receiving adequate treatment for osteoporosis as defined by National Osteoporosis Foundation guidelines. If osteoporosis is not commonly recognized after individuals fracture, it is even less likely that asymptomatic individuals will be identified.26
Recommended screening by physical therapists for signs of osteoporosis includes a thorough medical history and a review of previous diagnostic testing results. In addition, information regarding the patient's leisure and home activities should be obtained.6,10 This will allow the therapist not only to set appropriate goals and expectations, but also will provide the opportunity to educate the patient on activities that may be potentially harmful. A thorough physical therapy examination enables the clinician to establish baseline measures and to design an intervention that will lead to optimal outcomes. Since osteoporosis often leads to loss of height and postural changes, these issues should be assessed during the examination. Use of a flexible ruler to quantify degree of thoracic kyphosis and lumbar lordosis has shown to be a reliable and valid form of measurement.27–29 Since certain postures and activities (eg, trunk flexion, side-bending, and rotation) may pose risk for patients with spinal osteoporosis, any individual at risk should be observed performing typical activities of daily living to determine the need for education on alternative movement strategies.6
Physical therapists are responsible for designing exercise programs, as well as educating clients on bone health for activities of daily living. Current recommendations for interventions for persons with osteoporosis include resistance and weight-bearing exercise, trunk extensor strengthening, respiratory training, functional activities, fall prevention, and environmental modifications. Diverse activities are encouraged, and 45 and 60 minutes of weight-bearing exercise 4 times per week are recommended to maximize stress on the skeletal system and encourage bone remodeling.1,5–18,30,31
When prescribing exercises for persons suspected of having osteoporosis, physical therapists must be aware of certain contraindications. For those with vertebral osteoporosis, activities such as golfing, bowling, biking, rowing, sit-ups, or other exercises where trunk flexion, side-bending, or spinal rotation is involved should be excluded.1 Sinaki and Mikkelsen8 studied the effects of flexion and extension exercises in women 49 to 60 years of age. They found a significantly higher number of vertebral compression fractures occurred in patients with postmenopausal osteoporosis who followed a flexion exercise program compared with those using extension exercises.8 Wilson and Myers32,33 developed a model to determine the factor of risk for everyday activities based on an individual's bone density. For individuals with low bone mineral density, many activities of daily living, such as lifting a bag of groceries, can place enough force through the vertebral bodies to cause an compression fracture. Many exercises and activities commonly prescribed for strengthening may place loads on the spine that are too much for vertebral bodies to withstand.
Despite the contribution that physical therapists can make to osteoporosis prevention and intervention, it is not clear what clinicians understand about the disease and its management. The purpose of this study was to assess physical therapists' knowledge and confidence in screening for osteoporosis. Additionally, this study surveyed practice behaviors in selecting interventions for patients with osteoporosis.
The researchers developed a survey instrument specifically for the study using a combination of sources, including a survey used to assess physicians' knowledge of low back pain23 and the second author's dissertation34 for general design and format. The survey was based on recent findings regarding appropriate screening, examination, and intervention with this population.1–3,5,6,10 Two physical therapy faculty members experienced both in survey research and in geriatric physical therapy evaluated the instrument for face and content validity and clarity. The survey was then reviewed by a geriatric clinical specialist and an orthopedic clinical specialist. Minor revisions were made for clarity based on feedback from these individuals.
The survey focused on osteoporosis and physical therapists' knowledge and confidence in screening and managing the disorder. It was 6 pages in length, and consisted of questions varying in format. See Appendix 1 for sample questions. Demographic information such as age, sex, education, work experience, and caseload was collected using multiple choice and open-ended questions. A 5-point Likert scale was used to obtain information regarding confidence about screening for osteoporosis screening; possible responses included “very confident,” “confident,” “somewhat confident,” “unsure,” or “not confident at all.” Respondents were asked to rate the frequency with which they screen for osteoporosis based on a number of known diagnoses, outward signs, or reported characteristics (such as cigarette smoking), using a 5-point Likert scale ranging from “always” to “never.” A similar format was used to capture exercise and education activities, with choices of “prescribe routinely,” “prescribe with modifications or caution,” or “would never prescribe.” The survey could be completed in 10 to 15 minutes.
Exercises to include as indicated versus contraindicated were selected for inclusion in the survey based on a number of resources. Indicated exercises included those designed to strengthen trunk extensors, such as prone trunk extension and “superman” (combined bilateral shoulder flexion and hip extension in prone.) Exercises such as these have been shown to be effective not only in increasing strength of the trunk,9,13 but also in improved posture,14 decreased risk of fracture,8,15 and improved physical performance.14 Other indicated exercises included exercises designed to strengthen the lower extremities, such as wall slides,16–18 or to improve flexibility without placing the spine in a position that increases compressive forces.32 Contraindicated exercises included any that emphasize trunk flexion, such as abdominal crunches, and activities such as standing from sitting using a “nose over toes” strategy. Such forward flexion has been shown to increase risk of vertebral fracture, as demonstrated by the “factor of risk” model developed by Myers and Wilson,32 and by the comparison of trunk flexion and extension programs by Sinaki and Mikkelsen.8
The self-administered mail survey was sent to a random sample of 250 of 2,123 Illinois physical therapists belonging to the Illinois Physical Therapy Association. Respondents were excluded if they were not licensed to practice physical therapy in the state of Illinois, or if they did not routinely work with women over the age of 40 years in their practice setting.
The study was approved by the Bradley University Committee on Use of Human Subjects in Research. Consent to participate in the study was indicated by the return of the completed survey. An alphabetical list of members was numbered, and numbers were randomly selected via the random number generator function in Microsoft Office Excel 2007 (Microsoft Corporation, Redmond, Washington, 898052). The first mailing was sent out in June 2007. This was followed by a second mailing September 2007 to those who did not respond to the first mailing.
All responses from the surveys were coded numerically and entered manually into SPSS 15.0 (SPSS, Chicago, Illinois). Questions that required a specific numeric response, such as the number of hours spent in direct patient care, were coded as ranges. For example, up to 5 hours was coded as “1”, 6 to 10 hours was coded as “2,” and so on. Descriptive statistics were computed for all demographic questions, relevant risk factors, and exercises.
One hundred nine respondents returned the survey resulting in a survey response rate of 44.8%. Of the 109 surveys returned, 83 respondents reported that they currently examine women aged 40 to 90 years and were included in analysis. Descriptive characteristics of the subject demographics and employment characteristics are shown in Table 1. Respondents were predominantly women and worked full-time in outpatient facilities. On average respondents had 13.7 (10.8) years of employment experience as physical therapists and were involved in patient care for 31.3 (10.5) hours per week. More than half reported examining or treating one or more patients diagnosed with osteoporosis weekly.
Information regarding respondents' entry-level and postprofessional physical therapy education is provided in Table 2. A small majority (42.2%) had an entry-level bachelor's degree in physical therapy; 38.6% had a masters' degree, and 16% had entry level doctorate. Nearly half (45.3%) reported previous completion or current enrollment in a postprofessional degree program, with 14.5% reporting a transitional doctor of physical therapy degree. One percent of respondents were certified Geriatric Clinical Specialists.
The majority of respondents reported receiving 6 hours or less of lecture and laboratory on osteoporosis examination and treatment in their entry level education. Only one third of respondants reported that screening for osteoporosis was covered in their educational program, whereas half reported that treatment of osteoporosis was addressed. Fifty-one percent reported that they had not attended any continuing education courses in geriatrics; whereas 36.1% reported attending a course pertaining to geriatrics since graduating.
When asked questions regarding examination and screening practices, only 8% of respondents indicated that they always screen for osteoporosis; 33.8% reported rarely or never screening for the condition. The majority of respondents were confident (34.9%) or somewhat confident (47%) in their ability to recognize risk factors associated with osteoporosis, however, 12.0% reported being unsure of their ability.
Figure 1 illustrates risk factors that may prompt a therapist to screen for osteoporosis. The majority of respondents correctly identified female sex, change in height or posture, history of multiple fractures, family history, sedentary lifestyle, immobility/bed rest, and low postmenopausal body weight as risk factors that would always or often prompt them to screen for osteoporosis. In contrast, less than 50% correctly identified that they would always or often screen their patients for additional risk factors of Asian ethnicity, alcoholism, or breast cancer. Other diagnoses and conditions, such as lupus, rheumatoid arthritis, and lactose intolerance were classified as ones that 50% to 75% of respondents would always or often prompt an osteoporosis screen.
Respondents were asked to identify practice patterns they used when prescribing exercise for a patient with osteoporosis or at risk for osteoporosis. Both indicated (Figure 2) and contraindicated (Figure 3) exercises for individuals with osteoporosis were listed as choices in the survey. Eight-two percent indicated that they would routinely prescribe log rolling and 51.8% routinely teach their clients wall slides for strengthening. Nearly 50% prescribe the “hip-hinge” maneuver for sit to stand transfers (48.2%) and chin tucks for improving posture (47%). Other indicated exercises less frequently prescribed included spine extension in prone (19.3%), “superman” (9.6%), hamstring stretching in supine (41.0%), and episodic rest periods in supine (44.6%).
In regards to contraindicated exercises, more than 50% of respondents identified that they would never prescribe abdominal strengthening in sitting using a weight machine (61.4%) and abdominal crunches with rotation for oblique strengthening (56.6%). Nearly 80% reported that they would never prescribe toe touches in standing. In contrast, however, many indicated that they routinely prescribe the “nose over toes” maneuver for sit to stand transfers (36.1%), episodic rest periods in sitting (37.3%), resisted trunk rotation in sitting or standing with theraband (12.0%), and abdominal crunches (9.6%). Each of these are deemed inappropriate increasing risk of spinal fracture for persons with osteoporosis by experts8,32,33
The primary purpose of the study was to determine if physical therapists are (1) able identify risk factors in their patients that would prompt them to screen for osteoporosis, and (2) prescribe appropriate and safe exercises for these individuals. More than 50% of the physical therapists surveyed indicated they had at least one new client referral with the diagnosis of osteoporosis per week. If this accurately reflects practice, then it is imperative that physical therapists be knowledgeable in examining and treating individuals with osteoporosis. Given that approximately 52% of women are estimated to have low bone mass (osteopenia), physical therapists must to be able to identify risk factors for those patients who have not yet been diagnosed but have potential to slow or halt progression to osteoporosis.21
Respondents reported limited exposure to osteoporosis (less than 6 hours) in their entry-level professional education. This information, combined with the finding that more than 50% of respondents had never attended a continuing education course focusing on geriatric care or health issues suggests that physical therapists treating this population may not be equipped with adequate knowledge to treat individuals with osteoporosis optimally. Furthermore, in as much as most of the physical therapists surveyed reported confidence in identifying risk factors for osteoporosis, it is unlikely that they identify this condition as a high priority in furthering their education.
The results of the study show that only one-third of respondents always or often screen for osteoporosis in their practice. One possible explanation may be related to educational background because one-third of the respondents were unable to recall learning how to screen for osteoporosis in their physical therapy program. The emphasis of formal screening has increased in recent years, secondary to both the development and publication of the Guide to Physical Therapist Practice in 1998 and 200135 and the most recent accreditation standards adopted by the Commission on Accreditation for Physical Therapy Education 36 that became effective in 2000. Both of these documents, as well as the Normative Model of Physical Therapist Professional Education,37 place greater emphasis on screening for problems outside physical therapy scope of practice, and subsequent referral to appropriate professionals. It may be that individuals with greater exposure to these new documents may utilize screening practice more consistently. However, this relationship was not investigated in the current study.
Most physical therapists participating in the survey demonstrated knowledge of contraindicated exercises; 80% reported never prescribing toe touches for this population. However, even the 9.6% who reported routinely prescribing abdominal crunches is problematic. Sinaki and Mikkelsen8 demonstrated more than 20 years ago that trunk flexion, specifically abdominal crunches, places an individual at increased risk for compression fracture. Although 60% never cue their patients to stand from a seated position using a “nose over toes” strategy, that leaves 40% that may instruct their clients to use a strategy that places significant compressive forces on their spine multiple times per day.33
Although it is important to avoid prescribing exercises that increase risk of spinal fracture to individuals with osteoporosis, it is also important to prescribe appropriate exercise that will provide maximal benefit. Less than 20% routinely prescribe trunk extension strengthening in prone, despite the evidence available regarding the benefits of this type of exercise.8–9,13–14 For example, after a 2-year program of progressive resistive back strengthening, respondents had higher bone density, fewer fractures, and greater strength 8 years after discontinuing the program.9 Providing optimal care means more than just not harming the patient. With available evidence demonstrating positive outcomes with specific intervention for osteoporosis, physical therapists must be able to prescribe appropriate programs for maximal benefit.
This study did have some limitations. Although the response rate of 44.8% was relatively high for a survey, the sample size was relatively small, and may not fully represent the population of therapists from which it was drawn. Because the study was not funded, there were financial constraints that limited the number of surveys that could be sent. Although only those respondents treating women between the ages of 40 and 90 years were included in the study, we did not collect further information regarding the frequency with which they treat these individuals. Therefore, our sample may include individuals treating older individuals exclusively as in a long-term care facility, as well as those treating them infrequently, such as in an outpatient setting. However, even if a therapist treats just an individual at risk for osteoporosis per week the examination and intervention needs to be appropriate and safe.
There were a number of limitations in the wording of survey items. Most of the survey questions pertained to the individual's current practice; however, those related to entry-level education on osteoporosis did require the individual to recall events that had occurred several years ago. As a result, the accuracy of this information may be compromised. In addition, the options provided for some of the questions made clear interpretation problematic. For example, respondents were allowed to check multiple areas of practice and types of facilities. This resulted in multiple combinations of practice and setting classifications. Respondents were asked the number of continuing education courses they had attended related to geriatrics; more precise information would have been obtained had they been asked the number of courses taken specifically related to osteoporosis.
This study found that most respondents correctly identified the majority of risk factors that would prompt a physical therapist to screen for osteoporosis. Additionally, our findings suggest that physical therapists are knowledgeable of contraindicated exercises, however, a small number persist in routinely prescribing exercises that place the individual with osteoporosis at risk for a vertebral fracture. Overall, the results of the study indicate physical therapists need more education in regards to osteoporosis screening, examination, and intervention. Additional studies should consider surveying the educational programs regarding the amount of education actually given in osteoporosis.
Illinois is currently a limited direct access state, where physical therapists may legally examine patients, but need a physician's referral for subsequent intervention. Another possibility for further study would be to survey physical therapists practicing in states with direct access to determine if unlimited direct access affects practice patterns in regards to osteoporosis.
Information regarding appropriate and inappropriate therapeutic exercise for individuals with osteoporosis is readily available. However, therapists must first realize a need for further education before seeking this information. It is hoped that the results of the current study will shed light on this need.
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Appendix 1. Examples of items from the survey. Cited Here...
osteoporosis; physical therapy; women's health