^{I was carrying my dog (who weighs about 10kg) downstairs, when I missed the last step with my foot, and although I didn’t fall to the ground, I felt sudden and excruciating pain in the middle of my back, where I now know the vertebral fracture occurred (L1 vertebra in the CT scan above). The pain after my accident was 1,000 out of 10 (seriously) initially from the fractured vertebra area, then radiating out round the back and sides of the abdomen. I needed morphine before I could be moved. The pain was eventually controlled with the correct dose of Meptazinol (a strong pain killer) but only if taken absolutely regularly. I had to log roll out of bed, could walk a short distance and climb stairs with a struggle. I had to spend long periods of time reclined with pillows supporting my back. In the right position this was comfortable. Gradually over a long period of time the rests became shorter, the ‘active’ times became longer and I could begin to sit up in bed for short periods. Going out had to be arranged like a military operation. I never went anywhere unless I knew I would be either able to lie down or get home quickly, as once the discomfort began the only relief was lying down. If I didn’t do this I just suffered more later until I couldn’t keep going and the recovery period was a lot longer. Once I was off painkillers it seemed to be muscle spasm, which would bring me to a standstill sooner than getting back pain. Each time I improved, a different set of muscles would start to complain at coming back into use.}

^{It has taken over 2 years to feel any real recovery. From July 2007 I had weeks when I felt better only to ‘overdo’ things slightly and take several weeks to recover. I feel it was Dr Poole telling me to absolutely not do anything at all heavy with my back in a vulnerable position that made all the difference. I had been being careful up to then, but after that I stopped doing anything contrary to his advice altogether. I went back to work after 16 weeks as a part time physio assistant (normally working on busy, heavy wards) to do a range of light duties. This was a struggle and after 3 weeks I came to a standstill one morning. One of our young physios saw my discomfort and arranged for me to have hydrotherapy 2-3 times a week for several weeks- giving up his lunch hour to do this. From the very first session the relief was amazing. I could feel the muscles relaxing and stretching out and gained huge benefit from this. I was receiving physio through the main department at this time, which also helped. That summer I swam as much as possible and attended pilates classes which were of considerable benefit. I couldn’t possibly have worked full time and only coped because I was getting a lift to and from work and my husband was running the house.}

^{I would have found it helpful if my GP had given me a better idea of how long I was going to be off work, but he was trying to be kind so as not to alarm me too much. With hindsight, I feel I went back to work too early and should have had a gradual return 2-3 mornings a week to start with. An idea of how long the recovery was likely to be – if that was at all possible- would have helped me to cope better. Having the knowledge then, which Dr Poole has now about the injury would have helped me, by removing the worry of other possible conditions and by allowing me to understand what had actually happened. After an injury like this, it is very difficult to be aware of where you are along the road to recovery. By the end of the first 2 years, I could only travel for about an hour in the car and walk 1.5 miles comfortably…}

Postscript 6 Years On

^{What I am able to do depends on how busy I have been previously, how heavy the task is, the positioning required and the repetitiveness of the task. I can garden because I can change position regularly. With cooking, I cannot and that is a problem. Luckily my husband likes to cook. I certainly could not cater for a dinner party. I still cannot walk more than 2-3 miles comfortably. When some friends stayed with us recently, I had to sit down in a museum after walking around town for about an hour, and then could not go for a walk on the Sunday – I needed to rest or I would not have been able to cope with work the next day. I have to pace my life and depend on my husband a lot. Inactivity leads to deconditioning, loss of fitness and muscle. There is a psychological impact and an impact on one’s lifestyle and ability to manage it…}

Commentary by Dr Ken Poole Consultant in Metabolic Bone Diseases and Rheumatology

Gillian’s journey highlights a care gap in one of the most life-changing consequences of osteoporosis; acutely painful vertebral fracture. Around a quarter of patients with osteoporotic vertebral fractures present with enough pain to see a physician, have an x-ray and a radiological diagnosis¹. These are called ‘clinical vertebral fractures’. Gillian’s life changed in an instant, when a simple missed step resulted in a fracture to her osteoporotic first lumbar vertebra (a true ‘fragility’ fracture as there was no fall, not even from a ‘standing height or less’). As rheumatologists we often listen to our patients attempting to convey to us the severity and impact of their ‘indescribable’ pain.

Gillian, with her considerable clinical experience described the searing sensation when her vertebra collapsed as reaching, “a thousand out of ten”. Here there was no outward or visible deformity but the fracture inside was as real as a broken arm in a sling. Despite undoubted advances in fragility fracture research over the last 3 decades, Gillian’s graphic account reminds us of the paucity of medicines, therapies and devices at our disposal to help people with acutely painful fracture. She also reminds us that our reassurances that the pain will go when the fracture heals may not always be appropriate. Although Gillian elected to take alendronate (from more than a dozen highly effective drugs which are proven to prevent further vertebral fracture), this was a side issue as Gillian struggled with physical disability and unrelenting pain on movement. Anyone can work out his or her own risk of fragility fracture using the simple calculator at QFracture  or FRAX. Perhaps a ‘clinical vertebral fracture’ patient journey like Gillian’s should be incorporated into these tools, since the unhappy face emoticon 🙁 (fracture) versus happy 🙂 (fracture-free) doesn’t adequately convey the implications of a vertebral fracture on someone’s life, even in patient-friendly ‘decision-aid’ literature².

It is in managing the acute situation where we need more effective treatments and clinical guidance. My clinics have plenty of the unlucky ‘quarter’ whose fractures were painful. We do have a limited evidence-base for improving such pain with analgesics, short-term calcitonin or pamidronate^3,4, spinal orthoses⁵ and vertebral augmentation⁶, but there is little research into vertebral fracture outcomes to help us tailor our advice to Gillian about what to expect during recovery⁷. Gillian’s path to pain-free recovery was long and slow, with physical modalities such as hydrotherapy helping the most. Despite some trials in manual therapy⁸, there are no data on the efficacy of hydrotherapy in acute vertebral fracture.

“Bad news goes about in clogs, good news in stockinged feet,” says the Welsh proverb. For instance, ‘rare’ and ‘very rare’ potential side effects of osteoporosis medications now dominate many of our osteoporosis consultations⁹. Many people are stopping their osteoporosis medication as misinformation abounds¹⁰. Systematic exaggeration in adverse health news reporting helps journal metrics and the ‘impact’ metrics of the authors but may be harmful for people receiving their information after intentionally controversial press releases and willing uptake by the news media¹¹.

But there are moments of light. Dispelling at least one highly controversial bad news myth, a recently reported 5-year trial of more than 12000 women screened for osteoporosis with a questionnaire established that there was no psychological harm from being screened or treated, but there was a 28% reduction in women breaking their hips¹². Good news indeed for people like Gillian.

 

This article is dedicated to the late Peter Lapsley, who was Patient Editor of the BMJ

Competing interests: KESP has received research grant funding from Amgen, Addenbrooke’s Charitable Trust, Arthritis Research UK, the Evelyn Trust, Lilly, the Medical Research Council and the National Institute for Health Research (NIHR). KESP has also participated, through Cambridge Enterprise, in advisory board meetings and in delivering educational presentations for pharmaceutical companies. Cambridge Enterprise donates the honoraria received for these activities to registered charities.

 

References

1. Ross PD. Clinical consequences of vertebral fractures. The American journal of medicine 1997;103(2A):30S-42S; discussion 42S-43S.
2. Cranney A, O’Connor AM, Jacobsen MJ, et al. Development and pilot testing of a decision aid for postmenopausal women with osteoporosis. Patient education and counseling 2002;47(3):245-55.
3. Knopp-Sihota JA, Newburn-Cook CV, Homik J, et al. Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures: a systematic review and meta-analysis. Osteoporos Int 2012;23(1):17-38. doi: 10.1007/s00198-011-1676-0
4. Armingeat T, Brondino R, Pham T, et al. Intravenous pamidronate for pain relief in recent osteoporotic vertebral compression fracture: a randomized double-blind controlled study. Osteoporos Int 2006;17(11):1659-65. doi: 10.1007/s00198-006-0169-z
5. Pfeifer M, Begerow B, Minne HW. Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: a randomized trial. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 2004;83(3):177-86.
6. Georgy B. Can meta-analysis save vertebroplasty? AJNR American journal of neuroradiology 2011;32(4):614-6. doi: 10.3174/ajnr.A2377
7. Suzuki N, Ogikubo O, Hansson T. The prognosis for pain, disability, activities of daily living and quality of life after an acute osteoporotic vertebral body fracture: its relation to fracture level, type of fracture and grade of fracture deformation. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2009;18(1):77-88. doi: 10.1007/s00586-008-0847-y
8. Bennell KL, Matthews B, Greig A, et al. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC musculoskeletal disorders 2010;11:36. doi: 10.1186/1471-2474-11-36
9. Shane E, Burr D, Abrahamsen B, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 2014;29(1):1-23. doi: 10.1002/jbmr.1998
10. Khosla S, Shane E. A Crisis in the Treatment of Osteoporosis. JBMR 2016;31(8):1485-87.
11. Sumner P, Vivian-Griffiths S, Boivin J, et al. The association between exaggeration in health related science news and academic press releases: retrospective observational study. BMJ 2014;349:g7015. doi: 10.1136/bmj.g7015
12. Shepstone L, Lenaghan E, Clarke S, et al. A Randomized Controlled Trial of Screening in the Community to Reduce Fractures in Older Women in the Uk (the Scoop Study). Osteoporosis International 2016;27:S42-S43.