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Ancient Wisdom and Accurate Assessment in the Cost-Conscious Era

Yang, Robert K. MD; Sinaki, Mehrsheed MD

American Journal of Physical Medicine & Rehabilitation: May 2005 - Volume 84 - Issue 5 - p 391-392
doi: 10.1097/01.PHM.0000159977.87597.D8
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From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.

All correspondence should be addressed to Mehrsheed Sinaki, MD, Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

A 91-yr-old woman was referred for a rehabilitation program after osteoporosis was diagnosed. Her presenting complaints were upper back pain beginning around the cervicothoracic junction and radiating down to the mid-thoracic region. She also reported considerable kyphotic posture. Bone mineral densitometry done as part of a standardized work-up before referral to rehabilitation showed T scores of −5.3 for the spine and −3.4 for the hip (World Health Organization guidelines for diagnosis of osteoporosis, T score of −2.5 SD below the peak bone mass for a normal young adult), and lumbar spine radiographs were unremarkable.

The patient’s musculoskeletal examination was notable for thoracic hyperkyphosis and tenderness to palpation in the mid-thoracic and cervicothoracic areas. Her range of motion, strength, reflexes, sensation, and dural tension signs were unremarkable.

Physical therapeutic exercises1 were provided to the patient, as were educational materials and biomechanical principles for care of the back for a home program. A weighted kypho-orthosis (Posture Training Support, Camp Healthcare, Jackson, MI)2 also was tried but not prescribed, pending completion of the patient’s work-up (thoracic spine radiographs).

This patient was resistant to additional studies that were recommended, such as thoracic spine radiography, and to the recommended pharmacotherapy because of financial concerns. After much persuasion, she relented to these recommendations. The thoracic radiograph is shown in Figure 1.



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This case highlights an important aspect of multidisciplinary care—different specialists may focus on different aspects of the disease. Although our case illustrates that the standard work-up was sufficient from the medical perspective for guiding the prescription of antiresorptive agents, one important study from the biomechanical standpoint—thoracic spine radiography—was not done initially.

The patient’s concern regarding finances complicated treatment. She was initially resistant to the thoracic spine studies because of the financial factor and the perception that her work-up was complete. She was also concerned about the cost of all the treatments recommended to her. In the current climate of cost justification, insurers and patients may balk at the “additional” costs of such testing.

In this case, radiography provided valuable anatomic detail of the thoracic hyperkyphosis in that four vertebral compression fractures were discovered. Biomechanical modeling studies of a similar case estimated that these deformities can increase spinal compressive forces 24% and increase the required mid-thoracic paraspinal force by 40%.3 These forces can substantially alter a patient’s prognosis and could be vital in convincing a patient to comply with the prescribed regimen of treatment.

There is a parable about three blind men examining an elephant. One man felt the ears and reported that the elephant was like a fan. Another man felt the tusk and reported that the elephant was like a spear. Another man felt a leg and reported that the elephant was like a tree. All of their observations contained an element of truth, but all of them were off the mark. This parable highlights the importance of considering the entire picture, even when providing specialty care.

In patients with osteoporosis, thoracic and lumbar spine radiographs are necessary for accurate assessment of the musculoskeletal status before proper exercise and bracing can be prescribed.

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1. Sinaki M: Musculoskeletal challenges of osteoporosis. Aging (Milano) 1998;10:249–62
2. Kaplan RS, Sinaki M, Hameister MD: Effect of back supports on back strength in patients with osteoporosis: A pilot study. Mayo Clin Proc 1996;71:235–41
3. Keller TS, Harrison DE, Colloca CJ, et al: Prediction of osteoporotic spine deformity. Spine 2003;28:455–62
© 2005 Lippincott Williams & Wilkins, Inc.