Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures

Association of combined healthy lifestyle factors with incident osteoporosis in patients with and without type 2 diabetes

PURPOSE

The association between type 2 diabetes mellitus (T2DM), lifestyle factors, and the risk of osteoporosis (OP) is well-established. However, the impact of a healthy lifestyle on diabetes-related osteoporosis needs further investigation. Our objective was to explore if a combination of healthy lifestyle factors could mitigate the risk of OP in individuals with type 2 diabetes.

METHODS

This longitudinal analysis included 237,725 middle-aged and older participants. An overall lifestyle score, ranging from 0 to 7, was calculated by assigning a point for each of the seven healthy lifestyle factors, including no current smoking, non-excessive alcohol consumption, regular physical activity, healthy diet, adequate sleep duration, less sedentary behavior, and adequate sunshine exposure.

RESULTS

During a median follow-up 12.21 years, 5760 OP cases were documented. Participants with T2DM showed a higher risk of OP than those without diabetes. Compared with participants without diabetes who had a lifestyle score of 6-7, the hazard ratios (HRs) for OP were 1.58 (95% CI 1.23-2.03), 1.62 (95% CI 1.16-2.25), and 2.58 (95% CI 1.64-4.05) for participants with T2DM who had a lifestyle score of 4, 3, and 0-2, respectively. There was a graded association between higher lifestyle scores and lower risks of incident OP among participants without diabetes as well as among those with T2DM. We estimated that the population attributable fraction for not adhering to 6-7 lifestyle behaviors was 15.7%.

CONCLUSIONS

Participants with T2DM who adhered to a variety of healthy lifestyle factors demonstrated a substantially reduced risk of developing OP.

The impact of yoga on aging physiology: A review

Frailty represents diminished reserve across multiple physiologic systems, accompanied by increased vulnerability to stressors and increased morbidity and mortality. With population aging, strategies to prevent and manage frailty are priorities in clinical medicine and public health. Current evidence-based approaches to frailty management are multimodal in nature. Yoga, an increasingly popular and highly adaptable mind-body practice, is multi-component, incorporating physical postures, breathing practices, meditation, and other elements, and may be a strategy for frailty management. Here, we summarize the evidence linking yoga practice to mitigation of age-related degradation across multiple physiologic systems, including cardiovascular, pulmonary, musculoskeletal, and nervous systems. We discuss putative mechanisms of action including modulation of the hypothalamic-pituitary-adrenal axis. Finally, we consider implications for clinical practice and future research.

Development, Acceptability, and Usability of a Virtual Intervention for Vertebral Fractures

OBJECTIVE

This project aimed to develop a virtual intervention for vertebral fractures (VIVA) to implement the international recommendations for the nonpharmacological management of osteoporotic vertebral fractures and to test its acceptability and usability.

METHODS

VIVA was developed in accordance with integrated knowledge translation principles and was informed by the Behavioral Change Wheel, the Theoretical Domains Framework, and the affordability, practicability, effectiveness and cost-effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria. The development of the prototype of VIVA involved 3 steps: understanding target behaviors, identifying intervention options, and identifying content and implementation options. The VIVA prototype was delivered to 9 participants to assess its acceptability and usability.

RESULTS

VIVA includes 7 1-on-1 virtual sessions delivered by a physical therapist over 5 weeks. Each session lasts 45 minutes and is divided in 3 parts: education, training, and behavioral support/goal setting. Four main themes emerged from the acceptability evaluation: perceived improvements in pain, increased self-confidence, satisfaction with 1-on-1 sessions and resources, and ease of use. All of the participants believed that VIVA was very useful and were very satisfied with the 1-on-1 sessions. Four participants found the information received very easy to practice, 4 found it easy to practice, and 1 found it somewhat difficult to practice. Five participants were satisfied with the supporting resources, and 4 were very satisfied. Potential for statistically significant improvements was observed in participants' ability to make concrete plans about when, how, where, and how often to exercise.

CONCLUSION

VIVA was acceptable and usable to the participants, who perceived improvements in pain and self-confidence.

IMPACT

The virtual implementation of the recommendations for the nonpharmacological management of vertebral fractures showed high acceptability and usability. Future trials will implement the recommendations on a larger scale to evaluate their effectiveness.

Morroniside ameliorates glucocorticoid-induced osteoporosis and promotes osteoblastogenesis by interacting with sodium-glucose cotransporter 2

CONTEXT

Morroniside (MOR) possesses antiosteoporosis (OP) effects, but its molecular target and relevant mechanisms remain unknown.

OBJECTIVE

We investigated the effects of MOR on glucocorticoid-induced OP and osteoblastogenesis and its underlying mechanisms.

MATERIALS AND METHODS

The effects of MOR (10-100 μM) on the proliferation and differentiation of MC3T3-E1 cells were studied in vitro. The glucocorticoid-induced zebrafish OP model was treated with 10, 20 and 40 μM MOR for five days to evaluate its effects on vertebral bone density and related osteogenic markers. In addition, molecular targets prediction and molecular docking analysis were carried out to explore the binding interactions of MOR with the target proteins.

RESULTS

In cultured MC3T3-E1 cells, 20 μM MOR significantly increased cell viability (1.64 ± 0.12 vs. 0.95 ± 0.16; p < 0.01) and cell differentiation (1.57 ± 0.01 vs. 1.00 ± 0.04; p < 0.01) compared to the control group. MOR treatment significantly ameliorated vertebral bone loss in the glucocorticoid-induced OP zebrafish model (0.86 ± 0.02 vs. 0.40 ± 0.03; p < 0.01) and restored the expression of osteoblast-specific markers, including ALP, Runx2 and Col-І. Ligand-based target prediction and molecular docking revealed the binding interaction between MOR and the glucose pockets in sodium-glucose cotransporter 2 (SGLT2).

DISCUSSION AND CONCLUSIONS

These findings demonstrated that MOR treatment promoted osteoblastogenesis and ameliorated glucocorticoid-induced OP by targeting SGLT2, which may provide therapeutic potential in managing glucocorticoid-induced OP.

Screening for Osteoporosis Risk Among Community-Dwelling Older Adults: A Scoping Review

BACKGROUND AND PURPOSE

Due to potential health-related consequences of osteoporosis (OP), health care providers who do not order imaging, such as physical therapists, should be aware of OP screening tools that identify individuals who need medical and rehabilitation care. However, current knowledge and guidance on screening tools is limited. Therefore, we explored OP screening tools that are appropriate and feasible for physical therapy practice, and evaluated tools' effectiveness by examining their clinimetric properties.

METHODS

A systematic search of the following databases was performed: PubMed, PEDro, PsycINFO, CINAHL, and Web of Science. Articles were included if the study population was 50 years and older, had a diagnosis of OP, if the screening tool was within the scope of physical therapy practice, and was compared to either a known diagnosis of OP or bone densitometry scan results. Included articles underwent multiple reviews for inclusion and exclusion, with each review round having a different randomly selected pair of reviewers. Data were extracted from included articles for participant demographics, outcome measures, cut-off values, and clinimetric properties. Results were categorized with positive and negative likelihood ratios (+LR/-LR) based on the magnitude of change in the probability of having or not having OP.

RESULTS

+LRs ranged from 0.15 to 20.21, with the Fracture Risk Assessment Tool (FRAX) and Study of Osteoporotic Fractures (SOF) having a large shift in posttest probability. -LRs ranged from 0.03 to 1.00, with the FRAX, Male Osteoporosis Risk Estimation Scores, Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation having a large shift in posttest probability.

CONCLUSION

Tools with moderate-large shift for both +LR and -LR recommended for use are: (1) OST; (2) FRAX; and (3) SOF. The variability in cut-off scores and clinimetric properties based on gender, age, and race/ethnicities made it impossible to provide one specific recommendation for an OP screening tool. Future research should focus on OP risk prediction among males and racial and ethnic groups.

Anti-osteoporosis mechanism of resistance exercise in ovariectomized rats based on transcriptome analysis: a pilot study

Postmenopausal osteoporosis is the main cause of fractures in women. Resistance exercise has a positive effect on bone mineral density in postmenopausal osteoporosis patients, but its mechanism is unclear. The purpose of this study was to explore the mechanism of resistance exercise in improving ovariectomized osteoporotic rats based on the transcriptome sequencing technique. Eighteen female Sprague-Dawley rats were randomly divided into the sham-operated group, the non-exercise group, and the resistance exercise group. The rat model of postmenopausal osteoporosis was established by bilateral ovariectomy. Ten weeks after the operation, the resistance exercise group received 2 weeks of adaptive training, and 12 weeks of resistance exercise began in the 13th week. The rats were trained 5 days per week, in 4 sets of 3 repetitions per day. After the intervention, all rats were sacrificed, and the body weight, bone mineral density, trabecular bone microarchitecture, and bone biomechanics were examined. At the same time, RNA-seq and enrichment analysis of gene ontology and Kyoto Encyclopedia of Genes and Genomes were performed on the left tibias, followed by Elisa and RT-qPCR verification. It had been found that resistance exercise can effectively counteract the weight gain of ovariectomized osteoporotic rats, and has a good effect on bone mineral density and trabecular bone microarchitecture. Enrichment analysis showed that regulation of gene expression and osteoclast differentiation is the most closely related biological process and signaling pathway shared by RE/Ovx and NE/Ovx groups. Our results revealed that resistance exercise can play a role in inhibiting osteoclast activation and preventing the enhancement of osteoclast bone resorption function in ovariectomized osteoporotic rats by inhibiting Fos/Fosb-regulated TRAP activation and relieving Calcr inhibition, which has important application value in preventing bone loss caused by estrogen deficiency.

International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures

We identified a knowledge gap in the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.

MAIN RESULTS

This international consensus process established multidisciplinary biopsychosocial recommendations on pain, nutrition, safe movement, and exercise for individuals with acute and chronic vertebral fractures.

SIGNIFICANCE

These recommendations will guide clinical practice and inform interventions for future research.

PURPOSE

To establish international consensus on recommendations for the non-pharmacological and non-surgical management of osteoporotic vertebral fractures.

METHODS

We adopted a five-step modified Delphi consensus process: (1) literature search and content analysis, (2) creation of the survey, (3) selection of the expert panel, (4) first round of the rating process, and (5) second round of the rating process. The first round included 49 statements and eight open-ended questions; the second round included 30 statements. Panelists were asked to rate their agreement with each of the statements using a 9-point scale, with the option to provide further comments. Consensus for each statement was determined by counting the number of panelists whose rating was outside the 3-point region containing the median.

RESULTS

We invited 76 people with degree in medicine, physiotherapy, kinesiology, and experience in the management of osteoporotic vertebral; 31 (41%) and 27 (36%) experts agreed to participate to the first and the second round, respectively. The mean percentage agreement after the first and second rounds was 76.6% ± 16.0% and 90.7% ± 6.5%, respectively. We established consensus on recommendations on pain, early satiety, weight loss, bracing, safe movement, and exercise for individuals with acute and chronic vertebral fractures.

CONCLUSION

Our international consensus provides multidisciplinary biopsychosocial recommendations to guide the management of osteoporotic vertebral fractures and inform interventions for future research.

Association between opportunistic vertebral bone density measurements and new vertebral fractures after percutaneous vertebral cementoplasty: a case-control study

OBJECTIVES

To study the relationship between opportunistic CT bone density measurements and the occurrence of new vertebral fractures after percutaneous vertebral cementoplasty (PVC) of osteoporotic vertebral compression fractures (OVCF).

METHODS

A prospective analysis of retrospective data of 275 patients with OVCF treated by PVC between 2014 and 2019 with a clinico-radiological follow-up one year after treatment was conducted. Opportunistic bone density measurements were obtained at the trabecular bone of the L1 or an adjacent vertebra in Hounsfield units performed on the preoperative CT study. These density measurements values ​​were then compared between patients with and without new OCVF and in various population subgroups.

RESULTS

There were 275 patients included, with 53 (19%) presenting a new OCVF and 24 (9%) developing a fracture cascade. The median opportunistic density measurements ​​in patients with recurrent OCVF were lower than those without (median 52[40.5]) HU and 77[49] HU)(p < 0.00001). Among the patients with new OVCF the median opportunistic density measurements in patients with fracture cascades were also lower than those without (44 HU and 62 HU, respectively) (p < 0.0096). Patients with density measurements under 61 HU were 3.6 times more likely to present recurrent fractures and those with density under 54 HU were 9.8 times more likely to develop a fracture cascade. The 36 HU threshold yielded a high specificity (90-91%) for the prediction of recurrent fractures and fracture cascade but with low sensitivity (respectively 26% and 37%).

CONCLUSION

Low opportunistic vertebral density measurements are associated with a higher risk of OVCF and fracture cascades after PVC.

KEY POINTS

• Low opportunistic density measurements are associated with a higher risk of OVCF and fracture cascades after PVC. • Measuring bone density before performing a PVC could help predict the risk of new vertebral fracture after treatment • Patient management could be adapted according to bone density.

[Impact of osteoporosis on physical performance parameters of middle-aged and elderly individuals-a cross-sectional study]

BACKGROUND

Osteoporosis (OP) in the elderly is accompanied by reduced muscle mass and reduced muscle strength, also known as sarcopenia. This results in functional limitations and a high risk of falls and injuries. The determination of physical performance parameters such as grip strength and trunk strength on the one hand, and balance abilities on the other, provide information about the individual's general neuromuscular condition and serve as an indicator of physical performance in the elderly. The extent to which previous osteoporotic vertebral fractures (VFs) restrict an individual's physical performance has not been adequately investigated yet.

MATERIAL AND METHODS

In total, 118 persons, with a mean age of 71.5 ± 9 years, participated in the clinical trial (ethics committee approval number A2020-0041). Patients were divided into an OP group (58 patients) and a control group (CG; 60 patients). OP patients with (VFs) and without vertebral fractures (0VFs) were viewed separately in the subgroup analysis. Data concerning physical status, including hand grip strength (HGS), the chair-rising test (CRT), tandem stance (TS), tandem gait (TG), and single-leg stance (SLS) were available for all patients. All data were analyzed using SPSS, Version 23.0.

RESULTS

No significant difference (p > 0.05) was registered between the OP and CG groups with regard of HGS, CRT, TG, TS, and SLS. In the subgroup analysis, OP patients with VFs had a lower HGS than OP patients without 0 VFx (VFs 24.3 ± 10.2 kg vs. 0 VFs 29.7 ± 9.5 kg, p = 0.026). TS was maintained longer by OP patients 0 VFs (VFs 7.8 ± 3.2 s vs. 0 VFs 9.5 ± 1.8 s, p = 0.008). The latter were also able to maintain their balance in TG over more numerous steps (VFs 4.8 ± 3.0 vs. 0 VFs 6.7 ± 2.4, p = 0.011). In a regression analysis, body size, gender, and age were shown to be independent factors influencing HGS (p < 0.001).

CONCLUSION

Patient age, constitution, and gender have a relevant influence on HGS, with baseline conditions after diagnosed OP at comparable levels in this age group. In a subgroup of OP patients with VFs, there is a close relationship between bone and muscle with an increasing deterioration of the musculoskeletal system. For prophylaxis of osteosarcopenia, early training seems reasonable.

Exercise and the prevention of major osteoporotic fractures in adults: a systematic review and meta-analysis with special emphasis on intensity progression and study duration

The role of exercise in preventing osteoporotic fractures is vague, and further recommendations for optimized exercise protocols are very rare. In the present work, we provided positive evidence for exercise effects on the number of osteoporotic fractures in adults, albeit without observing any significant relevance of intensity progression or study duration.

INTRODUCTION

Osteoporotic fractures are a major challenge confronting our aging society. Exercise might be an efficient agent for reducing osteoporotic fractures in older adults, but the most promising exercise protocol for that purpose has yet to be identified. The present meta-analysis thus aimed to identify important predictors of the exercise effect on osteoporotic fractures in adults.

METHODS

We conducted a systematic search of six literature databases according to the PRISMA guideline that included controlled exercise studies and reported the number of low-trauma major osteoporotic fractures separately for exercise (EG) and control (CG) groups. Primary study outcome was incidence ratio (IR) for major osteoporotic fractures. Sub-analyses were conducted for progression of intensity (yes vs. no) during the trial and the study duration (≤ 12 months vs. > 12 months).

RESULTS

In summary, 11 studies with a pooled number of 9715 participant-years in the EG and 9592 in the CG were included. The mixed-effects conditional Poisson regression revealed positive exercise effects on major osteoporotic fractures (RR: 0.75, 95% CI: 0.54-0.94, p = .006). Although studies with intensity progression were more favorable, our subgroup analysis did not determine significant differences for diverging intensity progression (p = .133) or study duration (p = .883). Heterogeneity among the trials of the subgroups (I² ≤ 0-7.1%) was negligible.

CONCLUSION

The present systematic review and meta-analysis provided significant evidence for the favorable effect of exercise on major osteoporotic fractures. However, diverging study and exercise characteristics along with the close interaction of exercise parameters prevented the derivation of reliable recommendations for exercise protocols for fracture reductions.

PROSPERO ID

CRD42021250467.

Using the specificity and overload principles to prevent sarcopenia, falls and fractures with exercise

The aim of this narrative review is to discuss the evidence on exercise for fall, fracture and sarcopenia prevention, including evidence that aligns with the specificity and progressive overload principles used in exercise physiology, implementation strategies and future research priorities. We also provide a brief discussion of the influence of protein intake and creatine supplementation as potential effect modifiers. We prioritized evidence from randomized controlled trials and systematic reviews. Resistance training can improve muscle mass, muscle strength and a variety of physical performance measures in older adults. Resistance training may also prevent bone loss or increase bone mass, although whether it needs to be done in combination with impact exercise to be effective is less clear, because many studies use multicomponent interventions. Exercise programs prevent falls, and subgroup and network meta-analyses suggest an emphasis on balance and functional training, or specifically, anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility, to maximize efficacy. Resistance training for major muscle groups at a 6-12 repetitions maximum intensity, and challenging balance exercises should be performed at least twice weekly. Choose resistance training exercises aligned with patient goals or movements done during daily activities (task specificity), alongside balance exercises tailored to ability and aspects of balance that need improvement. Progress the volume, level of difficulty or other aspects to see continuous improvement (progressive overload). A critical future priority will be to address implementation barriers and facilitators to enhance uptake and adherence.

Musculoskeletal Biomarkers Response to Exercise in Older Adults

Exercise is an essential component of any good health style, being particularly important for older adults to counteract the effects of aging, including sarcopenia and osteoporosis, which can result in lower fall probability. Exercise programs for older adults are especially designed for that population. A rigorous evaluation of those programs is necessary to assure most benefit is achieved. Serum biomarkers of proteins intrinsic to musculoskeletal homeostasis could contribute objectively to the assessment of the benefits of exercise. In this work, in addition to the usual physical fitness and balance tests, ELISA assays quantified the serum levels of six proteins and one polysaccharide important for the homeostasis of muscle (troponin T and alpha-actinin), tendon/ligament (tenomodulin), cartilage (cartilage oligomeric matrix protein and hyaluronan) and bone (osteocalcin and sclerostin), before and after 8 weeks of an exercise program tailored to older adults, Stay Strong Stay Healthy, offered at a Community Center and at an Independent Senior Living facility. Statistical significance was determined by non-parametric tests (Wilcoxon Signed Ranks and Mann-Whitney U). Physical fitness and balance improved as expected along with a significant decrease in sclerostin, pointing to less inhibition of bone deposition. However, when considering each type of dwelling separately, older adults always saw a significant decrease of the isoform of troponin T associated with fast-twitch muscles, suggesting that daily levels of physical activity may also have a role in the benefit of older adults from exercise.

Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis

Exercise and physical activity can improve bone strength and the risk of falls, which may offer benefits in the prevention and management of osteoporosis. However, uncertainty about the types of exercise that are safe and effective instigates lack of confidence in people with osteoporosis and health professionals. Existing guidelines leave some questions unresolved. This consensus statement aimed to determine the physical activity and exercise needed to optimise bone strength, reduce fall and fracture risk, improve posture and manage vertebral fracture symptoms, while minimising potential risks in people with osteoporosis. The scope of this statement was developed following stakeholder consultation. Meta-analyses were reviewed and where evidence was lacking, individual studies or expert opinion were used to develop recommendations. A multidisciplinary expert group reviewed evidence to make recommendations, by consensus when evidence was not available. Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. For safety, we recommend avoiding postures involving a high degree of spinal flexion during exercise or daily life. People with vertebral fracture or multiple low trauma fractures should usually exercise only up to an impact equivalent to brisk walking. Those at risk of falls should start with targeted strength and balance training. Vertebral fracture symptoms may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with specialist advice to encourage return to normal activities. Everyone with osteoporosis may benefit from guidance on adapting postures and movements. There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks.

Exercise Recommendation for People With Bone Metastases: Expert Consensus for Health Care Providers and Exercise Professionals

PURPOSE

Exercise has been underutilized in people with advanced or incurable cancer despite the potential to improve physical function and reduce psychosocial morbidity, especially for people with bone metastases because of concerns over skeletal complications. The International Bone Metastases Exercise Working Group (IBMEWG) was formed to develop best practice recommendations for exercise programming for people with bone metastases on the basis of published research, clinical experience, and expert opinion.

METHODS

The IBMEWG undertook sequential steps to inform the recommendations: (1) modified Delphi survey, (2) systematic review, (3) cross-sectional survey to physicians and nurse practitioners, (4) in-person meeting of IBMEWG to review evidence from steps 1-3 to develop draft recommendations, and (5) stakeholder engagement.

RESULTS

Recommendations emerged from the contributing evidence and IBMEWG discussion for pre-exercise screening, exercise testing, exercise prescription, and monitoring of exercise response. Identification of individuals who are potentially at higher risk of exercise-related skeletal complication is a complex interplay of these factors: (1) lesion-related, (2) cancer and cancer treatment-related, and (3) the person-related. Exercise assessment and prescription requires consideration of the location and presentation of bone lesion(s) and should be delivered by qualified exercise professionals with oncology education and exercise prescription experience. Emphasis on postural alignment, controlled movement, and proper technique is essential.

CONCLUSION

Ultimately, the perceived risk of skeletal complications should be weighed against potential health benefits on the basis of consultation between the person, health care team, and exercise professionals. These recommendations provide an initial framework to improve the integration of exercise programming into clinical care for people with bone metastases.

Analysis of Effects of PTEN-Mediated TGF-β/Smad2 Pathway on Osteogenic Differentiation in Osteoporotic Tibial Fracture Rats and Bone Marrow Mesenchymal Stem Cell under Tension

Purpose. To discuss effects of phosphatase and tensin homolog protein (PTEN)-mediated transforming growth factor-β (TGF-β)/Smad homologue 2 (Smad2) pathway on osteogenic differentiation in osteoporotic (OP) tibial fracture rats and bone marrow mesenchymal stem cell (BMSC) under tension. Methods. A tibial fracture model was established. The rats were divided into sham-operated group and model group, and tibia tissue was collected. Purchase well-grown cultured rat BMSC, and use the Flexercell in vitro cell mechanics loading device to apply tension. The expression of PTEN was detected by qRT-PCR. After the BMSCs were transfected with si-PTEN and oe-PTEN, the force was applied to detect cell differentiation. The expression of TGF-β/Smad2 protein was detected by Western blot. The formation of calcium nodules in BMSC was detected by alkaline phosphatase (ALP) staining and alizarin red (AR) staining. Results. The expression of PTEN was higher in the model group and tension MSC group, and the expression of TGF-β and Smad2 protein was lower. The expression of TGF-β and Smad2 protein in oe-PTEN group was lower than the oe-NC group and control group. The expression of TGF-β and Smad2 protein in si-PTEN group was higher than the si-NC group and control group. The results of ALP staining and AR staining also confirmed the above results. Conclusion. PTEN-mediated TGF-β/Smad2 pathway may play a key role in the osteogenic differentiation of OP tibial fracture rats. Downregulation of PTEN and upregulation of TGF-β/Smad2 signal can promote the osteogenic differentiation of BMSC under tension.

Essential Components of Physical Therapist Management of Patients With Osteoporosis: A Delphi Study

BACKGROUND AND PURPOSE

Osteoporosis is a systemic, metabolic bone disease that affects bone quality, increases susceptibility to low-trauma bone fracture, and has downstream effects on falls and fragility fractures. Osteoporosis is a multifactorial disease process that requires management from multiple health care providers including physicians, nurses, and physical therapists. However, the paucity of information regarding comprehensive physical therapist management for patients with osteoporosis indicated the need for an evidence-based document. The purpose of this document was to provide the best available expert guidance for clinicians in the selection of screening tools, essential tests and measures, treatment goals, and interventions for patients with osteoporosis.

METHODS

A Delphi process was used. Thirty-one physical therapists with expertise in the care of patients with osteoporosis participated in a series of 3 sequential surveys designed to build and reach agreement on the management of patients with osteoporosis. The desired survey outcomes were to: (1) identify the range of examination and plan of care components considered important to physical therapists' care for patients with osteoporosis, (2) determine which components should be considered essential, and (3) achieve consensus on the final list of essential components and related operational definitions.

RESULTS

A clear consensus on the essential components of examination and interventions was achieved. In general, there were 4 to 6 items across each category of history, tests and measures, education/goals, and treatment.

CONCLUSIONS

The prioritization of these management items will better support clinicians working with adults who have osteoporosis.

Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy

A clinical practice guideline on physical therapist management of patients with suspected or confirmed osteoporosis was developed by a volunteer guideline development group (GDG) that was appointed by the Academy of Geriatric Physical Therapy (APTA Geriatrics). The GDG consisted of an exercise physiologist and 6 physical therapists with clinical and methodological expertise. The guideline was based on a systematic review of existing clinical practice guidelines, followed by application of the ADAPTE methodological process described by Guidelines International Network for adapting guidelines for cultural and professional utility. The recommendations contained in this guideline are derived from the 2021 Scottish Intercollegiate Guideline Network (SIGN) document: Management of Osteoporosis and the Prevention of Fragility Fractures. These guidelines are intended to assist physical therapists practicing in the United States, and implementation in the context of the US health care system is discussed.

The effects of Pilates on health-related outcomes in individuals with increased risk of fracture: a systematic review

This systematic review examined the effect of Pilates on health-related outcomes in individuals with increased fracture risk to inform the 2021 Clinical Practice Guidelines for Management of Osteoporosis and Fracture Prevention in Canada. Seven electronic databases were searched to December 2020. Studies of Pilates in men and postmenopausal women aged ≥50 years with low bone mineral density (BMD), history of fragility fracture, or moderate-high risk of fragility fracture were included. Two reviewers independently screened studies and performed risk of bias assessment. Of 7286 records and 504 full-text articles, 5 studies were included, encompassing data from 143 participants (99% female). Data were insufficient for meta-analyses. There is low-certainty evidence that Pilates improved physical functioning and health-related quality of life. The effect of Pilates on falls and BMD is uncertain. No evidence was available for the effect of Pilates on mortality, fractures, or adverse events. Overall, Pilates may improve physical functioning and quality of life. Evidence of benefits relative to harms of Pilates in people with increased fracture risk, particularly males, is limited. PROSPERO registration: CRD42019122685. Novelty: Pilates may improve physical functioning and quality of life in women with osteoporosis. Evidence of the effect of Pilates on BMD, falls, fractures, or adverse events is limited.

Exercise and physical activity in individuals at risk of fracture

This is a review of evidence and practical tips on exercise for individuals with osteoporosis, including individuals with hip and vertebral fractures. Balance and functional training, with or without strength training, can prevent falls. Several types of exercise can improve outcomes that are important to patients, such as physical functioning or quality of life. Individuals with osteoporosis should prioritize balance, functional and resistance training ≥ twice weekly, where exercises, volume, intensity, and progression are aligned with the patient's goals and abilities. Patients who want to participate in other activities (e.g., walking, impact exercise, yoga, Pilates) can do them in addition to, but not instead of, balance and functional or strength training, if they can be done safely or modified. Avoid generic advice like "Don't bend or twist", which is difficult or impossible to operationalize, and may create fear and activity avoidance. Instead, be specific about the types of activities to avoid or modify, and provide tips on how to make daily activities safer, or signpost to resources from national osteoporosis societies. For example, not all bending or twisting is bad; it is activities that involve rapid, repetitive, sustained, weighted, or end range of motion twisting or flexion of the spine that may need to be modified, especially in individuals at high risk of fracture.

A pas de deux of osteoporosis and sarcopenia: osteosarcopenia

The musculoskeletal conditions osteoporosis and sarcopenia are highly prevalent in older adults. Osteoporosis is characterized by low bone mass and microarchitectural deterioration of bone, whereas sarcopenia is identified by the loss of muscle strength, function and mass. Osteoporosis represents a major health problem contributing to millions of fractures worldwide on an annual basis, whereas sarcopenia is associated with a range of adverse physical and metabolic outcomes. They both affect physical and social function, confidence and quality of life as well as contributing to high health-care costs worldwide. Osteosarcopenia is the term given when both conditions occur concomitantly and it has been suggested that interactions between these two conditions may accelerate individual disease progression as co-existence of osteoporosis and sarcopenia is associated with higher morbidity from falls, fracture, disability as well as mortality. In this review, we will outline the epidemiology, pathogenesis and clinical consequences of osteosarcopenia and discuss available management strategies.

Low Risk of Fracture With End-Range Movements of the Hip in People With Low Bone Mineral Density: A Narrative Review

Background: The risks of end-range movements for people with osteoporosis, specifically at the hips and shoulder, are not well understood. Objectives: To synthesize literature on the safety of stretching for people with osteoporosis by searching: 1) biomechanical literature to determine how much force results from an end-range maneuverer and is required to fracture joint components (focusing on the hip joint) and 2) clinical literature to describe techniques used, populations studied, effects, and reported adverse events. Methods: We conducted two separate search strategies in PubMed, EMBASE, and Scopus (1955-2020). Results: 16 articles described either biomechanical or clinical effects of passive and active end ranges of the hip joint. The largest load in the hip, described in the literature was in a crescent lunge during yoga. The moment produced in a crescent lunge is much smaller than that of the tensile strength of osteoporotic bone, suggesting the crescent lunge movement could be considered safe. Clinically, no adverse events were reported in exercise, stretching or yoga interventions. Conclusion: This review found no evidence that end range movements of the hip are unsafe, but there is little evidence. No studies were identified that explored the risk of humeral fracture during end range stretches.

Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis

AIMS AND OBJECTIVES

To systematically review and compare the efficacy of different exercise interventions on bone mineral density (BMD, g/cm² ) in patients with osteoporosis and osteopenia.

BACKGROUND

It is vitally important to prevent and treat bone loss in patients with osteoporosis and osteopenia. Exercise can effectively increase bone density and slow down bone loss in middle-aged and older people. However, it is still unclear which type of exercise intervention is the most effective on bone mineral density.

DESIGN

Systematic review and network meta-analysis (NMA) according to PRISMA.

METHODS

Randomised controlled trials of different exercise treatments for osteopenia and primary osteoporosis were included. A Frequentist network meta-analysis was conducted to appraise the efficacy of different types of exercise. The outcome was bone mineral density of different parts of the body.

RESULTS

Ninety-seven studies were included. The network meta-analysis showed that combined exercise, resistance exercise, aerobic exercise and mind-body exercise had a significant effect in improving the bone density of lumbar spine. The surface under the cumulative ranking area (SUCRA) values for mind-body exercise was 0.99 and ranked first. For BMD of the femoral neck, all kinds of exercise interventions increased the bone density significantly compared with no exercise and the optimal type was mind-body exercise (SUCRA = 0.99). In terms of the total hip bone mineral density, aerobic exercise and resistance exercise could improve hip bone density, with the resistance exercise (SUCRA = 0.95) ranking as first.

CONCLUSIONS

This NMA demonstrated the mind-body exercise might be the optimal exercise type to increase the BMD of the lumbar spine and femoral neck and resistance exercise is the most promising type for total hip BMD.

The international Pediatric Oncology Exercise Guidelines (iPOEG)

Physical activity (PA) and exercise are safe and beneficial for children and adolescents affected by cancer. Yet, this population is not active enough to receive benefits. PA guideline and recommendation statements can support individual behavior and practice change. The purpose of this project was to develop the international Pediatric Oncology Exercise Guidelines (iPOEG), comprised of guideline and recommendation statements, to promote PA among children and adolescents affected by cancer. Guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to the iPOEG network (n = 9 core team members, n = 122 expert consensus committee members). Surveys included closed- and open-ended items informed by a literature synthesis and an in-person meeting. Responses were analyzed using descriptive statistics and content analysis. Consensus was defined as ≥ 80% agreement. Response rates to online surveys ranged from 82% to 91%. The iPOEG network agreed on four guideline and five recommendation statements, which highlight that movement is important for all children and adolescents affected by cancer. These statements are generic in nature as more research is still required to provide specific guidance on the frequency, intensity, time, and type of PA for this population. Nevertheless, the iPOEG statements represent available evidence and expert opinion, collectively suggesting that it is time for children and adolescents affected by cancer to move more.

Physical activity is safe and beneficial for children and adolescents affected by cancer. Yet, most are not active enough to receive benefits. Guideline and recommendation statements can help change individual behavior and practice. To develop such statements, guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to an international network (n = 131 experts). Surveys asked closed- and open-ended questions informed by a literature synthesis and an in-person meeting. Findings from the online surveys resulted in the international Pediatric Oncology Exercise Guidelines statements, which highlight that it is time for children and adolescents affected by cancer to move more.

Vertebral fracture during one repetition maximum testing in a breast cancer survivor: A case report

RATIONALE

One repetition maximum (1-RM) testing is a standard strength assessment procedure in clinical exercise intervention trials. Because no adverse events (AEs) are published, expert panels usually consider it safe for patient populations. However, we here report a vertebral fracture during 1-RM testing.

PATIENT CONCERNS

A 69-year-old breast cancer survivor (body-mass-index 31.6 kg/m2), 3 months after primary therapy, underwent 1-RM testing within an exercise intervention trial. At the leg press, she experienced pain accompanied by a soft crackling.

DIAGNOSIS

Imaging revealed a partially unstable cover plate compression fracture of the fourth lumbar vertebra (L4) with a vertical fracture line to the base plate, an extended bone marrow edema and a relative stenosis of the spinal canal.

INTERVENTIONS

It was treated with an orthosis and vitamin D supplementation. Another imaging to exclude bone metastases revealed previously unknown osteoporosis.

OUTCOMES

The patient was symptom-free 6.5 weeks after the event but did not return to exercise.

CONCLUSION

This case challenges safety of 1-RM testing in elderly clinical populations.

LESSONS

Pre-exercise osteoporosis risk assessment might help reducing fracture risk. However, changing the standard procedure from 1-RM to multiple repetition maximum (x-RM) testing in studies with elderly or clinical populations would be the safest solution.

Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT

BACKGROUND

Falls and fractures are a major problem.

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions.

DESIGN

Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice.

SETTING

Primary care.

PARTICIPANTS

People aged ≥ 70 years.

INTERVENTIONS

All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling.

MAIN OUTCOME MEASURES

The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit.

RESULTS

Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported.

LIMITATIONS

The rate of fractures was lower than anticipated.

CONCLUSIONS

Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective.

FUTURE WORK

Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71002650.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.

Exploring thoracic kyphosis and incident fracture from vertebral morphology with high-intensity exercise in middle-aged and older men with osteopenia and osteoporosis: a secondary analysis of the LIFTMOR-M trial

Our aim was to explore change in kyphosis and vertebral fracture incidence following 8 months of high-intensity resistance and impact training (HiRIT) or machine-based isometric axial compression (IAC) training in men with osteopenia and osteoporosis. HiRIT and IAC improved posture. HiRIT participants did not experience progression or incident vertebral fracture. IAC participants did experience progression and incident vertebral fracture.

INTRODUCTION

The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial examined efficacy and safety of an eight-month, supervised, high-intensity progressive resistance and impact training (HiRIT) program compared with machine-based isometric axial compression (IAC) training in middle-aged and older men with low areal bone mineral density (aBMD). The primary purpose of the current work was to explore change in thoracic kyphosis and incident fracture from vertebral morphology following eight-months of HiRIT or IAC training. The secondary purpose was to explore change in clinical kyphosis measures for HiRIT, IAC and a non-randomized, matched control group.

METHODS

Men (≥ 45 yrs), with low aBMD, were recruited and randomized to HiRIT or IAC, or designated control. Clinical measures of thoracic kyphosis with inclinometry were determined. Cobb angle of kyphosis and vertebral fracture assessment using the Genant semi-quantitative method were determined from lateral thoracolumbar DXA (Medix DR, Medilink, France). Per-protocol (n = 40) and intention-to-treat (n = 93) analyses were conducted.

RESULTS

Forty participants (HiRIT n = 20, IAC n = 20; 66.1 ± 7.8 yrs.; lumbar spine T-score - 0.1 ± 0.8; femoral neck T-score - 1.5 ± 0.5) underwent clinical kyphosis measures and thoracolumbar DXA at baseline and follow-up. No between-group differences were detected in kyphosis change, however, within-group improvements in neutral (HiRIT - 2.3 ± 0.8°; IAC - 2.5 ± 0.8°) and 'standing tall' (HiRIT - 2.4 ± 0.8°; IAC - 2.0 ± 0.8°) postures were observed (p < 0.05). HiRIT improved Cobb angle (- 3.5 ± 1.5°, p = 0.027) from baseline. Over the 8 months, no incident vertebral fractures nor progression of prevalent vertebral fractures occurred for HiRIT participants. Five incident fractures of thoracic vertebrae occurred for IAC and one wedge fracture progressed. Ninety-three participants underwent clinical kyphosis measures at both time-points (HiRIT n = 34, IAC n = 33, control n = 26). HiRIT exhibited a reduction in 'standing tall' kyphosis compared to control (- 2.3 ± 0.6° versus 1.4 ± 0.7°, p < 0.05), but no other between-group differences were detected.

CONCLUSIONS

Although there was no difference in change between intervention groups, thoracic kyphosis appeared to improve in both HiRIT and IAC with exercise exposure. HiRIT improved 'standing tall' posture in comparison to usual activities. HiRIT was not associated with vertebral fracture progression or incident vertebral fracture, but for some IAC participants there was evidence of progression of vertebral fracture severity and incident vertebral fractures, in our small sample. Larger trials are required to confirm the observations of the current work, which was exploratory in nature.

Rehabilitation of Patients With Osteoporotic Fractures

Osteoporosis is a silent, asymptomatic disease until a fragility fracture is sustained. Fractures greatly affect the physical functioning and health-related quality of life and are associated with increased mortality and morbidity rates. Furthermore, once a fragility fracture occurs, the patient is more susceptible to sustain further fractures. Repeated falls are the main causes of fractures in patients with osteoporosis. The management of osteoporosis postfracture is a combination of medical treatment, nutritional interventions, and rehabilitation in order to improve activities of daily living to prevent falls and increase safety while reducing the loss of bone mass. In this article the principles of fracture prevention and physical rehabilitation of patients with osteoporosis postvertebral and hip fragility fractures will be discussed, as well as the rehabilitation management to prevent further falls and fractures.

A 12-week exercise program improves functional status in postmenopausal osteoporotic women: randomized controlled study

BACKGROUND

Beside the importance of implementing physical activity in treatment of patients with osteoporosis, the multicomponent exercise program and assessment of its functional outcomes performed by five performance-based measures, have not been explored yet.

AIM

The present study evaluated the effect of the 12 weeks exercise program on functional outcomes of postmenopausal patients with densitometric diagnosed osteoporosis.

DESIGN

The study was designed as randomized control study.

SETTING

Female outpatients with diagnosed postmenopausal osteoporosis were included in the study.

POPULATION

The study included women from urban area.

METHODS

Patients were randomized in two groups: exercise group (EG) and control group (CG). Patients in the exercise group (N.=47) participated in a 12 weeks exercise program, which consisted of resistance training, balance exercise and aerobic exercise, while patients from control group (N.=49) had not participated in any exercise program during the intervention period. Functional outcomes determined by Time Up and Go Test (TUG), Sit To Stand test (STS) and One Leg Stance Test (OLST) were evaluated at baseline and 4 and 12 weeks after treatment, while Fall Efficacy Scale (FES-I) and Knowledge About Osteoporosis Questionnaire (OKAT-S) were assessed at baseline and after 12 weeks, respectively.

RESULTS

There were noticed statistically significant improvement in all observed measurements in EG after 4 and 12 weeks, respectively. Comparison between groups showed statistically significant difference in EG compared to CG in all functional outcomes in observed periods (P<0.001 for all). OLST significantly changed only in EG, not in CG, in both experimental periods. After 4 weeks, in CG there were no statistically significant changes in any of the monitored parameters, while after 12 weeks improvements were detected with TUG, STS, FES-I and OKAT-S.

CONCLUSIONS

Twelve weeks exercise program, as an effective, inexpensive and easily performed method, improved functional status in postmenopausal osteoporotic women.

CLINICAL REHABILITATION IMPACT

In the present study we found that supervised exercise program in postmenopausal osteoporotic female patients significantly improved their muscle strength and balance and decreased fear of falling. Thus, it is proposed to be a part of clinical protocol for osteoporosis treatment.

Investigation of the Relationship Between Peak Vertical Accelerations and Aerobic Exercise Intensity During Graded Walking and Running in Postmenopausal Women

How exercise intensity targets, calibrated according to oxygen consumption, relate to vertical impacts during weight-bearing exercise is currently unknown. The authors investigated the relationship between vertical peaks (VPs) and metabolic equivalents (METs) of oxygen consumption in 82 women during walking and running. The magnitude of VPs, measured using a hip-worn triaxial accelerometer, was derived from recommended aerobic exercise intensity targets. VPs were 0.63 ± 0.18g at the lower recommended absolute exercise intensity target (3 METs) but >1.5g at the upper end of moderate-intensity activities (1.90 ± 1.13g at 6 METs). Multilevel linear regression analyses identified speed and type of locomotion as the strongest independent predictors of VPs, explaining 54% and 11% of variance, respectively. The authors conclude that, in contrast to lower intensities, exercising close to or above the 6-MET threshold generates VPs of osteogenic potential, suggesting this could provide simultaneous benefits to decrease all-cause mortality and osteoporosis risk.

The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women

PURPOSE

To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium.

METHODS

The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts.

RESULTS

Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered.

CONCLUSION

BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.

The Effects of Home Exercise in Older Women With Vertebral Fractures: A Pilot Randomized Controlled Trial

BACKGROUND

Regular exercise is advocated in osteoporosis guidelines to prevent fractures. Few studies have evaluated the effect of exercise on functional performance, posture, and other outcomes that are important to patients after vertebral fractures.

OBJECTIVE

This pilot study will explore the effect of home exercise versus control on functional performance, posture, and patient-reported outcome measures.

DESIGN

This study was a parallel 2-arm pilot feasibility trial with 1:1 randomization to exercise or attentional control groups.

SETTING

This study took place in 5 Canadian and 2 Australian academic or community hospitals/centers.

PARTICIPANTS

This study included 141 women ≥65 years of age with radiographically confirmed vertebral fractures.

INTERVENTION

A physical therapist delivered exercise and behavioral counseling in 6 home visits over 8 months and monthly calls. Participants were to exercise ≥3 times weekly. Controls received equal attention.

MEASUREMENTS

Functional performance, posture, quality of life, pain, and behavior-change outcomes were assessed at baseline and after 6 (questionnaires only) and 12 months. Adherence to exercise was assessed by calendar diary. All t tests examined between-group mean differences (MD) in change from baseline in intention-to-treat and per-protocol analyses.

RESULTS

There was a small effect of exercise on 5 times sit-to-stand test versus control (MD = -1.58 [95% CI = -3.09 to -0.07], intention-to-treat; MD = -1.49 [95% CI = -3.12 to 0.16], per-protocol). There were no other major or statistically significant MDs for any other measured outcomes after follow-up. Adherence declined over time.

LIMITATIONS

Treatment effects on variables may have been underestimated due to multiple comparisons and underpowered analyses.

CONCLUSIONS

Our exploratory estimate of the effect of exercise on functional leg muscle strength was consistent in direction and magnitude with other trials in individuals with vertebral fractures. Declining adherence to home exercise suggests that strategies to enhance long-term adherence might be important in future confirmatory trials.

Impact of exercise on bone mineral density, fall prevention, and vertebral fragility fractures in postmenopausal osteoporotic women

Osteoporosis is the most prevalent bone disease worldwide and predisposes affected individuals to fragility fractures. Exercise has been shown to have multiple health benefits in post-menopausal osteoporotic women, but often recommendations regarding the benefits of specific exercise types are vague. Improving bone mineral density (BMD) is an essential component in any program to prevent osteoporotic vertebral fractures. The objective of this report is to briefly review the current understanding on the impact of exercise on BMD in postmenopausal women as it pertains to fragility fractures. Broad categories of exercises include aerobic, resistance, stretching, and balance. Tai Chi, Yoga, and Pilates are a heterogeneous group of specific exercise modalities that can span multiple categories. Current literature suggests that only resistance type exercises have a convincing impact on BMD. Core-strengthening exercises and attention to posture/balance can help mitigate falls. A number of barriers affect patient compliance and accessibility to exercise. In summary, exercise should be included in any multi-modality osteoporosis treatment plan with the goal of sustained exercise throughout life. If possible, osteoporotic women should be on a resistance-based regimen incorporating weight-bearing exercises, and also target posture and balance. Healthcare providers and educators should have resources readily available for patients.

Physical activity and skeletal health in adults

The purpose of this Review is to examine the associations between physical activity and skeletal health, with an emphasis on observational studies with fracture outcomes and randomised controlled trials (RCTs) of physical activity interventions in adults older than 40 years. In general, increased physical activity-primarily leisure time activity or moderate or vigorous physical activity-is associated with a 1-40% lower risk of hip and all fractures. The primary limitation of these studies relates to health status; healthy people are more likely to exercise and less likely to fracture. Although there is no sufficiently powered RCT of exercise with a fracture outcome, there is evidence that some types of exercise prevent falls and bone loss, and meta-analyses support the anti-fracture effectiveness of exercise. RCTs and meta-analyses suggest that programmes combining impact exercise with moderate or high-intensity progressive resistance exercise might maintain or improve bone mass and prevent fractures, and that functional strength and balance training prevents falls.

Effects of 12-Week Exercise Program on Enzyme Activity of Serum Matrix Metalloproteinase-9 and Tissue Inhibitor of Metalloproteinase-1 in Female Patients with Postmenopausal Osteoporosis: A Randomized Control Study

Background

Osteoporosis is a disease characterized by decreased bone density and destruction of bone microarchitecture. Indicators for altered bone homeostasis are changes in the serum level of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs). The purpose of the current study was to evaluate the effect of a 12-week exercise program on enzyme activity of serum MMP-9 and TIMP-1 in postmenopausal osteoporotic patients. Materials and methods. Participants were randomized in two groups: exercise (EG) (N = 37) and control (CG) (N = 37) and control (CG) (

Results

Significant differences between pretreatment and posttreatment enzyme activities of serum MMP-9 (p=0.009), TIMP-1 (p=0.009), TIMP-1 (p=0.009), TIMP-1 (

Conclusion

Our results suggest that a 12-week exercise program has an influence on enzyme activity of serum MMP-9, revealing a possible role of MMPs in initiating training-specific adaptation. Although measurements of circulating MMP-9 and TIMP-1 allowed us to detect effects of exercise, as of today, they have no real role in the diagnosis of osteoporosis and/or follow-up of osteoporotic patient's response to treatment. MMP-9 might be used as an important prognostic marker for the evaluation of patient's response to exercise. Larger-randomized controlled studies need to be performed to expand this area of knowledge. This trial is registered with trial registration number: NCT03816449).

[Multidisciplinary approach to the rehabilitation of patients with osteoporosis]

The article outlines the modern concept of rehabilitation of patients with osteoporosis (OP), the cornerstone of which is the use of a multidisciplinary approach. This approach involves not only the participation of specialists of various specializations and levels in the process of rehabilitation treatment, but the formation of a new functional unit - a multidisciplinary team, whose members actively interact with each other from the first days to the completion of the rehabilitation course at every stage of the course; they together make a rehabilitation diagnosis based on the International Classification of Functioning, Disability and Health (ICF); they formulate rehabilitation goals, evaluate rehabilitation potential, discuss and develop a rehabilitation program and evaluate its effectiveness by using modern scales, tests and questionnaires to assess the change in the condition of the patient"s life at all levels and the quality of life in general. Taking into account the principle of multidisciplinarity, approaches to preparation of rehabilitation programs for patients with OP are described using various methods: those of therapeutic gymnastics, mechanotherapy, physiotherapy, balneotherapy, occupational therapy, psychotherapy, drug treatment and orthosis. Particular attention in the process of rehabilitation of patients with OP is given to physical therapy and orthosis, which are aimed at reducing pain, improving coordination, posture, as well as reducing the risk of falls and fractures. The literature review presented in the article allows us to conclude that the use of a multidisciplinary approach in the rehabilitation of patients with OP makes it possible to significantly improve the quality of life of patients even with severe forms of the disease.

Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT

BACKGROUND

A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role.

OBJECTIVE

The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session.

DESIGN

This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies.

SETTING

This trial was based in 21 NHS physiotherapy departments.

PARTICIPANTS

The participants were people with symptomatic OVF.

INTERVENTIONS

Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT).

MAIN OUTCOME MEASURES

Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version.

RESULTS

A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events.

CONCLUSIONS

This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49117867.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.

Feasibility and Reliability of Functional Muscle Tests in Lung Transplant Recipients

Supplemental digital content is available in the text.

Objective

This study investigates the feasibility, reliability, and correlations of recommended functional tests in lung transplant recipients shortly after surgery.

Design

This is an observational study.

Methods

Fifty patients (28 females) performed well-standardized maximum isometric back extension in a sitting position, handgrip strength, and Biering-Sørensen endurance tests shortly before discharge from the acute hospital, shortly thereafter, and 2 mos later after subacute rehabilitation.

Results

Back extension testing was well feasible, but only two thirds of the patients could perform the Biering-Sørensen test at baseline and they experienced a greater number of minor but no major adverse events. Absolute reliability measures and the intraclass correlation coefficients were excellent for the strength (0.97–0.98 [0.95–0.99]) and good for the endurance tests (0.69 [0.26–0.87]). Handgrip revealed high correlation with back strength (≥0.75) but not with Biering-Sørensen scores.

Conclusions

Well-controlled maximum back strength testing is feasible and reliable, and the scores are highly correlated with grip strength in lung transplant recipients shortly before hospital discharge. The Biering-Sørensen test should be limited to patients without dominant weakness and/or fear. Future research should investigate whether grip instead of back extension strength can safely be used for proper exercise prescription.

Exercise for improving outcomes after osteoporotic vertebral fracture

BACKGROUND

Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To assess the effects (benefits and harms) of exercise intervention of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo among adults with a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. Our secondary objectives were to evaluate the effects of exercise on the following outcomes: falls, pain, physical performance, health-related quality of life (disease-specific and generic), and adverse events.

SEARCH METHODS

We searched the following databases until November 2017: the Cochrane Library (Issue 11 of 12), MEDLINE (from 2005), Embase (from 1988), CINAHL (Cumulative Index to Nursing and Allied Health Literature, from 1982), AMED (from 1985), and PEDro (Physiotherapy Evidence Database, from 1929). Ongoing/recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. For this update, the search results were limited from 2011 onward.

SELECTION CRITERIA

We included all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data using a pre-tested data extraction form. Disagreements were resolved by consensus, or third-party adjudication. We used Cochrane's tool for assessing risk of bias to evaluate each study. Studies were grouped according to duration of follow-up (i.e. a) 4-12 weeks; b) 16-24 weeks; c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For dichotomous data, we reported risk ratios (RR) and corresponding 95% confidence intervals (95% CI). For continuous data, we reported mean differences (MD) of the change from baseline and 95% CI. Data were pooled for Timed Up and Go test, self-reported physical function measured by the QUALEFFO-41 physical function subscale score (scale of zero to 100; lower scores indicate better self-reported physical function), and disease-specific quality of life measured by the QUALEFFO-41 total score (scale of zero to 100; lower scores indicate better quality of life) at 12 weeks using a fixed-effect model.

MAIN RESULTS

Nine trials (n = 749, 68 male participants; two new trials in this review update) were included. Substantial variability across the trials prevented any meaningful pooling of data for most outcomes. Risk of bias across all studies was variable; low risk across most domains in four studies, and unclear/high risk in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias.One trial reported no between-group difference in favor of the effect of exercise on incident fragility fractures after 52 weeks (RR 0.54, 95% CI 0.17 to 1.71; very low-quality evidence with control: 184 per 1000 and exercise: 100 per 1000, 95% CI 31 to 315; absolute difference: 8%, 95% CI 2 to 30). One trial reported no between-group difference in favor of the effect of exercise on incident falls after 52 weeks (RR 1.06, 95% CI 0.53 to 2.10; very low-quality evidence with control: 262 per 1000 and exercise: 277 per 1000; 95% CI 139 to 550; absolute difference: 2%, 95% CI -12 to 29). These findings should be interpreted with caution because of the very serious risk of bias in these studies and the small sample sizes resulting in imprecise estimates.We are uncertain that exercise could improve pain, self-reported physical function, and disease-specific quality of life, because certain studies showed no evidence of clinically important differences for these outcomes. Pooled analyses revealed a small between-group difference in favor of exercise for Timed Up and Go (MD -1.13 seconds, 95% CI -1.85 to -0.42; studies = 2), which did not change following a sensitivity analysis (MD -1.09 seconds, 95% CI -1.78 to -0.40; studies = 3; moderate-quality evidence). Exercise improved QUALEFFO-41 physical function score (MD -2.84 points, 95% CI -5.57 to -0.11; studies = 2; very low-quality evidence) and QUALEFFO-41 total score (MD -3.24 points, 95% CI -6.05 to -0.43; studies = 2; very low-quality evidence), yet it is unlikely that we observed any clinically important differences. Three trials reported four adverse events related to the exercise intervention (costal cartilage fracture, rib fracture, knee pain, irritation to tape, very low-quality evidence).

AUTHORS' CONCLUSIONS

In conclusion, we do not have sufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events. Our updated review found moderate-quality evidence that exercise probably improves physical performance, specifically Timed Up and Go test, in individuals with vertebral fracture (downgraded due to study limitations). However, a one-second improvement in Timed Up and Go is not a clinically important improvement. Although individual trials did report benefits for some pain and disease-specific quality of life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution given the very low-quality evidence due to inconsistent findings, study limitations and imprecise estimates. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture in men is scarce. A high-quality randomized trial is needed to inform safety and effectiveness of exercise to lower incidence of fracture and falls and to improve patient-centered outcomes (pain, function) for individuals with vertebral fractures (minimal sample size required is approximately 2500 untreated participants or 4400 participants if taking anti-osteoporosis therapy).

Physical Activity and Sports-Real Health Benefits: A Review with Insight into the Public Health of Sweden

Positive effects from sports are achieved primarily through physical activity, but secondary effects bring health benefits such as psychosocial and personal development and less alcohol consumption. Negative effects, such as the risk of failure, injuries, eating disorders, and burnout, are also apparent. Because physical activity is increasingly conducted in an organized manner, sport’s role in society has become increasingly important over the years, not only for the individual but also for public health. In this paper, we intend to describe sport’s physiological and psychosocial health benefits, stemming both from physical activity and from sport participation per se. This narrative review summarizes research and presents health-related data from Swedish authorities. It is discussed that our daily lives are becoming less physically active, while organized exercise and training increases. Average energy intake is increasing, creating an energy surplus, and thus, we are seeing an increasing number of people who are overweight, which is a strong contributor to health problems. Physical activity and exercise have significant positive effects in preventing or alleviating mental illness, including depressive symptoms and anxiety- or stress-related disease. In conclusion, sports can be evolving, if personal capacities, social situation, and biological and psychological maturation are taken into account. Evidence suggests a dose–response relationship such that being active, even to a modest level, is superior to being inactive or sedentary. Recommendations for healthy sports are summarized.

Application of ICF conceptual framework in Osteoporosis

Background: Osteoporosis (OP) is a metabolic bone disease defined by low bone strength and deterioration of bone tissue, which has wide clinical presentations. The World Health Organization's International Classification of Functioning Disability and Health (ICF) provides a common language, classification system, and conceptual framework to describe the consequences of health conditions in terms of body function and structure, activities and participation, environmental and personal factors. Objectives: The ICF conceptual framework was used, in this paper, to integrate OP research-based knowledge into clinical application using clinical vignettes. Results: Body functions and structures, activities and participation, environmental factors and personal factors are described, and the inter-connection among these factors is explored. The vignettes highlight the importance of different components of the ICF framework and to demonstrate how the ICF framework can capture individual differences in how disability can be experienced in OP. Conclusion: The ICF conceptual framework provides a holistic representation of disability by facilitating a critical appraisal of the health status of people with OP. The framework creates an awareness of the broad and multidimensional nature of OP on the health of individual patients, integrates dimensions of functioning, and highlights the complexity of the evaluation and management of OP.

Adverse events and safety issues associated with physical activity and exercise for adults with osteoporosis and osteopenia: A systematic review of observational studies and an updated review of interventional studies

OBJECTIVES

We conducted a systematic review to identify adverse effects of physical activity and/or exercise for adults with osteoporosis/osteopenia. We synthesised evidence from observational studies, and updated three previously published systematic reviews.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, grey literature and reference lists of relevant studies. Selection criteria were: (1) observational studies in patients with osteoporosis/osteopenia; and (2) in accordance with the criteria used in the previous reviews. A narrative synthesis was conducted for the observational data. Random effects meta-analysis was undertaken for the review updates.

RESULTS

For the observational synthesis 14 studies were included. The majority of studies reported no adverse events, reduced incidence/improvement, or no significant change after physical activity or exercise. Activities that involved spinal flexion (certain yoga moves and sit-ups) were associated with a greater risk of vertebral fractures but these events were rare. For the update of reviews, 57 additional studies were identified. Exercise was generally associated with a greater number of minor adverse events including mild muscle/joint pain. Serious adverse events were rare and could not be attributed to the intervention.

CONCLUSION

Patients with osteoporosis/osteopenia can safely participate in structured exercise programmes, whether at home or in supervised facilities. Systematic review registration for observational studies: PROSPERO 2017: CRD42017070551.

Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription

BACKGROUND

Osteoporosis and related fragility fractures are a global public health problem in which pharmaceutical agents targeting bone mineral density (BMD) are the first line of treatment. However, pharmaceuticals have no effect on improving other key fracture risk factors, including low muscle strength, power and functional capacity, all of which are associated with an increased risk for falls and fracture, independent of BMD. Targeted exercise training is the only strategy that can simultaneously improve multiple skeletal and fall-related risk factors, but it must be appropriately prescribed and tailored to the desired outcome(s) and the specified target group.

OBJECTIVES

In this review, we provide an overview of the general principles of training and specific loading characteristics underlying current exercise guidelines for the prevention of osteoporosis, and an update on the latest scientific evidence with regard to the type and dose of exercise shown to positively influence bone mass, structure and strength and reduce fracture risk in postmenopausal women.

Muscle and Bone Health in Postmenopausal Women: Role of Protein and Vitamin D Supplementation Combined with Exercise Training

Menopause is an age-dependent physiological condition associated with a natural decline in oestrogen levels, which causes a progressive decrease of muscle mass and strength and bone density. Sarcopenia and osteoporosis often coexist in elderly people, with a prevalence of the latter in elderly women. The profound interaction between muscle and bone induces a negative resonance between the two tissues affected by these disorders worsening the quality of life in the postmenopausal period. It has been estimated that at least 1 in 3 women over age 50 will experience osteoporotic fractures, often requiring hospitalisation and long-term care, causing a large financial burden to health insurance systems. Hormonal replacement therapy is effective in osteoporosis prevention, but concerns have been raised with regard to its safety. On the whole, the increase in life expectancy for postmenopausal women along with the need to improve their quality of life makes it necessary to develop specific and safe therapeutic strategies, alternative to hormonal replacement therapy, targeting both sarcopenia and osteoporosis progression. This review will examine the rationale and the effects of dietary protein, vitamin D and calcium supplementation combined with a specifically-designed exercise training prescription as a strategy to counteract these postmenopausal-associated disorders.

Which strength and balance activities are safe and efficacious for individuals with specific challenges (osteoporosis, vertebral fractures, frailty, dementia)?: A Narrative review

Physical activity guidelines advocate the inclusion of strength and balance activities, twice a week, for adults and older adults, but with caveat that in some individuals there will be certain movements and activities that could lead to adverse events. This scoping review summarizes the evidence about how safe and efficacious these activities are in older adults with specific challenges that might make them more prone to injury (e.g. having recently fractured or at risk of fracture (osteoporosis) or those who are frail or who have cognitive impairment). The review identified that for prevention of falls in people with a falls history and/or frailer older adults, structured exercise programmes that incorporate progressive resistance training (PRT) with increasing balance challenges over time are safe and effective if performed regularly, with supervision and support, over at least 6 months. Some minor adverse effects mainly transient musculoskeletal pain) have been reported. For those with a higher risk of falls and fractures (very poor balance, vertebral fractures), supervised structured exercise programmes are most appropriate. People with diagnosed osteoporosis should be as active as possible and only avoid activities with a high risk of falls if they are naïve to those activities. For those in transition to frailty who have poor strength and balance, exercises that are known to help maintain strength and balance (such as Tai Chi) are effective in preventing a decline in falls risk. For the very frail older adult, supervised structured exercise that has PRT, balance training and some endurance work, supervised and progressed by a trained person are advocated.

Promoting Well-Being in Old Age: The Psychological Benefits of Two Training Programs of Adapted Physical Activity

In the last few decades, the relationship between physical conditions and mental health has increasingly attracted the interest of researchers and professionals across disciplines. This relationship is especially relevant in old age, as the challenges posed by aging at various levels represent crucial concerns for policy makers. Due to the remarkable increase in life expectancy across countries, sustainable prevention strategies are needed to help individuals preserve psychophysical well-being in old age. In particular, the regular practice of a moderately intense physical activity is recommended by the World Health Organization to enhance balance, prevent falls, strengthen muscles, and promote psychophysical well-being. Daily physical exercise represents a beneficial and low-cost strategy, easily accessible to the general population and potentially customizable to specific needs through brief training programs. Based on these premises, the present research aimed at longitudinally evaluating mental well-being among 58 Italian people aged 67-85, who were involved in two Adapted Physical Activity (APA) training programs. Inclusion criteria for participation comprised high autonomy levels in daily activities, no cognitive impairment, sedentary habits or only occasional performance of moderate physical activity. Based on physical and functional assessment, 39 participants joined a program of adapted motor activity (PoliFit; Study 1), while 19 participants attended a variant program specifically designed for people with osteoporosis (OsteoFit; Study 2). Well-being dimensions were assessed through the Mental Health Continuum-Short Form, the Emotion Regulation Questionnaire and the Satisfaction with Life Scale. Physical functioning were evaluated before and after the programs through the Short Physical Performance Battery and the Handgrip Dynamometer Jamar Test. Findings highlighted that, besides physical benefits, participants reported significantly more adaptive emotion regulation strategies after both training programs; in addition, participants attending OsteoFit reported significantly higher levels of emotional well-being. Results suggest the potential of moderate physical activity in promoting mental health, emphasizing the additional role of training programs as cost-effective opportunities for elderly people to socialize and improve emotional functioning. Overall, the findings support the view of old age as a stage of competence development and adaptive adjustment, rather than a phase of mere psychophysical decline.

"Left to my own devices, I don't know": using theory and patient-reported barriers to move from physical activity recommendations to practice

Knowledge exchange with community-dwelling individuals across Ontario revealed barriers to implementation of physical activity recommendations that reflected capability, opportunity, and motivation; barriers unique to individuals with osteoporosis include fear of fracturing, trust in providers, and knowledge of exercise terminology. Using the Behaviour Change Wheel, we identified interventions (training, education, modeling) and policy categories (communication/marketing, guidelines, service provision).

INTRODUCTION

Physical activity recommendations exist for individuals with osteoporosis; however, to change behavior, we must address barriers and facilitators to their implementation. The purposes of this project are (1) to identify barriers to and facilitators of uptake of disease-specific physical activity recommendations (2) to use the findings to identify behavior change strategies using the Behaviour Change Wheel (BCW).

METHODS

Focus groups and semi-structured interviews were conducted with community-dwelling individuals attending osteoporosis-related programs or education sessions in Ontario. They were stratified by geographic area, urban/rural, and gender, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and interventions were identified.

RESULTS

Two hundred forty community-dwelling individuals across Ontario participated (mean ± SD age = 72 ± 8.28). Barriers were as follows: capability: disease-related symptoms hinder exercise and physical activity participation, lack of exercise-related knowledge, low exercise self-efficacy; opportunity: access to exercise programs that meet needs and preferences, limited resources and time, physical activity norms and preferences; motivation: incentives to exercise, fear of fracturing, trust in exercise providers. Interventions selected were training, education, and modeling. Policy categories selected were communication/marketing, guidelines, and service provision.

CONCLUSIONS

Barriers unique to individuals with osteoporosis included the following: lack of knowledge on key exercise concepts, fear of fracturing, and trust in providers. Behavior change techniques may need tailoring to gender, age, or presence of comorbid conditions.

Inter-rater reliability of DartfishTM movement analysis software for measuring maximum flexion and extension at the hip and knee in older adults with osteoporosis and osteopenia

Various methods are used to measure hip and knee joint motion angles; however, their use is often limited by cost or inability to measure dynamic movements. The assessment of movement patterns is clinically useful in individuals with osteoporosis (OP) and osteopenia (OPe) through its potential to optimize fracture risk assessment. This study evaluates the inter-rater reliability of using Dartfish^TM 2-D Motion Analysis Software to measure maximum flexion and extension angles at the hip and knee in individuals with OP or OPe while performing five tasks of the Safe Functional Motion test. Twelve participants were videotaped performing the pour, footwear, newspaper, sweep, and sit-to-floor tasks. Five raters used Dartfish^TM to analyze maximum flexion and extension angles at the hip and knee, and an intra-class correlation coefficients (ICC) and SEM were calculated for each measurement. In all five tasks, ICC and SEM values ranged from 0.23 to 0.95, and 1.75 to 11.54 degrees, respectively, with maximum knee flexion angles generally having higher ICC, and lower SEM point estimates. The results indicate that Dartfish^TM measurements of maximum knee flexion angles in uniplanar tasks demonstrate a moderate to excellent degree of inter-rater reliability, while measurements at the hip joint should be used with caution. Given that the results of this study display moderate to excellent reliability, they lay the groundwork for future research aimed at determining the validity of these measurements. Such research would help to further develop the base of evidence surrounding the usefulness of Dartfish^TM Motion Analysis in fracture risk analysis among individuals with OP.

Exercise to improve functional outcomes in persons with osteoporosis: a systematic review and meta-analysis

Osteoporosis affects many aspects of daily life. The aim of this systematic review was to assess the effects of exercise interventions on functional outcomes in persons with osteoporosis, in comparison with controls.

METHODS

Four databases were searched and yielded 1587 citations. Two reviewers independently determined study eligibility, rated risk of bias, appraised methodological quality of studies, and resolved discordance by consensus.

RESULTS

A total of 28 studies examining 2113 participants met inclusion criteria; 25 studies were suitable for meta-analyses. Four categories of exercise were identified using the ProFaNE taxonomy. After removing studies with high risk of bias and sorting them into intervention sub-types, we were able to sufficiently reduce the heterogeneity. The standardized mean difference (SMD) favored multicomponent exercise for mobility (- 0.56, 95% CI [- 0.81, - 0.32], p = 0.06, I² = 51%); balance (0.50, 95% CI [0.27, 0.74], p = 0.28, I² = 21%); and self-reported measures of functioning (- 0.69, 95% CI [- 1.04, - 0.34], p = 0.02, I² = 61%). Trials were judged at low or unclear risk of selection bias, indicating inadequate reporting and at high risk of performance bias due to lack of participant blinding. The mean methodological quality rating of the studies was 63.5% indicating moderate quality.

CONCLUSIONS

A multicomponent exercise program of high-speed training combined with simulated functional tasks is promising to enhance functional outcomes. Due to substantial clinical heterogeneity of the target groups and specific demands of exercise modes, it is unclear which exercise program is optimal.