Postmenopausal osteoporosis: fracture consequences and treatment efficacy vary by skeletal site

Effects of conservative treatment of 2-week rigorous bed rest on muscle disuse atrophy in osteoporotic vertebral fracture patients

Objective: Osteoporotic vertebral fracture (OVF) is conventionally treated with conservative management such as bed rest, but a relatively prolonged bed rest has the potential risk of muscle disuse atrophy. This study aimed to examine whether the 2-week of rigorous bed rest affects muscle disuse atrophy in OVF patients.

Patients and Methods: A total of 54 OVF patients (16 males; 38 females; mean age, 80.2 ± 9.2 years) were treated with an initial 2-week rigorous bed rest by hospitalization with persistent rehabilitation. Cognitive function, swallowing function, grip strength, and lower extremity circumference were evaluated at three-time points (admission, end of bed rest, and discharge).

Results: Of the 51 patients who were able to walk independently before the injury, one patient (2.0%) had to use a wheelchair after the injury. During hospitalization, cognitive function decline was observed in 33.3% of patients, but not in patients with Revised Hasegawa’s Dementia Scale score ≥25 at admission. Swallowing function decline was observed in one patient, and none of the patients developed aspiration pneumonia during hospitalization. The grip strength significantly improved both at the end of bed rest (P=0.04) and discharge (P=0.02). Although the lower extremity circumference significantly decreased at the end of bed rest (P<0.01), it was recovered afterward. The lower extremity circumference did not significantly differ between the admission and discharge (P=0.17).

Conclusion: Our results suggested that conservative treatment of OVF through an initial 2-week rigorous bed rest with persistent hospital rehabilitation poses a low risk of muscle disuse atrophy. If cognitive dysfunction is observed on admission, close monitoring for exacerbation should be performed during the hospital stay.

Depression and risk of hip fracture: a systematic review and meta-analysis of cohort studies

Recently published studies on the association between depression and hip fracture (HF) are inconsistent. Therefore, we performed this meta-analysis with the main aim to clarify the association between depression and HF, and also to identify possible susceptible groups. Relevant literature published until February 2019 was obtained and screened according to established inclusion criteria. Two researchers independently processed quality assessment and data extraction prior to the meta-analysis. Pooled hazard ratios (HRs) with 95%CI (confidence intervals) were calculated. To explore the sources of heterogeneity, subgroup analyses were performed based on study design, study region, NOS scores, follow-up duration, diagnostic criteria, sex, national income level, and adjustments (bone mineral density (BMD), antidepressant, calcium intake, and smoking). Ten studies with 13 estimates, involving 375,438 participants and 4576 HFs, were included. It was found that patients with depression had a higher risk of HF than non-depressed patients (HR = 1.21; 95%CI 1.11-1.31). Sensitivity analysis results show that the association is relatively stable. The studies that were not adjusted for confounders (e.g., antidepressant, BMD, calcium intake, and smoking) had higher overall HR compared to the studies that adjusted for the corresponding confounding factors. HFs are more likely to occur in European and male depression patients. This meta-analysis provided evidence of a modest positive association between depression and the risk of HFs, and the association is stronger in European and male patients. Implementation of practical measures to prevent and treat depression is of great public health significance.

Initial non-weight-bearing therapy is important for preventing vertebral body collapse in elderly patients with clinical vertebral fractures

Purpose

The aim of the present conventional observational study was to compare the clinical outcomes of initial non-weight-bearing therapy and conventional relative rest therapy among elderly patients with clinical vertebral fractures.

Methods

In total, 196 consecutive patients with clinical vertebral fractures (mean age: 78 years) who were hospitalized for treatment between January 1999 and March 2007 were analyzed. Initial non-weight-bearing therapy consisted of complete bed rest allowing rolling on the bed without any weight-bearing to the spine for 2 weeks, followed by rehabilitation wearing a soft brace. The indications for initial non-weight-bearing therapy were vertebral fracture involving the posterior portion of the vertebral body at the thoraco-lumbar spine, mild neurological deficit, instability of the fracture site, severe pain, multiple vertebral fractures arising from trauma, malalignment at the fracture site, and mild spinal canal stenosis caused by the fracture. Patients who met the indication criteria were treated with initial non-weight-bearing therapy (n = 103), while the other patients were treated with conventional relative rest (n = 93). All the patients were uniformly treated with intramuscular elcatonin to relieve pain. The primary endpoint was progression of the vertebral fracture. The secondary endpoints included bony union and subjective back pain. The follow-up period was 12 weeks.

Results

Compared with the conventional relative rest group, the collapse rate of the anterior and posterior portions of the vertebral body was significantly smaller in the initial non-weight-bearing group. The bony union rate was 100% in the initial non-weight-bearing group and 97% in the conventional relative rest group. The number of patients who experienced back pain was significantly lower in the initial non-weight-bearing group than in the conventional relative rest group.

Conclusion

These results suggest that initial non-weight-bearing therapy is important for preventing vertebral body collapse and for relieving pain among elderly patients with clinical vertebral fractures.

First fractures among postmenopausal women with osteoporosis

After the occurrence of the first fracture, osteoporosis is no longer a "silent" disease, and the patient's risk for future fracture is increased several fold. We assessed the location of first osteoporotic fractures among women with osteoporosis. The Multiple Outcomes of Raloxifene Evaluation (MORE) trial was a fracture outcomes study of postmenopausal women with osteoporosis. All subjects received supplements containing 500 mg elemental calcium and 400-600 IU vitamin D. We assessed the location of first fractures among women with osteoporosis and no previous fractures at baseline from the placebo group of this trial after 3 years of follow-up. Prespecified fracture sites included vertebral fractures and nonvertebral fractures as defined in the MORE study protocol. Among 875 women (mean age, 64.5 +/- 7.4 years) with no prevalent vertebral or nonvertebral fractures, 9% experienced their first fracture event during the trial. Fractures of radius and spine each occurred in 3% of patients. Fractures at other individual sites included ankle (0.6%), metatarsal (0.6%), humerus (0.5%), rib (0.5%), patella (0.3%), leg (0.2%), hip (0.2%), and clavicle (0.1%). These data suggest that for postmenopausal women with osteoporosis but no previous fractures, skeletal care should include a focus on preventing spine and radius fractures.

Hip and non-spine fracture risk reductions differ among antiresorptive agents: Evidence from randomised controlled trials

A number of antiresorptive agents reduce the risk of vertebral fractures, but few have shown consistent effects on hip and other non-spine fractures. Meta-analysis provides a more precise estimate than individual trials when results are consistent across pooled trials. Earlier meta-analyses summarised the results for vertebral and non-spine fractures. New data have emerged for hormone therapy (HT), alendronate (ALN), risedronate (RIS) and ibandronate (IBN). We surveyed recent reports of randomised, placebo-controlled trials with non-spine and/or hip fracture data, and used meta-analysis where appropriate to test for heterogeneity and derive pooled estimates. The magnitude of effect on hip fracture appears to be similar to that for non-spine fracture for each drug, but differs among drugs. Based on the current data, ALN reduces the risk of hip and non-spine fracture by 49-55%, HT by 25-36% and RIS by 26-27%. There is insufficient and/or inconsistent evidence of an effect on these fractures for IBN, calcitonin and raloxifene.

Osteoporosis risk assessment and ethnicity: validation and comparison of 2 clinical risk stratification instruments

BACKGROUND

Dual energy x-ray absorptiometry (DXA), coupled with early treatment, may reduce morbidity and mortality associated with osteoporosis. Clinical tools to enhance selection of women for DXA screening have not been developed or validated in an ethnically diverse population.

OBJECTIVE

To compare the performance of the osteoporosis risk assessment instrument (ORAI) and the simple calculated osteoporosis risk estimation (SCORE) instrument across 3 racial/ethnic groups to identify women who would benefit from DXA scans.

DESIGN

Blinded comparison of the instruments in a cross-sectional sample.

PARTICIPANTS

Two-hundred twenty-six postmenopausal women were recruited from a university-based family medicine clinic. Women with a prior diagnosis of osteoporosis or those taking bone active medications were excluded.

MEASUREMENTS

Participants completed a questionnaire that contained the ORAI and the SCORE questions; 203 completed a DXA scan.

RESULTS

The sensitivity and specificity for the ORAI (0.68, [0.49 to 0.88, 95% CI]; 0.66, [0.59 to 0.73, 95% CI]) and the SCORE instrument (0.54, [0.34 to 0.75, 95% CI]; 0.72, [0.65 to 0.78, 95% CI]) differed significantly from previous reports. Overall, the accuracy of the ORAI (66.5%) and SCORE instrument (70.0%) were similar (McNemar's test P value = .37). The accuracy between instruments differed significantly in African-American women (McNemar's test, P value <.001). In African Americans, the SCORE instrument correctly identified more women without osteoporosis, but missed 70% of those with osteoporosis.

CONCLUSIONS

The performance of the ORAI and SCORE instrument differed significantly from previous reports. Although both can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.