Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials

Effects of whole-body vibration on bone mineral density in postmenopausal women: an overview of systematic reviews

OBJECTIVE

The aim of this study is to evaluate the findings of existing systematic reviews (SRs) and provide scientific evidence on the efficacy and safety of whole-body vibration (WBV) in improving bone mineral density (BMD) in postmenopausal women, to provide recommendations and guidance for future high-quality clinical research and SRs.

METHODS

We conducted searches in six databases (SinoMed, CNKI, Cochrane Library, Embase, PubMed, Web of Science) from the inception of the databases until July 31, 2023. The language was limited to Chinese or English. The methodological quality, risk of bias, and evidence grade of outcomes were evaluated using AMSTAR-2, ROBIS, and GRADE, respectively. Additionally, the degree of overlap in randomized controlled trials (RCTs) among the SRs was calculated using corrected covered area (CCA). Furthermore, we performed quantitative synthesis or descriptive analysis of the relevant data. All relevant operations were independently conducted by two individuals.

RESULTS

A total of 15 SRs were included in the analysis, out of which three were qualitative descriptions and 12 were meta-analyses. According to AMSTAR-2, only two SRs were rated as low or moderate, while the remaining 13 SRs were rated as critically low quality. The ROBIS assessment indicated that seven SRs had a low risk of bias, while 8 SRs had a high risk of bias. The overall findings suggest that WBV does not have a significant advantage in improving BMD in postmenopausal women. Furthermore, the CCA results revealed a high overlap in RCTs across five outcomes among the 15 SRs. Only five SRs reported specific adverse reactions/events experienced by participants after WBV interventions, and none of the SRs reported any severe adverse events.

CONCLUSION

The existing evidence cannot establish definitive advantages of WBV in improving BMD in postmenopausal women. Therefore, we do not recommend the use of WBV for improving BMD in postmenopausal women. However, WBV may have potential value in maintaining BMD in postmenopausal women, further research is needed to confirm these findings.

Characteristics and Frequency of Physical Activity and Exercise-Related Side Effects in People Receiving Peritoneal Dialysis

OBJECTIVE

People receiving peritoneal dialysis may receive health benefits from physical activity or exercise. However, on-going uncertainty and fear regarding safety may result in this population missing out on the health benefits of participation. The aim of this study was to explore the characteristics and frequency of physical activity and/or exercise-related side effects (e.g., symptoms such as pain or shortness of breath) and negative health events (e.g., stroke or hyper/hypoglycemia) experienced by people receiving peritoneal dialysis.

METHODS

An international online survey involving adults receiving peritoneal dialysis was conducted with questions related to nature, occurrence, and impact of side effects and/or negative health events experienced during or soon after participation in physical activity or exercise.

RESULTS

Fifty-two people completed the survey reporting 151 side effects that were related to physical activity and exercise and 67 that were possibly related. Fatigue (58% of respondents), muscle/joint soreness or pain (54%), and dizziness (43%) were the most frequently reported side-effect types. The majority occurred occasionally (58% of all side effects), if not rarely (24%) and participation in on-going physical activity or exercise was typically prevented only occasionally (39%) or not at all (31%). Side effects were mainly self-managed (54% of all side effects) or did not require treatment (19%) and had low (38%) or no effect (30%) on ability to do daily activities.

CONCLUSIONS

People receiving peritoneal dialysis generally experience side effects that can be considered a normal response to physical activity or exercise engagement. Furthermore, the risk of serious or peritoneal dialysis-specific side effects as a result of physical activity or exercise appears to be low. The results add to the emerging evidence suggesting physical activity and exercise appear to be safe for people receiving peritoneal dialysis.

Mechanical strain regulates osteogenesis via Antxr1/LncRNA H19/Wnt/β-catenin axis

Alleviating bone loss is an essential way to prevent osteoporotic fractures. Proper exercise improves bone density without the side effects of long-term medications, but the mechanism is unclear. Our study explored the role of Antxr1/LncRNA H19/Wnt/β-catenin axis in the process of exercise-mediated alleviation of bone loss. Here we discovered that moderate-intensity treadmill exercise alleviates bone loss caused by ovariectomy and ameliorates bone strength accompanied by an increased lncRNA H19 expression. Concomitantly, Antxr1, a mechanosensitive protein was found downregulated by exercise but upregulated by ovariectomy. Interestingly, knockdown expression of Antxr1 increased lncRNA H19 expression and Wnt/β-catenin signaling pathway in bone marrow mesenchymal stem cells, whereas overexpression of Antxr1 decreased lncRNA H19 expression and Wnt/β-catenin signaling pathway. Hence, our study demonstrates the regulation of Antxr1/LncRNA H19/Wnt/β-catenin axis in the process of mechanical strain-induced osteogenic differentiation, which provides further mechanistic insight into the role of mechanical regulation in bone metabolism.

Predictors of osteoporotic fracture in postmenopausal women: a meta-analysis

Osteoporosis affects more than 200 million women worldwide, with postmenopausal women being particularly susceptible to this condition and its severe sequelae disproportionately, such as osteoporotic fractures. To date, the current focus has been more on symptomatic treatment, rather than preventive measures. To address this, we performed a meta-analysis aiming to identify potential predictors of osteoporotic fractures in postmenopausal women, with the ultimate goal of identifying high-risk patients and exploring potential therapeutic approaches. We searched Embase, MEDLINE and Cochrane with search terms (postmenopausal AND fracture) AND ("risk factor" OR "predictive factor") in May 2022 for cohort and case-control studies on the predictors of osteoporotic fracture in postmenopausal women. Ten studies with 1,287,021 postmenopausal women were found eligible for analyses, in which the sample size ranged from 311 to 1,272,115. The surveyed date spanned from 1993 to 2021. Our results suggested that age, BMI, senior high school and above, parity ≥ 3, history of hypertension, history of diabetes mellitus, history of alcohol intake, age at menarche ≥ 15, age at menopause < 40, age at menopause > 50, estrogen use and vitamin D supplements were significantly associated with osteoporotic fracture in postmenopausal women. Our findings facilitate the early prediction of osteoporotic fracture in postmenopausal women and may contribute to potential therapeutic approaches. By focusing on preventive strategies and identifying high-risk individuals, we can work toward reducing the burden of osteoporosis-related fractures in this vulnerable population.

Fatty Degeneration of the Autochthonous Muscles Is Significantly Associated with Incidental Non-Traumatic Vertebral Body Fractures of the Lower Thoracic Spine in Elderly Patients

PURPOSE

We investigated loco-regional degenerative changes' association with incidentally found non-traumatic vertebral body fractures of the lower thoracic and lumbar spine in older patients. Methods: The patient collective included patients in the age range of 50 to 90 years. Vertebral bodies from T7 to L5 were included. Vertebral body fractures were classified according to Genant. The following loco-regional osseous and extra-osseous degenerative changes were included: osteochondrosis, spondylarthritis, facet joint asymmetries, spondylolisthesis, scoliosis as well as fatty degeneration and asymmetry of the autochthonous back muscles. Patients with traumatic and tumor-related vertebral body fractures were excluded. Non-traumatic fractures of the lower thoracic and lumbar spine were evaluated separately. The Mann-Whitney U-test was used, and relative risks (RRs) were calculated for statistics. Pearson's correlations (Rs) were used to correlate grades of degenerative changes and fracture severities. Results: 105 patients were included. Fatty deposits in the autochthonous muscles of the lower thoracic and the lumbar spine were associated with non-traumatic vertebral body fractures in the lower thoracic spine (p = 0.005, RR = 4.92). In contrast, muscle fatness of the autochthonous muscles was not a risk factor for lumbar spine fractures (p = 0.157, RR = 2.04). Additionally, we found a moderate correlation between fatty degeneration of the autochthonous muscles and the severity of fractures in the lower thoracic spine (RR = 0.34, p < 0.001). The other degenerative changes did not present any significant difference or correlation between the evaluated groups. Conclusions: Fatty degeneration of the autochthonous spinal musculature is associated with incidentally found non-traumatic fractures of the lower thoracic spine.

A summary of the Malaysian Clinical Practice Guidelines on the management of postmenopausal osteoporosis, 2022

Objectives

The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP).

Methods

A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation.

Results

This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients' fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate.

Conclusions

The pathways for the management of postmenopausal OP in Malaysia have been updated. Incorporation of fracture risk stratification can guide appropriate treatment.

Association between exercise and risk of fractures in new-onset type 2 diabetes: a retrospective cohort study

In this population-based retrospective cohort study, exercising before and after the diagnosis of type 2 diabetes was significantly associated with lower risk of fractures. This result suggested that exercising might be effective in reducing fracture risk.

PURPOSE

Patients with diabetes have a significantly higher risk of fractures. We aimed to investigate the association between exercise and fracture risk in new-onset type 2 diabetes.

METHODS

This retrospective cohort study using the Korean National Health Insurance Service database included 170,148 patients with new-onset type 2 diabetes who underwent two cycles of health checkup between 2009-2012 and 2011-2014. The patients were classified into four groups (non-exercising, newly exercising, previously exercising, and continuously exercising) and followed up until the date of fracture, death, or December 31, 2018. Hip fractures, vertebral fractures, and any fractures were defined using diagnostic codes.

RESULTS

The proportions of non-exercising, newly exercising, previously exercising, and continuously exercising patients were 65.1%, 15.7%, 10.9%, and 8.3%, respectively. Continuously exercising patients showed the lowest risk for fractures, followed by newly exercising patients using the non-exercising group as a reference. The adjusted hazard ratios (95% confidence intervals) for hip fracture, vertebral fracture, and any fracture were 0.69 (0.50-0.94), 0.73 (0.63-0.84), and 0.90 (0.83-0.97), respectively, in the continuously exercising group and 0.76 (0.61-0.95), 0.85 (0.76-0.94), and 0.93 (0.88-0.98) in the newly exercising group. The risk was lower in patients who lost less than 5% of their body weight than in those who lost 5% or more.

CONCLUSION

Exercising was associated with lower risk of fractures in newly diagnosed diabetes. However, exercise accompanied by excessive weight loss may not have a significant association with a lower risk of fractures.

Osteosarcopenia in NAFLD/MAFLD: An Underappreciated Clinical Problem in Chronic Liver Disease

Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), affects a significant portion of the population worldwide. NAFLD is characterised by fat accumulation in the liver, while NASH is associated with inflammation and liver damage. Osteosarcopenia, which combines muscle and bone mass loss, is an emerging clinical problem in chronic liver disease that is often underappreciated. The reductions in muscle and bone mass share several common pathophysiological pathways; insulin resistance and chronic systemic inflammation are the most crucial predisposing factors and are related to the presence and gravity of NAFLD and to the worsening of the outcome of liver disease. This article explores the relationship between osteosarcopenia and NAFLD/MAFLD, focusing on the diagnosis, prevention and treatment of this condition in patients with CLD.

Menopause Osteoporosis and Bone Intervention Using Lifestyle Exercise: A Randomized Controlled Study

Background

The aim of the study was to examine the feasibility for postmenopausal women of a bone-strengthening jumping intervention, which has been previously successful for premenopausal women.

Materials and Methods

Forty-nine participants (mean ± standard deviation [SD] age = 57.8 ± 4.3 years) were randomized into either an exercise intervention or sham-control group in a double-blinded fashion. The intervention consisted of 10 maximal, rest-inserted countermovement jumps, performed three times a week on a hard surface without shoes for 8 months. Sham-control participants performed unilateral balance exercises of equivalent duration.

Results

The jumps were well tolerated, with women in the jumping group completing 95% of the prescribed exercise. Of the participants who completed the study (n = 23 intervention, n = 16 control), there were no significant differences in broadband ultrasound attenuation (BUA) using quantitative ultrasound (QUS) of the calcaneum within and between groups (mean ± SD BUA = 64.9 ± 7.3 and 66.6 ± 6.5 dB/MHz for intervention pre- and post-trial, respectively, versus mean ± SD BUA = 63.6 ± 4.2 and 64.4 ± 4.5 dB/MHz for sham-controls pre- and post-trial, respectively) or for any QUS parameters, although there was a 3% increase in BUA for intervention participants.

Conclusions

Recruitment and participation rates were feasible for this duration of study and the exercise was acceptable. For a future study of this nature, 48 participants would be required to ensure adequate power, especially as lifestyle variations and post-menopausal hypoestrogenism prevent substantial gains in bone strength with high-impact exercise.

Nutrient Patterns and Risk of Osteopenia in Postmenopausal Women

Nutrient patterns (NPs) and the synergistic effect between nutrients have been shown to be associated with changes in bone mineral density (BMD). This study aimed to identify NPs and to associate them with BMD categories in postmenopausal women. This cross-sectional, observational, analytical study was carried out with women in menopause for at least 12 months, aged ≥50 years. Sociodemographic, lifestyle, and clinical variables were investigated. BMD was assessed using dual energy X-ray absorptiometry. A dietary assessment was conducted using a food frequency questionnaire, and three nutrient patterns (NP1, NP2, and NP3) were extracted from the principal component analysis. Multivariate logistic regression was applied to investigate the association between BMD classifications and NP consumption. A total of 124 women, aged on average, 66.8 ± 6.1 years, were evaluated. Of these, 41.9% had osteopenia and 36.3% had osteoporosis. The NP1 (OR: 6.64, [CI95%: 1.56-28.16]; p = 0.010), characterized by vitamin B12, pantothenic acid, phosphorus, riboflavin, protein (total and animal), vitamin B6, potassium, vitamin D, vitamin E, calcium, cholesterol, β-carotene, omega 3, magnesium, zinc, niacin, and selenium; and the NP2 (OR: 5.03, [CI95%: 1.25-20.32]; p = 0.023), characterized by iron, vegetable protein, thiamine, folate, fibers (soluble and insoluble), PUFA, vitamin A, vitamin K, alpha-tocopherol, copper, sodium, and retinol, was inversely associated with osteopenia. The lower consumption of NP1 and NP2 by postmenopausal women was associated with a higher risk of osteopenia, but not osteoporosis.

Quantitative Ultrasound Examination (QUS) of the Calcaneus in Long-Term Martial Arts Training on the Example of Long-Time Practitioners of Okinawa Kobudo/Karate Shorin-Ryu

Quantitative research of bone tissue related to physical activity (PA) and sport has a preventive dimension. Increasing the parameters of bone tissue strength, especially reaching the maximum value of peak bone strength in childhood, adolescence, and early adulthood due to practicing sports can contribute to maintaining bone health throughout life. Practicing martial arts (tai chi, traditional karate, judo, and boxing) can effectively improve the quality of bone and reduce the risk of falls and fractures. The study aimed to evaluate the calcaneus bones among Okinawa Kobudo/Karate Shorin-Ryu practitioners using the quantitative ultrasound method as an indicator for assessing bone fracture risk. Forty-four adult martial arts practitioners with a mean age of 36.4 participated in this study. Quantitative ultrasound (QUS) with a portable Bone Ultrasonometer was used in this study. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and the stiffness index (SI) were measured. Subjects were assigned to two groups of black and color belts, according to the advancement in Kobudo/karate practice. The measurements of the SI, BUA, SOS, T-score, and Z-score were significantly higher in subjects from the advanced, long-term practice (black belts) (p < 0.05). The long-term martial arts training in traditional karate and Kobudo significantly impacts the parameters of the calcaneus quantitative ultrasound measurements. Significantly higher bone density was observed among the black belt holders. Long-term practice subjects achieved results far beyond the norm for their age groups. Further studies using non-invasive methods of bone quantification are needed to determine the specific conditions for preventing osteoporosis through physical activity, sports, and martial arts, particularly the duration of the activity, the magnitude of loads, and other related factors.

Impact of Physical Rehabilitation on Bone Biomarkers in Non-Metastatic Breast Cancer Women: A Systematic Review and Meta-Analysis

Rehabilitation might improve bone health in breast cancer (BC) patients, but the effects on bone biomarkers are still debated. Thus, this meta-analysis of randomized controlled trials (RCTs) aims at characterizing the impact of rehabilitation on bone health biomarkers in BC survivors. On 2 May 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for RCTs assessing bone biomarker modifications induced by physical exercise in BC survivors. The quality assessment was performed with the Jadad scale and the Cochrane risk-of-bias tool for randomized trials (RoBv.2). Trial registration number: CRD42022329766. Ten studies were included for a total of 873 patients. The meta-analysis showed overall significant mean difference percentage decrease in collagen type 1 cross-linked N-telopeptide (NTX) serum level [ES: -11.65 (-21.13, -2.17), p = 0.02)] and an increase in bone-specific alkaline phosphatase (BSAP) levels [ES: +6.09 (1.56, 10.62). According to the Jadad scale, eight RCTs were considered high-quality studies. Four studies showed a low overall risk of bias, according to RoBv.2. The significant effects of rehabilitation on bone biomarkers suggested a possible implication for a precision medicine approach targeting bone remodeling. Future research might clarify the role of bone biomarkers monitoring in rehabilitation management of cancer treatment induced bone-loss.

The impact of rehabilitation in bone loss management of patients with spinal cord injury: A systematic review

BACKGROUND

Spinal cord injury (SCI) is a disabling condition characterized by multilevel skeletal muscle impairment and rapid cortical and trabecular bone loss. Rehabilitation is a cornerstone of the long-term management of patients with SCI; however, the optimal rehabilitation strategy for improving bone health has not been fully characterized.

OBJECTIVE

To characterize the current evidence supporting different rehabilitation interventions improving bone health in patients with SCI.

METHODS

On November 17th, 2022, five databases (PubMed, Scopus, Web of Science, Cochrane, and PEDro) were systematically searched for randomized controlled trials (RCTs) assessing SCI patients undergoing rehabilitation interventions. The primary outcomes were bone macroscopical effects. Secondary outcomes were changes in bone metabolisms and functional outcomes.

RESULTS

Out of 499 records, 11 RCTs met the eligibility criteria and were included. Electrical stimulation combined with physical exercise was assessed by 5 studies, standing intervention was assessed by 3 studies, vibration was assessed by 1 study, ultrasound therapy was assessed by 1 study, and electroacupuncture combined with a pulsed magnetic field was assessed by 1 study. The rehabilitation intervention was administered combined with pharmacological treatment (3 studies) or alone (8 studies). Positive effects in terms of BMD were reported by 3 studies. The quality assessment revealed some concerns in 9 out of 11 studies, in accordance with the Cochrane Risk of Bias assessment - version 2.

CONCLUSION

Our data suggest that multicomponent interventions including rehabilitation might be considered a suitable option to improve bone health management in SCI patients. Further studies are mandatory to characterize the optimal combination of non-pharmacological interventions reducing bone loss and improving the risk of fractures in patients with SCI.

Wearing an Activating Spinal Orthosis and Physical Training in Women With Osteoporosis and Back Pain: A Postintervention Follow-Up Study

Objective

To assess the duration of benefits on back pain and back extensor strength in women with osteoporosis who had previously participated in a randomized controlled trial (RCT) involving either exercise or wearing a spinal orthosis.

Design

A 6-month postintervention follow-up of women who were involved in the interventions in the RCT.

Setting

The study was conducted in a primary health care center in Stockholm, Sweden.

Participants

In this follow-up study 31 women participated in the spinal orthosis group, and 31 women participated in the exercise group, with a median age of 76 years in both groups (N=62). All women were diagnosed as having osteoporosis, had back pain with or without vertebral fracture, and were 60 years or older, which were the inclusion criteria in the RCT.

Interventions

The participants received no controlled supervision. The spinal orthosis group was asked to wear the orthosis, and the training group was asked to follow an exercise program for another 6 months voluntarily.

Main Outcome Measures

Back extensor strength was measured with a computerized device; back pain was estimated by the visual analog scale and by Borg CR-10.

Results

After 6 months there were no significant differences between the groups in back extensor strength or back pain. Analyses within the groups showed that achieved results during 6 months intervention in the RCT were maintained after 6 months of voluntary use of the spinal orthosis and training. In the spinal orthosis group, back extensor strength mean was 81.7 N, and back pain median was 3 mm. In the training group back extensor strength mean was 72.8 N, and back pain median was 3 mm. There were no changes for any other measurements performed.

Conclusions

Voluntary use of the spinal orthosis or exercise during a 6-month follow-up period maintained the increase in back extensor muscle strength obtained during the RCT. Estimation of back pain was not influenced. This indicates that the women had continued to use the spinal orthosis and exercise.

Cognitive and balance dysfunctions due to the use of zolpidem in the elderly: a systematic review

Zolpidem is one of the most widely prescribed hypnotic (non-benzodiazepine) agents for sleep disorder. Recently, an increase in the demand for this drug has been observed, mainly in the elderly population.

Objective

This study aims to analyze the acute effect of zolpidem on cognitive and balance dysfunctions in the elderly population.

Methods

A study was conducted by two independent researchers in four virtual scientific information bases and included randomized controlled trials. The studies evaluated elderly patients using zolpidem. Cognitive and balance dysfunctions were analyzed.

Results

Six articles were included. The mean age of the participants in the studies was 69 years. The following zolpidem dosages were evaluated: 5, 6.25, 10, and 12.5 mg. Comparing zolpidem and placebo, relating to the cognitive dysfunctions, there is no statistically significant difference between the groups. However, in relation to balance dysfunctions, there is a statistically significant difference between the intervention and the comparison, favoring placebo.

Conclusions

Zolpidem, even in usual doses (5 mg and 10 mg), has shown to increase the risk for balance dysfunctions. However, this does not occur in relation to cognitive changes.

Evaluation of postural stability in patients screened for osteoporosis: A retrospective study of 1086 cases

BACKGROUND

Although the interactions between balance, falls and fracture risk have been demonstrated in various aspects, the clinical focus of fracture risk evaluation has been on bone properties, e.g., bone mineral density (BMD). Accordingly, the role of balance parameters in the setting of osteoporosis assessment remained to be further explored.

RESEARCH QUESTION

Is postural stability assessed by Romberg quiet stance posturography influenced by BMD or prior fragility fractures in a cohort of more than 1000 patients screened for osteoporosis?

METHODS

Patients who completed both Romberg test and dual energy X-ray absorptiometry (DXA) were included retrospectively from a large database. Quantification of the Romberg test was performed by using posturography. Center of pressure (CoP) movements were tracked and the corresponding path length for ten seconds as well as an ellipse area including 90 % of all CoP were calculated. To determine potential predictors of posturography, simple and multiple linear regression analyses were performed including DXA results, grip strength, age, sex and BMI. As a secondary outcome, the influence of a previous fragility fracture on postural stability was evaluated.

RESULTS

Overall, 1086 patients (801 women, 285 men) met the inclusion criteria. Lower femoral BMD T-score (p < 0.05), higher age (p < 0.001) and male sex (p < 0.001) were associated with higher Romberg path length (both eyes open and eyes closed). Both women and men with any previous fragility fracture showed significantly increased values in the path length with eyes open (p < 0.05) and eyes closed (women p < 0.001, men p < 0.05) compared to those without a history of a fragility fracture.

SIGNIFICANCE

Our study indicates that postural stability is affected by femoral BMD, age and sex. As a history of prior fragility fracture was associated with postural instability, assessment and management of impaired balance in everyday clinical practice is advisable for optimal fracture prevention.

Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider

Objective

To perform a systematic literature review (SLR) about the effect of non-pharmacological interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures.

Methods

Eight clinical questions based on two criteria guided the SLR: (1) adults≥50 years at high risk of osteoporotic fracture and (2) interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Interventions focused on diagnostic procedures to identify risk of falling, therapeutic approaches and implementation strategies. Outcomes included fractures, falls, risk of falling and change in bone mineral density. Systematic reviews and randomised controlled trials were preferentially selected. Data were synthesised using a qualitative descriptive approach.

Results

Of 15 917 records, 43 articles were included. Studies were clinically and methodologically diverse. We identified sufficient evidence that structured exercise, incorporating progressive resistance training delivered to people who had undergone hip fracture surgery, and multicomponent exercise, delivered to people at risk of primary fracture, reduced risk of falling. The effectiveness of multidisciplinary fracture liaison services in reducing refracture rate was confirmed. There was insufficient evidence found to support the effectiveness of nutrients and falls prevention programmes in this patient population.

Conclusion

Despite study heterogeneity, our SLR showed beneficial effects of some interventions delivered by non-physician health professionals and the positive impact of multidisciplinary team working and patient educational approaches to prevent and manage osteoporotic fractures. These results informed a EULAR taskforce that developed points to consider for non-physician health professionals to prevent and manage osteoporotic fractures.

Uncovering the Bone-Muscle Interaction and Its Implications for the Health and Function of Older Adults (the Wellderly Project): Protocol for a Randomized Controlled Crossover Trial

BACKGROUND

Bone and muscle are closely linked anatomically, biochemically, and metabolically. Acute exercise affects both bone and muscle, implying a crosstalk between the two systems. However, how these two systems communicate is still largely unknown. We will explore the role of undercarboxylated osteocalcin (ucOC) in this crosstalk. ucOC is involved in glucose metabolism and has a potential role in muscle maintenance and metabolism.

OBJECTIVE

The proposed trial will determine if circulating ucOC levels in older adults at baseline and following acute exercise are associated with parameters of muscle function and if the ucOC response to exercise varies between older adults with low muscle quality and those with normal or high muscle quality.

METHODS

A total of 54 men and women aged 60 years or older with no history of diabetes and warfarin and vitamin K use will be recruited. Screening tests will be performed, including those for functional, anthropometric, and clinical presentation. On the basis of muscle quality, a combined equation of lean mass (leg appendicular skeletal muscle mass in kg) and strength (leg press; one-repetition maximum), participants will be stratified into a high or low muscle function group and randomized into the controlled crossover acute intervention. Three visits will be performed approximately 7 days apart, and acute aerobic exercise, acute resistance exercise, and a control session (rest) will be completed in any order. Our primary outcome for this study is the effect of acute exercise on ucOC in older adults with low muscle function and those with high muscle function.

RESULTS

The trial is active and ongoing. Recruitment began in February 2018, and 38 participants have completed the study as of May 26, 2019.

CONCLUSIONS

This study will provide novel insights into bone and muscle crosstalk in older adults, potentially identifying new clinical biomarkers and mechanistic targets for drug treatments for sarcopenia and other related musculoskeletal conditions.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12618001756213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375925.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18777.

Higher-Impact Physical Activity Is Associated With Maintenance of Bone Mineral Density But Not Reduced Incident Falls or Fractures in Older Men: The Concord Health and Aging in Men Project

High-impact physical activities with bone strains of high magnitude and frequency may benefit bone health. This study aimed to investigate the longitudinal associations between changes in loading intensities and application rates, estimated from self-reported physical activity, with bone mineral density (BMD) changes over 5 years and also with incident falls over 2 years and long-term incident fractures in community-dwelling older men. A total of 1599 men (mean age 76.8 ± 5.4 years) from the Concord Health and Aging in Men Project (CHAMP) were assessed at baseline (2005-2007) and at 2- and 5-year follow-up. At each time point, hip and lumbar spine BMD were measured by dual-energy X-ray absorptiometry, and physical activity energy expenditure over the past week was self-reported via the Physical Activity Scale for the Elderly (PASE) questionnaire. Sum effective load ratings (ELRs) and peak force were estimated from the PASE questionnaire, reflecting the total and highest loading intensity and application rate of physical activities, respectively. Participants were contacted every 4 months over 2 years to self-report falls and over 6.0 ± 2.2 years for fractures. Hip fractures were ascertained by data linkage for 8.9 ± 3.6 years. Compared with sum ELR and PASE scores, peak force demonstrated the greatest standardized effect size for BMD maintenance at the spine (β = 9.77 mg/cm² ), total hip (β = 14.14 mg/cm² ), and femoral neck (β = 13.72 mg/cm² ) after adjustment for covariates, including PASE components (all p < .01). Only PASE scores were significantly associated with reduced falls risk (standardized incident rate ratio = 0.90, 95% confidence interval 0.81-1.00, p = .04). All physical activity measures were significantly associated with reduced incident fractures in univariate analyses, but none remained significant after multivariable adjustments. Older men who engaged in physical activity of high and rapid impact maintained higher BMD, while higher energy expenditure was associated with reduced falls risk. Coupling traditional physical activity data with bone loading estimates may improve understanding of the relationships between physical activity and bone health. © 2020 American Society for Bone and Mineral Research (ASBMR).

An Overview of the Molecular Mechanisms Contributing to Musculoskeletal Disorders in Chronic Liver Disease: Osteoporosis, Sarcopenia, and Osteoporotic Sarcopenia

The prevalence of osteoporosis and sarcopenia is significantly higher in patients with liver disease than in those without liver disease and osteoporosis and sarcopenia negatively influence morbidity and mortality in liver disease, yet these musculoskeletal disorders are frequently overlooked in clinical practice for patients with chronic liver disease. The objective of this review is to provide a comprehensive understanding of the molecular mechanisms of musculoskeletal disorders accompanying the pathogenesis of liver disease. The increased bone resorption through the receptor activator of nuclear factor kappa (RANK)-RANK ligand (RANKL)-osteoprotegerin (OPG) system and upregulation of inflammatory cytokines and decreased bone formation through increased bilirubin and sclerostin and lower insulin-like growth factor-1 are important mechanisms for osteoporosis in patients with liver disease. Sarcopenia is associated with insulin resistance and obesity in non-alcoholic fatty liver disease, whereas hyperammonemia, low amount of branched chain amino acids, and hypogonadism contributes to sarcopenia in liver cirrhosis. The bidirectional crosstalk between muscle and bone through myostatin, irisin, β-aminoisobutyric acid (BAIBA), osteocalcin, as well as the activation of the RANK and the Wnt/β-catenin pathways are associated with osteosarcopenia. The increased understandings for these musculoskeletal disorders would be contributes to the development of effective therapies targeting the pathophysiological mechanism involved.

Association between post-traumatic stress disorder symptoms and bone fractures after the Great East Japan Earthquake in older adults: a prospective cohort study from the Fukushima Health Management Survey

Background

It has been reported that psychological stress affects bone metabolism and increases the risk of fracture. However, the relationship between bone fractures and post-traumatic stress disorder (PTSD) is unclear. This study aimed to evaluate the effects of disaster-induced PTSD symptoms on fracture risk in older adults.

Methods

This study evaluated responses from 17,474 individuals aged ≥ 65 years without a history of fractures during the Great East Japan Earthquake who answered the Mental Health and Lifestyle Survey component of the Fukushima Health Management Survey conducted in 2011. The obtained data could determine the presence or absence of fractures until 2016. Age, sex, physical factors, social factors, psychological factors, and lifestyle factors were subsequently analyzed. Survival analysis was then performed to determine the relationship between the fractures and each factor. Thereafter, univariate and multivariate Cox proportional hazard models were constructed to identify fracture risk factors.

Results

In total, 2,097 (12.0%) fractures were observed throughout the follow-up period. Accordingly, univariate and multivariate Cox proportional hazard models showed that PTSD symptoms (total PTSD checklists scoring ≥ 44) [hazard ratio (HR): 1.26; 95% confidence interval (CI): 1.10–1.44; P = 0.001], history of cancer (HR: 1.49; 95% CI: 1.24–1.79; P < 0.001), history of stroke (HR: 1.25; 95% CI: 1.03–1.52; P = 0.023), history of heart disease (HR: 1.30; 95% CI: 1.13–1.50; P < 0.001), history of diabetes (HR: 1.23; 95% CI: 1.09–1.39; P < 0.001), current smoking (HR: 1.29; 95% CI: 1.02–1.63; P = 0.036), and high dissatisfaction with sleep or no sleep at all (HR: 1.33; 95% CI: 1.02–1.74; P = 0.035) promoted a significant increase in fracture risk independent of age and sex.

Conclusions

The present study indicates that disaster-induced PTSD symptoms and insomnia contribute to increased fracture risk among older adults residing in evacuation areas within the Fukushima Prefecture.

Non-Pharmacological Interventions in Osteosarcopenia: A Systematic Review

BACKGROUND

Osteosarcopenia is a geriatric syndrome defined by the concomitant presence of osteopenia/osteoporosis (loss of bone mineral density (BMD)) and sarcopenia (loss of muscle mass and/or function), which increases the risk of falls, fractures, and premature mortality.

OBJECTIVE

To examine the efficacy of non-pharmacological (exercise and/or nutritional) interventions on musculoskeletal measures and outcomes in osteosarcopenic adults by reviewing findings from randomized controlled trials (RCTs).

METHODS

This review was registered at PROSPERO (registration number: CRD42020179292) and conducted in accordance with the PRISMA guidelines. Electronic databases were searched for RCTs assessing the effect of at least one non-pharmacological intervention (any form of exercise and/or supplementation with protein, vitamin D, calcium or creatine) on any musculoskeletal measure/outcome of interest (BMD, bone strength/turnover, muscle mass and strength, physical performance, falls/fractures) in adults with osteosarcopenia as defined by any proposed criteria.

RESULTS

Two RCTs (of n=106 older osteosarcopenic adults (≥65 years)) assessing the effects of progressive resistance training (RT) (via resistance bands or machines; 2-3 times/week; ~60 minutes in duration) were eligible for inclusion. The two RCTs demonstrated moderate quality evidence that RT increases muscle mass, strength, and quality, with changes in strength and quality occurring before muscle mass (12 vs 28 weeks). There was low quality evidence that RT increases lumbar spine BMD and maintains total hip BMD when performed for 12 and 18 months, respectively, and moderate quality evidence that RT has no effect on markers of bone turnover or physical performance. No major adverse effects were recorded in either of the RCTs. There were no eligible RCTs examining the impact of nutritional interventions.

CONCLUSION

Chronic RT is safe and effective at potentiating gains in muscle mass, strength, and quality, and increasing or maintaining BMD in older osteosarcopenic adults. No RCT has examined the effects of protein, vitamin D, calcium, or creatine against a control/placebo in this high-risk population.

2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older

OBJECTIVE

To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older.

METHODS

Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated.

RESULTS

Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6.

CONCLUSION

These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.

Differential Risk of Incident Fractures Depending on Intensity and Frequency of Physical Activity According to Cognitive Status: A Nationwide Longitudinal Study

Background: Previous studies have demonstrated an increased risk of fractures in subjects with various degrees of cognitive impairments. Recently, there has been growing recognition of the vital effect of physical activity (PA) on delay and prevention of fractures in older adults.

Objectives: This study aimed to evaluate the optimal intensity and frequency of PA needed to prevent fractures in cognitively preserved older adults (CP), participants with subjective cognitive decline (SCD), and dementia patients using a large-scale nationwide cohort study.

Methods: Data from a nationwide health screening program for individuals at the transitional age of 66 years were used in this study. A total of 968,240 subjects was enrolled, followed from 2007 to 2014, and classified as CP (n = 759,874), SCD (n = 195,365), or dementia group (n = 13,001). Adjusted hazard ratios (aHRs) by demographic and known risk factors for fractures were evaluated to identify the impact of various frequency and intensity PA on the occurrence of hip, vertebral, and limb fractures.

Results: In CP participants, the most noticeable reduction of hip and vertebral fracture risk was shown in those performing vigorous-intensity PA at least three times per week. In the SCD group, the risk decrement in hip and vertebral fractures was most prominent in subjects who performed multiple-intensity PAs at least three times a week regardless of intensity. In the dementia group, only high-frequency walking and high-frequency & multiple-intensity PA decreased the risk of hip fractures compared with absence of PA.

Conclusion: These findings suggest a role for various PA intensity and frequency levels to prevent hip and vertebral fractures according to cognitive status. Further study is needed to validate the effects of PA intensity and frequency proposed in this study on fractures according to cognitive status.

Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour

BACKGROUND

Various physical activity interventions for prevention and treatment of osteoporosis have been designed and evaluated, but the effect of such interventions on the prevention of osteoporosis in older people is unclear. The aim of this review was to investigate the association between physical activity and osteoporosis prevention in people aged 65 years and above.

METHODS

A systematic review was conducted and searches for individual studies were conducted in PubMed (January 2010 to March 2020) and for systematic reviews were conducted in PubMed, Embase, CINAHL and SPORTDiscus (January 2008 to July 2020). Records were screened according to the following eligibility criteria: i) population: adults aged 65 years and older; ii) exposure: greater volume, duration, frequency, or intensity of physical activity; iii) comparison: no physical activity or lesser volume, duration, frequency, or intensity of physical activity; iv) outcome: osteoporosis related measures (e.g., bone mineral density). The methodological quality of included studies was assessed and meta-analysis summarised study effects. The GRADE approach was used to rate certainty of evidence.

RESULTS

We included a total of 59 studies, including 12 observational studies and 47 trials. Within the included trials, 40 compared physical activity with no intervention controls, 11 compared two physical activity programs, and six investigated different doses of physical activity. Included studies suggest that physical activity interventions probably improve bone health among older adults and thus prevent osteoporosis (standardised effect size 0.15, 95% CI 0.05 to 0.25, 20 trials, moderate-certainty evidence, main or most relevant outcome selected for each of the included studies). Physical activity interventions probably improve lumbar spine bone mineral density (standardised effect size 0.17, 95% CI 0.04 to 0.30, 11 trials, moderate-certainty evidence) and may improve hip (femoral neck) bone mineral density (standardised effect size 0.09, 95% CI - 0.03 to 0.21, 14 trials, low-certainty evidence). Higher doses of physical activity and programs involving multiple exercise types or resistance exercise appear to be most effective. Typical programs for which significant intervention impacts were detected in trials were undertaken for 60+ mins, 2-3 times/week for 7+ months. Observational studies suggested a positive association between long-term total and planned physical activity on bone health.

CONCLUSIONS

Physical activity probably plays a role in the prevention of osteoporosis. The level of evidence is higher for effects of physical activity on lumbar spine bone mineral density than for hip. Higher dose programs and those involving multiple exercises and resistance exercises appear to be more effective.

Physical fitness in older women with osteoporosis and vertebral fracture after a resistance and balance exercise programme: 3-month post-intervention follow-up of a randomised controlled trial

Background

Exercise is recommended for individuals with vertebral fractures, but few studies have investigated the effect of exercise on outcomes of importance for this population. Post-intervention effects of exercise are even less studied. The objective of this study was to evaluate habitual walking speed and other health-related outcomes after cessation of a 3-month exercise intervention.

Methods

This follow-up study was conducted 3 months post-intervention of a randomised controlled trial. A total of 149 community-dwelling Norwegian women aged 65 years or older, diagnosed with osteoporosis and vertebral fracture were randomised into either exercise or control group. Primary outcome was habitual walking speed at 3 months. Secondary outcomes were other measures of physical fitness – including the Four Square Step Test (FSST), functional reach, grip strength and Senior Fitness Test – measures of health-related quality of life and fear of falling. Herein we report secondary data analysis of all outcomes at 6 months (3 months post-intervention). Data were analysed according to the intention-to-treat principle, linear mixed regression models were employed.

Results

For the primary outcome, habitual walking speed, there was no statistically significant difference between groups (0.03 m/s, 95%CI − 0.02 to 0.08, p = 0.271) at the 3-month post-intervention follow-up. For secondary outcomes of physical fitness, statistically significant differences in favour of the intervention group were found for balance using the FSST (− 0.68 s, 95%CI − 1.24 to − 0.11, p = 0.019), arm curl (1.3, 95%CI 0.25 to 2.29, p = 0.015), leg strength using the 30-s sit to stand (1.56, 95%CI 0.68 to 2.44, p = 0.001) and mobility using the 2.45-m up and go (− 0.38 s, 95%CI − 0.74 to − 0.02, p = 0.039). There was a statistically significant difference between the groups regarding fear of falling in favour of the intervention group (− 1.7, 95%CI − 2.97 to − 0.38, p = 0.011). No differences between groups were observed for health-related quality of life.

Conclusion

The results show the improved effects of a multicomponent exercise programme on outcomes like muscle strength, balance and mobility as well as fear of falling in a group of older women with osteoporosis and vertebral fracture 3 months post-intervention.

Trial registration

ClinicalTrials.gov Identifier: NCT02781974. Registered 25.05.16. Retrospectively registered.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society

BACKGROUND

The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities.

METHODOLOGY

A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS.

RESULTS/CONCLUSION

A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Effects of whole-body vibration and high impact exercises on the bone metabolism and functional mobility in postmenopausal women

INTRODUCTION

This study determined the effects of whole-body vibration (WBV) and high-impact exercises on postmenopausal women.

MATERIALS AND METHODS

In this randomized controlled 6-month interventional trial, 58 eligible postmenopausal women were assigned to WBV training group, high-impact training group, or control group. Bone mineral density (BMD) of the lumbar spine and femur were measured by dual-energy X-ray absorptiometry. Additionally, the serum osteocalcin (OC) and C-terminal telopeptide of type I collagen levels were also measured. The functional mobility was assessed using the Timed Up and Go (TUG) test, and fall index was measured using static posturography. The health-related quality of life (HRQoL) and depressive symptoms were assessed using the Quality of Life Questionnaire of the European Foundation for Osteoporosis and Beck Depression Inventory, respectively.

RESULTS

The BMD at the femoral neck (p = 0.003) and L₂-L₄ (p = 0.005) regions increased significantly in the WBV group compared to the control group. However, in the high-impact exercise group there were no significant effects on the lumbar spine and femoral neck. The serum OC decreased significantly in the WBV group and increased significantly in both the high-impact exercise and control groups (p < 0.001). The TUG scores decreased significantly in both training groups compared to the control group (p < 0.05). Finally, in both exercise groups, HRQoL and depressive symptoms improved (p < 0.001).

CONCLUSIONS

Our data suggest that the WBV can prevent bone loss in postmenopausal women. These findings also indicate that WBV and high-impact training programs improve functional mobility, HRQoL and depressive symptoms in postmenopausal women.

A randomised feasibility study assessing an intervention to keep adults physically active after falls management exercise programmes end

BACKGROUND

Physical inactivity contributes to disability and falls in older adults. Falls prevention exercise (FaME) programmes improve physical activity and physical function and reduce falling rates. Improvements in physical function are reduced, and falls rates increase, if physical activity is not maintained. This research investigated the feasibility and acceptability of an intervention that aimed to maintain physical activity in older adults exiting FaME.

METHODS

The Keeping Adults Physically Active (KAPA) intervention comprised of six group sessions of motivational interviewing, delivered monthly by trained and mentor-supported postural stability instructor's after the FaME programme ceased. The KAPA intervention included participant manuals, illustrated exercise books, physical activity diaries and pedometers. A feasibility study was conducted in 8 FaME classes. The study design was a two-arm, cluster randomised, multi-site feasibility study comparing the KAPA intervention with usual care. A sample of 50 community-dwelling adults aged 65 years old or older were recruited. Recruitment, retention and attendance rates, self-reported physical activity and participant interviews were used to examine the feasibility and acceptability of the KAPA intervention.

RESULTS

Fifty of the sixty-seven (74.6%) participants invited into the study agreed to take part, 94.2% of the available KAPA sessions were attended and 92.3% of the recruited participants provided outcome data. The KAPA participants expressed positive views about the venues and postural stability instructors and reported enjoying the group interactions. Intervention participants discussed increasing their physical activity in response to the peer-support, illustrated home exercise booklet, physical activity diaries and pedometers. Most discussed the written tasks to be the least enjoyable element of the KAPA intervention. The proportion of participants reporting at least 150 minutes of moderate to vigorous physical activity per week rose from 56.3 to 62.5% in the intervention arm and from 41.4 to 52.0% in the usual care arm.

CONCLUSIONS

The participants found the KAPA intervention acceptable. Participants reported the exercise booklet, peer support and the physical activity monitoring tools encouraged them to keep active. A full-scale trial is needed to assess whether physical activity can be significantly maintained in response to the KAPA intervention.

TRIAL REGISTRATION

Retrospectively registered on ClinicalTrials.gov (NCT03824015).

Exercise-based correlates to calcaneal osteogenesis produced by a chronic training intervention

Thirty workouts on a gravity-independent device (Impulse Training Systems, Newnan GA) evoked significant calcaneal bone mineral content (BMC, +29%) and density (BMD, +33%) gains. High speeds and impact loads were produced per repetition. We examined exercise performance variables from the 30-workout intervention to identify correlates to delta (∆) calcaneal BMC and BMD variance. Workouts included hip extension and seated calf press exercises done with subject's left legs. ∆ values were obtained from the first and 12th workouts for the hip extension movement, and for the first and 24th workouts for the seated calf press exercise. Per exercise the following variables were quantified: peak force (∆PF), peak acceleration (∆PA), impulse (∆I), and dwell times (∆DT). Dwell times are the elapsed time between the end of the eccentric phase, and the start of the next repetition's concentric phase. Pearson Coefficients assessed correlations between performance and criterion variables. With hip extension ∆DT calculated with data from the first and 12th workouts, there were significant correlations with calcaneal ∆BMC (r = -0.64) and ∆BMD (r = -0.63). With seated calf press ∆DT derived as the difference from the first and 24th workouts, there was a significant correlation with calcaneal ∆BMC (r = -0.48), but only a trend (r = -0.45) with ∆BMD as the criterion. No other variables correlated with significant amounts of calcaneal ∆BMC and ∆BMD variance. Negative correlations infer shorter dwell times evoked greater gains. The gravity-independent device warrants continued inquiry to treat and abate calcaneal losses.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

This trial was based in 21 NHS physiotherapy departments.

PARTICIPANTS

The participants were people with symptomatic OVF.

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49117867.

FUNDING

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

Determining known-group validity and test-retest reliability in the PEQ (personalized exercise questionnaire)

BACKGROUND

To determine the known-group validity, a type of construct validity, and the test-retest reliability of a newly developed tool, the Personalized Exercise Questionnaire (PEQ), that assesses the barriers, facilitators, and preferences to exercise in individuals with low bone mass and osteoporosis.

METHODS

A comparative design was used to assess known-group validity and a test-retest design to examine the reproducibility. Ninety-five participants with low bone mass and osteoporosis were recruited from an outpatient clinic in Hamilton, Ontario. The questionnaire was administered to 95 participants at baseline and a subset of 42 participants completed the survey again one week later. The known-group validity of the PEQ was determined using four hypotheses that compared two known groups based on employment level, age, socioeconomic status, and physical activity level. The reproducibility of individual responses was analyzed using the Kappa Coefficient (κ).

RESULTS

There was known-group validity for three of the four hypotheses. Test-retest reliability scores ranged from no agreement to almost perfect agreement; seven items had almost perfect agreement (κ: 0.81-1.00), 12 substantial agreement (κ: 0.68-0.74), six moderate agreement (κ: 0.56-0.60), two fair agreement (κ: 0.36-0.40), one slight agreement (κ = 0.23) and one no agreement (κ = - 0.03).

CONCLUSION

Preliminary support for the usefulness of the PEQ is indicated since the majority of the items had at least substantial agreement and known-group validity was moderately supported for some items.

TRIAL REGISTRATION

This study was retrospectively registered with ClinicalTrials.gov , NCT03125590, on April 24, 2017.

The fracture predictive ability of a musculoskeletal composite score in old men - data from the MrOs Sweden study

Background

Detection of high-risk individuals for fractures are needed. This study assessed whether level of physical activity (PA) and a musculoskeletal composite score could be used as fracture predictive tools, and if the score could predict fractures better than areal bone mineral density (aBMD).

Methods

MrOs Sweden is a prospective population-based observational study that at baseline included 3014 men aged 69–81 years. We assessed femoral neck bone mineral content (BMC), bone area, aBMD and total body lean mass by dual energy X-ray absorptiometry, calcaneal speed of sound by quantitative ultrasound and hand grip strength by a handheld dynamometer. PA was assessed by the Physical Activity Scale for the Elderly (PASE) questionnaire. We followed the participants until the date of first fracture, death or relocation (median 9.6 years). A musculoskeletal composite score was calculated as mean Z-score of the five measured traits. A Cox proportional hazards model was used to analyze the association between the musculoskeletal traits, the composite score and incident fractures (yes/no) during the follow-up period. Data are presented as hazard ratios (HR) with 95% confidence intervals (95% CI) for fracture for a + 1 standard deviation (SD) change (+ 1 Z-score) in the various musculoskeletal traits as well as the composite score. We used a linear regression model to estimate the association between level of PA, measured as PASE-score and the different musculoskeletal traits as well as the composite score.

Results

A + 1 SD higher composite score was associated with an incident fracture HR of 0.61 (0.54, 0.69), however not being superior to aBMD in fracture prediction. A + 1 SD higher PASE-score was associated with both a higher composite score and lower fracture incidence (HR 0.83 (0.76, 0.90)).

Conclusions

The composite score was similar to femoral neck aBMD in predicting fractures, and also low PA predicted fractures. This highlights the need of randomized controlled trials to evaluate if PA could be used as a fracture preventive strategy.

The Efficacy and Safety of Lower-Limb Plyometric Training in Older Adults: A Systematic Review

BACKGROUND

The aging process is associated with a progressive decline of neuromuscular function, increased risk of falls and fractures, impaired functional performance, and loss of independence. Plyometric training may mitigate or even reverse such age-related deterioration; however, little research on the effects of plyometric exercises has been performed in older adults.

OBJECTIVE

The objective of this systematic review was to evaluate the safety and efficacy of plyometric training in older adults.

METHODS

Papers reporting on randomized trials of plyometric training in older adults (≥ 60 years) and published up to December 2017 were sought in the PubMed, SPORTDiscus, Scopus, and EMBASE databases, and their methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. A narrative synthesis of the findings is presented in this systematic review.

RESULTS

Of the 2236 identified papers, 18 were included in the review, reporting on 12 different studies with a mean PEDro score of 6.0 (range 4-7). Altogether, 289 subjects (176 females and 113 males) were included in 15 intervention groups with plyometric components (n = 8-36 per group); their mean age ranged from 58.4 to 79.4 years. The plyometric training lasted from 4 weeks to 12 months. Muscular strength, bone health, body composition, postural stability, and jump and physical performance were the most often reported outcomes. No study reported increased occurrence of injuries or other adverse events related to plyometric exercises.

CONCLUSION

Plyometric training is a feasible and safe training option with potential for improving various performance, functional, and health-related outcomes in older persons.

The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients

Physical exercise is considered an effective means to stimulate bone osteogenesis in osteoporotic patients. The authors reviewed the current literature to define the most appropriate features of exercise for increasing bone density in osteoporotic patients. Two types emerged: (1) weight-bearing aerobic exercises, i.e., walking, stair climbing, jogging, and Tai Chi. Walking alone did not appear to improve bone mass; however it is able to limit its progressive loss. In fact, in order for the weight-bearing exercises to be effective, they must reach the mechanical intensity useful to determine an important ground reaction force. (2) Strength and resistance exercises: these are carried out with loading (lifting weights) or without (swimming, cycling). For this type of exercise to be effective a joint reaction force superior to common daily activity with sensitive muscle strengthening must be determined. These exercises appear extremely site-specific, able to increase muscle mass and BMD only in the stimulated body regions. Other suggested protocols are multicomponent exercises and whole body vibration. Multicomponent exercises consist of a combination of different methods (aerobics, strengthening, progressive resistance, balancing, and dancing) aimed at increasing or preserving bone mass. These exercises seem particularly indicated in deteriorating elderly patients, often not able to perform exercises of pure reinforcement. However, for these protocols to be effective they must always contain a proportion of strengthening and resistance exercises. Given the variability of the protocols and outcome measures, the results of these methods are difficult to quantify. Training with whole body vibration (WBV): these exercises are performed with dedicated devices, and while it seems they have effect on enhancing muscle strength, controversial findings on improvement of BMD were reported. WBV seems to provide good results, especially in improving balance and reducing the risk of falling; in this, WBV appears more efficient than simply walking. Nevertheless, contraindications typical of senility should be taken into account.

Clinical decision making and application of an active rehabilitation program for a person with the neuromuscular symptoms of Allgrove syndrome: a case report

BACKGROUND

Allgrove syndrome is a multisystem disorder first described in 1978 and is classically associated with esophageal achalasia, alacrima, and adrenal insufficiency. Allgrove syndrome is caused by homozygous and/or compound heterozygous mutations on Chromosome 12q13, designated as "AAA" (Achalasia, Addisonianism Alacrima). AAA encodes the protein ALADIN (Alacrima, Achalasia, aDrenal Insufficiency Neurologic disorder), a member of the nuclear porin family forming the nuclear pore complex.

PURPOSE

The purpose of this case report is to illustrate the clinical decision making and results following an active rehabilitation program on a patient with Allgrove syndrome. A detailed physical examination is also provided to contribute to the body of knowledge regarding the clinical presentation of this disorder.

CONCLUSION

It appears that in this case, this patient with Allgrove syndrome demonstrated a significant increase in endurance, balance, and a return to functional activities and participation following a 10-week physical therapy program consisting of task-oriented exercise, aerobic training, postural control exercises, and patient education. Due to the pathophysiology of Allgrove syndrome, these patients cannot be exercised in a traditional manner. It is prudent to perform these interventions with precautions including frequent monitoring of vitals, rest breaks in cool environments, close supervision during balance tasks, and submaximal exercise at a Borg scale of moderate intensity. C.A.'s overall improvements illustrate the potential value of complementing the medical management of persons with Allgrove syndrome with active exercise interventions.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lifestyle Management of Diabetes: Implications for the Bone-Vascular Axis

PURPOSE OF REVIEW

To describe the main pathways involved in the interplay between bone and cardiovascular disease and to highlight the possible impact of physical activity and medical nutrition therapy on the bone-vascular axis.

RECENT FINDINGS

Diabetes increases the risk of both cardiovascular disease and bone fragility fractures, sharing common pathogenic pathways, including OPG/RANK/RANKL, the FGF23/Klotho axis, calciotropic hormones, and circulating osteogenic cells. This may offer new therapeutic targets for future treatment strategies. As lifestyle intervention is the cornerstone of diabetes treatment, there is potential for an impact on the bone-vascular axis. Evidence published suggests the bone-vascular axis encompasses key pathways for cardiovascular disease. This, along with studies showing physical activity plays a crucial role in the prevention of both bone fragility and cardiovascular disease, suggests that lifestyle intervention incorporating exercise and diet may be helpful in managing skeletal health decline in diabetes. Studies investigating the controversial role of high-fiber diet and dietary vitamin D/calcium on bone and cardiovascular health suggest an overall benefit, but further investigations are needed in this regard.

Effect of the Auricular Acupoint Associated with Physical Exercise in Elderly People: A Randomized Clinical Test

OBJECTIVE

To analyze the effect of auricular acupoint associated with physical exercise on balance, mobility, and fear of falling in the elderly.

METHOD

The study is characterized as a clinical, controlled, and randomized trial with 22 elderly people divided into two groups: kinesiotherapy group (n = 11) and kinesiotherapy/auriculotherapy group (n = 11). The instruments used for evaluation were Falls Efficacy Scale International; Berg Balance Scale, and Timed up and Go Test. The intervention was performed with frequency 2×/week for 8 weeks. In the kinesiotherapy/auriculotherapy group, in addition to kinesiotherapy, auriculotherapy was applied in specific acupoints. The Shapiro-Wilk test was used to determine the normality of the data, and for comparison, analysis of variance was used for repeated measures of two factors.

RESULTS

There was a significant intragroup reduction for the Timed up and Go Test (p = 0.00) and Falls Efficacy Scale International (p = 0.00), and significant intragroup Berg Balance Scale (p = 0.00) for both groups.

CONCLUSION

The auricular acupoint did not influence the balance, mobility, and fear of falling in the elderly studied.

Frequency and Associated Factors of Bone Fractures in Russians: The Ural Eye and Medical Study

With information about frequency of bone fractures in Russia mostly missing, we assessed the frequency of previous bone fractures in a Russian population. The population-based study Ural Eye and Medical Study included 5899 (80.5%) out of 7328 eligible individuals (mean age: 59.0 ± 10.7 years; range: 40–94 years). The history of previous bone fractures was assessed in a standardized interview for 5397 (91.5%) individuals. Mean frequency of any previous bone fracture was 1650/5397 (30.6%; 95% confidence interval (CI): 29, 3, 31.8). In multivariate analysis, higher frequency of bone fractures was associated with male sex (P < 0.001; odds ratio (OR): 1.67; 95% CI: 1.41, 2.00), urban region (P < 0.001; OR: 1.45; 95% CI: 1.23, 1.72), higher prevalence of vigorous activity during leisure (P < 0.001; OR: 1.42; 95% CI: 1.20, 1.68), current smoking (P = 0.001; OR: 1.46; 95% CI: 1.16, 1.82) and higher prevalence of cardiovascular disease (P = 0.007; OR: 1.29; 95% CI: 1.07, 1.56), low blood pressure episodes with hospital admission (P = 0.001; OR: 2.08; 95% CI: 1.37, 3.16), tumbling (P < 0.001; OR: 2.58; 95% CI: 1.37, 3.16) and thoracic spine pain (P < 0.001; OR: 1.43; 95% CI: 1.18, 1.73). In women, menopause (P < 0.001; OR: 2.17; 95% CI: 1.47, 3.22) was additionally associated. The most common single-bone fractures involved leg and knee (229/5397; 4.2%), hand in general (n = 169; 3.1%) or hand wrist only (n = 97; 1.8%), arm (n = 94; 1.7%) and ankle (n = 67; 1.2%). Severe fractures included spine (n = 35; 0.6%), os sacrum (n = 10; 0.2%), skull (n = 6; 0.1%), pelvis (n = 5; 0.1%) and hip (n = 22; 0.4%). Most frequent combined fractures included as most important part the leg (n = 90; 1.7%), spine (n = 18; 0.3%), and hip (n = 18; 0.3). These data give hints on the epidemiology of bone fractures in Russia.

Exercise Early and Often: Effects of Physical Activity and Exercise on Women's Bone Health

In 2011 over 1.7 million people were hospitalized because of a fragility fracture, and direct costs associated with osteoporosis treatment exceeded 70 billion dollars in the United States. Failure to reach and maintain optimal peak bone mass during adulthood is a critical factor in determining fragility fracture risk later in life. Physical activity is a widely accessible, low cost, and highly modifiable contributor to bone health. Exercise is especially effective during adolescence, a time period when nearly 50% of peak adult bone mass is gained. Here, we review the evidence linking exercise and physical activity to bone health in women. Bone structure and quality will be discussed, especially in the context of clinical diagnosis of osteoporosis. We review the mechanisms governing bone metabolism in the context of physical activity and exercise. Questions such as, when during life is exercise most effective, and what specific types of exercises improve bone health, are addressed. Finally, we discuss some emerging areas of research on this topic, and summarize areas of need and opportunity.

Loss of skeletal muscle mass in patients with chronic liver disease is related to decrease in bone mineral density and exercise tolerance

AIM

This study aimed to identify the relationship between loss of skeletal muscle mass and clinical factors such as osteoporosis in patients with chronic liver disease.

METHODS

The subjects were 112 patients (85 men and 27 women) with hepatocellular carcinoma who were scheduled to undergo hepatectomy. Skeletal muscle reduction was diagnosed according to the cut-off level of the skeletal mass index (SMI) for Asians (men <7.0 kg/m² , women <5.4 kg/m² ). Osteoporosis was diagnosed according to T-score ≤-2.5 standard deviation. The SMI and T-score were assessed using the results of dual-energy X-ray absorption. Peak oxygen consumption (PeakVO₂ ), an index of exercise tolerance, was evaluated using the cardiopulmonary exercise test. The characteristics of patients with low SMI (low SMI group) were compared with those of patients whose SMI was not low (control group). Outcomes are presented as median (interquartile range).

RESULTS

The T-score was significantly lower in the low SMI group (control vs. low SMI -1.1 [1.8] vs. -1.6 [1.9], P = 0.049). T-score positively correlated with SMI (r = 0.409, P < 0.0001). PeakVO₂ was significantly decreased in the low SMI group (17.7 [6.3] vs. 14.4 [4.5], P = 0.006). In multivariate logistic regression analysis, T-score (odds ratio [OR], 3.508; 95% confidence interval [CI], 1.074-11.456; P = 0.038) and PeakVO₂ (OR, 3.512; 95% CI, 1.114-11.066; P = 0.032) were significantly related to SMI, independent of age and sex.

CONCLUSIONS

Skeletal muscle reduction in chronic liver disease is closely related to exercise tolerance and osteoporosis, and these factors are believed to be associated with physical inactivity in daily life.

Development and validation of a new tool to measure the facilitators, barriers and preferences to exercise in people with osteoporosis

Background

Despite the widely known benefits of exercise and physical activity, adherence rates to these activities are poor. Understanding exercise facilitators, barriers, and preferences may provide an opportunity to personalize exercise prescription and improve adherence. The purpose of this study was to develop the Personalized Exercise Questionnaire (PEQ) to identify these facilitators, barriers, and preferences to exercise in people with osteoporosis.

Methods

This study comprises two phases, instrument design and judgmental evidence. A panel of 42 experts was used to validate the instrument through quantitative (content validity) and qualitative (cognitive interviewing) methods. Content Validity Index (CVI) is the most commonly used method to calculate content validity quantitatively. There are two kinds of CVI: Item-CVI (I-CVI) and Scale-level CVI (S-CVI).

Results

Preliminary versions of this tool showed high content validity of individual items (I-CVI range: 0.50 to 1.00) and moderate to high overall content validity of the PEQ (S-CVI/UA = 0.63; S-CVI/Ave = 0.91). Through qualitative methods, items were improved until saturation was achieved. The tool consists of 6 domains and 38 questions. The 6 domains are: 1) support network; 2) access; 3) goals; 4) preferences; 5) feedback and tracking; and 6) barriers. There are 35 categorical questions and 3 open-ended items.

Conclusions

Using an iterative approach, the development and evaluation of the PEQ demonstrated high item-content validity for assessing the facilitators, barriers, and preferences to exercise in people with osteoporosis. Upon further validation it is expected that this measure might be used to develop more client-centered exercise programs, and potentially improve adherence.

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1914-5) contains supplementary material, which is available to authorized users.

The Feldenkrais Method improves functioning and body balance in people with intellectual disability in supported employment: A randomized clinical trial

Loss of functioning and age-related health problems tend to appear earlier in individuals with intellectual disability (ID) than in their non-disabled peers. The Feldenkrais method (FM) is a movement-based form of learning that enhances body balance and physical functioning. We carried out an intervention based on Awareness Through Movement, a form of the FM. Thirty-two middle-aged (48.94±6.01years old) adults with ID who were in supported employment were recruited and randomly assigned to the experimental group (EG) or control group (CG). The EG received 30 Awareness Through Movement classes while the CG did not receive any movement-based intervention. Physical functioning (body balance, gait speed and chair stands) was assessed with the Short Physical Performance Battery (SPPB) and balance by stabilometry. After 30 FM classes, individuals in the EG had significantly improved their chair stand test score (p<0.005) and SPPB total score (p<0.005), and reduced their sway area (p<0.05) in the stabilometric test. These results indicate that the FM could be a good tool for the prevention of loss of functioning and body balance in middle-aged individuals with ID.

Effects of exercise improves muscle strength and fat mass in patients with high fracture risk: A randomized control trial

BACKGROUND

The deterioration of the musculoskeletal system imposes significant impact on physical activity. Exercise is an important strategy which minimizes these changes. It is not clear which type of exercise provides better improvement on low physical performance, low muscle mass and low strength of sarcopenia. We aim to develop an integrated care (IC) model and compare its relative efficacy in limb fat free mass, muscle strength, and physical performance with low extremities exercise (LEE) in community dwelling older adults with high risk of fractures (Fracture Risk Assessment Tool (FRAX^®)) ≧3% for hip fracture, ≧20% for major osteoporotic fracture or 1-min osteoporosis risk test (≧1 point) or fall (≧2 falls in previous year).

METHODS

Patients were assigned randomized to participate in either IC or LEE group (n = 55 each) for 3 months. All participants received education including home-based exercise. The IC group consisted of different modalities of exercise while the LEE group performed machine-based low extremities exercise. Fat free mass, muscle strength, and physical performance were measured at their baseline and 3-months follow-up.

RESULTS

Mean age was 73.8 ± 7 years with 69.1% women. Entire cohort demonstrated significant increment in fat free mass, muscle strength (4 indicators) and physical performance (3 indicators). However, between group differences were not significant.

CONCLUSION

With regular supervise exercise; both groups are equally effective in decreasing fat mass and increasing physical performance, muscle mass and strength. However, the IC group required fewer resources and thus more financially feasible in a community setting.

Critical issues and current challenges in osteoporosis and fracture prevention. An overview of unmet needs

Osteoporosis is a silent disease with increasing prevalence due to the global ageing population. Decreased bone strength and bone quality is the hallmark of osteoporosis which leads to an increased risk of fragility fractures in elderly. It has been estimated that approximately ~50% of women will suffer during their lifetime from an osteoporotic fracture. This must be considered as a major health concern, as it has previously been established that fragility fracture has been associated with decreased quality of life due to increased disability, more frequent hospital admission and most importantly, osteoporotic fractures have been related to an augmented mortality risk. Anti-osteoporotic drugs are available for improving bone quality. Although there is access to these therapeutic options, there remain multiple unmet needs in the field of osteoporosis and fracture care, for example, the primary prevention of osteoporosis in young individuals (to reach a high peak bone mass), the optimization of the use of imaging techniques [dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA) and new techniques measuring bone quality], the use of nonmedical treatment options and surgical techniques of fracture healing. In this review, we will discuss topics that play a role in the occurrence and prevention of fractures, and we give an overview of and insight into the critical issues and challenges around osteoporosis and fracture prevention.

Brazilian guidelines for the diagnosis and treatment of postmenopausal osteoporosis

Osteoporosis is the leading cause of fractures in the population older than 50 years. This silent disease affects primarily postmenopausal women and the elderly, and the morbidity and mortality rates are high. The main goal of treating osteoporosis is the prevention of fractures. The identification of populations at risk through early diagnosis and treatment is essential. The last Brazilian guideline for the treatment of postmenopausal osteoporosis was elaborated in 2002. Since then, new strategies for diagnosis and risk stratification have been developed, and drugs with novel action mechanisms have been added to the therapeutic arsenal. The Osteoporosis and Osteometabolic Diseases Committee of the Brazilian Society of Rheumatology, in conjunction with the Brazilian Medical Association and other Societies, has developed this update of the guidelines for the treatment of postmenopausal osteoporosis according to the best scientific evidence available. This update is intended for professionals in many medical and health specialties involved in the treatment of osteoporosis, for physicians in general and for health-related organizations.