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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