Non-pharmacological Management of Osteoporotic Vertebral Fractures: A Qualitative Analysis of Patient and Health-Care Professional Perspectives and Experiences
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Introduction: Osteoporosis is a chronic disease that is characterized by a femoral neck or lumbar spine bone mineral density (BMD) less than 2.5 standard deviations below the mean of young adult females and encompasses changes to bone structure and bone quality, resulting in reduced strength and increased risk of fracture. Vertebral fractures are the most prevalent fracture in women with osteoporosis, affecting at least 20% of the older population. Vertebral fracture incidence and prevalence increase steadily with age and may appear without any symptoms. Once someone becomes symptomatic, they can experience a plethora of changes to their physical, social, and psychological functioning. Currently, information on non-pharmacological strategies to address consequences of vertebral fracture exist; however, lack of awareness of guidelines and inconsistences among the literature on the effect of non-pharmacological strategies may reduce their use and effectiveness. Objective: We have discovered that a gap in research exists in treatment/management of vertebral fractures, especially the use of non-pharmacological interventions. Considering that recommendations available are targeted towards individuals living with osteoporosis with or without vertebral fractures, our objective was to understand health care professionals' (HCPs) and individuals living with vertebral fractures’ experiences and perceptions of post-vertebral fracture rehabilitation, use of non-pharmacological strategies, and virtual rehabilitation. Methods: We performed a qualitative analysis using semi-structured interviews. Semi-structured interviews were conducted over web conference or telephone with both individuals living with vertebral fractures and HCPs within Canada. We used criterion sampling to recruit physicians (mainly geriatricians, family physicians and physiatrists) and allied health professionals (physiotherapists and nurses who work in geriatrics). We also used purposeful sampling to recruit individuals who are BoneFitTM trained, are specialists in osteoporosis care, are clinician researchers with experience with this population, or clinicians who self-declare an interest and see patients with osteoporosis. Individuals living with vertebral fractures were recruited from the Canadian Osteoporosis Patient Network (COPN), social media, and our Bone health and Exercise Science Lab email distribution list. Individuals living with vertebral fractures were included if they had been diagnosed with a vertebral fracture in the past, regardless of location of fracture. Questions for the interview guide were centred on non-pharmacological treatments such as exercise, spine sparing and movement modification, pain management, and nutrition. Considering that our intention is to inform the development of an online exercise/education intervention to provide information on exercises, nutrition, pain management and safe movement, we also asked about the attributes that both individuals living with vertebral fractures and HCPs would find important in the development of an online tool. To inform the semi-structured interview guide, we used the Diffusion of Innovations Theory, and the APEASE criteria. Interviews were audio recorded and transcribed verbatim. Once the interviews were completed and transcribed, two researchers conducted an inductive thematic and content analysis. Results: 13 HCPs (7F, 6M, aged 46 ± 12 years) were interviewed. Two major themes emerged from our interviews: acuity of fracture matters when selecting rehabilitation strategies; and roadblocks to rehabilitation. Early rehabilitation interventions included pain and osteoporosis medicine, education on harmful and high-risk movements, and non-pharmacological strategies to help reduce patient pain and increase early mobilization. Rehabilitation in the chronic stage of vertebral fractures incorporated more exercise-based strategies to help increase strength, mobility and functionality and was informed by a comprehensive assessment. Regardless of the stage of recovery, barriers such as delayed identification of fracture, delayed or no referral to physiotherapy, and lack of knowledge of osteoporosis or vertebral fracture among HCPs may reduce the access to or effectiveness of non-pharmacological interventions. HCPs believed that virtual rehabilitation that includes an online educational component, an online assessment, and online exercise classes in groups tailored to individuals could be a feasible alternative; however, concerns related to the online assessment such as the inability to perform manual strength testing, and patient confidence in using technology were voiced. 10 individuals living with vertebral fractures (9F, 1M, aged 71 ± 7.9 years) were interviewed. Five major themes emerged from our interviews: chronic pain from spine fractures contributes to activity limitations and other consequences; fracture identification may be delayed, influencing care trajectory; living with fear; being dissatisfied with fracture management; and non-pharmacological strategies can help patients “get back into the game of life”. We have identified that the experience of vertebral fracture recovery among patients involves a substantial amount of back pain, mobility related issues, and psychological and social impairments. Rehabilitation provided to patients was dependent on the identification of fracture and was delayed, either from patient reluctance to see a HCP initially, or due to issues related to radiological diagnosis and access to an X-ray. Pain medication was perceived as helpful in reducing pain but non-pharmacological alternatives to reduce pain and improve mobility was emphasized as important, and patients believed that they should be advised. Rehabilitation in the chronic stages of vertebral fracture recovery involved more non-pharmacological interventions, such as weight-bearing exercise and education on safe movement and activity modifications and was facilitated by physiotherapy. To improve access to non-pharmacological options, education and exercise delivered online via virtual rehabilitation was perceived positively and could be an acceptable and feasible strategy; however, participants were concerned about access to technology and the individualization of programs in a group setting. Conclusion: We have identified that rehabilitation provided by HCPs was dependent on the acuity or stability of fracture, and that non-pharmacological strategies were facilitated by physiotherapy. To select and individualize physical therapy interventions, physiotherapists emphasized using assessments to determine patient goals, physical functioning, and identify co-morbidities. To improve access and address barriers, virtual rehabilitation could be a feasible and effective alternative for patients but may require further evaluation. We have identified that individuals who suffer a vertebral fracture report chronic back pain that influences their ability to perform activities of daily living, impacting psychological and social well-being. To address consequences of vertebral fractures pain medication was used and considered helpful, but that non-pharmacological strategies, facilitated by physiotherapy, was considered important and should be advised; however, barriers to fracture identification and access and referral to physiotherapy may limit the use of these options. To improve access to non-pharmacological strategies, patients believe that virtual rehabilitation could be a feasible and effective alternative but may require further evaluation.
Cite this version of the work
Nicholas Tibert (2021). Non-pharmacological Management of Osteoporotic Vertebral Fractures: A Qualitative Analysis of Patient and Health-Care Professional Perspectives and Experiences. UWSpace. http://hdl.handle.net/10012/17348