Special Medical Reports

VERNA L. ROSE

NOF Urges Bone Density Tests for Certain Postmenopausal Women and All Women Over Age 65

The National Osteoporosis Foundation (NOF) has issued recommendations for the prevention, risk factor assessment, diagnosis and treatment of osteoporosis, including specific guidelines on the use of bone mineral density tests. "The Physician's Guide to Prevention and Treatment of Osteoporosis" was developed by an expert committee of the NOF in collaboration with 10 multidisciplinary medical organizations. C. Conrad Johnston, Jr., M.D., Indiana University, Indianapolis, was chair of the development committee.

The recommendations are based on evidence from randomized clinical trials. The guide primarily addresses white postmenopausal women, because sufficient data are not available to formulate comparable recommendations for men, premenopausal women and women of other races. The NOF recommends that risk factors identified for white women be applied to other populations on an individual basis to help make therapeutic decisions. The guidelines also do not address secondary causes of osteoporosis but contain a list of medications and diseases that are associated with an increased risk of osteoporosis.

The NOF document includes an overview of osteoporosis and a discussion of the medical and economic impact of the disease in the United States. Other sections in the guide discuss basic pathophysiology, risk factor assessment (see table), diagnosis, universal recommendations for all adults concerning prevention of osteoporosis, pharmacologic options, and physical medicine and rehabilitation.

Risk Factors for Osteoporotic Fracture The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

A single copy or bulk copies of the guide can be ordered by contacting the NOF, 1150 17th St., N.W., Ste. 500, Washington, DC 20036-4603; telephone: 202-223-2226; fax: 202-223-2237. Single copies are free of charge; packets of 10 are available for a small fee. The NOF is also producing a pocket guide and a patient guide to compliment the physician guidelines. The NOF Web address is http://www.nof.org.

The following information includes the key recommendations discussed in the NOF guidelines:

• All women should be counseled about the risk factors for osteoporosis (see table). Risk factors for osteoporotic fracture include personal history of fracture as an adult, history of fracture in a first-degree relative, white race, advanced age, female sex, dementia, poor health/frailty, cigarette smoking, low body weight (under 127 lb [58 kg]), estrogen deficiency, lifelong low calcium intake, alcoholism, impaired eyesight despite adequate correction, recurrent falls and inadequate physical activity. According to the NOF, osteoporosis is a "silent" risk factor for fracture; one out of two white women will have an osteoporotic fracture at some point in her lifetime.
• The NOF recommends that all postmenopausal women with a fracture be evaluated for osteoporosis using bone mineral density testing to determine if the woman has osteoporosis and to determine disease severity. According to the NOF, measurements of bone mineral density at any skeletal site can predict the risk of fracture, but a measurement of the hip is the best predictor of hip fractures, and hip measurement can predict fractures at other sites as well. The measurement of bone density can also be used to monitor changes in bone density associated with medical conditions or therapy.
• The NOF recommends bone mineral density testing in all postmenopausal women under age 65 who have one or more additional risk factors for osteoporosis (in addition to menopause).
• Bone mineral density testing is also recommended in all women aged 65 and older regardless of additional risk factors.
• All adults should be advised to consume an adequate intake of dietary calcium (at least 1,200 mg per day, including supplements if necessary) and vitamin D (400 to 800 IU per day for persons at risk of deficiency).
• All patients should be counseled to avoid smoking and to limit alcohol intake to moderate levels. All patients should be encouraged to participate in regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.
• Physicians should consider osteoporosis treatment for all postmenopausal women who present with vertebral fractures or hip fractures. The NOF emphasizes that these sites are the most common sites for osteoporotic fractures.
• Bone mineral tests provide physicians with a T score expressed in standard deviation; the more negative the number, the greater the risk of fracture. Each standard deviation represents a 10 to 12 percent bone loss, and a T score of -2.5 indicates osteoporosis. The NOF recommends therapy to reduce fracture risk in women with a bone mineral density T score below -2.0 in the absence of risk factors, and in women with a T score below -1.5 if other risk factors are present.
• Approved pharmacologic options for osteoporosis prevention or treatment are hormone replacement therapy, alendronate, raloxifene and calcitonin. The guideline notes that hormone replacement therapy represents the greatest benefit relative to cost for all of the pharmacologic treatments. Evidence indicates a 50 to 80 percent decrease in vertebral fractures and a 25 percent decrease in nonvertebral fractures after five years of use of hormone replacement therapy. The NOF emphasizes that "all postmenopausal women should be counseled to consider hormone replacement therapy or estrogen replacement therapy and offered guidance in weighing its risks and benefits."

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NIH Issues Consensus Statement on the Rehabilitation of Persons with Traumatic Brain Injury

The National Institutes of Health (NIH) has issued a consensus development conference statement on the rehabilitation of persons with traumatic brain injury. The conference that culminated in the consensus statement was convened by the NIH to evaluate the scientific data concerning rehabilitation practices for persons with traumatic brain injury. After listening to presentations and audience discussion at the conference, an independent panel chaired by Kristijan T. Ragnarsson, M.D., Mt. Sinai Medical Center, New York City, weighed the scientific evidence and presented a statement. Particular emphasis was placed on rehabilitation of cognitive, behavioral and psychosocial difficulties associated with mild, moderate and severe traumatic brain injury.

The consensus statement can be found on the NIH Web site at http://odp.od.nih.gov/consensus/. The document can also be obtained from the NIH Consensus Program Information Center, P.O. Box 2577, Kensington, MD 20891; telephone: 888-644-2667.

The consensus statement addresses the following key questions: (1) What is the epidemiology of traumatic brain injury in the United States, and what are its implications for rehabilitation? (2) What are the consequences of traumatic brain injury in terms of pathophysiology, impairments, functional limitations, disabilities, societal limitations and economic impact? (3) What is known about mechanisms underlying functional recovery following traumatic brain injury, and what are implications for rehabilitation? (4) What are the common therapeutic interventions for the cognitive and behavior sequelae of traumatic brain injury, what is their scientific basis, and how effective are they? (5) What are the common models of comprehensive, coordinated, multidisciplinary rehabilitation for persons with traumatic brain injury, what is their scientific basis, and what is known about their short-term and long-term outcomes? (6) Based on the answers to the previous questions, what can be recommended regarding rehabilitation practice for persons with traumatic brain injury? (7) What research is needed to guide the rehabilitation of persons with traumatic brain injury?

Traumatic brain injury is identified in the report as brain injury from externally inflicted trauma that may result in significant impairment of a person's physical, cognitive and psychosocial functioning. The report states that traumatic brain injury is a heterogeneous disorder of major public health significance. An estimated 1.5 to 2 million persons incur traumatic brain injuries annually. The causes include vehicular incidents, falls, acts of violence and sports accidents. Because of more effective emergency treatment in recent years, the number of persons who survive a traumatic brain injury has increased greatly. Each year, as many as 90,000 persons have a brain injury resulting in long-term and substantial loss of functioning. Traumatic brain injury is the leading cause of long-term disabililty among children and young adults.

Traumatic brain injuries are divided into three categories: mild, moderate and severe. The report notes that mild traumatic brain injury is significantly underdiagnosed, and early intervention is often neglected. The panelists believe that the surveillance systems of the Centers for Disease Control and Prevention for traumatic brain injuries should be expanded to include "emergency department encounters" as well as hospital discharges and death records. Knowing the incidence, prevalence, etiology and natural history can help determine the types of rehabilitation services that are needed for persons with traumatic brain injury.

The following list of recommendations regarding rehabilitation practices for persons with traumatic brain injury has been excerpted from the report:

• Rehabilitation programs for persons with moderate or severe traumatic brain injury should be interdisciplinary and comprehensive.
• Rehabilitation services should be matched to the needs, strengths and capacities of each person with traumatic brain injury.
• Rehabilitation should include cognitive and behavioral assessment and intervention.
• Patients and their families should have a central role in the planning and design of the individualized rehabilitation programs and research endeavors.
• Persons with traumatic brain injury should have access to rehabilitative services through the entire course of recovery, which could last for many years after the injury.
• Substance abuse evaluation and treatment should be a component of rehabilitation programs.
• Medications used for behavioral management have significant side effects in persons with traumatic brain injury, may impede the rehabilitation progress and should therefore be reserved only for compelling circumstances.
• Medications used for cognitive enhancement can be effective, but the benefits should be carefully evaluated and documented in each individual.
• Community-based, nonmedical services should be components of the extended care and rehabilitation programs available to persons with traumatic brain injury. These services include but are not necessarily limited to clubhouses for socialization, day programs and social skill development, supported living programs and independent living centers, and formal education programs at all levels.
• Families of persons with traumatic brain injury should themselves receive support. This can include in-home assistance and ongoing counseling.
• Rehabilitation efforts should include modification of the person's home, social and work environments to enable fuller participation in all venues.
• Special programs are needed to identify and treat persons with mild traumatic brain injury.
• Specialized, interdisciplinary and comprehensive treatment programs are necessary to address particular medical, rehabilitation, social, family and educational needs of young children with traumatic brain injury.
• Specialized, interdisciplinary and comprehensive treatment programs are necessary to address particular medical, rehabilitation, family and social needs of persons older than age 65 with traumatic brain injury.
• Educational programs are needed to increase the degree to which community care providers are aware of the problems experienced by persons with traumatic brain injury.

The report also includes a list of recommendations for future research that is needed to help guide the rehabilitation of persons with traumatic brain injury. These recommendations include the following:

• Gender differences in survival rates, patterns of severity and long-term manifestations of traumatic brain injury need to be studied.
• The duration, natural history and life course manifestations of mild, moderate and severe traumatic brain injury should be studied.
• The relationship between the pathophysiology of traumatic brain injury and the effectiveness of different interventions should be studied.
• Basic and common classification systems of traumatic brain injury are needed.
• Uniform standards and minimal data sets to describe injury type, severity and significant interacting variables, which could provide a total injury profile across a continuum of recovery should be developed.
• The long-term consequences of traumatic brain injury of varying severity, including the consequences of aging on persons with traumatic brain injury, should be studied.
• The epidemiology of mild traumatic brain injury should be studied.
• The consequences and effects of rehabilitation after traumatic brain injury should be studied.
• The effectiveness of community-based rehabilitation for persons with traumatic brain injury should be studied.
• Severity risk-adjustment models for studies of persons with traumatic brain injury should be established.

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