The role of first contact physiotherapists in the identification and management of vertebral fragility fractures and osteoporosis : a case report

Abstract

Purpose: Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture and a powerful predictor of further future vertebral and/or hip fracture without treatment. These fractures cause significant morbidity and risk of mortality. Therefore, identification of a recent VFF is an indication to consider specialist osteoporosis anabolic drug treatment. However, recognition of the signs and symptoms of VFF remains a challenge, with up to 70% going undiagnosed. The evolving role of First Contact Physiotherapists (FCPs) in primary care presents an opportunity for physiotherapists to help reduce the Osteoporosis Care Gap, but little is known about their scope of practice for osteoporosis. Methods: A case report was written to demonstrate an example of the scope of practice of an Advanced Level FCP. A lady in her 70s presented to her GP surgery with lower back pain following a fall from a chair. Her medical history included hypothyroidism and hypercholesterolaemia. She had six consultations with various clinicians at the surgery and was prescribed analgesia, before being assessed by the FCP three months after onset. Despite having no tenderness to percussion over the thoracic or lumbar spinous processes, a diagnosis of VFF was suspected because of ongoing pain following low energy trauma, pain when sitting and lying supine, and an increased thoracic kyphosis. Results: The FCP referred the patient for urgent thoracic and lumbar x-rays, which confirmed VFF of T10 and L1. The patient was initially prescribed alendronic acid, calcium, and vitamin D. Blood tests were ordered to exclude secondary causes of osteoporosis. An urgent bone density scan was requested, alongside a referral to rheumatology for consideration of more potent anabolic drug treatment due to the high risk of future fracture. The patient was also referred to the falls service for exercise advice and home equipment. The patient was prescribed specialist osteoporosis drug treatment (romosozumab) under the care of rheumatology. One year later, she was not needing analgesia, and she had not had any further falls or fractures. Conclusion(s): This case report highlights the difficulty in diagnosing VFF, with several missed opportunities to refer for x-ray initially. A delayed diagnosis of VFF can result in suboptimal symptom management and subsequent increased healthcare utilisation, as well as missed opportunities to enact prompt secondary prevention and particularly specialist treatment, to reduce the risk of further fragility fractures. The FCP in this case report demonstrated advanced clinical reasoning, as well competency in radiology and bloods requesting and interpretation, non-medical independent prescribing, and timely appropriate onward referral. This highlights the valuable role FCPs can have in improving osteoporosis care. Impact: It is recognised that this case report cannot be used to demonstrate scope of practice and competency of all FCPs nationally. FCPs are required to complete a Roadmap to Practice demonstrating advanced level musculoskeletal knowledge and critical thinking, but there are no osteoporosis-specific competencies. Further research to ascertain osteoporosis knowledge and scope of practice amongst FCPs across the United Kingdom would be beneficial to highlight any training needs and establish best practice.

1st Keyword: “First Contact Physiotherapist” 2nd Keyword: “Vertebral fragility fracture” 3rd Keyword: Osteoporosis

Ethics approval: The HRA decision-making tool was used, which confirmed that no ethical approval was required.

Funding acknowledgements: This work was completed as part of the Birmingham Health Partners West Midlands Pre-Doctoral Bridging Programme but received no direct funding.