Bone Density and Manipulation

Coming out of physical therapy school, one of the many things I was uncertain about was when it was okay to manipulate a joint in the geriatric population. Obviously, some of the usual standard contraindications are included: fracture, instability, etc. However, bone density deficits can be difficult to identify in evaluations as patients don't always have recent (or sometimes any) knowledge of their bone health.

To assess bone density, a patient has a DEXA scan performed. The standard deviation then plays a role in assessing how severe any density issues may be. If the score is less than 1 standard deviation from the norm, it is still within the normal range. If the score is within 1-2.5 standard deviations of the norm, the area is identified as osteopenic. If the score is greater than 2.5 standard deviations from the norm, the area is osteoporotic. Should a patient present with either osteopenia or osteoporosis, it is not recommended to manipulate the joint.

​It would be wonderful if it was as simple as that. However, not every patient knows if they have poor bone density. They may not have gotten a recent DEXA scan. Because of this, we should consider other factors that may contribute to poor bone health and lead to density issues: long-term corticosteroid use, cancer, older age, female, poor nutrition, and more. Should a patient have any or several of these factors, they may very likely have bone density issues as well. This is further evidence that a thorough evaluation (especially subjective history) is essential in patient management. Their history may indicate the safety with joint manipulation.

​-Dr. Chris Fox, PT, DPT, OCS

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