Patients with chronic obstructive pulmonary disease are at an increased risk for many things, ranging from shortness of breath and poor exercise tolerance to chest tightness and wheezing. But surprisingly, as many as 35% to 72% of patients with COPD are reported to be osteopenic, and 36% to 60% of COPD sufferers have osteoporosis, according to a review article published in Chest. According to the review, studies have found vertebral fractures present in 29% to 63% of patients with COPD.

“Reduced bone mass in these patients increases their risk for fracture, particularly in those patients with more advanced stages of COPD,” says Robyn Fuchs, PhD, assistant professor, department of physical therapy, school of health and rehabilitation sciences, at Indiana University, in Indianapolis. Not only does COPD share risk factors such as smoking, inactivity, age, malnutrition, and steroid use with osteoporosis, but COPD itself may be a causative risk factor for osteoporosis.

“Assume the patient with COPD has osteoporosis until proven otherwise,” agrees Chris L. Wells, PT, PhD, CCS, ATC, assistant professor, department of physical therapy and rehabilitation science at the University of Maryland School of Medicine, in Baltimore. “I have worked with patients that have been more impaired by their bone disease than their pulmonary dysfunction.”

New understanding of COPD as a systemic disease with an inflammatory component may help explain many of the debilitating manifestations of skeletal muscle mass and bone density loss seen in patients with COPD. “The etiology to decline in muscle and bone loss is multifactorial, including chronic tissue hypoxia, respiratory dysfunction, and prolonged and high doses of corticosteroids and agonist medications,” Wells says. “There are many changes in the skeletal muscle of patients with COPD, from a decline in aerobic enzymes, decrease in mitochondria, atrophy of type I and type II fibers, and impairment in protein metabolism that supports muscle health and growth.”

Along with changes to muscle structure, age-related bone and vascular changes occur prematurely in patients with COPD quite early in the disease process, according to a study published in the American Journal of Respiratory and Critical Care Medicine. Concomitant increases in aortic calcium deposits and decreases in bone mineral density may go undetected until a fracture occurs.

According to Amy Bayliss, PT, DPT, assistant clinical professor, department of physical therapy, school of health and rehabilitation sciences, Indiana University, previous fractures are an indicator for therapists to suspect low-density bones. The negative spiral of COPD and fractures serves not only to reduce mobility, but vertebral fractures may cause structural kyphosis and back pain that can reduce lung volume, further compromising airflow in patients with COPD.

Keyword: Gentle

A gentle touch is needed for patients with COPD who also have osteoporosis. “Direct techniques on the chest such as percussion and vibration may be too vigorous for some patients with osteoporosis,” Bayliss says. “A physical therapist can modify the treatment to use a device called an acapella to gain effective airway clearance. This device is very safe for a patient with COPD and osteoporosis.”

Setting a steady pace, not racing to finish treatments quickly, is imperative. “It is important to not hurry any patient with COPD, since pacing their activities to minimize shortness of breath is an essential part of their physical therapy program,” Bayliss says.

Fuchs agrees: “Patients should be monitored for both cardiac stress as well dyspnea level so that they know to stop and rest long before they reach an exercise intensity that would be dangerous,” she says. “It is important, particularly in a setting where the patient with COPD is undergoing any type of exercise/stress testing, to remember that in cases where the airways are compromised, something as simple as a forceful cough may be enough to generate a fracture.”

Weight-bearing exercises to maintain bone mass, one of the core elements of physical therapy for osteoporosis, should be a standard part of therapy for patients with COPD. Strengthening exercises designed to improve ADL function also are recommended, according to the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation.

“It is important to remember that patients with COPD have an increased risk for fracture, particularly in patients with advanced COPD,” Fuchs says. “It is important to work closely with a physician to assess the patient’s bone health via an annual DXA scan, particularly if the patient is undergoing new treatments that may have an impact on their bone health.”

Prognosis: PT

Physical therapy can play an important role in a patient’s prognosis when dealing with COPD. “Many clinical trials and my clinical experience has shown that the more functional and physically and mentally active a person remains, the more likely they will remain involved within their family and community,” Wells says. “Quality of life will be sustained, and the patient is likely to have a lower incidence of complications.” In addition to improving physical function and independence, patients also may derive psychosocial benefits such as improved mood and decreased anxiety as they expand their control over the disease.

The greatest success for this group of patients is preventative care, Bayliss believes: “If PTs consider all patients with COPD are at risk for osteoporosis, they can be proactive before fractures occur. Examples of being proactive can be educating your patient about osteoporosis, discussing healthy nutrition, the importance of exercise, and assessing balance risk to reduce falls. One way I have worked with [these] patients to intervene early is establishing a relationship with local pulmonologists and being willing to attend community support groups to provide this early education.”

Resources
* Biskobing DM. COPD and osteoporosis. Chest. 2002;121(2):609–20.
* Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF, Mahler DA, Make B, Rochester CL, Zuwallack R, Herrerias C. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-based clinical practice guidelines. Chest. 2008;133(3):830.
* Sabit R, Bolton CE, Edwards PH, Pettit RJ, Evans WD, McEnier CM, Wilkinson IB, Cockcroft JR, Shale DJ. Arterial stiffness and osteoporosis in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007;175(12):1259–65.