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Cirone D, Berbrier DE, Gibbs JC, Usselman CW. Health-related physical fitness in women with polycystic ovary syndrome versus controls: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:17-36. [PMID: 36920532 DOI: 10.1007/s00404-023-07004-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Polycystic ovary syndrome (PCOS) is a common endocrinopathy associated with cardiometabolic dysfunction. PURPOSE (1) To compare HRPF indices, including cardiorespiratory fitness (CRF), muscle strength, and muscle endurance, between women with and without PCOS (i.e., controls). (2) To explore the impact of moderating factors, i.e., insulin sensitivity, androgen levels, physical activity levels, and body mass index, on these indices. METHODS Articles comparing HRPF between PCOS and control groups were identified until February 27th, 2022. Random-effects meta-analyses were conducted and moderating factors were explored with subgroup and meta-regression analyses. RESULTS Twenty studies were included. Compared to controls, CRF was lower in women with PCOS (n = 15, - 0.70 [- 1.35, - 0.05], P = 0.03, I2 = 95%). Meta-regression analyses demonstrated that fasting insulin (P = 0.004) and homeostatic model assessment of insulin resistance (P = 0.006) were negatively associated with CRF, while sex-hormone binding globulin levels (P = 0.003) were positively associated. Absolute muscle strength was not different between PCOS and controls (n = 7, 0.17 [- 0.10, 0.45], P = 0.22, I2 = 37%). One study evaluated muscle endurance and reported lower core endurance in PCOS subjects compared to controls. CONCLUSION These data suggest that PCOS may be associated with impaired CRF. It remains unclear whether muscle strength and endurance differ between women with PCOS and controls. As this data set was limited by a small sample size, potential for bias, and inconsistent findings, additional studies accounting for the heterogeneous presentation of PCOS as well as improved matching between PCOS and controls for characteristics known to affect HRPF would help elucidate the impact of PCOS on indices of HRPF. PROSPERO REGISTRATION NUMBER CRD42020196380.
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Affiliation(s)
- Domenica Cirone
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Canada
| | - Danielle E Berbrier
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Canada
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, QC, Canada
| | - Charlotte W Usselman
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Canada.
- McGill Research Centre for Physical Activity and Health, McGill University, Montreal, Canada.
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Ponzano M, Tibert N, Brien S, Funnell L, Gibbs JC, Keller H, Laprade J, Morin SN, Papaioannou A, Weston ZJ, Wideman TH, Giangregorio LM. Development, Acceptability, and Usability of a Virtual Intervention for Vertebral Fractures. Phys Ther 2023; 103:pzad098. [PMID: 37555708 DOI: 10.1093/ptj/pzad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/30/2023] [Accepted: 05/31/2023] [Indexed: 08/10/2023]
Abstract
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.
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Affiliation(s)
- Matteo Ponzano
- School of Health and Exercise Sciences, University of British Columbia, Kelowna BC, Canada
- International Collaboration on Repair Discoveries (ICORD), Blusson Spinal Cord Centre (BSCC), University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas Tibert
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Sheila Brien
- Canadian Osteoporosis Patient Network, Osteoporosis, Toronto, ON, Canada
| | - Larry Funnell
- Canadian Osteoporosis Patient Network, Osteoporosis, Toronto, ON, Canada
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Activity, McGill University, Montreal, QC, Canada
| | - Heather Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | - Judi Laprade
- Division of Anatomy, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Zachary J Weston
- Canadian Society for Exercise Physiology (CSEP), Ottawa Ontario, Canada
- Faculty of Human and Social Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Timothy H Wideman
- School of Physical & Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Lora M Giangregorio
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
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Hawley SE, Bell ZW, Huang Y, Gibbs JC, Churchward-Venne TA. Evaluation of sex-based differences in resistance exercise training-induced changes in muscle mass, strength, and physical performance in healthy older (≥60 y) adults: A systematic review and meta-analysis. Ageing Res Rev 2023; 91:102023. [PMID: 37507092 DOI: 10.1016/j.arr.2023.102023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/03/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023]
Abstract
The objective of this systematic review and meta-analysis was to determine if there are sex-based differences in adaptations to resistance exercise training in healthy older adults. Following the screening process, data from 36 studies comparing older males and females (602 males; 703 females; ≥60 years of age) for changes in skeletal muscle size, muscle strength, and/or physical performance following the same resistance exercise training intervention were extracted. Mean study quality was 16/29 (modified Downs and Black checklist), considered moderate quality. Changes in absolute upper-body (Effect Size [ES] = 0.81 [95% CI 0.54, 1.09], P < 0.001), and lower-body (ES = 0.40 [95% CI 0.24, 0.56], P < 0.001) strength were greater in older males than females. Alternatively, changes in relative upper-body (ES = -0.46 [95% CI -0.77, -0.14], P < 0.01), and lower-body (ES = -0.24 [95% CI -0.42, -0.06], P < 0.01) strength were greater in older females than males. Changes in absolute, but not relative, whole-body fat-free mass (ES = 0.18 [95% CI 0.04, 0.33], P < 0.05) were greater in older males than females. There were no sex-based differences for absolute or relative changes in limb muscle size, muscle fiber size, or physical performance.
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Affiliation(s)
- Stephanie E Hawley
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Zachary W Bell
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Yijia Huang
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Tyler A Churchward-Venne
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada; Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
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Tibert N, Ponzano M, Brien S, Funnell L, Gibbs JC, Jain R, Keller HH, Laprade J, Morin SN, Papaioannou A, Weston Z, Wideman TH, Giangregorio L. Non-pharmacological management of osteoporotic vertebral fractures: health-care professional perspectives and experiences. Disabil Rehabil 2023:1-8. [PMID: 37493172 DOI: 10.1080/09638288.2023.2239146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
PURPOSE To understand experiences and perceptions on non-pharmacological treatment of vertebral fractures and virtual-care from the perspective of care professionals' (HCPs). DESIGN AND SETTING We conducted semi-structured interviews with 13 HCPs within Canada (7 F, 6 M, aged 46 ± 12 years) and performed a thematic and content analysis from a post-positivism perspective. RESULTS Two themes were identified: acuity matters when selecting appropriate interventions; and roadblocks to receiving non-pharmacological interventions. We found that treatment options were dependent on the acuity/stability of fracture and were individualized accordingly. Pain medication was perceived as important, but non-pharmacological strategies were also considered helpful in supporting recovery. Participants discussed barriers related to the timely identification of fracture, referral to physiotherapy, and lack of knowledge among HCPs on how to manage osteoporosis and vertebral fractures. HCPs reported positive use of virtual-care, but had concerns related to patient access, cost, and comprehensive assessments. CONCLUSION HCPs used and perceived non-pharmacological interventions as helpful and selected specific treatments based on the recency of fracture and patient symptoms. HCPs' also believed that virtual-care that included an educational component, an assessment by a physiotherapist, and an exercise group was a feasible alternative, but concerns exist and may require further evaluation.Implications for RehabilitationNon-pharmacological strategies in combination with pain medication may be a more effective strategy to support recovery than pain medication alone but should be informed by fracture acuity and patient symptoms.To improve access to physiotherapy and other non-pharmacological treatment options during the acute or chronic management of vertebral fractures, it may be worthwhile to explore the effectiveness and feasibility of virtual-care.
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Affiliation(s)
- Nicholas Tibert
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Matteo Ponzano
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Sheila Brien
- Canadian Osteoporosis Patient Network, Osteoporosis Canada; Toronto, Canada
| | - Larry Funnell
- Canadian Osteoporosis Patient Network, Osteoporosis Canada; Toronto, Canada
| | | | - Ravi Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, North York, Canada
| | - Heather H Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
- Schlegel-UW Research Institute for Aging, and Department of Kinesiology and Health Sciences, Waterloo, Canada
| | - Judi Laprade
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Suzanne N Morin
- McGill University, Montréal, Canada
- Research Institute of McGill University Health Centre, Montréal, Canada
| | | | - Zach Weston
- Lazaridis School of Business & Economics, Wilfrid Laurier University, Waterloo, Canada
| | | | - Lora Giangregorio
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
- Schlegel-UW Research Institute for Aging, and Department of Kinesiology and Health Sciences, Waterloo, Canada
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Tibert N, Ponzano M, Brien S, Funnell L, Gibbs JC, Jain R, Keller H, Laprade J, Morin SN, Papaioannou A, Weston Z, Wideman TH, Giangregorio L. Non-pharmacological management of osteoporotic vertebral fractures: Patient perspectives and experiences. Clin Rehabil 2023; 37:713-724. [PMID: 36510450 DOI: 10.1177/02692155221144370] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To understand perceptions on rehabilitation after vertebral fracture, non-pharmacological strategies, and virtual care from the perspective of individuals living with vertebral fractures. DESIGN AND SETTING We conducted semi-structured interviews online and performed a thematic and content analysis from a post-positivism perspective. PARTICIPANTS Ten individuals living with osteoporotic vertebral fractures (9F, 1 M, aged 71 ± 8 years). RESULTS Five themes emerged: pain is the defining limitation of vertebral fracture recovery; delayed diagnosis impacts recovery trajectory; living with fear; being dissatisfied with fracture management; and "getting back into the game of life" using non-pharmacological strategies. CONCLUSION Participants reported back pain and an inability to perform activities of daily living, affecting psychological and social well-being. Physiotherapy, education, and exercise were considered helpful and important to patients; however, issues with fracture identification and referral limited the use of these options. Participants believed that virtual rehabilitation was a feasible and effective alternative to in-person care, but perceived experience with technology, cost, and individualization of programs as barriers.
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Affiliation(s)
- Nicholas Tibert
- Department of Kinesiology and Health Sciences, 8430University of Waterloo, Waterloo, ON, Canada
| | - Matteo Ponzano
- Department of Kinesiology and Health Sciences, 8430University of Waterloo, Waterloo, ON, Canada
| | | | | | | | - Ravi Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - Heather Keller
- Department of Kinesiology and Health Sciences, 8430University of Waterloo, Waterloo, ON, Canada
- Schlegel-UW Research Institute for Aging, and Department of Kinesiology and Health Sciences, Waterloo, ON, Canada
| | | | - Suzanne N Morin
- 5620McGill University, Montréal, QC, Canada
- Research Institute of McGill University Health Centre, Montréal, QC, Canada
| | | | - Zach Weston
- 8431Wilfrid Laurier University, Waterloo, ON, Canada
| | | | - Lora Giangregorio
- Department of Kinesiology and Health Sciences, 8430University of Waterloo, Waterloo, ON, Canada
- Schlegel-UW Research Institute for Aging, and Department of Kinesiology and Health Sciences, Waterloo, ON, Canada
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Ponzano M, Tibert N, Brien S, Funnell L, Gibbs JC, Keller H, Laprade J, Morin SN, Papaioannou A, Weston Z, Wideman TH, Giangregorio LM. Publisher Correction: International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. Osteoporos Int 2023; 34:1139. [PMID: 37036475 DOI: 10.1007/s00198-023-06717-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Affiliation(s)
- Matteo Ponzano
- School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia, Okanagan Campus, 1238 Discovery Avenue, Kelowna, BC, V1V 1V9, Canada.
- International Collaboration On Repair Discoveries (ICORD), Blusson Spinal Cord Centre (BSCC), University of British Columbia, Vancouver, BC, Canada.
| | - N Tibert
- Department of Kinesiology and Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2T0G6, Canada
| | - S Brien
- Canadian Osteoporosis Patient Network, Osteoporosis Canada, 201 - 250 Ferrand Dr, Toronto, ON, M3C 3G8, Canada
| | - L Funnell
- Canadian Osteoporosis Patient Network, Osteoporosis Canada, 201 - 250 Ferrand Dr, Toronto, ON, M3C 3G8, Canada
| | - J C Gibbs
- Department of Kinesiology and Physical Activity, McGill University, 845 Rue Sherbrooke O, Montréal, QC, H3A0G4, Canada
| | - H Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2T0G6, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
| | - J Laprade
- Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5S, Canada
| | - S N Morin
- Department of Medicine, McGill University, 845 Rue Sherbrooke O, Montréal, QC, H3A0G4, Canada
| | - A Papaioannou
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, L8S4L8, Canada
| | - Z Weston
- Canadian Society for Exercise Physiology (CSEP), Ottawa, Canada
- Wilfrid Laurier University, 75 University Ave W, Waterloo, ON, N2L3C5, Canada
| | - T H Wideman
- School of Physical & Occupational Therapy, McGill University, 845 Rue Sherbrooke O, Montréal, QC, H3A0G4, Canada
| | - L M Giangregorio
- Department of Kinesiology and Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2T0G6, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
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Ponzano M, Tibert N, Brien S, Funnell L, Gibbs JC, Keller H, Laprade J, Morin SN, Papaioannou A, Weston Z, Wideman TH, Giangregorio LM. International consensus on the non-pharmacological and non-surgical management of osteoporotic vertebral fractures. Osteoporos Int 2023; 34:1065-1074. [PMID: 36799981 DOI: 10.1007/s00198-023-06688-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 01/26/2023] [Indexed: 02/18/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Matteo Ponzano
- School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia, Okanagan Campus, 1238 Discovery Avenue, Kelowna, BC, V1V 1V9, Canada.
- International Collaboration On Repair Discoveries (ICORD), Blusson Spinal Cord Centre (BSCC), University of British Columbia, Vancouver, BC, Canada.
| | - N Tibert
- Department of Kinesiology and Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2T0G6, Canada
| | - S Brien
- Canadian Osteoporosis Patient Network, Osteoporosis Canada, 201 - 250 Ferrand Dr, Toronto, ON, M3C 3G8, Canada
| | - L Funnell
- Canadian Osteoporosis Patient Network, Osteoporosis Canada, 201 - 250 Ferrand Dr, Toronto, ON, M3C 3G8, Canada
| | - J C Gibbs
- Department of Kinesiology and Physical Activity, McGill University, 845 Rue Sherbrooke O, Montréal, QC, H3A0G4, Canada
| | - H Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2T0G6, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
| | - J Laprade
- Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5S, Canada
| | - S N Morin
- Department of Medicine, McGill University, 845 Rue Sherbrooke O, Montréal, QC, H3A0G4, Canada
| | - A Papaioannou
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, L8S4L8, Canada
| | - Z Weston
- Canadian Society for Exercise Physiology (CSEP), Ottawa, Canada
- Wilfrid Laurier University, 75 University Ave W, Waterloo, ON, N2L3C5, Canada
| | - T H Wideman
- School of Physical & Occupational Therapy, McGill University, 845 Rue Sherbrooke O, Montréal, QC, H3A0G4, Canada
| | - L M Giangregorio
- Department of Kinesiology and Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON, N2T0G6, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
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Gibbs JC, Patsakos EM, Maltais DB, Wolfe DL, Gagnon DH, Craven BC. Rehabilitation interventions to modify endocrine-metabolic disease risk in individuals with chronic spinal cord injury living in the community (RIISC): A systematic search and review of prospective cohort and case-control studies. J Spinal Cord Med 2023; 46:6-25. [PMID: 33596167 PMCID: PMC9897753 DOI: 10.1080/10790268.2020.1863898] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
CONTEXT Endocrine-metabolic disease (EMD) is associated with functional disability, social isolation, hospitalization and even death in individuals living with a chronic spinal cord injury (SCI). There is currently very low-quality evidence that rehabilitation interventions can reduce EMD risk during chronic SCI. Non-randomized trials and alternative study designs are excluded from traditional knowledge synthesis. OBJECTIVE To characterize evidence from level 3-4 studies evaluating rehabilitation interventions for their effectiveness to improve EMD risk in community-dwelling adults with chronic SCI. METHODS Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, Cochrane Database of Systematic Reviews, and PsychInfo were completed. All longitudinal trials, prospective cohort, case-control studies, and case series evaluating the effectiveness of rehabilitation/therapeutic interventions to modify/associate with EMD outcomes in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean changes from baseline were reported for EMD outcomes. The Downs and Black Checklist was used to rate evidence quality. RESULTS Of 489 articles identified, 44 articles (N = 842) were eligible for inclusion. Individual studies reported statistically significant effects of electrical stimulation-assisted training on lower-extremity bone outcomes, and the combined effects of exercise and dietary interventions to improve body composition and cardiometabolic biomarkers (lipid profiles, glucose regulation). In contrast, there were also reports of no clinically important changes in EMD outcomes, suggesting lower quality evidence (study bias, inconsistent findings). CONCLUSION Longitudinal multicentre pragmatic studies involving longer-term exercise and dietary intervention and follow-up periods are needed to fully understand the impact of these rehabilitation approaches to mitigate EMD risk. Our broad evaluation of prospective cohort and case-control studies provides new perspectives on alternative study designs, a multi-impairment paradigm approach of studying EMD outcomes, and knowledge gaps related to SCI rehabilitation.
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Affiliation(s)
- Jenna C. Gibbs
- Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, QC, Canada,Correspondence to: Jenna C. Gibbs, Department of Kinesiology and Physical Education, McGill University, Currie Gym Office A208, 475 Pine Avenue West, Montreal, Quebec, H2W 1S4, Canada; Ph: 514-398-4184 ext. 00473.
| | - Eleni M. Patsakos
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada
| | - Desiree B. Maltais
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Dalton L. Wolfe
- Parkwood Institute Research, Lawson Health Research Institute, London, ON, Canada,Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Dany H. Gagnon
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada,School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - B. Catharine Craven
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada,Division of Physical Therapy and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Presseau J, Kasperavicius D, Rodrigues IB, Braimoh J, Chambers A, Etherington C, Giangregorio L, Gibbs JC, Giguere A, Graham ID, Hankivsky O, Hoens AM, Holroyd-Leduc J, Kelly C, Moore JE, Ponzano M, Sharma M, Sibley KM, Straus S. Selecting implementation models, theories, and frameworks in which to integrate intersectional approaches. BMC Med Res Methodol 2022; 22:212. [PMID: 35927615 PMCID: PMC9351159 DOI: 10.1186/s12874-022-01682-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective. Methods We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights. Results We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the ‘Identify the problem’ phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the ‘Assess barriers/facilitators to knowledge use’ phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the ‘Select, tailor, implement interventions’ phase (mean = 6.36, SD = 1.08). Conclusions Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future. Trial registration Open Science Framework Registration: osf.io/qgh64. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01682-x.
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Affiliation(s)
- Justin Presseau
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada. .,School of Psychology, University of Ottawa, Ottawa, Canada.
| | - Danielle Kasperavicius
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | | | - Jessica Braimoh
- Department of Social Science, York University, Toronto, ON, Canada
| | | | - Cole Etherington
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lora Giangregorio
- Department of Kinesiology and Health Sciences, and Schlegel Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, QC, Canada
| | - Anik Giguere
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Ian D Graham
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Olena Hankivsky
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Alison M Hoens
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Jayna Holroyd-Leduc
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Christine Kelly
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Matteo Ponzano
- Department of Kinesiology and Health Sciences, and Schlegel Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
| | - Malika Sharma
- Division of Infectious Diseases, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kathryn M Sibley
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Sharon Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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10
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Sibley KM, Kasperavicius D, Rodrigues IB, Giangregorio L, Gibbs JC, Graham ID, Hoens AM, Kelly C, Lalonde D, Moore JE, Ponzano M, Presseau J, Straus SE. Development and usability testing of tools to facilitate incorporating intersectionality in knowledge translation. BMC Health Serv Res 2022; 22:830. [PMID: 35761251 PMCID: PMC9238081 DOI: 10.1186/s12913-022-08181-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background The field of knowledge translation (KT) has been criticized for neglecting contextual and social considerations that influence health equity. Intersectionality, a concept introduced by Black feminist scholars, emphasizes how human experience is shaped by combinations of social factors (e.g., ethnicity, gender) embedded in systemic power structures. Its use has the potential to advance equity considerations in KT. Our objective was to develop and conduct usability testing of tools to support integrating intersectionality in KT through three key phases of KT: identifying the gap; assessing barriers to knowledge use; and selecting, tailoring, and implementing interventions. Methods We used an integrated KT approach and assembled an interdisciplinary development committee who drafted tools. We used a mixed methods approach for usability testing with KT intervention developers that included semi-structured interviews and the System Usability Scale (SUS). We calculated an average SUS score for each tool. We coded interview data using the framework method focusing on actionable feedback. The development committee used the feedback to revise tools, which were formatted by a graphic designer. Results Nine people working in Canada joined the development committee. They drafted an intersectionality primer and one tool that included recommendations, activities, reflection prompts, and resources for each of the three implementation phases. Thirty-one KT intervention developers from three countries participated in usability testing. They suggested the tools to be shorter, contain more visualizations, and use less jargon. Average SUS scores of the draft tools ranged between 60 and 78/100. The development committee revised and shortened all tools, and added two, one-page summary documents. The final toolkit included six documents. Conclusions We developed and evaluated tools to help embed intersectionality considerations in KT. These tools go beyond recommending the use of intersectionality to providing practical guidance on how to do this. Future work should develop guidance for enhancing social justice in intersectionality-enhanced KT. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08181-1.
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Affiliation(s)
- Kathryn M Sibley
- Department of Community Health Sciences, University of Manitoba, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0W3, Canada. .,George and Fay Yee Centre for Healthcare Innovation, 379- 753 McDermot Avenue, Winnipeg, MB, R3E 0W3, Canada.
| | - Danielle Kasperavicius
- Knowledge Translation Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | | | - Lora Giangregorio
- Department of Kinesiology and Health Sciences, and Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, QC, Canada
| | - Ian D Graham
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Alison M Hoens
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Christine Kelly
- Department of Community Health Sciences, University of Manitoba, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0W3, Canada
| | - Dianne Lalonde
- Learning Network, Centre for Research & Education on Violence Against Women & Children, Western University, London, ON, Canada
| | | | - Matteo Ponzano
- Department of Kinesiology and Health Sciences, and Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
| | - Justin Presseau
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Sharon E Straus
- Division of Infectious Diseases, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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11
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De Souza MJ, Ricker EA, Mallinson RJ, Allaway HCM, Koltun KJ, Strock NCA, Gibbs JC, Kuruppumullage Don P, Williams NI. Bone mineral density in response to increased energy intake in exercising women with oligomenorrhea/amenorrhea: the REFUEL randomized controlled trial. Am J Clin Nutr 2022; 115:1457-1472. [PMID: 35170727 PMCID: PMC9170471 DOI: 10.1093/ajcn/nqac044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 02/10/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Energy deficiency can result in menstrual disturbances and compromised bone health in women, a condition known as the Female Athlete Triad. OBJECTIVES The REFUEL randomized controlled trial assessed the impact of increased energy intake on bone health and menstrual function in exercising women with menstrual disturbances. METHODS Exercising women with oligomenorrhea/amenorrhea (Oligo/Amen) were randomly assigned to an intervention group (Oligo/Amen + Cal, n = 40, mean ± SEM age: 21.3 ± 0.5 y; weight: 55.0 ± 1.0 kg; BMI: 20.4 ± 0.3 kg/m2) who increased energy intake 20%-40% above baseline energy needs for 12 mo or a control group (Oligo/Amen Control, n = 36; mean ± SEM age: 20.7 ± 0.5 y; weight: 59.1 ± 1.3 kg; BMI: 21.3 ± 0.4 kg/m2). Energy intake and expenditure, metabolic and reproductive hormones, body composition, and areal bone mineral density (aBMD) were assessed. RESULTS Oligo/Amen + Cal improved energy status [increased body mass (2.6 ± 0.4 kg), BMI (0.9 ± 0.2 kg/m2), fat mass (2.0 ± 0.3 kg), body fat percentage (2.7% ± 0.4%), and insulin-like growth factor 1 (37.4 ± 14.6 ng/mL)] compared with Oligo/Amen Control and experienced a greater likelihood of menses (P < 0.05). Total body and spine aBMD remained unchanged (P > 0.05). Both groups demonstrated decreased femoral neck aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.0002 g/cm2 ; time main effect P = 0.043) and month 12 (-0.011 g/cm2; 95% CI: -0.021, -0.001 g/cm2; time main effect P = 0.023). Both groups demonstrated a decrease in total hip aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.002 g/cm2; time main effect P = 0.004). CONCLUSIONS Although higher dietary energy intake increased weight, body fat, and menstrual frequency, bone mineral density was not improved, compared with the control group. The 12-mo intervention may have been too short and the increase in energy intake (∼352 kcal/d), although sufficient to increase menstrual frequency, was insufficient to increase estrogen or improve aBMD. Future research should refine the optimal nutritional and/or pharmacological interventions for the recovery of bone health in athletes and exercising women with Oligo/Amen.This trial was registered at clinicaltrials.gov as NCT00392873.
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Affiliation(s)
- Mary Jane De Souza
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Emily A Ricker
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Rebecca J Mallinson
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Heather C M Allaway
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Kristen J Koltun
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Nicole C A Strock
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Jenna C Gibbs
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | | | - Nancy I Williams
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
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12
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Manji R, Ponzano M, Ashe MC, Wark JD, Kendler D, Papaioannou A, Cheung AM, Adachi JD, Thabane L, Scherer SC, Ziebart C, Gibbs JC, Giangregorio LM. Exploring the Association between Pain and Fracture Characteristics in Women with Osteoporotic Vertebral Fractures. Physiother Can 2022. [DOI: 10.3138/ptc-2020-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: The purpose of this study was to estimate the association between pain and the number, severity, and location of fractures in women with osteoporotic vertebral fractures. Method:We used an 11-point numeric pain rating scale to assess pain during movement in the preceding week and lateral spinal radiographs to confirm number, location, and severity of vertebral fractures. In model 1, we assessed the association between pain during movement and the number, severity, and location of fractures. We adjusted model 2 for pain medication use and age. Results: The mean age of participants was 76.4 (SD 6.9) years. We found no statistically significant associations between pain and fracture number (estimated β = 0.23, 95% CI: ‒0.27, 0.68), fracture severity (estimated β = ‒0.46, 95% CI: ‒1.38, 0.49), or fracture location at T4–T8 (estimated β = 0.06, 95% CI: ‒1.26, 1.34), T9–L1 (estimated β = 0.35, 95% CI: ‒1.17, 1.74), or L2–L4 (estimated β = 0.40, 95% CI: ‒1.01, 1.75). Age and pain medication use were not significantly associated with pain. Model 1 accounted for 4.7% and model 2 for 7.2% of the variance in self-reported pain. Conclusion: The number, location, and severity of fractures do not appear to be the primary explanation for pain in women with vertebral fractures. Clinicians must consider other factors contributing to pain.
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Affiliation(s)
- Rahim Manji
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Matteo Ponzano
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Maureen C. Ashe
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
| | - John D. Wark
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Bone & Mineral Medicine and Department of Diabetes & Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - David Kendler
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Ontario, Canada
| | - Angela M. Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Samuel C. Scherer
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Christina Ziebart
- School of Physical Therapy, Western University, London, Ontario, Canada
| | - Jenna C. Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Lora M. Giangregorio
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Schlegel–UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
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13
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Strock NC, De Souza MJ, Allaway HC, Gibbs JC, Williams NI. 12-month RCT To Increase Dietary Intake Does Not Exacerbate Disordered Eating In Amenorrheic/Oligomenorrheic Exercising Women. Med Sci Sports Exerc 2021. [DOI: 10.1249/01.mss.0000763188.23795.f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Turcotte AF, O’Connor S, Morin SN, Gibbs JC, Willie BM, Jean S, Gagnon C. Association between obesity and risk of fracture, bone mineral density and bone quality in adults: A systematic review and meta-analysis. PLoS One 2021; 16:e0252487. [PMID: 34101735 PMCID: PMC8186797 DOI: 10.1371/journal.pone.0252487] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/15/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The association between obesity and fracture risk may be skeletal site- and sex-specific but results among studies are inconsistent. Whilst several studies reported higher bone mineral density (BMD) in patients with obesity, altered bone quality could be a major determinant of bone fragility in this population. OBJECTIVES This systematic review and meta-analysis aimed to compare, in men, premenopausal women and postmenopausal women with obesity vs. individuals without obesity: 1) the incidence of fractures overall and by site; 2) BMD; and 3) bone quality parameters (circulating bone turnover markers and bone microarchitecture and strength by advanced imaging techniques). DATA SOURCES PubMed (MEDLINE), EMBASE, Cochrane Library and Web of Science were searched from inception of databases until the 13th of January 2021. DATA SYNTHESIS Each outcome was stratified by sex and menopausal status in women. The meta-analysis was performed using a random-effect model with inverse-variance method. The risks of hip and wrist fracture were reduced by 25% (n = 8: RR = 0.75, 95% CI: 0.62, 0.91, P = 0.003, I2 = 95%) and 15% (n = 2 studies: RR = 0.85, 95% CI: 0.81, 0.88), respectively, while ankle fracture risk was increased by 60% (n = 2 studies: RR = 1.60, 95% CI: 1.52, 1.68) in postmenopausal women with obesity compared with those without obesity. In men with obesity, hip fracture risk was decreased by 41% (n = 5 studies: RR = 0.59, 95% CI: 0.44, 0.79). Obesity was associated with increased BMD, better bone microarchitecture and strength, and generally lower or unchanged circulating bone resorption, formation and osteocyte markers. However, heterogeneity among studies was high for most outcomes, and overall quality of evidence was very low to low for all outcomes. CONCLUSIONS This meta-analysis highlights areas for future research including the need for site-specific fracture studies, especially in men and premenopausal women, and studies comparing bone microarchitecture between individuals with and without obesity. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42020159189.
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Affiliation(s)
- Anne-Frédérique Turcotte
- Endocrinology and Nephrology Unit, CHU de Québec-Université Laval Research Center, Québec (QC), Canada
- Obesity, Type 2 Diabetes and Metabolism Unit, Institut universitaire de cardiologie et de pneumologie de Québec–Université Laval Research Center, Québec (QC), Canada
- Department of Medicine, Faculty of Medicine, Laval University, Québec (QC), Canada
| | - Sarah O’Connor
- Institut universitaire de cardiologie et de pneumologie de Québec–Université Laval Research Center, Québec (QC), Canada
- Department of Pharmacy, Faculty of Pharmacy, Laval University, Québec (QC), Canada
- Bureau d’information et études en santé des populations, Institut national de santé publique du Québec, Québec (QC), Canada
| | - Suzanne N. Morin
- Department of Medicine, Faculty of Medicine, McGill University, Montreal (QC), Canada
| | - Jenna C. Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal (QC), Canada
| | - Bettina M. Willie
- Department of Pediatric Surgery, Shriners Hospital for Children-Canada, Research Centre, McGill University, Montreal (QC), Canada
| | - Sonia Jean
- Department of Medicine, Faculty of Medicine, Laval University, Québec (QC), Canada
- Bureau d’information et études en santé des populations, Institut national de santé publique du Québec, Québec (QC), Canada
| | - Claudia Gagnon
- Endocrinology and Nephrology Unit, CHU de Québec-Université Laval Research Center, Québec (QC), Canada
- Obesity, Type 2 Diabetes and Metabolism Unit, Institut universitaire de cardiologie et de pneumologie de Québec–Université Laval Research Center, Québec (QC), Canada
- Department of Medicine, Faculty of Medicine, Laval University, Québec (QC), Canada
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15
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Terada T, Scott K, Way KL, Tulloch HE, Pipe AL, Chirico D, Reid RD, Gibbs JC, Reed JL. Meeting the Canadian strength training recommendations: Implications for the cardiometabolic, psychological and musculoskeletal health of nurses. J Nurs Manag 2020; 29:681-689. [PMID: 33128824 DOI: 10.1111/jonm.13204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 11/30/2022]
Abstract
AIM To examine the proportion of nurses meeting the strength training recommendation and its associated cardiometabolic, psychological and musculoskeletal benefits. BACKGROUND Strength training targets poor physical and mental health often reported by nurses; however, it is unknown whether nurses are meeting the strength training guidelines. METHODS Nurses from 14 hospitals completed a 7-day physical activity log. Nurses were considered meeting the recommendation if they reported ≥2 strength training sessions per week. Cardiometabolic, psychological and musculoskeletal health, and levels of motivation were compared between nurses meeting and not meeting the guidelines. RESULTS Of the 307 nurses (94% female; age: 43 ± 12 years), 29 (9.4%) met the strength training recommendation. These nurses had lower body mass index (24.1 ± 2.6 vs. 27.3 ± 5.5 kg/m2 , p = .007) and waist circumference (73.8 ± 8.3 vs. 81.1 ± 11.7 cm, p = .017); and higher vigour-activity (18.0 ± 5.8 vs. 15.6 ± 6.5 points, p = .046) and self-determined motivation (relative autonomic index: 54.9 ± 20.3 vs. 45.0 ± 23.8 points, p = .042) scores than nurses not meeting the recommendation. CONCLUSION While the proportion of nurses meeting the strength training recommendation was small (<10%), they had lower body mass and waist circumference, and higher vigour-activity. IMPLICATIONS FOR NURSING MANAGEMENT Strategies to increase the strength training engagement may improve the cardiometabolic health and increase vigour among nurses.
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Affiliation(s)
- Tasuku Terada
- Division of Cardiac Prevention and Rehabilitation, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Kyle Scott
- Division of Cardiac Prevention and Rehabilitation, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, ON, Canada.,Faculty of Health Sciences, School of Human Kinetics, University of Ottawa, Ottawa, ON, Canada
| | - Kimberley L Way
- Division of Cardiac Prevention and Rehabilitation, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, ON, Canada.,Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Heather E Tulloch
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Andrew L Pipe
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Daniele Chirico
- Division of Cardiac Prevention and Rehabilitation, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, ON, Canada.,TotalCardiology™ Research Network, Calgary, AB, Canada
| | - Robert D Reid
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, QC, Canada
| | - Jennifer L Reed
- Division of Cardiac Prevention and Rehabilitation, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, ON, Canada.,Faculty of Health Sciences, School of Human Kinetics, University of Ottawa, Ottawa, ON, Canada.,Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
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16
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Hassan S, Seung SJ, Clark RE, Gibbs JC, McArthur C, Mittmann N, Thabane L, Kendler D, Papaioannou A, Wark JD, Ashe MC, Adachi JD, Templeton JA, Giangregorio LM. Describing the resource utilisation and costs associated withvertebral fractures: the Build Better Bones with Exercise (B3E) Pilot Trial. Osteoporos Int 2020; 31:1115-1123. [PMID: 32219499 DOI: 10.1007/s00198-020-05387-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/10/2020] [Indexed: 11/26/2022]
Abstract
UNLABELLED This analysis examined costs/resources of 141 women with vertebral fractures, randomised to a home exercise programme or control group. Total, mean costs and the incremental cost-effectiveness ratio (ICER) were calculated. Quality of life was collected. Cost drivers were caregiver time, medications and adverse events (AEs). Results show adding an exercise programme may reduce the risk of AEs. INTRODUCTION This exploratory economic analysis examined the health resource utilisation and costs experienced by women with vertebral fractures, and explored the effects of home exercise on those costs. METHODS Women ≥ 65 years with one or more X-ray-confirmed vertebral fractures were randomised 1:1 to a 12-month home exercise programme or equal attention control group. Clinical and health system resources were collected during monthly phone calls and daily diaries completed by participants. Intervention costs were included. Unit costs were applied to health system resources. Quality of life (QoL) information was collected via EQ-5D-5L at baseline, 6 and 12 months. RESULTS One hundred and forty-one women were randomised. Overall total costs (CAD 2018) were $664,923 (intervention) and $614,033 (control), respectively. The top three cost drivers were caregiver time ($250,269 and $240,811), medications ($151,000 and $122,145) and AEs ($58,807 and $71,981). The mean cost per intervention participant of $9365 ± $9988 was higher compared with the mean cost per control participant of $8772 ± $9718. The mean EQ-5D index score was higher for the intervention participants (0.81 ± 0.11) compared with that of controls (0.79 ± 0.13). The differences in quality-adjusted life year (QALY) (0.02) and mean cost ($593) were used to calculate the ICER of $29,650. CONCLUSIONS Women with osteoporosis with a previous fracture experience a number of resources and associated costs that impact their care and quality of life. Caregiver time, medications and AEs are the biggest cost drivers for this population. The next steps would be to expand this feasibility study with more participants, longer-term follow-up and more regional variability.
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Affiliation(s)
- S Hassan
- HOPE Research Centre, Sunnybrook Research Institute, Toronto, Ontario, M4N 3M5, Canada.
| | - S J Seung
- HOPE Research Centre, Sunnybrook Research Institute, Toronto, Ontario, M4N 3M5, Canada
| | - R E Clark
- University of Waterloo, Waterloo, Canada
| | - J C Gibbs
- McGill University, Montreal, Quebec, Canada
| | | | | | - L Thabane
- McMaster University, Hamilton, Canada
| | - D Kendler
- University of British Columbia, Vancouver, Canada
| | | | - J D Wark
- University of Melbourne, Melbourne, Australia
| | - M C Ashe
- University of British Columbia, Vancouver, Canada
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Gibbs JC, McArthur C, Wark JD, Thabane L, Scherer SC, Prasad S, Papaioannou A, Mittmann N, Laprade J, Kim S, Khan A, Kendler DL, Hill KD, Cheung AM, Bleakney R, Ashe MC, Adachi JD, Giangregorio LM. The Effects of Home Exercise in Older Women With Vertebral Fractures: A Pilot Randomized Controlled Trial. Phys Ther 2020; 100:662-676. [PMID: 31899499 PMCID: PMC7439228 DOI: 10.1093/ptj/pzz188] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/29/2019] [Accepted: 08/21/2019] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Jenna C Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Caitlin McArthur
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; and GERAS Centre for Aging Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John D Wark
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; and Bone and Mineral Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University
| | - Samuel C Scherer
- Department of Medicine, University of Melbourne; Royal Melbourne Hospital; and Broadmeadows Health Services, Northern Health, Melbourne, Australia
| | | | - Alexandra Papaioannou
- Department of Medicine, McMaster University; GERAS Centre for Aging Research, Hamilton Health Sciences; and Department of Health Research Methods, Evidence, and Impact, McMaster University
| | - Nicole Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Judi Laprade
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; and Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, Ontario, Canada
| | - Sandra Kim
- Department of Medicine, University of Toronto; and Centre for Osteoporosis and Bone Health, Women’s College Hospital, Toronto, Ontario, Canada
| | - Aliya Khan
- Department of Medicine, McMaster University
| | - David L Kendler
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith D Hill
- Grad Dip Physio, BAppSc (Physio), School of Primary and Allied Health Care, Peninsula Campus, Monash University, Frankston, Australia
| | - Angela M Cheung
- Department of Medicine, University of Toronto; and Osteoporosis Program and Centre of Excellence in Skeletal Health Assessment, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Robert Bleakney
- Department of Medical Imaging, University of Toronto; and Centre of Excellence in Skeletal Health Assessment, University Health Network and Sinai Health System
| | - Maureen C Ashe
- Department of Family Practice, University of British Columbia; and Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | | | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo; and Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada; and KITE, Toronto Rehab-University Health Network, Toronto, Ontario, Canada
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McArthur C, Gibbs JC, Ashe MC, Cheung AM, Hill KD, Kendler DL, Khan A, Prasad S, Thabane L, Wark JD, Giangregorio LM. The association between trunk muscle endurance, balance and falls self-efficacy in women with osteoporotic vertebral fractures: an exploratory analysis from a pilot randomized controlled trial. Disabil Rehabil 2019; 43:2268-2274. [PMID: 31786954 DOI: 10.1080/09638288.2019.1696418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Trunk muscle endurance may be associated with balance and falls self-efficacy for people with osteoporosis. However, all previous studies have examined trunk muscle strength rather than endurance. PURPOSE To explore the relationships between trunk muscle endurance and standing balance and falls self-efficacy for women with vertebral fractures. MATERIALS AND METHODS This is an exploratory, secondary analysis of baseline data of a pilot randomized controlled trial in Ontario, Canada. Thirty-one women with osteoporosis, aged 65 years or older, with at least one vertebral fracture were included. The associations between balance (Balance Outcome Measure for Elder Rehabilitation) and trunk muscle endurance (Timed Loaded Standing Test) and falls self-efficacy (Falls Efficacy Scale International) and trunk muscle endurance were tested via Spearman rank order correlation with Fisher's z transformations. RESULTS Trunk muscle endurance was correlated with better balance performance on the Balance Outcome Measure for Elder Rehabilitation [Spearman correlation coefficient, 0.71; 95% confidence interval: 0.47-0.85; p < 0.001], but not with falls self efficacy (Spearman correlation coefficient; -0.22; 95% confidence interval: -0.53 to 0.14; p = 0.23). CONCLUSIONS Trunk muscle endurance was moderately associated with better standing balance performance but not falls self-efficacy, highlighting the importance of trunk muscle endurance for standing balance for older adults with osteoporosis and vertebral fractures.Implications for RehabilitationOlder adults with osteoporosis and vertebral fractures who have better trunk muscle endurance may also have better standing balance.There was no association between trunk muscle endurance and how confident a person is that they will not fall while completing various activities of daily living.Trunk muscle endurance training could be included as part of a standing balance rehabilitation program for this population.
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Affiliation(s)
| | - Jenna C Gibbs
- Department of Kinesiology and Physical Activity, McGill University, Montreal, Canada
| | - Maureen C Ashe
- Department of Family Medicine, University of British Columbia, Vancouver, Canada
| | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Keith D Hill
- Department of Rehabilitation, Ageing and Independent Living, Curtin University, Victoria, Australia
| | - David L Kendler
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Aliya Khan
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Sadhana Prasad
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Department of Medicine, McMaster University, Hamilton, Canada
| | - John D Wark
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Canada.,Schlegel-UW Research Institute on Aging, Waterloo, Canada
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Gibbs JC, MacIntyre NJ, Ponzano M, Templeton JA, Thabane L, Papaioannou A, Giangregorio LM. Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev 2019; 7:CD008618. [PMID: 31273764 PMCID: PMC6609547 DOI: 10.1002/14651858.cd008618.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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).
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Affiliation(s)
- Jenna C Gibbs
- McGill UniversityDepartment of Kinesiology and Physical Education475 Pine Avenue WCurrie Gym Office A208MontrealQuebecCanadaH2W 1S4
| | - Norma J MacIntyre
- McMaster UniversitySchool of Rehabilitation Science1400 Main Street WestRoom 403HamiltonONCanadaL8S 4L8
| | - Matteo Ponzano
- University of WaterlooDepartment of Kinesiology200 University Ave WWaterlooONCanadaN2L 3G1
| | - Jeffrey Alan Templeton
- University of WaterlooDepartment of Kinesiology200 University Ave WWaterlooONCanadaN2L 3G1
| | - Lehana Thabane
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics50 Charlton Ave ERoom H325, St. Joseph's HealthcareHamiltonONCanadaL8N 4A6
| | - Alexandra Papaioannou
- McMaster UniversityDepartment of MedicineHamilton Health SciencesP.O. Box 2000, Chedoke Wilcox, 2nd FloorHamiltonONCanadaL8N 3Z5
| | - Lora M Giangregorio
- University of WaterlooDepartment of Kinesiology200 University Ave WWaterlooONCanadaN2L 3G1
- Schlegel‐UW Research Institute for AgingWaterlooONCanada
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20
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Ziebart C, Gibbs JC, McArthur C, Papaioannou A, Mittmann N, Laprade J, Kim S, Khan A, Kendler DL, Wark JD, Thabane L, Scherer SC, Prasad S, Hill KD, Cheung AM, Bleakney RR, Ashe MC, Adachi JD, Giangregorio LM. Are osteoporotic vertebral fractures or forward head posture associated with performance-based measures of balance and mobility? Arch Osteoporos 2019; 14:67. [PMID: 31243557 DOI: 10.1007/s11657-019-0626-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/17/2019] [Indexed: 05/05/2023]
Abstract
UNLABELLED The main objective of this study was to explore whether vertebral fracture characteristics or posture is independently associated with physical performance. Posture was significantly associated with physical performance but fracture characteristics were not, suggesting posture should be the focus of physical performance variance. PURPOSE The main objective of this study was to explore whether vertebral fracture characteristics (number, severity, location) or occiput-to-wall distance (OWD) is independently associated with physical performance. METHODS This was a secondary data analysis using baseline data from a randomized controlled trial, of community-dwelling women aged 65 years and older with a suspected vertebral fragility fracture. Lateral thoracic and lumbar spine radiographs were used to determine the number, location, and severity of fracture. The dependent variables were timed up and go (TUG), five times sit-to-stand, four-meter walk, and step test. The independent variables were number, severity, location of fracture, and OWD. Pain during movement and age were covariates. Multivariable regression analyses determined the association between each of the dependent and independent variables. RESULTS Participants' (n = 158) mean (standard deviation [SD]) age was 75.9 (6.5) years. They had a mean (SD) BMI, OWD, and number of fractures of 26.7 (5.3) kg/m2, 5.7 (4.6) cm, and 2.2 (1.8), respectively. OWD was independently associated with TUG (estimated coefficient [B] = 0.29, 95% confidence interval [CI] = 0.16, 0.42), five times sit-to-stand (B = 0.33, 95% CI = 0.12, 0.55), four-meter walk (B = 0.09, 95% CI = 0.05, 0.13), and step test (B = - 0.36, 95% CI = - 0.50, - 0.23) in the unadjusted model. OWD was independently associated with TUG (B = 0.25, 95% CI = 0.12, 0.38), five times sit-to-stand (B = 0.29, 95% CI = 0.07, 0.50), four-meter walk (B = 0.08, 95% CI = 0.03, 0.12), and step test (B = - 0.22, 95% CI = - 0.47, - 0.19) in the adjusted model. CONCLUSION OWD was significantly associated with physical performance but fracture characteristics were not. These analyses were exploratory and require replication in future studies.
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Affiliation(s)
- Christina Ziebart
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.,University of Western Ontario, London, ON, Canada
| | - Jenna C Gibbs
- Department of Kinesology and Physical Education, McGill University, Quebec, Canada
| | - Caitlin McArthur
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.,McMaster University, Hamilton, ON, Canada.,GERAS Centre for Aging Research, Hamilton, ON, Canada
| | - Alexandra Papaioannou
- McMaster University, Hamilton, ON, Canada.,GERAS Centre for Aging Research, Hamilton, ON, Canada
| | | | | | - Sandra Kim
- University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Aliya Khan
- McMaster University, Hamilton, ON, Canada
| | - David L Kendler
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John D Wark
- University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Lehana Thabane
- McMaster University, Hamilton, ON, Canada.,St Joseph's Healthcare-Hamilton, Hamilton, ON, Canada
| | - Samuel C Scherer
- University of Melbourne, Melbourne, Australia.,Broadmeadows Health Service, Melbourne, Australia
| | | | - Keith D Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | | | | | - Maureen C Ashe
- University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Hip Health and Mobility, Vancouver, British Columbia, Canada
| | - Jonathan D Adachi
- McMaster University, Hamilton, ON, Canada.,St Joseph's Healthcare-Hamilton, Hamilton, ON, Canada
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada. .,University Health Network, Toronto, ON, Canada. .,Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada.
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21
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Ziebart C, Adachi JD, Ashe MC, Bleakney RR, Cheung AM, Gibbs JC, Hill KD, Kendler DL, Khan AA, Kim S, McArthur C, Mittmann N, Papaioannou A, Prasad S, Scherer SC, Thabane L, Wark JD, Giangregorio LM. Exploring the association between number, severity, location of fracture, and occiput-to-wall distance. Arch Osteoporos 2019; 14:27. [PMID: 30820733 DOI: 10.1007/s11657-019-0582-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/19/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study of women with a suspected vertebral fracture determined the association between vertebral fracture characteristics and posture. The number of fractures was associated with posture. Severity of fracture was associated with posture when adjusting for pain. Fracture characteristics explain some variability in posture in women with a suspected vertebral fracture. PURPOSE Osteoporotic vertebral fractures are associated with increased morbidity and mortality. An accumulation of vertebral fractures may lead to forward head posture, which has been independently associated with mortality. It is unclear how fracture characteristics, including the number, severity, and location of fracture, contribute to occiput-to-wall distance (OWD). METHODS This was a cross-sectional secondary data analysis using baseline data from a randomized controlled trial, in community-dwelling women aged 65 years and older with a suspected vertebral fragility fracture. Lateral thoracic and lumbar spine radiographs were used to determine the number, location, and severity of fracture. Occiput-to-wall distance (OWD) was used to assess forward head posture. Pain during movement (0-10 scale) and age were considered as confounding variables. Multivariable regression models were used to evaluate relationships between fracture variables and OWD. RESULTS Participants (n = 158) were of mean age 75.9 (SD 6.5) years with a mean (SD) BMI = 26.7 (5.3) kg/m2, OWD = 5.7 (4.6) cm, and number of fractures = 2.4 (2.4). In unadjusted analyses, the number of fractures (B = 0.82, 95% CI = 0.04, 1.59) was associated with OWD. When adjusting for pain, severity of fractures (B = 1.08, 95% CI = 0.001, 2.15) was independently associated with OWD. Location was not associated with OWD in any of the models. CONCLUSIONS The number of fractures was significantly associated with OWD in the unadjusted model, explaining more of the variability in OWD than other fracture characteristics. Severity of fracture was associated with OWD in the adjusted model. However, pain may confound the relationship between OWD and fracture characteristics.
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Affiliation(s)
- Christina Ziebart
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
- University of Western Ontario, London, Canada
| | - Jonathan D Adachi
- McMaster University, Hamilton, Canada
- St Joseph's Healthcare-Hamilton, Hamilton, Canada
| | - Maureen C Ashe
- University of British Columbia, Vancouver, Canada
- Centre for Hip Health and Mobility, Vancouver, Canada
| | | | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, Canada
- University Health Network, Toronto, Canada
| | - Jenna C Gibbs
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | | | | | - Sandra Kim
- Department of Medicine, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
| | - Caitlin McArthur
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
- McMaster University, Hamilton, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Canada
| | | | - Alexandra Papaioannou
- McMaster University, Hamilton, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Canada
| | | | - Samuel C Scherer
- Broadmeadows Health Service, Broadmeadows, Australia
- University of Melbourne, Melbourne, Australia
| | - Lehana Thabane
- McMaster University, Hamilton, Canada
- St Joseph's Healthcare-Hamilton, Hamilton, Canada
| | - John D Wark
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Parkville, Australia
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
- University Health Network, Toronto, Canada.
- Schlegel-UW Research Institute for Aging, Waterloo, Canada.
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Giangregorio LM, Gibbs JC, Templeton JA, Adachi JD, Ashe MC, Bleakney RR, Cheung AM, Hill KD, Kendler DL, Khan AA, Kim S, McArthur C, Mittmann N, Papaioannou A, Prasad S, Scherer SC, Thabane L, Wark JD. 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. Osteoporos Int 2018; 29:2545-2556. [PMID: 30091064 DOI: 10.1007/s00198-018-4652-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
UNLABELLED We pilot-tested a trial of home exercise on individuals with osteoporosis and spine fracture. Our target enrollment was met, though it took longer than expected. Participants stayed in the study and completed the exercise program with no safety concerns. Future trials should expand the inclusion criteria and consider other changes. PURPOSE Osteoporotic fragility fractures create a substantial human and economic burden. There have been calls for a large randomized controlled trial examining the effect of exercise on fracture incidence. The B3E pilot trial was designed to evaluate the feasibility of a large trial examining the effects of home exercise on individuals at high risk of fracture. METHODS Community-dwelling women ≥ 65 years with radiographically confirmed vertebral compression fractures were recruited at seven sites in Canada and Australia. We randomized participants in a 1:1 ratio to a 12-month home exercise program or equal attention control group, both delivered by a physiotherapist (PT). Participants received six PT home visits in addition to monthly phone calls from the PT and a blinded research assistant. The primary feasibility outcomes of the study were recruitment rate (20 per site in 1 year), retention rate (75% completion), and intervention adherence rate (60% of weeks meeting exercise goals). Secondary outcomes included falls, fractures and adverse events. RESULTS One hundred forty-one participants were recruited; an average of 20 per site, though most sites took longer than anticipated. Retention and adherence met the criteria for success: 92% of participants completed the study; average adherence was 66%. The intervention group did not differ significantly in the number of falls (IRR 0.97, 95% CI 0.58 to 1.63) or fragility fractures (OR 1.11, 95% CI 0.60 to 2.05) compared to the control group. There were 18 serious adverse events in the intervention group and 12 in the control group. CONCLUSION An RCT of home exercise in women with vertebral fractures is feasible but recruitment was a challenge. Suggestions are made for the conduct of future trials.
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Affiliation(s)
- L M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada.
| | - J C Gibbs
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - J A Templeton
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - J D Adachi
- McMaster University, Hamilton, Ontario, Canada
- St Joseph's Healthcare-Hamilton, Hamilton, Ontario, Canada
| | - M C Ashe
- University of British Columbia, Vancouver, Canada
- Centre for Hip Health and Mobility, Vancouver, Canada
| | | | - A M Cheung
- University of Toronto, Toronto, Ontario, Canada
| | - K D Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - D L Kendler
- University of British Columbia, Vancouver, Canada
| | - A A Khan
- McMaster University, Hamilton, Ontario, Canada
| | - S Kim
- University of Toronto, Toronto, Ontario, Canada
- Women's College Hospital, Toronto, Ontario, Canada
| | - C McArthur
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
- McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Ontario, Canada
| | - N Mittmann
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A Papaioannou
- McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Ontario, Canada
| | - S Prasad
- McMaster University, Hamilton, Ontario, Canada
| | - S C Scherer
- Broadmeadows Health Service, Broadmeadows, Australia
- University of Melbourne, Melbourne, Australia
| | - L Thabane
- McMaster University, Hamilton, Ontario, Canada
- St Joseph's Healthcare-Hamilton, Hamilton, Ontario, Canada
| | - J D Wark
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Parkville, Australia
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Gibbs JC, Brown ZM, Wong AKO, Craven BC, Adachi JD, Giangregorio LM. Measuring Marrow Density and Area Using Peripheral Quantitative Computed Tomography at the Tibia: Precision in Young and Older Adults and Individuals With Spinal Cord Injury. J Clin Densitom 2018; 21:269-280. [PMID: 28359675 DOI: 10.1016/j.jocd.2017.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/25/2017] [Accepted: 02/13/2017] [Indexed: 12/15/2022]
Abstract
The objective of this study was to compare the test-retest precision error for peripheral quantitative computed tomography (pQCT)-derived marrow density and marrow area segmentation at the tibia using 3 software packages. A secondary analysis of pQCT data in young adults (n = 18, mean ± standard deviation 25.4 ± 3.2 yr), older adults (n = 47, 71.8 ± 8.2 yr), and individuals with spinal cord injury (C1-T12 American Spinal Injury Association Impairment Scale, classes A-C; n = 19, 43.5 ± 8.6 yr) was conducted. Repeat scans of the tibial shaft (66%) were performed using pQCT (Stratec XCT2000). Test-retest precision errors (root mean square standard deviation and root mean square coefficient of variation [RMSCV%]) for marrow density (mg/cm3) and marrow area (mm2) were reported for the watershed-guided manual segmentation method (SliceOmatic version 4.3 [Sliceo-WS]) and the 2 threshold-based edge detection methods (Stratec version 6.0 [Stratec-TB] and BoneJ version 1.3.14 [BoneJ-TB]). Bland-Altman plots and 95% limits of agreement were computed to evaluate test-retest discrepancies within and between methods of analysis and subgroups. RMSCV% for marrow density segmentation was >5% for all methods across subgroups (Stratec-TB: 12.2%-28.5%, BoneJ-TB: 14.5%-25.2%, and Sliceo-WS: 10.9%-23.0%). RMSCV% for marrow area segmentation was within 5% for all methods across subgroups (Stratec-TB: 1.9%-4.4%, BoneJ-TB: 2.6%-5.1%, and Sliceo-WS: 2.4%-4.5%), except using BoneJ-TB in older adults. Intermethod discrepancies in marrow density appeared to be present across the range of marrow density values and did not differ by subgroup. Intermethod discrepancies varied to a greater extent for marrow area and were found to be more frequently at mid- to higher-range values for those with spinal cord injury. Precision error for pQCT-derived marrow density segmentation exceeded 5% for all methods of analysis across a range of bone mineral densities and fat infiltration, whereas precision error for marrow area segmentation ranged from 2% to 5%. Further investigation is necessary to determine alternative acquisition and analysis methods for pQCT-derived marrow segmentation.
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Affiliation(s)
- Jenna C Gibbs
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.
| | - Zachary M Brown
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - Andy K O Wong
- Joint Department of Medical Imaging, Toronto General Research Institute, University Health Network, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, Toronto General Research Institute, University Health Network, Toronto, ON, Canada; Arthritis Program, Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - B Catharine Craven
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada; Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada; Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Schlegel Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
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Brown ZM, Gibbs JC, Adachi JD, Ashe MC, Hill KD, Kendler DL, Khan A, Papaioannou A, Prasad S, Wark JD, Giangregorio LM. Score Distributions of the Balance Outcome Measure for Elder Rehabilitation (BOOMER) in Community-Dwelling Older Adults With Vertebral Fracture. J Geriatr Phys Ther 2017; 42:E87-E93. [PMID: 29210932 DOI: 10.1519/jpt.0000000000000158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE We sought to evaluate the Balance Outcome Measure for Elder Rehabilitation (BOOMER) in community-dwelling women 65 years and older with vertebral fracture and to describe score distributions and potential ceiling and floor effects. METHODS This was a secondary data analysis of baseline data from the Build Better Bones with Exercise randomized controlled trial using the BOOMER. A total of 141 women with osteoporosis and radiographically confirmed vertebral fracture were included. Concurrent validity and internal consistency were assessed in comparison to the Short Physical Performance Battery (SPPB). Normality and ceiling/floor effects of total BOOMER scores and component test items were also assessed. Exploratory analyses of assistive aid use and falls history were performed. RESULTS AND DISCUSSION Tests for concurrent validity demonstrated moderate correlation between total BOOMER and SPPB scores. The BOOMER component tests showed modest internal consistency. Substantial ceiling effect and nonnormal score distributions were present among overall sample and those not using assistive aids for total BOOMER scores, although scores were normally distributed for those using assistive aids. The static standing with eyes closed test demonstrated the greatest ceiling effects of the component tests, with 92% of participants achieving a maximal score. CONCLUSIONS While the BOOMER compares well with the SPPB in community-dwelling women with vertebral fractures, researchers or clinicians considering using the BOOMER in similar or higher-functioning populations should be aware of the potential for ceiling effects.
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Affiliation(s)
- Zachary M Brown
- Department of Kinesiology, University of Waterloo, Waterloo, Canada
| | - Jenna C Gibbs
- Department of Kinesiology, University of Waterloo, Waterloo, Canada
| | | | - Maureen C Ashe
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - David L Kendler
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Aliya Khan
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Sadhana Prasad
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - John D Wark
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Schlegel-UW Research Institute for Aging, Waterloo, Canada
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Gibbs JC, Gagnon DH, Bergquist AJ, Arel J, Cervinka T, El-Kotob R, Maltais DB, Wolfe DL, Craven BC. Rehabilitation Interventions to modify endocrine-metabolic disease risk in Individuals with chronic Spinal cord injury living in the Community (RIISC): A systematic review and scoping perspective. J Spinal Cord Med 2017; 40:733-747. [PMID: 28703038 PMCID: PMC5778937 DOI: 10.1080/10790268.2017.1350341] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Endocrine-metabolic disease (EMD) risk following spinal cord injury (SCI) is associated with significant multi-morbidity (i.e. fracture, diabetes, heart disease), mortality, and economic burden. It is unclear to what extent rehabilitation interventions can modify EMD risk and improve health status in community-dwelling adults with chronic SCI. OBJECTIVES To characterize rehabilitation interventions and summarize evidence on their efficacy/effectiveness to modify precursors to EMD risk in community-dwelling adults with chronic SCI. METHODS Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, CDSR, and PsychInfo were completed. All randomized, quasi-experimental, and prospective controlled trials comparing rehabilitation/therapeutic interventions with control/placebo interventions in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean differences of change from baseline were reported for EMD risk outcomes. The GRADE approach was used to rate the quality of evidence. RESULTS Of 489 articles identified, 16 articles (11 studies; n=396) were eligible for inclusion. No studies assessed the effects of rehabilitation interventions on incident fragility fractures, heart disease, and/or diabetes. Individual studies reported that exercise and/or nutrition interventions could improve anthropometric indices, body composition/adiposity, and biomarkers. However, there were also reports of non-statistically significant between-group differences. CONCLUSIONS There was very low-quality evidence that rehabilitation interventions can improve precursors to EMD risk in community-dwelling adults with chronic SCI. The small number of studies, imprecise estimates, and inconsistency across studies limited our ability to make conclusions. A high-quality longitudinal intervention trial is needed to inform community-based rehabilitation strategies for EMD risk after chronic SCI.
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Affiliation(s)
- Jenna C. Gibbs
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada,University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada,Correspondence to: Dr. Jenna Gibbs, University of Waterloo, Department of Kinesiology, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | - Dany H. Gagnon
- Université de Montréal, École de Réadaptation, Montréal, QC, Canada
| | - Austin J. Bergquist
- University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada
| | - Jasmine Arel
- Université de Montréal, École de Réadaptation, Montréal, QC, Canada
| | - Tomas Cervinka
- University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada
| | - Rasha El-Kotob
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada,University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada
| | | | - Dalton L. Wolfe
- Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada,Lawson Health Research Institute, Parkwood Institute Research, London, ON, Canada
| | - B. Catharine Craven
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada,University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Gibbs JC, Giangregorio LM, Wong AKO, Josse RG, Cheung AM. Appendicular and whole body lean mass outcomes are associated with finite element analysis-derived bone strength at the distal radius and tibia in adults aged 40years and older. Bone 2017; 103:47-54. [PMID: 28614701 DOI: 10.1016/j.bone.2017.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/16/2017] [Accepted: 06/06/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this cross-sectional study was to determine how appendicular lean mass index (ALMI), and whole body lean (LMI) and fat mass indices (FMI) associate with estimated bone strength outcomes at the distal radius and tibia in adults aged 40 years and older. METHODS Dual energy X-ray absorptiometry (DXA) scans were performed to determine body composition, including whole body lean and fat mass, and appendicular lean mass. ALMI (appendicular lean mass/height2), LMI (lean tissue mass/height2) and FMI (fat mass/height2) were calculated. High-resolution peripheral quantitative computed tomography (HRpQCT) scans were performed to assess bone structural properties at the distal radius and tibia. Using finite element analysis, failure load (N), stiffness (N/mm), ultimate stress (MPa), and cortical-to-trabecular load ratio were estimated from HRpQCT scans. The associations between body composition (ALMI, LMI, FMI) and estimated bone strength were examined using bivariate and multivariable linear regression analyses adjusting for age, sex, and other confounding variables. RESULTS In 197 participants (127 women; mean±SD, age: 69.5±10.3y, body mass index: 27.95±4.95kg/m2, ALMI: 7.31±1.31kg/m2), ALMI and LMI were significantly associated with failure load at the distal radius and tibia (explained 39%-48% of the variance) and remained significant after adjusting for confounding variables and multiple testing (R2=0.586-0.645, p<0.001). ALMI, LMI, and FMI did not have significant associations with ultimate stress in our multivariable models. FMI was significantly associated with cortical-to-trabecular load ratio at the distal radius and tibia (explained 6%-12% of the variance) and remained significant after adjusting for confounders and multiple testing (R2=0.208-0.243, p<0.001). FMI was no longer significantly associated with failure load after adjusting for confounders. CONCLUSION These findings suggest that ALMI and LMI are important determinants of estimated bone strength, particularly failure load, at the distal radius and tibia, and may contribute to preservation of bone strength in middle-to-late adulthood.
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Affiliation(s)
- Jenna C Gibbs
- University of Waterloo, Department of Kinesiology, 200 University Ave W, Waterloo, ON N2L 3G1, Canada.
| | - Lora M Giangregorio
- University of Waterloo, Department of Kinesiology, 200 University Ave W, Waterloo, ON N2L 3G1, Canada; University Health Network-Toronto Rehabilitation Institute, Brain and Spinal Cord Rehabilitation Program, 520 Sutherland Drive, Toronto, ON M4G 3V9, Canada; Schlegel Research Institute for Aging, University of Waterloo, 250 Laurelwood Drive, Waterloo, ON N2J 0E2, Canada.
| | - Andy K O Wong
- University Health Network Osteoporosis Program, University of Toronto Centre of Excellence in Skeletal Health Assessment, 200 Elizabeth Street, EN7-221, Toronto, ON M5G 2C4, Canada.
| | - Robert G Josse
- St. Michael's Hospital, Department of Medicine, Osteoporosis Centre, 61 Queen St E, Toronto, ON M5C 2T2, Canada.
| | - Angela M Cheung
- University Health Network Osteoporosis Program, University of Toronto Centre of Excellence in Skeletal Health Assessment, 200 Elizabeth Street, EN7-221, Toronto, ON M5G 2C4, Canada.
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Giangregorio LM, Gibbs JC, Craven BC. Measuring muscle and bone in individuals with neurologic impairment; lessons learned about participant selection and pQCT scan acquisition and analysis. Osteoporos Int 2016; 27:2433-46. [PMID: 27026329 DOI: 10.1007/s00198-016-3572-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/14/2016] [Indexed: 10/22/2022]
Abstract
Peripheral quantitative computed tomography (pQCT) can be used to examine bone strength outcomes and muscle size and fatty infiltration. Our research team and others have used it to examine bone loss after spinal cord injury (SCI). However, the high prevalence of restricted lower extremity range of motion, spasticity, edema, excessive muscle atrophy, or severe osteoporosis necessitates changes to standard protocols for screening, positioning during scan acquisition, and analysis methods. This manuscript outlines the challenges that we experienced using pQCT in individuals with SCI, and provides solutions, ones that may also be applicable when using pQCT in individuals with other chronic conditions or in older adults. Suggestions for participant screening, positioning individuals for scanning while in a wheelchair, scan site selection, need for attendant assistance, and considerations in the presence of secondary complications, such as contracture, spasticity, and paralysis, are presented. In the presence of very low bone mineral density or severe muscle atrophy, the default analysis modes provided by the manufacturer may not provide valid estimates of bone or muscle indices; we propose alternates. We have used watershed segmentation methods to determine muscle size and density based on lower precision error compared to threshold-based edge-detection segmentation, particularly for adults with SCI, where more fatty infiltration was present. By presenting our "lessons learned," we hope to reduce the learning curve for researchers using pQCT in the future.
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Affiliation(s)
- L M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue W-BMH 1109, Waterloo, ON, Canada.
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.
- Research Scientist, Schlegel-UW Research Institute of Aging, Waterloo, ON, Canada.
| | - J C Gibbs
- Department of Kinesiology, University of Waterloo, 200 University Avenue W-BMH 1109, Waterloo, ON, Canada
| | - B C Craven
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Mallinson RJ, Williams NI, Gibbs JC, Koehler K, Allaway HCM, Southmayd E, De Souza MJ. Current and past menstrual status is an important determinant of femoral neck geometry in exercising women. Bone 2016; 88:101-112. [PMID: 27129885 DOI: 10.1016/j.bone.2016.01.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 12/19/2015] [Accepted: 01/11/2016] [Indexed: 11/21/2022]
Abstract
UNLABELLED Menstrual status, both past and current, has been established as an important determinant of bone mineral density (BMD) in young exercising women. However, little is known regarding the association between the cumulative effect of menstrual status and indices of bone health beyond BMD, such as bone geometry and estimated bone strength. PURPOSE This study explores the association between cumulative menstrual status and indices of bone health assessed using dual-energy x-ray absorptiometry (DXA), including femoral neck geometry and strength and areal BMD (aBMD), in exercising women. METHODS 101 exercising women (22.0±0.4years, BMI 21.0±0.2kg/m(2), 520±40min/week of self-reported exercise) participated in this cross-sectional study. Women were divided into three groups as follows based on their self-reported current and past menstrual status: 1) current and past regular menstrual cycles (C+P-R) (n=23), 2) current and past irregular menstrual cycles (C+P-IR) (n=56), 3) and current or past irregular cycles (C/P-RIR) (n=22). Current menstrual status was confirmed using daily urinary metabolites of reproductive hormones. DXA was used to assess estimates of femoral neck geometry and strength from hip strength analysis (HSA), aBMD, and body composition. Cross-sectional moment of inertia (CSMI), cross-sectional area (CSA), strength index (SI), diameter, and section modulus (Z) were calculated at the femoral neck. Low CSMI, CSA, SI, diameter, and Z were operationally defined as values below the median. Areal BMD (g/cm(2)) and Z-scores were determined at the lumbar spine, femoral neck, and total hip. Low BMD was defined as a Z-score<-1.0. Chi-square tests and multivariable logistic regression were performed to compare the prevalence and determine the odds, respectively, of low bone geometry, strength, and aBMD among groups. RESULTS Cumulative menstrual status was identified as a significant predictor of low femoral neck CSMI (p=0.005), CSA (p≤0.024), and diameter (p=0.042) after controlling for confounding variables. C+P-IR or C/P-RIR were four to eight times more likely to exhibit low femoral neck CSMI or CSA when compared with C+P-R. Lumbar spine aBMD and Z-score were lower in C+P-IR when compared with C+P-R (p≤0.003). A significant association between menstrual group and low aBMD was observed at the lumbar spine (p=0.006) but not at the femoral neck or total hip (p>0.05). However, after controlling for confounding variables, cumulative menstrual status was not a significant predictor of low aBMD. CONCLUSION In exercising women, the cumulative effect of current and past menstrual irregularity appears to be an important predictor of lower estimates of femoral neck geometry, as observed by smaller CSMI and CSA, which may serve as an another means, beyond BMD, by which menstrual irregularity compromises bone strength. As such, evaluation of both current and past menstrual status is recommended to determine potential risk for relatively small bone geometry at the femoral neck.
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Affiliation(s)
- Rebecca J Mallinson
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States.
| | - Nancy I Williams
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States.
| | - Jenna C Gibbs
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States; University of Waterloo, Department of Kinesiology, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada.
| | - Karsten Koehler
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States; University of Nebraska, Department of Nutrition and Health Sciences, Lincoln, NE 68583, United States.
| | - Heather C M Allaway
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States.
| | - Emily Southmayd
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States.
| | - Mary Jane De Souza
- Pennsylvania State University, Department of Kinesiology, Noll Laboratory, University Park, PA 16802, United States.
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Mallinson RJ, Williams NI, Gibbs JC, Koehler K, Allaway HC, Southmayd EA, De Souza MJ. Cumulative Menstrual Status is an Important Determinant of Femoral Neck Geometry in Exercising Women. Med Sci Sports Exerc 2016. [DOI: 10.1249/01.mss.0000486475.47478.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Koehler K, Hoerner NR, Gibbs JC, Zinner C, Braun H, De Souza MJ, Schaenzer W. Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones. J Sports Sci 2016; 34:1921-9. [PMID: 26852783 DOI: 10.1080/02640414.2016.1142109] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Low energy availability, defined as low caloric intake relative to exercise energy expenditure, has been linked to endocrine alterations frequently observed in chronically energy-deficient exercising women. Our goal was to determine the endocrine effects of low energy availability in exercising men. Six exercising men (VO2peak: 49.3 ± 2.4 ml · kg(-1) · min(-1)) underwent two conditions of low energy availability (15 kcal · kg(-1) fat-free mass [FFM] · day(-1)) and two energy-balanced conditions (40 kcal · kg(-1) FFM · day(-1)) in randomised order. During one low energy availability and one balanced condition, participants exercised to expend 15 kcal · kg(-1) FFM · day(-1); no exercise was conducted during the other two conditions. Metabolic hormones were assessed before and after each 4-day period. Following both low energy availability conditions, leptin (-53% to -56%) and insulin (-34% to -38%) were reduced (P < 0.05). Reductions in leptin and insulin were independent of whether low energy availability was attained with or without exercise (P > 0.80). Low energy availability did not significantly impact ghrelin, triiodothyronine, testosterone and IGF-1 (all P > 0.05). The observed reductions in leptin and insulin were in the same magnitude as changes previously reported in sedentary women. Further research is needed to understand why other metabolic hormones are more robust against low energy availability in exercising men than those in sedentary and exercising women.
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Affiliation(s)
- Karsten Koehler
- a Institute of Biochemistry , German Sport University , Cologne , Germany.,b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA.,c Department of Nutrition and Health Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA
| | - Neele R Hoerner
- a Institute of Biochemistry , German Sport University , Cologne , Germany
| | - Jenna C Gibbs
- b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA.,d Department of Kinesiology , University of Waterloo , Waterloo , Canada
| | - Christoph Zinner
- e Department of Sport Science , University of Würzburg , Würzburg , Germany
| | - Hans Braun
- a Institute of Biochemistry , German Sport University , Cologne , Germany
| | - Mary Jane De Souza
- b Department of Kinesiology , Pennsylvania State University , University Park , PA , USA
| | - Wilhelm Schaenzer
- a Institute of Biochemistry , German Sport University , Cologne , Germany
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Gibbs JC, Craven BC, Moore C, Thabane L, Adachi JD, Giangregorio LM. Muscle Density and Bone Quality of the Distal Lower Extremity Among Individuals with Chronic Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2015; 21:282-93. [PMID: 26689693 DOI: 10.1310/sci2104-282] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Understanding the related fates of muscle density and bone quality after chronic spinal cord injury (SCI) is an important initial step in determining endocrine-metabolic risk. OBJECTIVE To examine the associations between muscle density and indices of bone quality at the distal lower extremity of adults with chronic SCI. METHODS A secondary data analysis was conducted in 70 adults with chronic SCI (C2-T12; American Spinal Injury Association Impairment Scale [AIS] A-D; ≥2 years post injury). Muscle density and cross-sectional area (CSA) and bone quality indices (trabecular bone mineral density [TbBMD] at the distal tibia [4% site] and cortical thickness [CtTh], cortical area [CtAr], cortical BMD [CtBMD], and polar moment of inertia [PMI] at the tibial shaft [66% site]) were measured using peripheral quantitative computed tomography. Calf lower extremity motor score (cLEMS) was used as a clinical measure of muscle function. Multivariable linear regression analyses were performed to determine the strength of the muscle-bone associations after adjusting for confounding variables (sex, impairment severity [AIS A/B vs AIS C/D], duration of injury, and wheelchair use). RESULTS Muscle density was positively associated with TbBMD (b = 0.85 [0.04, 1.66]), CtTh (b = 0.02 [0.001, 0.034]), and CtBMD (b = 1.70 [0.71, 2.69]) (P < .05). Muscle CSA was most strongly associated with CtAr (b = 2.50 [0.12, 4.88]) and PMI (b = 731.8 [161.7, 1301.9]) (P < .05), whereas cLEMS was most strongly associated with TbBMD (b = 7.69 [4.63, 10.76]) (P < .001). CONCLUSIONS Muscle density and function were most strongly associated with TbBMD at the distal tibia in adults with chronic SCI, whereas muscle size was most strongly associated with bone size and geometry at the tibial shaft.
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Affiliation(s)
- Jenna C Gibbs
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - B Catharine Craven
- Lyndhurst Centre, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Cameron Moore
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Lyndhurst Centre, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Lyndhurst Centre, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada.,Schlegel Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
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Gibbs JC, McArthur C, Milligan J, Clemson L, Lee L, Boscart VM, Heckman G, Rojas-Fernandez C, Stolee P, Giangregorio LM. Measuring the implementation of a group-based Lifestyle-integrated Functional Exercise (Mi-LiFE) intervention delivered in primary care for older adults aged 75 years or older: a pilot feasibility study protocol. Pilot Feasibility Stud 2015; 1:20. [PMID: 27965799 PMCID: PMC5154042 DOI: 10.1186/s40814-015-0016-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 05/19/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Declines in function and quality of life, and an increased risk of cardiovascular events, falls, and fractures occur with aging and may be amenable to exercise intervention. Primary care is an ideal setting for identifying older adults in need of exercise intervention. However, a cost-effective, generalizable model of chronic disease management using exercise in a real-world setting remains elusive. Our objective is to measure the feasibility, potential effectiveness, and implementation of an evidence-based Lifestyle-integrated Functional strength and balance Exercise (LiFE) intervention adapted as a group-based format (Mi-LiFE) for primary care to promote increased physical activity levels in older adults aged 75 years or older. We hypothesize that the intervention will be feasible without modification if ≥30 individuals are recruited over 6 months, ≥75 % of our sample is retained, and ≥50 % of our sample complete exercises ≥3 days per week. METHODS/DESIGN A pre-post pilot study design will be used to evaluate feasibility, potential effectiveness, and implementation outcomes over a 6-month period in physically inactive older adults ≥75 years recruited from a local family health team practice. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework will be applied to evaluate the public health effects of the intervention including outcomes both at the individual and organizational levels. A physical therapist will teach participants how to integrate strength and balance activities into their daily lives over one individual and four group-based sessions, and two phone calls. Assessments will be completed at baseline and 6 months. Feasibility outcomes include recruitment over 6 months, retention at follow-up, and adherence measured by activity diaries. Change in patient-centered and implementation outcomes that will be evaluated include physical activity levels using accelerometers and International Physical Activity Questionnaire, physical performance using short physical performance battery, quality of life using EQ5D questionnaire, falls and harms using daily calendar diaries and self-report, fidelity using descriptive feedback, barriers and facilitators to implementation using thematic content analysis, and process outcomes. DISCUSSION The feasibility and implementation of the Mi-LiFE intervention in primary care for older adults will be evaluated, as well as the effects of the intervention on secondary outcomes. If the intervention appears feasible, we will use the resultant information to design a larger trial. TRIAL REGISTRATION ClinicalTrials.gov: NCTO2266225.
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Affiliation(s)
- Jenna C. Gibbs
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - Caitlin McArthur
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - James Milligan
- Centre for Family Medicine-Family Health Team, Department of Family Medicine, McMaster University, 10B Victoria Street South, Kitchener, ON N2G 1C5 Canada
| | - Lindy Clemson
- Faculty of Health Sciences, University of Sydney, 75 East Street Lidcombe, Sydney, NSW 2006 Australia
| | - Linda Lee
- Centre for Family Medicine-Family Health Team, Department of Family Medicine, McMaster University, 10B Victoria Street South, Kitchener, ON N2G 1C5 Canada
| | - Veronique M. Boscart
- School of Health & Life Sciences and Community Services, Conestoga College, 299 Doon Valley Drive, Kitchener, ON N2G 4M4 Canada
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - Carlos Rojas-Fernandez
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - Lora M. Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
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Allaway HCM, Williams NI, Gibbs JC, De Souza MJ. The Effect of Energy Status on Distance Running Performance Across a Competitive Season in Female Cross-country Runners. Med Sci Sports Exerc 2015. [DOI: 10.1249/01.mss.0000476391.36841.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Joy E, De Souza MJ, Nattiv A, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G, Barrack M, Burke L, Drinkwater B, Lebrun C, Loucks AB, Mountjoy M, Nichols J, Borgen JS. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep 2015; 13:219-32. [PMID: 25014387 DOI: 10.1249/jsr.0000000000000077] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.
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Affiliation(s)
- Elizabeth Joy
- 1Intermountain Healthcare, Salt Lake City, UT; 2Pennsylvania State University, University Park, State College, PA; 3University of California, Los Angeles, Los Angeles, CA; 4Harvard Medical School, Boston, MA; 5University of Toronto, Toronto, Ontario, Canada; 6Hospital for Special Surgery, New York, NY; 7Stanford University, San Francisco, CA; 8California State University Northridge, Northridge, CA; 9Australian Institute of Sport, Australia; 10Washington; 11University of Alberta, Edmonton, Alberta, Canada; 12Ohio University, Athens, OH; 13McMaster University, Guelph, Ontario, Canada; 14San Diego State University, San Diego, CA; and 15Norwegian School of Sport Sciences, Oslo, Norway
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Gibbs JC, Nattiv A, Barrack MT, Williams NI, Rauh MJ, Nichols JF, De Souza MJ. Low bone density risk is higher in exercising women with multiple triad risk factors. Med Sci Sports Exerc 2014; 46:167-76. [PMID: 23783260 DOI: 10.1249/mss.0b013e3182a03b8b] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
UNLABELLED The cumulative effect of the female athlete triad (Triad) risk factors on the likelihood of low bone mineral density (BMD) in exercising women is unclear. PURPOSE This study aimed to determine the risk of low BMD in exercising women with multiple Triad risk factors. METHODS We retrospectively examined cross-sectional data from 437 exercising women (mean ± SD age of 18.0 ± 3.5 yr, weighed 57.5 ± 7.1 kg with 24.5% ± 6.1% body fat) obtained at baseline from 4 prospective cohort studies examining Triad risk factors. Questionnaires were completed to obtain information on demographic characteristics, self-reported eating attitudes/behaviors, menstrual function, sport/activity participation, and medication use. Height and body weight were measured. BMD was measured using dual energy x-ray absorptiometry. Low BMD was defined as z-scores of <-1 and ≤-2. Chi-square tests were performed to determine the percentage of women with low BMD who met the criteria for individual (current oligo/amenorrhea, late menarche, low body mass index (BMI), elevated dietary restraint, lean sport/activity participation) or multiple (2, 3, 4, or 5) Triad risk factors. RESULTS Late menarche and low BMI were associated with the highest percentage of low BMD (z-score < -1), 55% and 54%, respectively, and low BMD (z-score ≤-2), 14% and 16%, respectively. The percentage of participants with low BMD (z-score < -1 and ≤-2) increased from 10% to 62% and from 2% to 18%, respectively, as women met the criteria for an increasing number of Triad risk factors. CONCLUSIONS A cumulative number of Triad risk factors were associated with an increased risk of low BMD, suggesting a dose-response association between the number of Triad risk factors and BMD in exercising women. Further research should be conducted to develop a user-friendly algorithm integrating these indicators of risk for low BMD in exercising women (particularly factors associated with low BMI/body weight, menstrual dysfunction, lean sport/activity participation, and elevated dietary restraint).
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Affiliation(s)
- Jenna C Gibbs
- 1The Pennsylvania State University, University Park, PA; 2University of California, Los Angeles, CA; 3California State University, Northridge, CA; 4San Diego State University, San Diego, CA; and 5University of California, San Diego, CA
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De Souza MJ, Williams NI, Nattiv A, Joy E, Misra M, Loucks AB, Matheson G, Olmsted MP, Barrack M, Mallinson RJ, Gibbs JC, Goolsby M, Nichols JF, Drinkwater B, Sanborn C(B, Agostini R, Otis CL, Johnson MD, Hoch AZ, Alleyne JMK, Wadsworth LT, Koehler K, VanHeest J, Harvey P, Weiss Kelly AK, Fredericson M, Brooks GA, O'Donnell E, Callahan LR, Putukian M, Costello L, Hecht S, Rauh MJ, McComb J. Misunderstanding the Female Athlete Triad: Refuting the IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S). Br J Sports Med 2014; 48:1461-5. [DOI: 10.1136/bjsports-2014-093958] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Gibbs JC, Williams NI, Mallinson RJ, Reed JL, Rickard AD, De Souza MJ. Effect of high dietary restraint on energy availability and menstrual status. Med Sci Sports Exerc 2014; 45:1790-7. [PMID: 23954993 DOI: 10.1249/mss.0b013e3182910e11] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Dietary restraint (DR) is a key eating behavior associated with menstrual disturbances (MD) in exercising women. However, the association between DR and energy availability (EA) has not been examined. PURPOSES The objective of this study is 1) to compare EA in women when categorized by DR score, to include an evaluation of the frequency of women with low EA, and 2) to compare the distribution of subclinical and clinical MD between DR groups. METHODS Exercising women (23 ± 4 yr; body mass index, 21.1 ± 1.9 kg·m; and exercise volume, 333 ± 198 min·wk) were retrospectively categorized by DR score into two groups: 1) women with high DR (n = 30) and 2) women with normal DR (n = 56). DR scores were obtained from the Three-Factor Eating Questionnaire. High DR score was defined as ≥13. Body composition was measured using dual-energy x-ray absorptiometry. EA was defined as energy intake - exercise energy expenditure per kilogram lean body mass (LBM). Low EA was defined as <30 kcal·kg LBM. Menstrual status was determined using daily urinary samples assayed for reproductive hormones. RESULTS EA was lower in the high DR versus the normal DR group (35.0 ± 12.9 vs 42.0 ± 12.9 kcal·kg LBM, P = 0.018). There was no difference (P = 0.866) in frequency of low EA between DR groups. There was a greater frequency of MD (amenorrhea, oligomenorrhea, anovulation, or luteal phase defect) in the high DR group (21/28, 75.0%) versus the normal DR group (24/47, 51.1%) (χ = 4.2, P = 0.041). CONCLUSION Our findings demonstrate that exercising women with high DR exhibited lower EA and a greater frequency of MD (subclinical and clinical) compared with women with normal DR. However, high DR was not associated with low EA in exercising women.
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Affiliation(s)
- Jenna C Gibbs
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA
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Geesmann B, Gibbs JC, Mester J, Koehler K. A 1,230-km Bike Marathon is Associated with Alterations in Key Metabolic Hormones and Metabolites. Med Sci Sports Exerc 2014. [DOI: 10.1249/01.mss.0000495148.90895.d9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Barrack MT, Gibbs JC, De Souza MJ, Williams NI, Nichols JF, Rauh MJ, Nattiv A. Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women. Am J Sports Med 2014; 42:949-58. [PMID: 24567250 DOI: 10.1177/0363546513520295] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women. PURPOSE To evaluate the effect of single or combined risk factors as defined by the female athlete triad-a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass-with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS At baseline, participants' (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded. RESULTS Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score <-1.0, and who exhibited 3 to 4 of the following: BMI <21.0 kg/m2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly (P < .05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7%), BMI <21.0 kg/m2 (15.3%), and low bone mass (BMD Z score <-1.0; 21.0%). The strongest 2- and 3-variable combined risk factors were low BMD (Z score <-1.0) + ≥12 h/wk of exercise, with 29.7% incurring a BSI (odds ratio [OR], 5.1; 95% CI, 2.2-12.1), and ≥12 h/wk of exercise + leanness sport/activity + dietary restraint, with 46.2% incurring a BSI (OR, 8.7; 95% CI, 2.7-28.3). CONCLUSION In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad-related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.
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Affiliation(s)
- Michelle T Barrack
- Michelle T. Barrack, California State University, Northridge, 18111 Nordhoff Street, Northridge, CA 91330, USA.
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Abstract
PURPOSE The female athlete triad (Triad) is a syndrome linking low energy availability (EA) with or without disordered eating (DE), menstrual disturbances (MD), and low bone mineral density (BMD) in exercising women. The prevalence of Triad conditions (both clinical and subclinical) has not been clearly established.The purpose of this review is to evaluate the studies that determined the prevalence of clinical or subclinical Triad conditions (low EA, DE, MD, and low BMD) in exercising women and in women participating in lean (LS) versus nonlean sports (NLS) using self-report and/or objective measures. METHODS A review of publications using MEDLINE and PubMed was completed. Randomized controlled trials and observational studies that evaluated the prevalence of clinical and subclinical Triad conditions (MD, low BMD, low EA, and DE) in exercising women were included. RESULTS Sixty-five studies were identified for inclusion in this review (n = 10,498, age = 21.8 ± 3.5 yr, body mass index = 20.8 ± 2.6 kg·m; mean ± SD). A relatively small percentage of athletes (0%-15.9%) exhibited all three Triad conditions (nine studies, n = 991). The prevalence of any two or any one of the Triad conditions in these studies ranged from 2.7% to 27.0% and from 16.0% to 60.0%, respectively. The prevalence of all three Triad conditions in LS athletes versus NLS athletes ranged from 1.5% to 6.7% and from 0% to 2.0%, respectively. LS athletes demonstrated higher prevalence rates of MD and low BMD (3.3% vs 1.0%), MD and DE (6.8%-57.8% vs 5.4%-13.5%), and low BMD and DE (5.6% vs 1.0%) than the NLS athletes. CONCLUSIONS Although the prevalence of individual/combined Triad conditions is concerning, our review demonstrates that additional research on the prevalence of the Triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem.
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Affiliation(s)
- Jenna C Gibbs
- Women's Health and Exercise Laboratory, Noll Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA
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De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. Br J Sports Med 2014; 48:289. [DOI: 10.1136/bjsports-2013-093218] [Citation(s) in RCA: 327] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Updated prevalence estimates of all 3 components of the Female Athlete Triad, a syndrome characterized by low energy availability, functional hypothalamic amenorrhea, and osteoporosis, is low (0 %-16 %), however, estimates of 1 or 2 concurrent components approach 50 %-60 % among certain athlete groups. Recent research identifies components of the Triad among female adolescent athletes, particularly those participating in leanness sports, such as endurance running. This is alarming, as adolescents require adequate nutrition and normal hormone function to optimize bone mineral gains during this critical developmental period. Current literature highlights new assessments, such as measurements of bone microarchitecture and hormone levels to better evaluate bone strength and the hormonal and metabolic profile of athletes with and at risk for the Triad. Recent data also provides support for additional potential consequences of the Triad, such as endothelial dysfunction and related cardiovascular effects, stress fractures, and musculoskeletal injuries. Additional prospective research is needed to evaluate long-term indicators and consequences of the Triad and identify effective behavioral treatment strategies.
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Affiliation(s)
- Michelle T Barrack
- Department of Family and Consumer Sciences, California State University, 18111 Nordhoff St, Northridge, CA, 91330-8308, USA,
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Scheid JL, Toombs RJ, Ducher G, Gibbs JC, Williams NI, De Souza MJ. Estrogen and peptide YY are associated with bone mineral density in premenopausal exercising women. Bone 2011; 49:194-201. [PMID: 21549231 DOI: 10.1016/j.bone.2011.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 03/11/2011] [Accepted: 04/14/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND In women with anorexia nervosa, elevated fasting peptide YY (PYY) is associated with decreased bone mineral density (BMD). Prior research from our lab has demonstrated that fasting total PYY concentrations are elevated in exercising women with amenorrhea compared to ovulatory exercising women. PURPOSE The purpose of this study was to assess the association between fasting total PYY, average monthly estrogen exposure and BMD in non-obese premenopausal exercising women. METHODS Daily urine samples were collected and assessed for metabolites of estrone 1-glucuronide (E1G) and pregnandiol glucuronide (PdG) for at least one menstrual cycle if ovulatory or a 28-day monitoring period if amenorrheic. Fasting serum samples were pooled over the measurement period and analyzed for total PYY and leptin. BMD and body composition were assessed by dual-energy X-ray absorptiometry. Multiple regression analyses were performed to determine whether measures of body composition, estrogen status, exercise minutes, leptin and PYY explained a significant amount of the variance in BMD at multiple sites. RESULTS Premenopausal exercising women aged 23.8±0.9years with a mean BMI of 21.2±0.4kg/m(2) exercised 346±48min/week and had a peak oxygen uptake of 49.1±1.8mL/kg/min. Thirty-nine percent (17/44) of the women had amenorrhea. Fasting total PYY concentrations were negatively associated with total body BMD (p=0.033) and total hip BMD (p=0.043). Mean E1G concentrations were positively associated with total body BMD (p=0.033) and lumbar spine (L2-L4) BMD (p=0.047). The proportion of variance in lumbar spine (L2-L4) BMD explained by body weight and E1G cycle mean was 16.4% (R(2)=0.204, p=0.012). The proportion of variance in hip BMD explained by PYY cycle mean was 8.6% (R(2)=0.109, p=0.033). The proportion of variance in total body BMD explained by body weight and E1G cycle mean was 21.9% (R(2)=0.257, p=0.003). CONCLUSION PYY, mean E1G and body weight are associated with BMD in premenopausal exercising women. Thus, elevated PYY and suppressed estrogen concentrations are associated with, and could be directly contributing to, low BMD in exercising women with amenorrhea, despite regular physical activity.
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Affiliation(s)
- J L Scheid
- Women's Health and Exercise Laboratory, Department of Kinesiology, Penn State University, University Park, PA, USA
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Reed JL, De Souza MJ, Gibbs JC, Hill BR, Williams NI. Sensitivity and Specificity of an Energy Availability Threshold in Differentiating Menstrual Status in Exercising Premenopausal Women. Med Sci Sports Exerc 2011. [DOI: 10.1249/01.mss.0000402871.18504.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Gibbs JC, Williams NI, Reed JL, Scheid JL, De Souza MJ. A High Cognitive Restraint Is Associated With Lower Levels Of Energy Availability In Exercising Women. Med Sci Sports Exerc 2011. [DOI: 10.1249/01.mss.0000402870.80385.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Gibbs JC, Williams NI, Scheid JL, Toombs RJ, De Souza MJ. High Drive For Thinness Is Associated With Severe Energy Deficiency-related Menstrual Disturbances In Exercising Women. Med Sci Sports Exerc 2010. [DOI: 10.1249/01.mss.0000385984.42867.dd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Krevans J, Gibbs JC. Parents' use of inductive discipline: relations to children's empathy and prosocial behavior. Child Dev 1996; 67:3263-77. [PMID: 9071781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Relations between parents' discipline, children's empathic responses, and children's prosocial behavior were examined in order to evaluate Martin Hoffman's claim that children's empathy and empathy-based guilt mediate the socialization of children's prosocial behavior. 78 sixth and seventh graders (138-172 months in age), their mothers, and teachers completed multiple measures of Hoffman's constructs. Results were largely consistent with theory. Parents' use of inductive as opposed to power-assertive discipline was related to children's prosocial behavior. Children of inductive parents were more empathic; and more empathic children were more prosocial. Moreover, children's empathy was found to mediate the relation between parents' discipline and children's prosocial behavior. Few relations were obtained for children's guilt indices, but post hoc analyses yielded theoretically consistent results. Contrary to expectations, parents' use of statements of disappointment was the component of the inductive discipline score which was most strongly related to children's prosocial behavior.
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Affiliation(s)
- J Krevans
- Cuyahoga Community College, Parma, OH 44130, USA
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Abstract
A revised and abbreviated version of the Adolescent Problems Inventory (API) was used to examine the relationship between social skills deficits and antisocial behavior. A factor analysis of the revised API yielded three factors (Immediate Response Demand, Deferred Response Demand, and Antisocial Peer Influence) which were differentially related to specific measures of antisocial responding. Results are discussed in the context of a multifactorial model of juvenile delinquency.
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Affiliation(s)
- S J Simonian
- Department of Pediatrics, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH 44109
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Abstract
The Sociomoral Reflection Objective Measure—Short Form—derived from the Sociomoral Reflection Objective Measure, a group-administered recognition measure of Kohlbergian moral reasoning—was psychometrically evaluated for use with 11th graders, juvenile delinquents, and 6th graders. The short form evidenced acceptable reliability and validity for use with 11th graders. Psychometric properties were comparable to those reported for the full scale. Since the short form takes 20 min. less to administer and is quicker to score, the short form was recommended for use with 11th graders in large-scale research. Results for both 6th graders and juvenile delinquents showed that the short form, like the full scale, does not have acceptable reliability and validity for these groups. Reliability and validity of the short form for other adolescent groups must be assessed.
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