Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture

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.

Finding the Optimal Resistance Training Intensity for Your Bones: Protocol for a Randomized Controlled Trial

OBJECTIVE

The purpose of this trial is to evaluate the effect of twice-weekly, moderate-to-high intensity progressive resistance training (PRT) for 1 year on lumbar spine bone mineral density (BMD) in individuals with low BMD, compared to attention control. Secondary analyses will examine if resistance training improves other health outcomes; if high intensity is more effective than moderate intensity resistance training for all outcomes; the cost of intervention versus benefit; the willingness to pay; and harms.

METHODS

For this study, 324 men or postmenopausal women aged ≥50 years with a femoral neck, total hip, or lumbar spine BMD T-score of ≤-1, or a Fracture Risk Assessment Tool probability of ≥20% for major osteoporotic fracture or ≥ 3% for hip fracture are being recruited to participate in a randomized controlled trial with 1:1:1 randomization. Participants will be stratified by site (3 centers) to twice-weekly, supervised PRT at moderate intensity (about 10 repetitions maximum), to high intensity PRT (≤6 repetitions maximum), or to a home posture and balance exercise program (attention control) for 1 year (resistance training to comparator allocation ratio of 2:1). The primary outcome is lumbar spine BMD via dual-energy X-ray absorptiometry. Secondary outcomes include trabecular bone score, proximal femur and total hip BMD and structure, bone-free and appendicular lean mass, physical functioning, falls, fractures, glucose metabolism, cost per life-year gained, adverse events, and quality of life. Between-group differences will be tested in intention-to-treat and per-protocol analyses using analysis of covariance, chi-square tests, or negative binomial or logistic regression, adjusting for site and baseline values.

IMPACT

The Finding the Optimal Resistance Training Intensity For Your Bones trial will support decision making on resistance training for people at risk of fracture.

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.

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.

The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors

PURPOSE

To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture.

METHODS

Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures.

RESULTS

Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy.

CONCLUSION

Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.

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.

Benefits and harms of non-surgical and non-pharmacological management of osteoporotic vertebral fractures: A systematic review and meta-analysis

BACKGROUND

Osteoporotic vertebral fractures affect a large number of older adults OBJECTIVES: Systematically review evidence of the benefits and harms of non-surgical and non-pharmacological management of people with osteoporotic vertebral fractures compared with standard care (control); and evaluate the benefits and harms of non-surgical and non-pharmacological management of people with osteoporotic vertebral fractures compared with an alternative non-pharmacological, non-invasive intervention.

DESIGN

Systematic review and meta-analysis of randomized controlled trials. Five electronic databases (CINAHL, EMBASE, MEDLINE, PUBMED, and COCHRANE) were searched. Eligible trials included participants with primary osteoporosis and at least one vertebral fracture diagnosed on radiographs, with treatment that was non-surgical and non-pharmacological involving more than one session.

RESULTS

Twenty randomized controlled trials were included with 2083 participants with osteoporotic vertebral fractures. Exercise, bracing, multimodal therapy, electrotherapy, and taping were investigated interventions. Meta-analyses provided low certainty evidence that exercise interventions compared to no exercise were effective in reducing pain in patients with osteoporotic vertebral fractures (mean difference (MD)= 1.01; 95% confidence interval (CI): 0.08, 1.93), and low certainty evidence that rigid bracing intervention compared with no bracing was effective in reducing pain in patients with osteoporotic vertebral fractures (MD= 2.61; 95%CI: 0.95, 4.27). Meta-analyses showed no differences in harms between exercise and no exercise groups. No health-related quality of life or activity improvements were demonstrated for exercise interventions, bracing, electrotherapy, or multimodal interventions.

CONCLUSIONS

Exercise and rigid bracing as management for patients with osteoporotic vertebral fractures may have a small benefit for pain without increasing risk of harm.

TRIAL REGISTRATION

PROSPERO registration number CRD42012002936.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment

BACKGROUND

The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

METHODS

A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

RESULTS

The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

CONCLUSION

It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

The MoveStrong program for promoting balance and functional strength training and adequate protein intake in pre-frail older adults: A pilot randomized controlled trial

BACKGROUND

Balance and functional strength training can improve muscle strength and physical functioning outcomes and decrease the risk of falls in older adults. To maximize the benefits of strength training, adequate protein intake is also important. However, the number of older individuals that consume enough protein or routinely engage in strength training remains low at less than 5% and even lower for activities that challenge balance. Our primary aim was to assess the feasibility of implementing a model (MoveStrong) of service delivery to teach older adults about balance and functional strength training and methods to increase protein intake.

METHODS

This study was a closed cohort stepped wedge randomized controlled trial. We recruited individuals ≥60 years considered pre-frail or frail with at least one chronic condition who were not currently engaging in regular strength training from Northern (rural) and Southern (urban) Ontario sites in Canada. The primary outcome was feasibility of implementation, defined by recruitment, retention, and adherence, and safety (defined by monitoring adverse events). We also reported participants' and providers' experience with MoveStrong, adaptations to the model based on participant's and provider's experience, and program fidelity.

RESULTS

We recruited 44 participants to the study and the average adherence rate was 72% with a retention of 71%. The program had a high-fidelity score. One person experienced a fall-related injury during exercise, while two other participants reported pain during certain activities. Five individuals experienced injuries or health problems that were not related to the program. Suggestions for future trials include modifying some exercises, exploring volunteer assistance, increasing the diversity of participants enrolled, and considering a different study design.

CONCLUSIONS

Our pilot trial demonstrates the feasibility of recruitment and adherence for a larger multisite RCT of balance and functional strength training with attention to protein intake in pre-frail and frail older adults.

COVID-19 nationwide lockdown and physical activity profiles among North-western Italian population using the International Physical Activity Questionnaire (IPAQ)

Background

The role of physical activity in enhancing health is well recognized. However, in the more industrialized countries, physical activity rates are declining, and the emerging COVID-19 pandemic may amplify this scenario. Thus, this study aimed to report the Italian population’s physical activity profile living in the North-western regions during the national lockdown.

Methods

Physical activity was assessed using the official Italian short form of IPAQ, intended for Social Networking Services (SNS). Participation was voluntary, and people could fill the questionnaire simply by clicking on a specific link.

Results

The final sample size was 612 Italians, male and female, equally distributed (49.1% male and 50.9% female). Data showed a percentage of 15.4% of inactive subjects (MET < 700), 61.8% of moderate-active (MET 700–2500), and 22.9% of active people (MET > 2500). Women were more inactive than men (p < 0.01; 57.4% vs 42.6%). Furthermore, participants were classified into four classes of age: 18–29; 30–44; 45–59; and 60–79. Class 18–29 was prevalent (p < 0.01, 68.3%) and showed higher levels of physical activity (p < 0.05).

Conclusions

Italians living in North-western regions maintained a moderate amount of physical activity during the quarantine. This behavior should be encouraged, particularly among women that usually appear to be less active than men.

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.

Progressive Resistance Training for Improving Health-Related Outcomes in People at Risk of Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Osteoporosis clinical practice guidelines recommend exercise to prevent fractures, but the efficacy of exercise depends on the exercise types, population studied, or outcomes of interest. The purpose of this systematic review was to assess the effects of progressive resistance training (PRT) on health-related outcomes in people at risk of fracture.

METHODS

Multiple databases were searched in October 2019. Eligible articles were randomized controlled trials of PRT interventions in men and women ≥50 years with low bone mineral density (BMD) or fracture history. Descriptive information and mean difference (MD) and SD were directly extracted for included trials. A total of 53 studies were included.

RESULTS

The effects of PRT on the total number of falls (incidence rate ratio [IRR] = 1.05; 95% CI = 0.91 - 1.21; 7 studies) and on the risk of falling (risk ratio [RR] = 1.23; 95% CI = 1.00 - 1.51; 5 studies) are uncertain. PRT improved performance on the Timed "Up and Go" test (MD = -0.89 seconds; 95% CI = -1.01 to -0.78; 13 studies) and health-related quality of life (standardized MD = 0.32; 95% CI = 0.22-0.42; 20 studies). PRT may increase femoral neck (MD = 0.02 g/cm2; 95% CI = 0.01-0.03; 521 participants, 5 studies) but not lumbar spine BMD (MD = 0.02 g/cm2; 95% CI = -0.01-0.05; 4 studies), whereas the effects on total hip BMD are uncertain (MD = 0.00 g/cm2; 95% CI = 0.00-0.01; 435 participants, 4 studies). PRT reduced pain (standardized MD = -0.26; 95% CI = -0.37 to -0.16; 17 studies). Sensitivity analyses, including PRT-only studies, confirmed these findings.

CONCLUSION

Individuals at risk of fractures should be encouraged to perform PRT, as it may improve femoral neck BMD, health-related quality of life, and physical functioning. PRT also reduced pain; however, whether PRT increases or decreases the risk of falls, the number of people experiencing a fall, or the risk of fall-related injuries is uncertain.

IMPACT

Individuals at risk of fractures should be encouraged to perform PRT, as it may have positive effects on femoral neck BMD, health-related quality of life, physical functioning, and pain, and adverse events are rare.

LAY SUMMARY

Exercise is recommended for people at risk of osteoporotic fractures. Our study showed that progressive resistance training improves physical functioning, quality of life, and reduces pain. The effects of progressive resistance training on the risk of falling are unclear. Adverse events are rare, and often minor (eg, soreness, pain, musculoskeletal injury). Considering the benefits and safety, people at risk of fractures should engage in progressive resistance training interventions.

Exploring Fear of Falling and Exercise Self-Efficacy in Older Women With Vertebral Fractures

Fear of falling is a common issue among older adults, which decreases quality of life and leads to an avoidance of activities they are still able to do. The goal of this secondary data analysis was to explore the relationship between fear of falling and exercise self-efficacy in 141 women with at least one nontraumatic Genant Grade 2 vertebral fracture. Fear of falling, exercise self-efficacy, history of falling, the number of falls, the use of assisting devices, and pain at rest or during movement were obtained using medical history and health status questionnaires. There was a negative association between fear of falling and exercise self-efficacy (pseudo R2 = .253; p = .004), which persisted when the analysis was adjusted for history and number of falls, use of assistive devices, and pain at rest (pseudo R2 = .329; p < .0001) or during movement (pseudo R2 = .321; p < .0001). Fear of falling may be negatively associated with exercise self-efficacy in older women with vertebral fracture.

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.

Management of hospitalised osteoporotic vertebral fractures

Management of hospitalised osteoporotic vertebral fracture patients was explored across all major trauma orthopaedic hospitals in Ireland. Findings, based on a survey of orthopaedic doctors and physiotherapists, indicate a lack of standardised clinical care pathways. This study will inform development of clinical audit mechanisms and health service development for this large and growing fracture population in both Ireland and internationally.

PURPOSE

To explore the management of hospitalised vertebral fragility fracture (VFF) patients in Ireland.

METHODS

A cross-sectional survey of orthopaedic doctors (specialist registrar level) and physiotherapists was conducted across all hospitals with major orthopaedic trauma units in Ireland. Data were analysed using descriptive statistics in SPSS (V24).

RESULTS

Responses were achieved from 100% (n = 16) of the hospitals (42 individual physiotherapists and 47 orthopaedic doctors). Conservative management was usual with both orthopaedic doctors (n = 37, 79%) and physiotherapists (n = 40, 96%) reporting prescription of bracing as common practice despite a lack of underpinning evidence. A majority (87%) of the doctors believed osteoporosis medications should commence prior to discharge from the acute setting, but 68% did not agree that responsibility for coordination and delivery of bone health assessment and fracture risk management rested with them. A majority (72%) of physiotherapists reported an absence or were unsure regarding existence of fracture liaison services. 73% of physiotherapists reported prescribing an inpatient or home (78%) exercise programme, including mobility, strength and balance exercise though detail on dose and adherence remain unknown. Wide variance in referral patterns to multi-disciplinary team (MDT) members existed although 79% of orthopaedic doctors supported an MDT approach.

CONCLUSION

Clinical care pathways for the hospitalised VFF population lack standardisation in Ireland. Key challenges reported by orthopaedic doctors and physiotherapists relate to pain management, osteoporosis medication prescription, clarity on indications for bracing and a lack of fracture liaison services. Clinical guidelines, defined clinical care pathways and high-quality clinical research trials are required for VFF management.

Physiotherapy rehabilitation for osteoporotic vertebral fracture-a randomised controlled trial and economic evaluation (PROVE trial)

The trial compared three physiotherapy approaches: manual or exercise therapy compared with a single session of physiotherapy education (SSPT) for people with osteoporotic vertebral fracture(s). At 1 year, there were no statistically significant differences between the groups meaning there is inadequate evidence to support manual or exercise therapy.

INTRODUCTION

To evaluate the clinical and cost-effectiveness of different physiotherapy approaches for people with osteoporotic vertebral fracture(s) (OVF).

METHODS

>Prospective, multicentre, adaptive, three-arm randomised controlled trial. Six hundred fifteen adults with back pain, osteoporosis, and at least 1 OVF participated.

INTERVENTIONS

7 individual physiotherapy sessions over 12 weeks focused on either manual therapy or home exercise compared with a single session of physiotherapy education (SSPT). The co-primary outcomes were quality of life and back muscle endurance measured by the QUALEFFO-41 and timed loaded standing (TLS) test at 12 months.

RESULTS

At 12 months, there were no statistically significant differences between groups. Mean QUALEFFO-41: - 1.3 (exercise), - 0.15 (manual), and - 1.2 (SSPT), a mean difference of - 0.2 (95% CI, - 3.2 to 1.6) for exercise and 1.3 (95% CI, - 1.8 to 2.9) for manual therapy. Mean TLS: 9.8 s (exercise), 13.6 s (manual), and 4.2 s (SSPT), a mean increase of 5.8 s (95% CI, - 4.8 to 20.5) for exercise and 9.7 s (95% CI, 0.1 to 24.9) for manual therapy. Exercise provided more quality-adjusted life years than SSPT but was more expensive. At 4 months, significant changes above SSPT occurred in endurance and balance in manual therapy, and in endurance for those ≤ 70 years, in balance, mobility, and walking in exercise.

CONCLUSIONS

Adherence was problematic. Benefits at 4 months did not persist and at 12 months, we found no significant differences between treatments. There is inadequate evidence a short physiotherapy intervention of either manual therapy or home exercise provides long-term benefits, but arguably short-term benefits are valuable.

TRIAL REGISTRATION

ISRCTN 49117867.

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.

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).