Yang Lin1, 2, Yang Yong-hong1, 2, He Hong-chen1, 2, Yu Peng-ming1, 2, He Cheng-qi1, 2

1Department of Rehabilitative Medicine, West China Hospital of Sichuan University, Chengdu  610041, Sichuan Province, China; 2Key Laboratory of Rehabilitative Medicine of Sichuan Province, Department of Rehabilitative Medicine, West China Hospital of Sichuan University, Chengdu  610041, Sichuan Province, China

Yang Lin★, Master, Lecturer, Department of Rehabilitative Medicine, West China Hospital of Sichuan University, Chengdu  610041, Sichuan Province, China; Key Laboratory of Rehabilitative Medicine of Sichuan Province, Department of Rehabilitative Medicine, West China Hospital of Sichuan University, Chengdu  610041, Sichuan Province, China
yanglin@21cn.com

Yang L, Yang YH, He HC, Yu PM, He CQ. Effect of spinal stabilization training on the vertebral osteoporotic compression fracture: An individualized program.
Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu. 2010;14(26): 4937-4940.

Abstract
BACKGROUND: Surgery is a main method to reconstruct the stability of spine after compression fracture. But the reconstruction of spinal stability for patients undergoing conventional therapy remains unclear.
OBJECTIVE: To explore whether spinal stability training is effective on improving pain and motor function of patients with vertebral osteoporotic fractures.
METHODS: Patients with vertebral osteoporotic fractures were divided into two groups. The study group was treated with conventional treatments and individualized spinal stabilization training, while the control group received conventional treatments alone. All the subjects were evaluated before and after treatment by numeric pain rating scale (NPRS), 3-meter timed up and go (TUG) and Oswestry functional limitation index (OFLI). The results were compared between the two groups.
RESULTS AND CONCLUSION: A total of 27 patients were included, including 16 patients in the study group and 11 in the control group. After 4-week treatment, TUG and OFLI in the study group decreased significantly compared with the control group (P < 0.05). But there was no statistical significance between the two groups in the level of NPRS and the amount of changes (P > 0.05). Symptoms and function of both groups were improved after treatments. Individualized spinal stability training is effective to restore the motor function and may be helpful for reducing pain for patients with vertebral osteoporotic fractures combined with conventional treatments.
 
INTRODUCTION

Osteoporosis (OP) is a systemic bone disease characterized by low bone mass, deterioration of micro structure of bone, and high susceptibility to fracture[1]. In the clinic, fractures in elderly men or women can be attributed to OP. Spinal vertebra is a common site of osteoporotic fracture. Studies have shown that the morphometric fracture in vertebra is 10.7/1 000 persons in women and 5.7/1 000 persons in men over 50 years old in Europe[2]. With the increment of life span and the advanced age population, fractures due to OP and the treating cost increase proportionally. So OP has become a serious social problem that affects the state of people health. Female is vulnerable to OP, and has higher risk of fracture. Reducing the pain and retaining the ability of motion is very essential for these female patients with osteoporotic fracture. After fracture, reconstruction of the stability of bone and joint is very important. For most of spinal fractures which do not need to receive surgery, the stability of spine has been impaired during fracture, resulting in severe pain and limitation of mobility. So it is assumed that individualized spinal stabilization training should be helpful for the patients with vertebral osteoporotic compression fractures. The present study investigated whether the individualized spinal stabilization training is helpful for the patients with symptomatic vertebral osteoporotic fractures.

SUBJECTS AND METHODS

Design
Clinical control study.
Setting
Rehabilitation and Acupuncture Center of West China Hospital, Sichuan University, China.

Subjects
Patients with osteoporotic spinal vertebral compression fracture received therapy in the Department of Rehabilitative Medicine, West China Hospital from December 2006 to January 2008. The inclusion and exclusion criteria are as follows:
Inclusion criteria: ① Diagnosed as primary osteoporosis, and the diagnosis standards were formed according to the standards recommended by World Health Organization: the bone mineral density of L3-5 less than standard 2.5st of young adults[3]. ② There was at least one vertebral compression fracture and the height of vertebral body decreases more than 25%. ③ According to the current history and other information, the fracture is attributed to osteoporosis.
Exclusion criteria: ① Pathological fracture caused by other reasons, such as tuberculosis, cancer. ② Other diseases which may influence the treatment stratagem planning and the study, such as serious pulmonary or cardiac disease. ③ The fracture caused spinal cord injury or other injuries and required special consideration or treatment, such as surgery.

Grouping
The patients were assigned to study and control groups. In the study, random and blind methods were not applied. The study group received individualized spinal stability training and conventional treatments, and the control group received conventional treatment stratagem alone.
 
Treatment
All the patients received the conventional treatments, including calcium and active vitamin D intake, injection of calcitionin or Elcitonin, and physical therapy including dynamic inference electrical treatment, infrared therapy, and normal exercise, such as extremity limb strengthening therapy, endurance therapy to retain the motor function. In addition, the study group underwent spinal stabilization training. If needed, bracing and other drugs such as non-steroid anti-inflammatory drug or tramadol may be used.
The exercise techniques of the study group included proprioceptive neuromuscular facilitation[4], core stability exercise[5], combined with stretching and strengthen technique[6-7], aiming at activating and training the core muscles (pelvic floor muscles, multifidus, transversus abdominal, etc.) and improving the spine stability.
All the treating programs were individualized. The exercises were performed 3-5 times per week.

Main outcome measures
Numeric pain rating scale (NPRS), 3-meter timed up and go (TUG) and Oswestry functional limitation index (OFLI).
NPRS: it is a usual instrument used to measure the intensity of pain subjectively. The scaleis is rated from 0 to 100, 0 means no pain, and 100 means the extreme pain. Patients will give his or her scale to state the intensity of pain he suffered in the last day.
TUG: It is an instrument used to measure the complex motor function, especially transfer function and balance. During evaluation, the patients were instructed from sitting in a chair without armrest to stand up and walk 3 meters and then back and sit down in the chair. The time cost was recorded.
OFLI: This includes 10 evaluation items and scores from 0 to 100. A score of 100 indicates functional limitation most seriously and a score of 0 indicates no limitation. The instrument is widely used to evaluate the limitation of ability linked with low back pain.
All the evaluations were performed before and after 4-week treatment. The assessments were performed by the physical therapists, who were in charge of the patient’s physic therapy.

Statistical analysis
The baseline was analyzed through t test. The changes of the measurements in the two groups were compared through independent sample t test. The statistical analysis was performed by soft ware SPSS 10.0.

RESULTS 

According to the inclusion and the exclusion criteria, 27 cases were included. Among them, 16 patients were assigned into the study group and received spinal stabilization exercise plus conventional treatments, and the other 11 patients were assigned into the control group and received conventional treatments alone. There was no statistical difference between the two groups in the following parameters: age, bone mineral density (BMD), NPRS, TUG and OFLI. The baseline characteristics are shown in Table 1.
After 4-week treatment, the measurements of the patients in the two groups are list in Table 2, and the changes in the two groups are shown in Table 3.
From Tables 2, 3, the measurements in the two groups increased to a higher level. The scores of TUG and OFLI in study group were significantly less than the control group (P < 0.05). There was no significant difference between the two groups in NGPS (P > 0.05).
During the four weeks of treatment, there were 3 patients claimed pain aggravated after training, which may be caused by excessive exercise or unsuited manner of exercises. After good rest, reevaluation, in combination with uses of analgesic and adjustment of exercise strategy, the pain was reduced. There were no withdraws in the study.

DISCUSSION

OP has now become a common bone disease in persons over 60 years old. Fracture is the most serious result of OP and becomes a cause of death. Vertebral fracture is one of the common sites. A study shows that spinal morphometric fracture is 10.7/1000 persons in women and 5.7/1000 persons in men over 50 years old in Europe[2]. More than 17 million dollars were predicted for OP in 2005 in America, and about 27% of total were cost in vertebral fracture events[8]. This increase loads of the society and families, and the amount increases continuously with increasing old persons. These conditions attract a lot of concentration from governments and health-related institutions.
Now a lot of treatments have been used for OP effectively, such as calcium, Vitamin D, calcitonin, bisphosphonates, bracing, surgeries, etc. They all have positive effects on the physiology, function, and quality of life[9-11].
However, the outcomes remain not favorable. High risk of fracture, and pain results in limitation of function, low motor capacity, and poor quality of life. Motor function loss remains a main complaint from patients and their families after discharged from hospitals. They cannot move freely, and they may fall, take part in some community activities and be limited at home.
The loss of motor function can be attributed to a lot of factors. Among all of them, impairment of spinal stability after fractures is a main factor. Vertebral compression fractures not only injury the integrity of bone structure, but also the surrounding soft tissues, altering the state of neuromuscular function, and seriously injury the stability of spine. Spinal stability is defined as the ability to maintain the patterns of displacement under physiologic loads and carry out the loads[12]. It is a crucial basis for function performance of body, including spinal and extremities movements, such as walking and lifting. A lot of function deficits can be attributed to poor spinal stability (may be also called core stability sometimes). Spinal stability is a basis of movement for spine and extremities[13]. After vertebral fracture, the patients cannot move the spine and extremities freely. Pain is aggravated even a small movement of spine or extremities.
According to the theory raised by Panjabi[14], the stabilization of spine mainly comes from three subsystems, which consist of spinal column (passive subsystem), spinal muscles (active subsystem) and neural control unit. Vertebrae compression fracture damages the spinal column and the surrounding soft tissue. The loss of spinal stability not only comes from the vertebral fractures, but also from the injuries of tendons, ligaments, muscles nerves and weakened neuromuscular function. It is very important to realize and understand the role of neuromuscular system in the spinal stability. Previous study showed that the spine could only carry out 90 N[15], much less than 1800 N in vivo[16], which indicated that the neuromuscular system had contributed a lot to that the spine stability and the amount of loads that the spine could carry out. So it is hypothesized that improving the neuromuscular function may be helpful for patients with vertebral compression fractures.
In the present study, the study group received conventional therapy and individualized stabilization training, and the control group received conventional therapy alone. We attempted to explore whether spinal stability training is helpful. Three parameters were evaluated, including NPGS, TUG and OFLI before and after 4 weeks of treatments.
NPGS is a good method to measure the intensity of subjective pain with a good reliability. It has been widely used in clinical measurement of pain. TUG is another instrument used to measure the ability of movement, balance and motor control of patients, and the result can also be used to predict the risk of fall. The slow TUG time indicates that the patients suffer from severe impaired mobility and high risk of fall[17-19]. OFLI is a form used to measure the amount of limited ability related to back pain[20]. The three parameters were used to analyze whether the spinal stabilization training could be helpful for the patients with osteoporotic vertebral fracture.
Results from the present study showed that the TUG time of the study group was significantly shorter and OLFI was lesser than the control group (P < 0.05), indicating that improving the stability of spine increases the mobility and the capacity of spine carrying out the loads.
Moreover, there was no difference in the changes of NPGS between the two groups (P > 0.05), which was incompatible with the improvement of function. But the level of NPGS might be measured based on difference levels of movement because the study group had less limitation in motor function. If the patients do the same level of activities, the study group may experience less pain than the control group. However, of course, the truth also may be that stabilization training does not benefit in reducing pain on the basis of conventional treatment.
On the other hand, even though three patients complained pain increasing during treatments, these events were treated successfully through some altering of training, indicating the spinal training protocol was safe only if individualized and careful plan.
The results were consistent with previous studies. It is understood that patients with vertebral osteoporotic fractures should receive exercises as early as possible, because rest in bed or modification of movement results in faster loss in bone mineral density[21], atrophy of the muscles and loss of motor functions. It is believed that blood supply and tissue requirement greatly influence the speed of healing. So it is accepted that early exercises could restore the motor capacity and accelerate the healing of the injured muscles, ligaments and fracture bones.
Stabilization training is effective for improving the function, preventing injuries during movement[22], and reducing the chronic low back pain[23]. The above results show that spinal stabilization training could ameliorate the model of muscle working and improve the function, and can be helpful for the patients with vertebral osteoporotic fractures.
Spinal stability is a basis for motor function, which may attribute to the loss of function after vertebral osteoporotic fractures. Results from the present study indicated that spinal stabilization training had a favorable effect on retaining and improving motor function and reducing the level of pain of patients with vertebral osteoporotic fractures. The individualized and well planned program achieved better effects.
However, the trail was limited by the study methods and the size of samples. Therefore, further studies are required.

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