The Role of PM&R in Pain Management for Osteoporotic Patients

Tirza Z Tamin, MD, PHD

Department of Physical Medicine and Rehabilitation,
Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia

Introduction
Osteoporosis (OP) is a pathological condition characterized by a decrease in the
density of bone, that manifests clinically as pain, fractures, and physical disability1.
Osteoporosis pain causes a significant worsening of functional capacity and
deterioration in the quality of life. Pain in osteoporosis can be acute or chronic. Acute
pain due to pathological fracture, as the fracture heals, the pain gradually ease but can
also be a chronic pain due to development of a skeletal deformity after the fracture,
unbalance of the strain on the muscle and damage to vertebral joints 2,3. The exact
mechanism for osteoporosis pain are poorly known, but some studies have tried to
clarify that2,4.

Mechanism of osteoporosis pain

For a long time, bone has been considered as inanimate tissue, today we knows that
bone is a widely innervated tissue. Bone innervation has a fundamental role in the
regulation of physiological phenomena as the local blood flow and bone remodelling.
The adult skeleton is primarily innervated by thinly myelinated sensory nerve fibers (A-
delta) and peptide-rich CGRP+ nerve fibers and receives little if any innervation by the
larger more rapidly conducting A-beta fibers or the TrkA-, unmyelinated peptide-poor C-
fibers2,5,6. Nociceptors in the bone tissue respond to mechanical, thermal, and chemical
stimuli. Injury or inflammation results in the release of a variety of chemical mediators
(e.g., prostaglandins, cytokines, and growth factors), which not only stimulate
osteoclast activity but also activate nociceptors and decrease their threshold for
activation.The alteration in bone turnover leads to microfractures of bone, which may be
one of the possible accepted origins of osteoporotic pain4,7.
 Picture 1. Factors that contribute to activation of peripheral bone marrow
nociceptors
Source : Frontiers in Neurology (2017)

Pain assesment and measurement

An adequate pain assessment is necessary for the patient to evaluate different
components of the pain such as2 :

 etiology
 interaction between the sensory and psychological component
 patient’s functional status
 response to analgesic and etiologic therapies
 tolerance to drugs, history of addicted personality or drugs abuse
 characteristics of pain (type, distribution, quality, intensity and duration)

Pain assessment is critical to optimal pain management interventions. While pain is a

highly subjective experience, its management necessitates objective standards of care.
Assessment of the scale of pain is done periodically to determine the effectiveness of
therapy and patient compliance. Many tools are useful to measure the pain intensity ie
Visual Analog Scale and Numeric Rate Scale2.
Differentiating pain by history
Osteoporosis known as the silent thief, it will not cause symptoms until a fracture
occurs. The most common areas for osteoporotic fractures are the midthoracic
and upper-lumbar spine, hip (proximal femur), and distal forearm (Colles fracture).

Patients who have sustained a vertebral compression fracture may note progressive
kyphosis with loss of height. The pain isdescribed variably as sharp, nagging, or dull.
Pain is localized to a specific vertebral leve; in the midthoracic to lupper lumbar spine.
Intensity of pain increases during standing or walking, intensity of pain decrease when
lying on the back. Pain is localized to a specific vertebral level in the midthoracic to
lower thoracic or upper lumbar spine. The pain is described variably as sharp, nagging,
or dull8,9.

Patients who have sustained a hip fracture may experience pain in groin, buttock
anterior thigh, medial thigh, and/or medial knee during weight-bearing or attempted
weight-bearing of the involved extremity. Diminished hip range of motion (ROM),
particularly internal rotation and flexion. External rotation of the involved hip while in the
resting position9.

Pharmacological treatment
Pharmacotherapy is essential for improving bone mass, but its efficacy in prevention
of skeletal deformities depends on musculoskeletal rehabilitation. There are two
categories of pharmacotherapy for management of osteoporosis: antiresorptive agents
that slow bone loss and anabolic agents that contribute to bone formation.
Antiresorptive agents include bisphosphonates, calcitonin, denosumab. Calcium,
vitamin D, and bisphosphonates are the most commonly advocated pharmacologic
treatments for involutional osteoporosis. Anabolic agents or osteoblast stimulator
agents include fluoride and PTH.

Bisphosphonates.Bisphosponates are considered as first-line pharmacological therapy.

Bisphosponates use its anti-osteoporosis effects by binding to hydroxyapatite in the
bone tissue, inhibiting osteoclast activity, and inducing apoptosis of osteoclasts4.

Raloxifene.

Vitamin D. Vitamin D plays a crucial role in calcium homeostasis, bone metabolism, and
balance and risk of falling. Low vitamin D levels are linked to impaired calcium
absorption and an increase in parathyroid hormone (PTH) which can result in excessive
bone resorption13.

Non pharmacological treatment

Non pharmacolgical treatment such as relaxation, energy conservation, and physical
exercises. Information needs to be obtained before prescribing a rehabilitaton program.
Doctor needs to consider the patient’s physical, functional, psycological, and social
status10.
Relaxation training. The training teaches how to build up focus and breathe deeply.
Relaxation will relaxes muscle and relieves aches and tension. A systematic review
conducted by Kwekkeboom and Gretarsdottir (2006), the study about the efficacy of
relaxation techniques in acute and chronic pain. Relaxation was found to have a
significant effect on pain outcomes in 8 of 15 randomised control studies 11,12.

Physical exercises

Flexibility exercises
It is necessary to perform exercises to maintain flexibility due to the body becomes
more rigid during aging, which results difficulties in movement leading to falls and
increasing risk of fracture. Flexibility exercises help to maintain the elasticity and the
length of the muscle, reduce pain (especially back pain,etc), and improve posture10.

Figure : Stretching the pectoralis major

Figure . Stretching the Upper Torso

Figure . Stretching the muscle of lumbar spine

References
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