Paying attention to early-warning signs

Imagine you are walking around at risk for a serious fracture, but don't even know it. Simply tripping on a sidewalk could change your life forever. Dr. Susan Jaglal sees this happen all the time - and she's determined to do something about it.

A Senior Scientist at Toronto Rehab, Dr. Jaglal's focus is older people who have previously had fractures from minor falls. These "low-trauma fractures" can be a warning sign of osteoporosis, a bone-thinning disease that affects many people, especially women, as they age.

"If you've had any type of low-trauma fracture - of the wrist, hip, shoulder, spine - you are twice as likely to break your hip at some later date," says Dr. Jaglal. "That's something we want to prevent. Hip fractures are the most costly to patients, families and the health care system. A lot of people, once they break their hip, go into a downward spiral."

In fact, a startling 20% of people who break a hip die within a year and 50% end up with a disability that affects their daily lives. Dr. Jaglal and colleagues have found that one in four hip fracture patients living at home end up in a nursing home after their injury.

An epidemiologist by training, Dr. Jaglal holds the new Toronto Rehabilitation Institute Chair at the University of Toronto. In this position, her goal over the next five years is to improve the delivery of rehabilitation services to achieve the best outcomes possible in patients with musculoskeletal conditions.

"Previously, we never had the opportunity to analyze data in a systematic way for rehabilitation," says Dr. Jaglal, who was a co-principal investigator in Hospital Report: Rehabilitation 2003 and is working on the next report. "But now we have common data, which increases our ability to compare and find hospitals that are really good performers - so that others can learn from them. And, we can look at rehabilitation from a health system perspective as well."

In her osteoporosis research, Dr. Jaglal's findings are also revealing. "People need to be more aware that fractures can be an early-warning sign of osteoporosis," she says. Surprisingly, according to her research, family physicians seldom mention osteoporosis to fracture patients. Dr. Jaglal's team discovered this while doing focus groups with family physicians.

"When we brought up the issue of fracture, a lot of the family physicians didn't make the connection between a wrist facture, for example, and osteoporosis," she says. "There is also confusion around how to actually manage osteoporosis. They wanted information that would make it easier for them."

To address this, Dr. Jaglal and her colleagues have developed a model for a more integrated system of post-fracture care. The new approach is being tested in five Ontario communities, with funding from the Ontario Ministry of Health and Long-Term Care.

The goal is to coordinate the efforts of emergency departments, fracture clinics, family physicians, rehabilitation professionals and community organizations so that they look for osteoporosis in fracture patients and take action to prevent more fractures.

A central feature is a step-by-step "tool kit" to guide health care providers in managing fractures and osteoporosis. 

To determine if a fracture patient has osteoporosis, doctors can order a bone density test. If the disease is present, there are treatment options. In addition to drug therapy, patients need a diet rich in calcium and Vitamin D, and exercise, says Dr. Jaglal.

This is where rehabilitation professionals play a crucial role. For starters, they can ensure people with osteoporosis exercise safely. High-impact exercises must be avoided. Rehabilitation experts can also prescribe muscle-strengthening programs to improve bone health. With their specialized knowledge, they can investigate balance and gait issues, teach practical ways to reduce the risk of falling, and perform home safety assessments, says Dr. Jaglal.

When Dr. Jaglal embarked on a PhD in hip fractures in the 1980s, she could see there was critical work to be done. "Osteoporosis was a whole new field then," she says. And there were predictions of a spiraling growth in the rate of hip fractures.

Today, Dr. Jaglal is cautiously optimistic. Her most recent findings suggest the rate of hip fractures in Canada is actually starting to drop. "Even though we have more people at risk with the aging and growing population, we project that our numbers of hip fractures are not going to go up."

Dr. Jaglal thinks the explanation lies in growing awareness. More people seem to know about the link between menopause - which causes bone loss - and osteoporosis. In fact, women who have recently gone through menopause are most likely to be screened for the disease, she says.