Musculoskeletal challenges of osteoporosis

Vitamin D Deficiency and Molecular Changes in Circulating MicroRNAs in Older Adults with Lower Back Pain

Background

MicroRNAs play an essential role in regulating pain processing within a wide range of clinical pain disorders.

Objectives

The present study aimed to evaluate the role of circulating miRNAs as biomarkers of lower back pain in older adults. In addition, the correlation between miRNAs and other related cofounders such as muscle function, adiposity, malnutrition, and Ca and vitamin D intake was assessed.

Methods

A total of 110 older subjects with an age range of 40-60 years were included in this study. The participants were classified according to a modified Oswestry lower back pain disability questionnaire (OSW) into subjects with minimal LBP (n = 40; LBP score: 0-20%), moderate LBP (n = 35; LBP score: 20-40%), and severe LBP (n = 35; LBP score: 41-60%). RT-PCR and immunoassays were used to study the circulating miRNA profile, vitamin D status, and CRP, IL-6, TNF-α, s-Ca, s-BAP, s-OC, and s-NTX levels. In addition, malnutrition and muscle performance were estimated in all subjects as other factors related to LBP.

Results

In this study, normal LBP-OSW cutoff values (8.96 ± 3.6) were reported in 36.4% of the total population, whereas 63.6% of the population had higher LBP-OSW scores, classified as follows: 31.8% with moderate LBP (LBP-OSW score: 31.4 ± 9.1) and 31.8% with severe LBP (LBP-OSW score: 54.9 ± 14.6). Four circulating miRNAs, namely, miR-146a, miR-558, miR-155, and miR-124a, as biomarkers of the intensity of back pain were identified in all participants. In subjects with moderate to severe LBP, the expression levels of miR-146a and miR-558 were significantly reduced and those of miR-155 and miR-124a were significantly increased compared to subjects with minimal LBP scores. Subjects with moderate to severe LBP showed a significant increase in adiposity markers, lower PA, muscle performance, malnutrition, and lower Ca and vitamin D intake compared to normal controls. In addition, serum levels of vitamin D and circulated plasma markers of inflammation and bone metabolism such as CRP, IL-6, TNF-α, s-Ca, s-BAP, s-OC, and s-NTX were significantly reduced in severe LBP cases compared to those with minimal LBP scores. The expressed circulating miRNAs were significantly associated with the measured muscle performance, adiposity, PA score, inflammation, and bone metabolism cofounders in subjects with higher LBP-OSW scores. The expressed miRNAs, along with other LBP cofounders, were significantly associated with ∼63.9-86.4% of the incidence of LBP in older adults.

Conclusions

In older adults with vitamin D deficiency, the severity of LBP was significantly associated with the expression of circulating miRNAs, adiposity, bone metabolism, inflammation, and muscle performance. In addition, the expressed miRNAs, along with other LBP cofounders, were significantly associated with ∼63.9-86.4% of the incidence of LBP in older adults. These results suggest the possibility of using microRNAs as therapeutics to alleviate established pain and as biomarkers in old adults with painful conditions.

Impacts of Psychological Stress on Osteoporosis: Clinical Implications and Treatment Interactions

The significant biochemical and physiological effects of psychological stress are beginning to be recognized as exacerbating common diseases, including osteoporosis. This review discusses the current evidence for psychological stress-associated mental health disorders as risk factors for osteoporosis, the mechanisms that may link these conditions, and potential implications for treatment. Traditional, alternative, and adjunctive therapies are discussed. This review is not intended to provide therapeutic recommendations, but, rather, the goal of this review is to delineate potential interactions of psychological stress and osteoporosis and to highlight potential multi-system implications of pharmacological interventions. Review of the current literature identifies several potentially overlapping mechanistic pathways that may be of interest (e.g., glucocorticoid signaling, insulin-like growth factor signaling, serotonin signaling) for further basic and clinical research. Current literature also supports the potential for cross-effects of therapeutics for osteoporosis and mental health disorders. While studies examining a direct link between osteoporosis and chronic psychological stress are limited, the studies reviewed herein suggest that a multi-factorial, personalized approach should be considered for improved patient outcomes in populations experiencing psychological stress, particularly those at high-risk for development of osteoporosis.

Management of chronic pain in osteoporosis: challenges and solutions

Osteoporosis (OP) is a pathological condition that manifests clinically as pain, fractures, and physical disability, resulting in the loss of independence and the need for long-term care. Chronic pain is a multidimensional experience with sensory, affective, and cognitive aspects. Age can affect each of these dimensions and the pain that is experienced. In OP, chronic pain appears to have sensory characteristics and properties of nociceptive and neuropathic pain. Its evaluation and treatment thus require a holistic approach that focuses on the specific characteristics of this population. Pain management must therefore include pharmacological approaches, physiotherapy interventions, educational measures, and, in rare cases, surgical treatment. Most rehabilitative treatments in the management of patients with OP do not evaluate pain or physical function, and there is no consensus on the effects of rehabilitation therapy on back pain or quality of life in women with OP. Pharmacological treatment of pain in patients with OP is usually insufficient. The management of chronic pain in patients with OP is complicated with regard to its diagnosis, the search for reversible secondary causes, the efficacy and duration of oral bisphosphonates, and the function of calcium and vitamin D. The aim of this review is to discuss the most appropriate solutions in the management of chronic pain in OP.

The relationship of thoracic kyphosis to gait performance and quality of life in women with osteoporosis

Thoracic kyphosis angle (TKA) increases with osteoporosis. This study aimed to investigate the relationship between magnitude of TKA and quality of life and gait performance in 34 osteoporotic women. Our results suggest that increasing TKA is significantly associated with decreasing quality of life (r = -0.48, p < 0.005) and gait performance (r = -0.74, p < 0.0005).

INTRODUCTION

Osteoporosis and its related effects are threatening health and quality of life especially in postmenopausal women. Increased thoracic kyphosis angle (TKA), as one of the most common adverse musculoskeletal changes, could be regarded as a quantitative index for osteoporotic patients' assessment. Dual digital inclinometer (DDI) is one of the latest tools for non-invasive TKA measurement. The main purpose of this study was to determine whether a relationship existed between the magnitude of TKA, gait performance, and quality of life in a group of osteoporotic women.

METHODS

Thirty-four osteoporotic women, aged 50-68, participated in this descriptive analytic study. The magnitude of TKA measured by using DDI and expressed as the kyphosis index (KI). Quality of life and gait performance were assessed using short form 36 (SF36) questionnaire and functional gait assessment test, respectively. Back extension range of motion (ROM) and back extensor strength were also assessed. Pearson's correlation test was used to analyze the data, with the significance level of p < 0.05.

RESULTS

The findings revealed a statistically significant negative correlation between KI and quality of life (r = -0.48, p < 0.005) and KI and gait performance (r = -0.74, p < 0.0005). There was also a significantly negative relation between KI and back extension ROM and back extensor strength (p < 0.05).

CONCLUSION

The results of this study demonstrated that increased thoracic kyphosis negatively affects gait performance and quality of life. This finding could be regarded as an important implication for therapist to pay more attention to the magnitude of thoracic kyphosis angle and its changes, when selecting appropriate therapeutic methods to improve gait performance and quality of life in osteoporosis women.

The diagnostic accuracy of the Revised Mini Nutritional Assessment Short Form for older people living in the community and in nursing homes

OBJECTIVE

The aim of this study was to determine the diagnostic accuracy of the CC-SF, which was developed to use calf circumference (CC) instead of BMI in the MNA-SF, for elderly people living in the community and in nursing homes. It also aimed separately to determine the correlation of CC-SF and BMI-SF with the full MNA.

STUDY DESIGN AND METHODS

The study included 640 elderly people living in their community and 243 elderly people living in nursing homes. Accuracy was assessed by determining the sensitivity and selectivity of the nutritional assessments. The correlations between the MNA-SFs and the full MNA were analyzed.

RESULTS

The correlation between MNA-SFs and full MNAs was strong, significant and almost identical both in the community and in nursing homes (r=0.86-0.88; p<0.001). The observed agreement between the BMI-SF and the full MNA was 82.2% in the community and 77.8% in the nursing homes. There was a substantial agreement by kappa values in the comparison of community and nursing homes (the Kappa value of the BMI-SF was 0.63 in the community and 0.62 in the nursing homes, and the kappa value of the CC-SF was 0.62 in the community and 0.63 in the nursing homes). When compared to the full MNA the MNA-SFs tended to underestimate nutritional status. Both MNA-SFs had similarly high sensitivity and selectivity, both in the community and nursing homes. (when dichotomized as "malnourished-at risk of malnutrition" versus " well nourished" and "malnourished" versus "at risk of malnutrition-well nourished") (over 80%).

CONCLUSION

In cases where BMI cannot be determined, the CC-SF is a good substitute for the BMI-SF.

Postmenopausal women with osteoporosis and musculoskeletal status: a comparative cross-sectional study

Background

With increased life expectancy of the world's population that has taken place in recent decades, there has been growth in the incidence of illnesses of the most advanced ages, including osteoporosis. However, changes in musculoskeletal disorders are not yet so clear. This study proposes to evaluate musculoskeletal alterations in osteoporotic postmenopausal women and healthy and correlate with bone mineral density of the lumbar spine.

Methods

Randomized, examiner-blinded, comparative cross-sectional study was designed with two groups of women attending the Menopause Clinic in the UNICAMP, 30 women with osteoporosis, while 33 women without osteoporosis comprised the second group. Diagnosis of the presence or absence of osteoporosis was based on bone densitometry performed on the lumbar spine. Volunteers were interviewed and underwent a physical examination with the same examiner, including the muscle strength and amplitude of movement of back flexion and extension, angles of thoracic kyphosis and lumbar lordosis, as well as static and dynamic balance.

Results

Mean back flexors and extensors strength was significantly lower in women with osteoporosis (P < 0.01). Flexion spinal range of motion was similar in both groups (P = 0.91). However, movement amplitude of spine extension was 20.5^o in women with osteoporosis and 28.4^o in women without osteoporosis. Thoracic kyphosis angles from T1 to T4 (P < 0.01) and lumbar lordosis angles (P = 0.02) were greater in women with osteoporosis. Seventy-three point three percent of women with osteoporosis and 78.8% of women without osteoporosis had good reply to static balance. Women in both groups had poor results to dynamic balance. No significant differences were observed in static or dynamic balance between women with and without osteoporosis. Vertebral fractures were present in 20% of women with osteoporosis and absent in women without osteoporosis.

Conclusions

Women with osteoporosis in the study population had poorer musculoskeletal status than women without osteoporosis. Further studies are necessary to evaluate whether correction of these alterations would be related to preventing falls and reducing fracture risk.

Keywords

Balance; Kyphosis; Mobility; Muscle strength; Osteoporosis; Postmenopausal

Yoga spinal flexion positions and vertebral compression fracture in osteopenia or osteoporosis of spine: case series

OBJECTIVE

The objective of this report is to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. We previously described subjects with known osteoporosis in whom vertebral compression fractures (VCFs) developed after spinal flexion exercise (SFE) and recommended that SFEs not be prescribed in patients with spinal osteoporosis.

METHODS

This report describes 3 healthy persons with low bone mass and yoga-induced pain or fracture.

RESULTS

All 3 patients had osteopenia, were in good health and pain-free, and had started yoga exercises to improve their musculoskeletal health. New pain and fracture areas occurred after participation in yoga flexion exercises.

CONCLUSIONS

The development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. Although exercise has been shown to be effective for improving bone mineral density and decreasing fracture risk, our subjects had development of VCFs and neck and back pain with yoga exercises. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss. The increased torque pressure applied to vertebral bodies during SFEs may be a risk. Exercise is effective and important for treatment of osteopenia and osteoporosis and should be prescribed for patients with vertebral bone loss. Some yoga positions can contribute to extreme strain on spines with bone loss. Assessment of fracture risk in older persons performing SFEs and other high-impact exercises is an important clinical consideration.

The role of exercise in the treatment of osteoporosis

The objective of exercise in the treatment of osteoporosis is to improve axial stability through improvement of muscle strength. Therefore, a back extension exercise program specific to one's musculoskeletal competence and pain can be performed in a sitting position and later advanced to the prone position. When fragility is resolved, back extension is performed against resistance applied to the upper back. To decrease pain and immobility in acute vertebral fracture, use of spinal orthoses become inevitable. Therapeutic exercise should address osteoporosis-related deformities of axial posture, which can increase risk of fall and fracture. Strengthening of the major appendicular muscles decreases fragility. The effect of strengthening exercise is augmented by proper intake of cholecalciferol and calcium. Thus, the role of a therapeutic exercise program is to increase muscle strength safely, decrease immobility-related complications, and prevent fall and fracture. As with pharmacotherapy, therapeutic exercises are individualized.

Effects of an adapted physical activity program in a group of elderly subjects with flexed posture: clinical and instrumental assessment

BACKGROUND

Flexed posture commonly increases with age and is related to musculoskeletal impairment and reduced physical performance. The purpose of this clinical study was to systematically compare the effects of a physical activity program that specifically address the flexed posture that marks a certain percentage of elderly individuals with a non specific exercise program for 3 months.

METHODS

Participants were randomly divided into two groups: one followed an Adapted Physical Activity program for flexed posture and the other one completed a non-specific physical activity protocol for the elderly. A multidimensional clinical assessment was performed at baseline and at 3 months including anthropometric data, clinical profile, measures of musculoskeletal impairment and disability. The instrumental assessment of posture was realized using a stereophotogrammetric system and a specific biomechanical model designed to describe the reciprocal position of the body segments on the sagittal plane in a upright posture.

RESULTS

The Adapted Physical Activity program determined a significant improvement in several key parameters of the multidimensional assessment in comparison to the non-specific protocol: decreased occiput-to-wall distance, greater lower limb range of motion, better flexibility of pectoralis, hamstrings and hip flexor muscles, increased spine extensor muscles strength. Stereophotogrammetric analysis confirmed a reduced protrusion of the head and revealed a reduction in compensative postural adaptations to flexed posture characterized by knee flexion and ankle dorsiflexion in the participants of the specific program.

CONCLUSION

The Adapted Physical Activity program for flexed posture significantly improved postural alignment and musculoskeletal impairment of the elderly. The stereophotogrammetric evaluation of posture was useful to measure the global postural alignment and especially to analyse the possible compensatory strategies at lower limbs in flexed posture.

Falls, fractures, and hip pads

Improvement of balance along with bone-enhancing pharmacotherapy can improve the level of an individual's physical activity and mobility. Balance can be improved with enhancement of postural proprioception and muscular strength. Postural deformities have been shown to impair quality of life of osteoporotic individuals. Kyphotic posture has been demonstrated to contribute to propensity to fall in osteoporotic individuals. Kyphotic posturing and gait disorders can be managed through proprioceptive training, use of a weighted kypho-orthosis, muscle re-education, and safe resistance exercises. Proprioceptive balance training can reduce falls and fracture. Sarcopenia and osteoporotic fractures create musculoskeletal challenges that cannot be met with pharmacotherapy alone. Bone loss, imbalance, and gait disorder along with cognitive concerns can increase with aging. Even in healthy persons, predisposition to falls increases with age-related neuromuscular changes. Muscle strength decreases approximately 50% from age 30 to 80. Furthermore, the amount of body sway increases with reduction of proprioception. Therefore, measures that can decrease imbalance can reduce the risk for falls and fracture. In normal balance, ankle strategies are recruited rather than hip strategies. Strengthening of the lower extremity muscles reduces the risk for falls. Gait aids can also decrease the risk for falls. During a fall, the risk for hip fracture increases 30-fold if there is direct impact to the hip. The use of hip protectors can decrease the risk for hip fracture during a sideways fall. Training in effective safe-landing strategies should be included in fall prevention programs.

Content comparison of osteoporosis-targeted health status measures in relation to the International Classification of Functioning, Disability and Health (ICF)

The most frequently used instruments for health-related quality of life (HRQL) in patients with osteoporosis are the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41) and the Osteoporosis Assessment Questionnaire (OPAQ 2.0 and OPAQ SV). Since HRQL- and International Classification of Functioning, Disability and Health (ICF)-based approaches have both strengths and weaknesses, it is expected that they will be used simultaneously in clinical practice and research. Therefore, we investigated the relationship between osteoporosis-targeted instruments and the ICF. All three selected instruments cover body functions, including pain in back and emotional functions. Sleep functions and energy are represented in the QUALEFFO-41 and OPAQ 2.0 but not in the OPAQ SV. Body structures and environmental factors are covered only by the OPAQ 2.0 and OPAQ SV. The ICF provides an excellent framework when comparing the content of osteoporosis-targeted HRQL instruments and may be useful when selecting health status instruments for clinical studies.

Vertebroplasty for osteoporotic spine fracture: prevention and treatment

There is a relatively high prevalence of osteoporotic vertebral compression fractures (VCFs) in the elderly population, especially in women aged 50 or older. The result of these VCFs is increased morbidity and mortality in the short and long term. Medical treatment of these fractures includes bed rest, orthotics, analgesic medication and time. Percutaneous vertebroplasty (PVP) consists of percutaneous injection of biomaterial, such as methylmethacrylate, into the VCF to produce stability and pain relief. Biomechanical testing has shown that PVP can restore strength and stiffness of the vertebral body to the pre-fracture levels. Clinical results show immediate and maintained pain relief in 70-95% of the patients. Possible major complications include cement leakage into the spinal canal or into the venous system. Additionally, percutaneous vertebroplasty may alter the normal loading behavior of the adjacent vertebral body, and there is an increased risk of adjacent segment VCF. Kyphoplasty is a new technique, which introduces a balloon into the vertebral body transpedicularly to reduce the VCF while creating a cavity for the cement injection. This technique has the benefit of kyphosis reduction as well as less cement leakage. Research continues into the development of injectable biomaterials that are resorbable and allow for new bone formation. Vertebroplasty and kyphoplasty are safe and effective in the treatment of osteoporotic VCFs. They may allow for a faster return to function, and thus avoid the morbidity associated with medical treatment.