AAPM&R Board Approves NOF Physician Guidelines for Osteoporosis Treatment

In Brief: In this report from AAPM&R’s liaison to the National Osteoporosis Foundation, Patricia Graham, MD, stresses the need for physiatrists to coordinate an interdisciplinary approach to dealing with osteoporosis. Graham recommends physiatrists start by using NOF’s updated Clinician’s Guide to Prevention and Treatment of Osteoporosis. The guidelines were recently approved by the AAPM&R Board of Governors.

The National Osteoporosis Foundation (NOF) has been charged by the Office of the Surgeon General to educate the general public and health professionals about osteoporosis. It has worked closely with the World Health Organization (WHO) to expand physician guidelines beyond those of 1992, which focused primarily on Caucasian, postmenopausal women. The new NOF guidelines were recently reviewed and approved by the AAPM&R Board of Governors.

The new guidelines now address wider populations. Incorporating updated, evidence-based epidemiologic studies adapted to the US population, the new guidelines dramatically improve our identification of patients at highest risk for developing osteoporosis and fractures by using absolute fracture risk methodology.

If modern medicine is by necessity a team sport, the challenges of osteoporosis require an “Extreme Sports” strategy. Osteoporosis has become a serious public health problem, with broad medical and economic impact in the United States. These patients are before us daily; the question is, are we as physiatrists facilitating their optimal care? Are we doing our part in instigating screening and treatment, and preventing chronic pain, disability, loss of community independence, and even death?

No disease entity seems to require the complex inter-disciplinary approach that osteoporosis requires. Establishing a system-wide protocol for diagnosis and treatment has confounded every nation in the world. As Former Surgeon General Richard Cardera once stated to the NOF Interdisciplinary Medical Council, “We know what we are supposed to do, but we are not doing it.”

No one is doing it because no one specialty can do so alone. The origins of osteoporosis stem from a multitude of hereditary, medical, surgical, lifestyle, and environ­mental issues, and its optimal treatment is multi-faceted. It is a metabolic (endocrinologic) disease in its physiology, yet clearly impacted by primary care issues, psychosocial and environmental factors, and lack of health care system communication. The end result is chronically uncoordinated treatment. In fact, the American Academy of Orthopaedic Surgeons (AAOS) reports that less than 20 percent of hip fractures in the United States prompt inquiry into bone mineral density status. From an epidemiologic standpoint, in terms of degree of associated disability, one hip fracture equals four compression fractures or 20 fractures elsewhere in the body.

Physiatrists are in a unique position in the struggle to bring the interdisciplinary approach to this disease and its associated disabili­ties: We see patients at risk daily; we are trained in coordinating care across many disciplines; and we are experts in the musculoskeletal and nervous systems, as well as in posture, balance, gait dysfunctions (90 percent of hip fractures are secondary to falls), pain manage­ment, orthotics, and spine interventions. We are a perfect fit.

Working with the new NOF Clinician’s Guide to Prevention and Treatment of Osteoporosis would be a good first step in dealing with osteoporosis: The guide represents a major breakthrough in estab­lishing a proper protocol to effect­ively evaluate and treat all patients with low bone mass, osteoporosis, and the associated risk of fragility fractures. Click here for more information or to download the guide.

The algorithm in the new NOF guidelines on absolute fracture risk (called FRAX^® by WHO) estimates a patient’s 10-year fracture probability, the likelihood of breaking a bone due to low bone mass or osteoporosis over a period of 10 years. This identifies patients with the highest fracture risk who need treatment the soonest (i.e., post­men­opausal women and older men with a diagnosis of osteo­-porosis). The criteria for treatment have also shifted beyond a simple BMD test T-score of (-)2.5 via DXA testing, capturing those patients with a clinical diagnosis such as a previous hip or spine fracture. Additionally, while the former guidelines advised clinicians to treat people with osteoporosis, they were unclear about what to do for people with osteopenia (T-score between - 1.0 and -2.5), whose numbers far exceed those with osteoporosis. Absolute fracture risk calculations help to resolve this dilemma by clearly specifying when treatment is medically appropriate and when it is not necessary to treat, based on the likelihood of fracture in the patient. Conse­quently, treatment decisions are individualized for each patient.

Given this public health conun­drum and our unique opportunity to assist in coordinating every aspect of care, I invite all physi­atrists to engage actively, daily, in their practice to screen and treat their patients for osteoporosis, and to establish a network of competent colleagues in their community to resolve the medical, surgical, and disability challenges before us. To this end, the Foundation for PM&R is actively seeking donations to address physiatric research in this area. As AAPM&R’s liaison to NOF, I hope to see a healthy contribution to this goal (both in funds and active research) to address the dearth of information on fall prevention; the contributions of exercise to bone building and balance improvement; and a more active role by physiatrists in screening, treatment, and pain management (including spine interventions) before and after fracture.

For more information, please contact the Academy office at (312) 464-9700.