Facilitators and barriers to exercise adherence in patients with osteopenia and osteoporosis: a systematic review

Non-pharmacological management of osteoporotic vertebral fractures: health-care professional perspectives and experiences

PURPOSE

To understand experiences and perceptions on non-pharmacological treatment of vertebral fractures and virtual-care from the perspective of care professionals' (HCPs).

DESIGN AND SETTING

We conducted semi-structured interviews with 13 HCPs within Canada (7 F, 6 M, aged 46 ± 12 years) and performed a thematic and content analysis from a post-positivism perspective.

RESULTS

Two themes were identified: acuity matters when selecting appropriate interventions; and roadblocks to receiving non-pharmacological interventions. We found that treatment options were dependent on the acuity/stability of fracture and were individualized accordingly. Pain medication was perceived as important, but non-pharmacological strategies were also considered helpful in supporting recovery. Participants discussed barriers related to the timely identification of fracture, referral to physiotherapy, and lack of knowledge among HCPs on how to manage osteoporosis and vertebral fractures. HCPs reported positive use of virtual-care, but had concerns related to patient access, cost, and comprehensive assessments.

CONCLUSION

HCPs used and perceived non-pharmacological interventions as helpful and selected specific treatments based on the recency of fracture and patient symptoms. HCPs' also believed that virtual-care that included an educational component, an assessment by a physiotherapist, and an exercise group was a feasible alternative, but concerns exist and may require further evaluation.

The acceptability of exercise prehabilitation before cancer surgery among patients, family members and health professionals: a mixed methods evaluation

PURPOSE

Exercise prehabilitation aims to increase preoperative fitness, reduce post-operative complications, and improve health-related quality of life. For prehabilitation to work, access to an effective programme which is acceptable to stakeholders is vital. The aim was to explore acceptability of exercise prehabilitation before cancer surgery among key stakeholders specifically patients, family members and healthcare providers.

METHODS

A mixed-methods approach (questionnaire and semi-structured interview) underpinned by the Theoretical Framework of Acceptability was utilised. Composite acceptability score, (summation of acceptability constructs and a single-item overall acceptability construct), and median of each construct was calculated. Correlation analysis between the single-item overall acceptability and each construct was completed. Qualitative data was analysed using deductive and inductive thematic analysis.

RESULTS

244 participants completed the questionnaire and n=31 completed interviews. Composite acceptability was comparable between groups (p=0.466). Four constructs positively correlated with overall acceptability: affective attitude (r=0.453), self-efficacy (r=0.399), ethicality (r=0.298) and intervention coherence (r=0.281). Qualitative data confirmed positive feelings, citing psychological benefits including a sense of control. Participants felt flexible prehabilitation program would be suitable for everyone, identifying barriers and facilitators to reduce burden.

CONCLUSION

Exercise prehabilitation is highly acceptable to key stakeholders. Despite some burden, it is a worthwhile and effective intervention. Stakeholders understand its purpose, are confident in patients' ability to participate, and regard it is an important intervention contributing to patients' psychological and physical wellbeing.

IMPLICATIONS

•Introduction should be comprehensively designed and clearly presented, providing appropriate information and opportunity for questions. •Programmes should be patient-centred, designed to overcome barriers and address patients' specific needs and goals. •Service must be appropriately resourced with a clear referral-pathway.

Perceptions Toward Exercise or Mindful Exercise Participation Among Patients With Primary Osteoporosis: A Qualitative Study

Exercise is significantly beneficial for patients with osteoporosis. However, physiological and psychological factors such as pain and kinesiophobia prevent patients from participating in exercise. Therefore, it is important to understand how these patients perceive participation in exercise. This qualitative study was conducted in China using conventional content analysis. Using a purposeful sampling method, 17 patients with primary osteoporosis were recruited. Data were collected through a semi-structured interview and managed using ATLAS.ti 21. Nine generic categories were developed from 26 subcategories and two main categories were identified: Barriers and facilitators, support systems, network resources, positive emotions, and reactions were the facilitators for exercise in this study. In addition, mindful exercise was positively viewed by the patients. Inefficient awareness, weak support systems, and burdens were identified as barriers. To improve compliance in clinical practice, targeted exercise protocols should be developed for patients based on these perceptions.

Development, Acceptability, and Usability of a Virtual Intervention for Vertebral Fractures

OBJECTIVE

This project aimed to develop a virtual intervention for vertebral fractures (VIVA) to implement the international recommendations for the nonpharmacological management of osteoporotic vertebral fractures and to test its acceptability and usability.

METHODS

VIVA was developed in accordance with integrated knowledge translation principles and was informed by the Behavioral Change Wheel, the Theoretical Domains Framework, and the affordability, practicability, effectiveness and cost-effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria. The development of the prototype of VIVA involved 3 steps: understanding target behaviors, identifying intervention options, and identifying content and implementation options. The VIVA prototype was delivered to 9 participants to assess its acceptability and usability.

RESULTS

VIVA includes 7 1-on-1 virtual sessions delivered by a physical therapist over 5 weeks. Each session lasts 45 minutes and is divided in 3 parts: education, training, and behavioral support/goal setting. Four main themes emerged from the acceptability evaluation: perceived improvements in pain, increased self-confidence, satisfaction with 1-on-1 sessions and resources, and ease of use. All of the participants believed that VIVA was very useful and were very satisfied with the 1-on-1 sessions. Four participants found the information received very easy to practice, 4 found it easy to practice, and 1 found it somewhat difficult to practice. Five participants were satisfied with the supporting resources, and 4 were very satisfied. Potential for statistically significant improvements was observed in participants' ability to make concrete plans about when, how, where, and how often to exercise.

CONCLUSION

VIVA was acceptable and usable to the participants, who perceived improvements in pain and self-confidence.

IMPACT

The virtual implementation of the recommendations for the nonpharmacological management of vertebral fractures showed high acceptability and usability. Future trials will implement the recommendations on a larger scale to evaluate their effectiveness.

Improving Adherence to Physical Therapy in the Development of Serious Games: Conceptual Framework Design Study

BACKGROUND

Insufficient levels of treatment adherence can have adverse effects on the outcomes of physical rehabilitation. To address this issue, alternative approaches to traditional therapies, such as serious games, have been designed to enhance adherence. Nevertheless, there remain gaps in the development of serious games concerning the effective implementation of motivation, engagement, and the enhancement of treatment adherence.

OBJECTIVE

This study aims to design a conceptual framework for the development of serious games that incorporate essential adherence factors to enhance patient compliance with physical rehabilitation programs.

METHODS

We formulated a conceptual framework using iterative techniques inspired by a conceptual framework analysis. Initially, we conducted a comprehensive literature review, concentrating on the critical adherence factors in physical rehabilitation. Subsequently, we identified, categorized, integrated, and synthesized the concepts derived from the literature review to construct the conceptual framework.

RESULTS

The framework resembles a road map, comprising 3 distinct phases. In the initial phase, the patient's characteristics are identified through an initial exploration. The second phase involves the development of a serious game, with a focus on enhancing treatment adherence by integrating the key adherence factors identified. The third phase revolves around the evaluation of the serious game. These phases are underpinned by 2 overarching themes, namely, a user-centered design and the GameFlow model.

CONCLUSIONS

The conceptual framework offers a detailed, step-by-step guide for creating serious games that incorporate essential adherence factors, thereby contributing to improved adherence in the physical rehabilitation process. To establish its validity, further evaluations of this framework across various physical rehabilitation programs and user groups are necessary.

Effects of an mHealth physical activity intervention to prevent osteoporosis in premenopausal women. A randomized controlled trial

OBJECTIVES

It is critical to develop prevention strategies for osteoporosis that reduce the burden fractures place on individuals and health systems. This study evaluated the effects of an mHealth intervention that delivered and monitored a non-supervised exercise program on bone mineral density (BMD).

DESIGN

Randomized controlled trial.

METHODS

60 premenopausal women aged 35-50 years were divided into an intervention group (IG) and a control group (CG). The IG followed a 6-month intervention aimed at increasing osteogenic physical activity, guided by two daily goals: walking at least 10,000 steps and completing 60 impacts over 4 g of acceleration. These goals were monitored using a wearable accelerometer linked to an mHealth app. The CG maintained their regular lifestyle and wore the accelerometer without feedback. BMD was estimated using dual-energy X-ray absorptiometry (DXA) scans at baseline and after 6 months, with group-by-time analyses conducted using ANCOVA. The intervention's impact on physical fitness and activity habits was also evaluated.

RESULTS

46 participants completed the study (IG = 24; CG = 22). The IG showed significant improvements compared to the CG in femoral neck BMD (IG: +0.003 ± 0.029 g/cm2 vs CG: -0.027 ± 0.031 g/cm2), trochanter BMD (IG: +0.004 ± 0.023 g/cm2 vs CG: -0.026 ± 0.030 g/cm2), and total hip BMD (IG: +0.006 ± 0.043 g/cm2 vs CG: -0.040 ± 0.048 g/cm2). The IG also demonstrated significant improvements in physical fitness measures, including peak torque and power at various speeds and positions. No adverse events related to the intervention were reported.

CONCLUSIONS

This non-supervised physical activity intervention delivered by wearable-technology and an mHealth app was effective in improving BMD, suggesting its potential for osteoporosis prevention.

Dropout and compliance to physical exercise in menopausal osteopenic women: the European "happy bones" project

Introduction

Decline in muscle mass and bone density seem to be two of the most disabling side effects of menopause that negatively affect women's quality of life. Promoting physical activity protocols in the workplace can represent a focal point in the prevention and management of several diseases. The study aims to evaluate the compliance and drop-out of menopausal osteopenic women engaged in combined training performed inside and outside the workplace. Strength and balance were analyzed to evaluate the effect of this protocol on osteoporosis prevention and the risk of falling.

Methods

73 menopausal women were enrolled in 5 European countries. They performed 72 lessons of a combined training proposed in the working place (IW) or sport center (SC).

Results

Out of the total 39 women enrolled in the IW, 12.8% had to leave the program, while out of the 34 women enrolled in SC, 41.2% did not complete the training. According to the compliance results, 47% of women that completed the trained IW and 85% in the SC recorded high compliance (p = 0.019). Moreover, the strength of the lower limbs (p < 0.001) and static balance (p = 0.001) significantly improved in the whole group.

Discussion

In conclusion, proposing well-structured training in the workplace for menopausal women seems to reduce drop-out. Strength and balance results suggest its positive impact on bone health and risk of falls, despite where it is performed.

Non-pharmacological management of osteoporotic vertebral fractures: Patient perspectives and experiences

OBJECTIVE

To understand perceptions on rehabilitation after vertebral fracture, non-pharmacological strategies, and virtual care from the perspective of individuals living with vertebral fractures.

DESIGN AND SETTING

We conducted semi-structured interviews online and performed a thematic and content analysis from a post-positivism perspective.

PARTICIPANTS

Ten individuals living with osteoporotic vertebral fractures (9F, 1 M, aged 71  ±  8 years).

RESULTS

Five themes emerged: pain is the defining limitation of vertebral fracture recovery; delayed diagnosis impacts recovery trajectory; living with fear; being dissatisfied with fracture management; and "getting back into the game of life" using non-pharmacological strategies.

CONCLUSION

Participants reported back pain and an inability to perform activities of daily living, affecting psychological and social well-being. Physiotherapy, education, and exercise were considered helpful and important to patients; however, issues with fracture identification and referral limited the use of these options. Participants believed that virtual rehabilitation was a feasible and effective alternative to in-person care, but perceived experience with technology, cost, and individualization of programs as barriers.

The effect of aquatic exercise on bone mineral density in older adults. A systematic review and meta-analysis

Introduction: Aquatic or water-based exercise is a very popular type of exercise in particular for people with physical limitations, joint problems and fear of falling. The present systematic review and meta-analysis aimed to provide evidence for the effect of aquatic exercise on Bone Mineral Density (BMD) in adults.

Methods: A systematic literature search of five electronic databases (PubMed/MEDLINE, Cochrane Library, Scopus, Web of Science and CINAHL) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was conducted until 2022/01/30, with an update to 2022/10/07. We included controlled trials with a duration of more than 6 months and at least two study groups, aquatic exercise (EG) versus non-training controls (CG) with no language restrictions. Outcome measures were standardized mean differences (SMD) with 95%-confidence intervals (95%-CI) for BMD changes at the lumbar spine (LS) and femoral neck (FN). We applied a random-effects meta-analysis and used the inverse heterogeneity (IVhet) model to analyze the data.

Results: Excluding an outlier study with an exceptionally high effect size for LS-BMD, we observed a statistically significant (p = .002) effect (EG vs. CG) of aquatic exercise for the LS-BMD (n = 10; SMD: 0.30; 95%-CI: 0.11–0.49). In parallel, the effect of aquatic exercise on FN-BMD was statistically significant (p = .034) compared to the CG (n = 10; SMD: 0.76, 95%-CI: 0.06–1.46). Of importance, heterogeneity between the trial results was negligible for LS (I2: 7%) but substantial for FN-BMD (I2: 87%). Evidence for risks of small study/publication bias was low for LS-BMD and considerable for FN-BMD.

Discussion: In summary, the present systematic review and meta-analysis provides further evidence for the favorable effect of exercise on bone health in adults. Due to its safety and attractiveness, we particularly recommend water-based exercise for people unable, afraid or unmotivated to conduct intense land-based exercise programs.

Using the specificity and overload principles to prevent sarcopenia, falls and fractures with exercise

The aim of this narrative review is to discuss the evidence on exercise for fall, fracture and sarcopenia prevention, including evidence that aligns with the specificity and progressive overload principles used in exercise physiology, implementation strategies and future research priorities. We also provide a brief discussion of the influence of protein intake and creatine supplementation as potential effect modifiers. We prioritized evidence from randomized controlled trials and systematic reviews. Resistance training can improve muscle mass, muscle strength and a variety of physical performance measures in older adults. Resistance training may also prevent bone loss or increase bone mass, although whether it needs to be done in combination with impact exercise to be effective is less clear, because many studies use multicomponent interventions. Exercise programs prevent falls, and subgroup and network meta-analyses suggest an emphasis on balance and functional training, or specifically, anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility, to maximize efficacy. Resistance training for major muscle groups at a 6-12 repetitions maximum intensity, and challenging balance exercises should be performed at least twice weekly. Choose resistance training exercises aligned with patient goals or movements done during daily activities (task specificity), alongside balance exercises tailored to ability and aspects of balance that need improvement. Progress the volume, level of difficulty or other aspects to see continuous improvement (progressive overload). A critical future priority will be to address implementation barriers and facilitators to enhance uptake and adherence.

An interpretive descriptive approach of patients with osteoporosis and integrating osteoporosis management advice into their lifestyle

Introduction

Methods

Results

Conclusion

Acute Effects of the Interval and Duration of Intermittent Exercise on Arterial Stiffness in Young Men

We proved the hypothesis that intermittent exercise would have a better effect on arterial stiffness by shortening the duration of intervals and increasing the number of bouts. Twenty healthy male college students (20.4 ± 0.4 years) were randomly assigned to a quiet control (CON), 30 min continuous exercise (CE), long-interval intermittent exercise with long intervals (IELL), long-interval intermittent exercise with short intervals (IELS), and short-interval intermittent exercise with short intervals (IESS). The intensity was set to 45% of the heart rate reserve. The brachial-ankle pulse wave (baPWV) was measured at baseline (BL), 0 min post-exercise, 20 min post-exercise, 40 min post-exercise, and 60 min post-exercise. BaPWV changes (⊿baPWV) from the BL in the same tests were used for the analysis. ⊿baPWV did not change significantly in the CON. ⊿baPWV decreased significantly at 0, 20, and 40 min in all exercise tests. ⊿baPWV decreased significantly at 60 min in IELS and IESS. At 60 min, the ⊿baPWV of IELS and IESS was still significantly lower than that of CON and CE, and the ⊿baPWV of IESS was still significantly lower than that of IELS. Hence, shortening the intervals of intermittent exercise and increasing the number of repetitions may enhance the effect of improving arterial stiffness.

Acute Effects of Whole-Body Electromyostimulation on Energy Expenditure at Resting and during Uphill Walking in Healthy Young Men

The effects of the different electrical frequencies of whole-body electrical stimulation (WB-EMS) on energy expenditure (EE) and the respiratory exchange ratio (RER) remain poorly understood. This study aimed to determine the effects of different WB-EMS electrical frequencies on EE and the RER during supine resting and uphill walking. A total of 10 healthy and recreationally active men (21.6 ± 3.3 years old) participated in the present study. Participants completed two testing sessions in a randomized order. In each session, a variety of impulse frequencies (1 hertz (Hz), 2 Hz, 4 Hz, 6 Hz, 8 Hz, and 10 Hz) were applied in a randomized order, allowing a 10 min passive recovery between them. Oxygen consumption and carbon dioxide production were measured to calculate EE and the RER. All frequencies increased EE at rest (all p ≤ 0.001), with 4 Hz being the frequency producing the highest increase (Δ = 8.89 ± 1.49 kcal/min), as did 6 Hz (Δ = 8.05 ± 1.52 kcal/min) and 8 Hz (Δ = 7.04 ± 2.16 kcal/min). An increment in the RER at rest was observed with 4 Hz, 6 Hz, 8 Hz and 10 Hz (all p ≤ 0.016), but not with 1 Hz and 2 Hz (p ≥ 0.923). During uphill walking, the frequency that elicited the highest increase in EE was 6 Hz (Δ = 4.87 ± 0.84 kcal/min) compared to the unstimulated condition. None of the impulse frequencies altered the RER during uphill walking. WB-EMS increases EE in healthy young men both during resting and uphill walking.

Effects of non-supervised exercise interventions on bone mineral density in adult women: a systematic review and meta‑analysis

Osteoporosis is a major health issue worldwide. This study analyzes the effects of non-supervised osteoporosis prevention programs on bone mineral density. Non-supervised exercise increases femoral neck and lumbar spine bone mineral density in adult women. Thus, it might be effective for preventing or treating osteoporosis or osteopenia in this population.

INTRODUCTION

Osteoporosis is a major health issue worldwide. Social distancing measures due to COVID-19 have hindered the chances to take part in supervised osteoporosis prevention exercise programs. The purpose of the present study is to systematically review and meta-analyze the effects of non-supervised osteoporosis prevention exercise programs on bone mineral density (BMD) in adult women.

METHODS

A comprehensive search of electronic databases (n = 7) was conducted including (a) prospective randomized controlled trials (RCTs) comparing at least one exercise group vs. a control group with sedentary lifestyle or sham exercises; (b) baseline and follow-up BMD values, or BMD changes from baseline, at any skeletal site; (c) women over 30 years old; and (d) non-supervised exercise programs only. Subgroup analyses were performed for menopausal status, intervention duration, type of exercise, and osteopenia/osteoporosis status.

RESULTS

Ten studies were included (n = 668). Random effect analyses showed that unsupervised exercise had beneficial effects on lumbar spine (LS) BMD with standardized mean difference (SMD) = 0.40 (95% confidence interval (CI): 0.03-0.77), and femoral neck (FN) BMD with SMD = 0.51 (95% CI: 0.16-0.85). Unsupervised exercise increased LS (SMD = 0.73 (95% CI: 0.13-1.33)) and FN BMD (SMD = 0.85 (95% CI: 0.33-1.37)) in women with osteopenia/osteoporosis, but not in healthy counterparts.

CONCLUSION

Non-supervised exercise improves FN and LS BMD in adult women. Beneficial effects of exercise on FN and LS BMD might be more pronounced in those with poor bone health compared with healthy counterparts. More RCTs prescribing non-supervised, osteogenic exercise are required in this population. It is necessary to investigate the efficacy of remote/assistive technologies for delivering and monitoring non-supervised exercise interventions.

Acute effects of low-volume intermittent versus higher-volume continuous exercise on arterial stiffness in healthy young men

To compare the acute effects of low-volume intermittent and higher-volume continuous exercise on arterial stiffness, 20 healthy men (22.4 ± 0.4 years) were randomized to non-exercise control (CON), high-volume Continuous Exercise (CE), lower-volume Intermittent exercise of Long bouts with Long interval (ILL), of Long bouts with Short interval (ILS), and of Short bouts with Short interval trial (ISS). Exercise intensity was 35% heart rate reserve. Arterial stiffness in Cardio-ankle vascular index (CAVI) was measured at baseline (BL), immediately (0 min) and 40 min after exercise. CAVI changes from BL in the same trial (⊿CAVI) were used for analysis. There was no significant ⊿CAVI change in CON. ⊿CAVI decreased significantly at 0 min in all exercise trials, and reverted to baseline at 40 min only in CE and ILL. At 40 min, ⊿CAVI in ILS and ISS remained significantly lower than that of CON and CE. When ILS and ISS were compared with CON at 40 min, only ⊿CAVI in ISS remained significantly lower than that of CON. Despite low volume, the effect of intermittent exercise on arterial stiffness could be either equal or superior to that of higher-volume continuous exercise.

Toward the recognition and management of sarcopenia in routine clinical care

Sarcopenia, the age-associated decline in skeletal muscle mass and function, is a major cause of functional decline and mortality in older adults. Despite its importance, sarcopenia often remains unrecognized and inadequately managed in routine clinical care. A major hinderance to its clinical integration is the variation in diagnostic tools for sarcopenia. Diagnostic tools include those of the European Working Group on Sarcopenia in Older People (versions 1 and 2), those of the Asian Working Group for Sarcopenia (versions 1 and 2), and that of the Sarcopenia Definition and Outcomes Consortium. The management decision process of sarcopenia warrants an evaluation of risk factors such as a sedentary lifestyle, inadequate exercise, poor nutritional intake, smoking, depression and living circumstances. Herein, we provide an evidence-based update of the prevention and management of sarcopenia and propose practical information to facilitate the disease's adoption into routine care.

Effectiveness of a community-delivered pneumatic machine resistance training programme (Gym Tonic) for older adults at neighbourhood senior centres - a randomized controlled trial

Background

Resistance training with pneumatic machines attenuates the age-associated loss in muscle strength and function in older adults. However, effectiveness of scaled-up pneumatic machine resistance training in the community is not known. We evaluated the effectiveness of a multi-site community-delivered 12-week pneumatic machine resistance programme (Gym Tonic (GT)) on muscle strength and physical function in older adults.

Methods

Three hundred eighteen community-dwelling older adults aged ≥65 years were randomized into 12-week (twice/week) coach-supervised-community-based-GT-programme(n = 168) and wait-list control groups(n = 150). After 12 weeks, the intervention group continued with GT-training and the control group received supervised-GT-programme for further 12 weeks (partial-crossover-design). Fried frailty score, lower-extremity muscle strength and physical function (i.e., fast and habitual gait-speed, balance, repeated-chair-sit-to-stand, short physical performance battery (SPPB)) were determined at baseline, 12 and 24 weeks. Analysis adopted a modified-intention-to-treat-approach.

Results

After 12 weeks, lower-extremity muscle strength improved by 11–26%(all p < 0.05) and fast gait-speed improved by 7%(p = 0.008) in GT-intervention group(n = 132) than controls(n = 118), regardless of frailty status. Other physical function performance did not differ between control and intervention groups after 12 weeks (all p > 0.05). Frailty score improved by 0.5 in the intervention but not control group(p = 0.004). Within the intervention group, lower-extremity muscle strength and physical function outcomes improved at 24 weeks compared with baseline (all p < 0.001). Within controls, lower-extremity muscle strength, SPPB, repeated-chair-sit-to-stand and fast gait-speed improved post-GT (24-week) compared to both pre-GT (12-week) and baseline. Programme adherence was high in intervention [0–12-weeks,90%(SD,13%); 12–24-weeks,89%(SD,17%)] and control [12–24-weeks,90%(SD,19%)] groups.

Conclusion

Community-delivered GT resistance training programme with pneumatic machines has high adherence, improves muscle strength and fast gait-speed, and can be effectively implemented at scale for older adults. Future studies could examine if including other multi-modal function-specific training to complement GT can achieve better physical/functional performance in power, balance and endurance tasks.

Trial registration

ClinicalTrials.gov, NCT04661618, Registered 10 December 2020 - Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11556-021-00273-x.

A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial

The goal of the MEDEX-OP trial was to compare the efficacy of a known effective high-intensity resistance and impact training (HiRIT) with a low-intensity exercise control (Buff Bones® [BB]), alone or in combination with antiresorptive bone medication, on indices of fracture risk (bone mass, body composition, muscle strength, functional performance), compliance, and safety. Primary study outcomes were 8-month change in lumbar spine (LS) and total hip (TH) bone mineral density (BMD). Healthy postmenopausal women with low bone mass (T-score ≤ -1.0) on or off stable doses (≥12 months) of antiresorptive medication were recruited. A total of 115 women (aged 63.6 ± 0.7 years; body mass index [BMI] 25.5 kg/m² ; femoral neck [FN] T-score -1.8 ± 0.1) were randomly allocated to 8-month, twice-weekly, 40-minute HiRIT (5 sets of 5 repetitions, >80% to 85% 1 repetition maximum) or BB (low-intensity, Pilates-based training), stratified by medication intake, resulting in four groups: HiRIT (n = 42), BB (n = 44), HiRIT-med (n = 15), BB-med (n = 14). HiRIT improved LS BMD (1.9 ± 0.3% versus 0.1 ± 0.4%, p < 0.001) and stature (0.2 ± 0.1 cm versus -0.0 ± 0.1 cm, p = 0.004) more than BB. Both programs improved functional performance, but HiRIT effects were larger for leg and back muscle strength and the five times sit-to-stand test (p < 0.05). There was a positive relationship between maximum weight lifted and changes in LS BMD and muscle strength in the HiRIT groups. Exploratory analyses suggest antiresorptive medication may enhance exercise efficacy at the proximal femur and lumbar spine. Exercise compliance was good (82.4 ± 1.3%) and both programs were well tolerated (7 adverse events: HiRIT 4; BB 3). HiRIT improved indices of fracture risk significantly more than Buff Bones®. More trials combining bone medication and bone-targeted exercise are needed. © 2021 American Society for Bone and Mineral Research (ASBMR).

Detecting subtle mobility changes among older adults: the Quantitative Timed Up and Go test

BACKGROUND

The Quantitative Timed Up and Go (QTUG) test uses wearable sensors, containing a triaxial accelerometer and an add-on triaxial gyroscope, to quantify performance during the TUG test with potential to capture more minor changes in mobility.

AIMS

To examine the responsiveness, minimum detectable change (MDC) and observed effect size of QTUG in a cohort of socially active adults aged 50 years and over participating in a structured community exercise program.

METHODS

54 participants (91% females, mean age 63.6 ± 6.5 years) completed repeated QTUG testing under single- and dual-task conditions. Responsiveness of the QTUG was assessed by correlation of change in standard TUG with QTUG change (Pearson's correlation coefficient). MDC and effect sizes (standardized mean difference and Cohen's d) were also calculated for QTUG.

RESULTS

There was a strong positive correlation between change in the standard TUG and change in QTUG (single task r = 0.91, p < 0.001). MDC in QTUG was calculated as 0.77 (Sd, 1.39; ICC 0.96) seconds (single task) and 2.33 (Sd 2.18; ICC 0.85) seconds (dual task). Several QTUG parameters showed improvements in mean values with small effect sizes (sit -to-stand transition time d = 0.418; walk time d = 0.398; cadence d = 0.306, swing time d = 0.314; step time d = 0.479; gait velocity d = 0.365; time to reach turn d = 0.322) under single-task conditions and with a moderate effect size (d = 0.549) in time taken to turn under the dual-task condition.

CONCLUSION

Initial evidence of QTUG's responsiveness to change in mobility in active middle to older age adults has been demonstrated with small to moderate effect sizes observed in specific QTUG parameters.

Simulated effects of early menopausal bone mineral density preservation on long-term fracture risk: a feasibility study

Prevention of early menopausal bone loss may reduce the future burden of osteoporosis. In this modelling exercise, an osteoporosis prevention strategy involving 5-year infusions of zoledronic acid, beginning early in menopause, reduced long-term fracture risk and the proportion of aging women with femoral neck densitometric osteoporosis. This strategy warrants further evaluation.

INTRODUCTION

Preventing early menopausal bone loss may substantially reduce the future burden of osteoporosis. We modelled the effects of infrequent zoledronic acid infusions on long-term fracture risk.

METHODS

Data from the Canadian Multicentre Osteoporosis Study (CaMos) were used to determine the expected natural history of femoral neck areal bone mineral density (BMD) and fracture risk (using FRAX®) from ages 50-80 for women with no antiresorptive drug exposures. We modelled the effects of three infusions of zoledronic acid (at ages 50, 55, 60) on long-term fracture risk, assuming this intervention would preserve BMD until age 65 years, followed by losses mirroring early menopausal BMD loss.

RESULTS

At age 65, untreated women and zoledronic acid recipients had expected mean (SD) femoral neck T-scores of - 1.5(1.0) and - 0.8(1.0), 10-year major osteoporotic fracture (MOF) risks of 9.8%(5.0) and 8.0%(3.7) and hip fracture risks of 1.7%(2.4) and 0.8%(1.2), respectively. At age 80, untreated women and zoledronic acid recipients had expected femoral neck T-scores of - 1.9(0.9) and - 1.4(0.9), MOF risks of 17.9%(8.2) and 14.9%(6.4) and hip fracture risks of 6.3%(6.2) and 4.4%(4.5), respectively. The expected proportion of women with femoral neck T-score ≤ - 2.5 was 14.9% for untreated women and 3.8% for zoledronic acid recipients at age 65, increasing to 28.1% and 12.0%, respectively, at age 80. Numbers-needed-to-treat to prevent one case of densitometric osteoporosis were 9 at age 65 and 5 at age 80.

CONCLUSION

Infrequent infusions of zoledronic acid, initiated early in menopause, are expected to reduce long-term fracture risk and result in a substantial reduction in the proportion of women with densitometric osteoporosis after age 65.

Physical activity motives, barriers, and preferences in people with obesity: A systematic review

Background

Although the benefits of physical activity (PA) are well known, physical inactivity is highly prevalent among people with obesity. The objective of this systematic review was to i) appraise knowledge on PA motives, barriers, and preferences in individuals with obesity, and ii) quantify the most frequently reported PA motives, barriers and preferences in this population.

Methods

Six databases (Pubmed, CINAHL, Psyarticle, SportDiscus, Web of science and Proquest) were searched by independent reviewers to identify relevant quantitative or qualitative articles reporting PA motives, barriers or preferences in adults with body mass index ≥ 30 kg/m² (last searched in June 2020). Risk of bias for each study was assessed by two independent reviewers with the Mixed Methods Appraisal Tool (MMAT).

Results

From 5,899 papers identified, a total of 27 studies, 14 quantitative, 10 qualitative and 3 mixed studies were included. About 30% of studies have a MMAT score below 50% (k = 8). The three most reported PA motives in people with obesity were weight management, energy/physical fitness, and social support. The three most common PA barriers were lack of self-discipline/motivation, pain or physical discomfort, and lack of time. Based on the only 4 studies available, walking seems to be the preferred mode of PA in people with obesity.

Conclusions

Weight management, lack of motivation and pain are key PA motives and barriers in people with obesity, and should be addressed in future interventions to facilitate PA initiation and maintenance. Further research is needed to investigate the PA preferences of people with obesity.

Once-Weekly Whole-Body Electromyostimulation Increases Strength, Stability and Body Composition in Amateur Golfers. A Randomized Controlled Study

Whole-body electromyostimulation (WB-EMS), an innovative training technology, is considered as a joint-friendly, highly customizable and particularly time-effective option for improving muscle strength and stability, body composition and pain relief. The aim of the present study was to determine the effect of 16 weeks of once-weekly WB-EMS on maximum isometric trunk (MITS), leg extensor strength (MILES), lean body mass (LBM) and body-fat content. A cohort of 54 male amateur golfers, 18 to 70 years old and largely representative for healthy adults, were randomly assigned to a WB-EMS (n = 27) or a control group (CG: n = 27). Bipolar low-frequency WB-EMS combined with low-intensity movements was conducted once per week for 20 min at the participants’ locations, while the CG maintained their habitual activity. The intention to treat analysis with multiple imputation was applied. After 16 weeks of once-weekly WB-EMS application with an attendance rate close to 100%, we observed significant WB-EMS effects on MITS (p < 0.001), MILES (p = 0.001), LBM (p = 0.034), but not body-fat content (p = 0.080) and low-back pain (LBP: p ≥ 0.078). In summary, the commercial setting of once-weekly WB-EMS application is effective to enhance stability, maximum strength, body composition and, to a lower extent, LBP in amateur golfers widely representative for a healthy male cohort.

Feasibility, safety and effectiveness of a pilot 16-week home-based, impact exercise intervention in postmenopausal women with low bone mineral density

The feasibility and efficacy of home-based, impact exercise are unclear. This pilot impact exercise intervention was feasible and safe, and improved bone health and physical function in postmenopausal women with low bone density. Appropriately designed randomised controlled trials are now required to determine whether such interventions can reduce fracture risk.

INTRODUCTION

The feasibility and efficacy of impact exercise in postmenopausal women with low bone mineral density (BMD) are unclear. We aimed to determine adherence, safety and changes in BMD, bone microarchitecture and physical function following a pilot home-based, impact exercise intervention in postmenopausal women with low BMD.

METHODS

Fifty community-dwelling postmenopausal women with BMD T-scores < - 1.0 participated in 16 weeks of home-based impact exercise progressively increasing to 50 multi-directional unilateral hops on each leg daily. Bone density and structure were assessed by lumbar spine and hip dual-energy X-ray absorptiometry (DXA), 3D modelling (3D-SHAPER) of hip DXA scans and distal tibial high-resolution peripheral quantitative computed tomography scans. Physical performance was assessed by repeated chair stand time and stair climb time.

RESULTS

Forty-four women (mean ± SD age 64.5 ± 7.5 years) completed the intervention, with adherence of 85.3 ± 17.3%. Reasons for withdrawal were related soreness (n = 2), unrelated injury (n = 1) and loss of interest (n = 3). Femoral neck areal BMD increased by 1.13 ± 3.76% (p = 0.048). Trabecular volumetric BMD (vBMD) increased at the total hip (2.27 ± 7.03%; p = 0.038) and femoral neck increased (3.20 ± 5.39%; p < 0.001). Distal tibia total vBMD increased by 0.32 ± 0.88% (p = 0.032) and cortical cross-sectional area increased by 0.55 ± 1.54% (p = 0.034). Chair stand and stair climb time improved by 2.34 ± 1.88 s (p < 0.001) and 0.27 ± 0.49 s (p < 0.001), respectively.

CONCLUSION

A 16-week home-based, impact exercise was feasible and may be effective in improving femoral neck areal BMD, total hip and distal tibial vBMD and physical function in postmenopausal women. Appropriately designed randomised controlled trials are now required to determine whether such interventions can reduce fracture risk in older populations.

Effects of COVID-19 Lockdown on Adherence to Individual Home- or Gym-Based Exercise Training among Women with Postmenopausal Osteoporosis

Adherence is important for an exercise program's efficacy. This study aims at investigating whether the COVID-19 lockdown had different consequences on the adherence to an exercise program specifically designed for women with postmenopausal osteoporosis when administered as individual home training (IHT) or gym group training (GGT). At the start of the lockdown, which imposed the temporary closure of any gym activities, GGT participants were invited to continue to exercise at home. IHT participants continued to exercise at home as usual. Adherence was recorded via logs and measured as the percentage of exercise sessions actually performed out of the total number of scheduled sessions in three 1-month periods: one before (PRE) and two after (M1 and M2) the beginning of lockdown. Before lockdown, IHT (66.8% ± 26.6) and GGT (76.3% ± 26.6) adherence were similar. During lockdown, IHT participation increased (M1: 81.5% ± 31.0; M2: 88.0% ± 28.3), while that of GGT showed no statistical differences (M1: 79.4% ± 34.2; M2: 80.6% ± 36.4). Exercise protocols based on supervised gym practice must consider the possibility of disruptive events, which could cause a sudden interruption of gym activity and include educational initiatives to instruct participants to exercise effectively and safely without a trainer's direct supervision.

Key Factors Associated with Adherence to Physical Exercise in Patients with Chronic Diseases and Older Adults: An Umbrella Review

Physical inactivity is a major concern and poor adherence to exercise programs is often reported. The aim of this paper was to systematically review published reviews on the study of adherence to physical exercise in chronic patients and older adults and to identify those adherence-related key factors more frequently suggested by reviews for that population. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results were classified considering the target population and participants’ characteristics to identify the most repeated factors obtained for each condition. Fifty-five articles were finally included. Fourteen key factors were identified as relevant to increase adherence to physical exercise by at least ten reviews: (a) characteristics of the exercise program, (b) involvement of professionals from different disciplines, (c) supervision, (d) technology, (e) initial exploration of participant’s characteristics, barriers, and facilitators, (f) participants education, adequate expectations and knowledge about risks and benefits, (g) enjoyment and absence of unpleasant experiences, (h) integration in daily living, (i) social support and relatedness, (j) communication and feedback, (k) available progress information and monitoring, (l) self-efficacy and competence, (m) participant’s active role and (n) goal setting. Therefore, adherence to physical exercise is affected by several variables that can be controlled and modified by researchers and professionals.

Perceived Barriers and Facilitators of Sports Rehabilitation Adherence in Injured Volleyball Athletes: A Qualitative Study From Greece

Adherence to exercise rehabilitation has been shown to be an important factor that may influence successful treatment. In professional athletes, a significant reduction in exercise adherence delays recovery. The aim of this study was to explore barriers to and facilitators of exercise rehabilitation adherence in injured volleyball athletes. Eight professional volleyball athletes were recruited, and qualitative data were collected using semistructured interviews. All athletes had completed their rehabilitation program after they had suffered a musculoskeletal injury. All data were analyzed using thematic analysis after the investigators ensured that saturation had been reached. Pain was identified as a significant barrier to exercise adherence by all athletes. The provision of social support, including mental, practical, and task related, also had a significant positive impact. The athletes’ ability to develop the necessary coping strategies and confidence on performing exercises at home was also mentioned as a factor that affected exercise adherence, although less often.

The combined effect of parathyroid hormone (1-34) and whole-body vibration exercise on physical performance in OSteoporotic women (PaVOS study): a secondary analysis from a randomised controlled trial

Background

The aim of this study was to investigate the effect on physical performance of combining whole-body vibration exercise (WBV) with parathyroid hormone 1-34 (teriparatide) compared to teriparatide alone.

Methods

A secondary analysis from a RCT where postmenopausal women with severe osteoporosis were randomised to WBV plus teriparatide (intervention) or teriparatide alone (control). WBV was applied three times/week (6x1min WBV:1 min rest, (peak acceleration 3.6 g)) for twelve months. Both groups received teriparatide 20 μg s.c./day. The primary endpoint (bone mineral density) is reported elsewhere. Physical performance measures (Short Physical Performance Battery (SPPB), Timed-Up-and-Go (TUG), leg extension power, and grip strength) were obtained at baseline, three-, six-, and twelve months, lean mass at baseline and twelve months. Data were analysed with mixed linear regression model or robust cluster regression in an intention to treat analysis.

Results

Thirty-five women aged (mean ± SD) 69 ± 7) years were recruited of which thirty-two (91%) completed the twelve months follow-up (WBV + teriparatide = 15, teriparatide = 17). SPPB score (mean ± SD) improved significantly at three months in the WBV + teriparatide group from 9.13 ± 2.03 to 10.35 ± 1.69 (p = 0.014) with a statistical trend towards a between-group change in favor of the WBV + teriparatide group (0.86 [95%CI(- 0.05,1.77), p = 0.065]). Both groups improved in leg extension power during the study period whereas no changes were seen in TUG, grip strength, or lean mass in either group. No statistical significant between-group differences were observed.

Conclusion

WBV may improve some short-term aspects of physical performance in severely osteoporotic postmenopausal women who are receiving teriparatide treatment.

Trial Registration

ClinicalTrials.gov, ID:NCT02563353.

Disease-related factors associated with exercise adherence in postmenopausal women with osteoporosis

Objectives:

Exercise is the most widely-used intervention for reducing bone loss and the incidence of falls and fractures in osteoporosis patients. However, disease-related changes can alter these patients’ adherence to exercise programs. This study attempted to describe the factors influencing exercise adherence in a group of postmenopausal women with osteoporosis.

Methods:

We conducted a retrospective cohort of postmenopausal women with osteoporosis. We collected data from each patient’s last clinical evaluation, as well as from their clinical file of the previous year.

Results:

A total of 288 women were included in the study, with an average age of 69.45 (Standard deviation ± 9.2 years). Around a quarter, 76 (26.3%), of the patients did not adhere to exercise, 91 (31.5%) did partially, and 121 (41.9%) did completely. In univariate analysis, the variables significantly associated with exercise adherence were age, height, spine pain intensity, joint pain, and prevalent fracture. In a logistic regression model, pharmacological treatment for osteoporosis and polypharmacy were associated with exercise adherence, while poor balance and hyperkyphosis were associated with non-adherence.

Conclusion:

Pharmacological treatment, polypharmacy, poor balance, and hyperkyphosis all appear to be associated with exercise adherence. As these findings are the significant predictors of exercise engagement, it is necessary to explore balance and postural changes and emphasize the importance of postural and balance training prescription in this group of patients.

A Comparison of Bone-Targeted Exercise Strategies to Reduce Fracture Risk in Middle-Aged and Older Men with Osteopenia and Osteoporosis: LIFTMOR-M Semi-Randomized Controlled Trial

The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial examined efficacy and safety of two novel exercise programs in older men with low BMD. Men with low hip and/or LS BMD were randomized to high-intensity progressive resistance and impact training (HiRIT) or machine-based isometric axial compression (IAC) and compared to a nonrandomized matched control (CON). Outcomes included: hip and LS BMD; calcaneal ultrasound parameters; anthropometry; body composition; function (timed up-and-go [TUG], five-times sit-to-stand [FTSTS]); back extensor strength (BES); leg extensor strength (LES); compliance and adverse events. Ninety-three men (67.1 ± 7.5 years; 82.1 ± 11.6 kg; 175.2 ± 6.7 cm; FN T-score -1.6 ± 0.6) were randomized to HiRIT (n = 34) or IAC (n = 33), or allocated to CON (n = 26). HiRIT improved trochanteric BMD (2.8 ± 0.8%; -0.1 ± 0.9%, p = .024), LS BMD (4.1 ± 0.7%; 0.9 ± 0.8%, p = .003), BUA (2.2 ± 0.7%; -0.8 ± 0.9%, p = .009), stiffness index (1.6 ± 0.9%; -2.0 ± 1.1%, p = .011), lean mass (1.5 ± 0.8%; -2.4 ± 0.9%, p = .002), TUG, FTSTS, BES, and LES (p < .05) compared with CON. IAC improved lean mass (0.8 ± 0.8%; -2.4 ± 0.9%, p = .013) and FTSTS (-4.5 ± 1.6%; 7.5 ± 2.0%, p < .001) compared with CON. HiRIT improved LS BMD (4.1 ± 0.7%; 2.0 ± 0.7%, p = .039), stiffness index (1.6 ± 0.9%; -1.3 ± 0.9%, p = .025), and FTSTS (-10.7 ± 1.6%; -4.5 ± 1.7%, p = .010) compared with IAC. Exercise compliance was high (HiRIT 77.8 ± 16.6%; IAC 78.5 ± 14.8%, p = .872). There were five minor adverse events (HiRIT, 2; IAC, 3). HiRIT was well-tolerated and improved bone, function and fracture risk more than CON or IAC. © 2020 American Society for Bone and Mineral Research.

Effects of supervised high-intensity resistance and impact training or machine-based isometric training on regional bone geometry and strength in middle-aged and older men with low bone mass: The LIFTMOR-M semi-randomised controlled trial

INTRODUCTION

Few data exist on the effects of bone-targeted exercise on geometric and biomechanical indices of bone strength in men. The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial was designed to compare the efficacy and safety of two novel, supervised, twice-weekly, high-intensity exercise programs in middle-aged and older men with osteopenia and osteoporosis on musculoskeletal health and risk factors related to falls and fractures. The current report includes secondary outcomes of the LIFTMOR-M exercise intervention trial.

PURPOSE

Our goal was to determine the effects of two supervised, twice-weekly, high-intensity exercise programs on bone geometry and strength of the proximal femur, and distal and proximal sites of the tibia and radius in middle-aged and older men with osteopenia and osteoporosis.

METHODS

Generally-healthy men (≥45 years), with low lumbar spine (LS) and/or proximal femur areal bone mineral density (aBMD), were recruited from the community. Eligible participants were randomised to either eight months of twice-weekly supervised high-intensity progressive resistance and impact training (HiRIT) or supervised machine-based isometric axial compression (IAC) exercise training. Intervention group outcomes were compared at baseline and eight months with a matched but non-randomised control group (CON) who self-selected to usual activities. DXA scans (Medix DR, Medilink, France) of the skeletally non-dominant proximal femur were analysed using 3D hip software (DMS Group, France) to derive femoral neck (FN) and total hip (TH) bone mineral content (BMC), volume, and volumetric bone mineral density (vBMD) for total, trabecular and cortical bone compartments. Total FN cortical thickness was determined as well as anterior, posterior, lateral and medial subregions. pQCT scans (XCT-3000, Stratec, Germany) of the 4 and 38% sites of the tibia, and 4 and 66% sites of the radius were conducted to determine a range of geometric and bone structural strength indices. Intervention effects were examined using univariate ANCOVA of percent change, and repeated measures ANCOVA of raw baseline and follow-up data, controlling for initial values, using intention-to-treat and per-protocol approaches.

RESULTS

Ninety-three men (67.1 ± 7.5 yrs, 175.2 ± 6.7 cm, 82.1 ± 11.6 kg, 26.7 ± 3.5 kg/m²) with lower than average aBMD (LS T-score -0.06 ± 1.04, FN T-score -1.58 ± 0.58, TH T-score -1.00 ± 0.58) were recruited, and designated CON (n = 26) or randomised to HiRIT (n = 34) or IAC (n = 33). Compliance to the supervised exercise programs did not differ (HiRIT 77.8 ± 16.6% versus IAC 78.5 ± 14.8%, p = 0.872). HiRIT improved medial FN cortical thickness compared with CON (5.6 ± 1.7% versus -0.1 ± 1.9%, p = 0.028) and IAC (5.6 ± 1.7% versus 0.7 ± 1.7%, p = 0.044). Distal tibia total BMC, vBMD, area and bone strength index, and trabecular BMC and bone strength index all declined for CON compared with maintenance for both HiRIT and IAC (all p < 0.05). HiRIT maintained distal tibia trabecular area compared with a loss in CON (0.2 ± 0.5% versus -1.6 ± 0.5%, p = 0.013). HiRIT and IAC maintained distal radius total BMC compared with loss in CON (-0.1 ± 0.7% versus -3.7 ± 0.8%, p = 0.001; 1.3 ± 0.7% versus -3.7 ± 0.8%, p < 0.001, respectively). HiRIT and IAC maintained distal radius total bone strength index compared with loss in CON (1.4 ± 1.4% versus -6.0 ± 1.6%, p = 0.001; 0.2 ± 1.3% versus -6.0 ± 1.6%, p = 0.004, respectively). HiRIT reduced proximal radius cortical area compared with CON (-3.1 ± 1.0% versus 1.1 ± 1.2%, p = 0.011) and IAC (-3.1 ± 1.0% versus -0.2 ± 1.0%, p = 0.042). No between-group differences were detected in any pQCT-derived bone outcome at the diaphyseal tibia 38% site.

CONCLUSION

Findings indicate that supervised HiRIT provides a positive stimulus to cortical bone at the medial FN compared with supervised IAC exercise, and both HiRIT and IAC preserve bone strength at the distal tibia and distal radius. These effects may translate into a reduced risk of lower and upper extremity fracture in middle-aged and older men with low bone mass.

Enjoyment and acceptability of different exercise modalities to improve bone health in young adult women

ISSUE ADDRESSED

Osteoporosis presents a serious public health issue and physical activity is recognised as the most effective modifiable risk factor for the condition. The reasons behind physical activity participation, however, are complex. We therefore aimed to explore the experiences related to a bone-targeted exercise intervention, determine enjoyment and acceptability of each exercise mode, and identify barriers and facilitators to osteogenic exercise for young adult women.

METHODS

The present study was conducted within the Osteoporosis Prevention Through Impact and Muscle-loading Approaches to Exercise (OPTIMA-Ex) trial, a three-arm RCT comparing musculoskeletal outcomes from two supervised, high-intensity, exercise programs (impact and resistance training) with an unsupervised low-intensity exercise control. A mixed-methods approach was used, including quality of life and physical activity enjoyment questionnaires and qualitative analysis of semi-structured interviews.

RESULTS

All groups had improvements in the 'mental health' domain of the quality of life measure; however, the two supervised exercise groups had greater levels of physical activity enjoyment. The qualitative analysis revealed that overall the trial activities were positively, yet the two supervised groups had 'richer' exercise experiences. Motivations for participation, barriers to physical activity and desired continuation of participation differed between all three groups.

CONCLUSIONS

Findings suggest that bone-targeted exercise interventions for young adult women must address perceived time demands and environmental barriers to participation in order to maximise compliance and adherence. SO WHAT?: As physical activity is the most effective lifestyle strategy to improve bone health and young adulthood an important window for its augmentation, increasing convenience, accessibility and understanding of osteoporosis preventative behaviours in this demographic is vital.

The Favorable Effects of a High-Intensity Resistance Training on Sarcopenia in Older Community-Dwelling Men with Osteosarcopenia: The Randomized Controlled FrOST Study

Purpose

Sarcopenia, the loss of muscle mass combined with the loss of muscle function, has become a public health issue. There is an urgent need for interventions. The study aimed to determine the effect of high-intensity resistance training (HI-RT), a time- and cost-efficient training modality, on sarcopenia in osteosarcopenic (OS) older men.

Methods

Forty-three community-dwelling men aged ≥72 years from Northern Bavaria, Germany, with OS were randomly assigned to either an active HI-RT group (HI-RT) or an inactive control group (CG). Both received dietary protein (up to 1.5 g/kg/day in HI-RT and 1.2 g/kg/day in CG) and Vitamin-D (up to 800 IE/d) supplements. The HI-RT was applied as a consistently supervised single-set training on resistance exercise machines using intensifying strategies, with two training sessions/week, structured into three phases (ranging from 8 to 12 weeks) totaling 28 weeks. The primary study endpoint was the Sarcopenia Z-score; secondary endpoints were changes in the underlying physiological parameters, skeletal muscle mass index (SMI), handgrip-strength and gait velocity.

Results

The results show a significant effect of the exercise intervention on the sarcopenia Z-score in the HI-RT (p<0.001) and a significant worsening of it in the CG (p=0.012) in the intention-to-treat analysis, as well as a significant intergroup change (p<0.001). Analysis upon the underlying parameters showed a significant increase of skeletal muscle mass index (SMI) in the HI-RT group (p<0.001) and a significant intergroup difference of SMI (p<0.001) and handgrip strength (p<0.001). There were no adverse effects related to dietary supplementation or training.

Conclusion

The results clearly confirm the favorable effects of HI-RT on sarcopenia. We conclude that HI-RT is a feasible, highly efficient and safe training modality for combating sarcopenia, also in the elderly.

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.

Application of ICF conceptual framework in Osteoporosis

Background: Osteoporosis (OP) is a metabolic bone disease defined by low bone strength and deterioration of bone tissue, which has wide clinical presentations. The World Health Organization's International Classification of Functioning Disability and Health (ICF) provides a common language, classification system, and conceptual framework to describe the consequences of health conditions in terms of body function and structure, activities and participation, environmental and personal factors. Objectives: The ICF conceptual framework was used, in this paper, to integrate OP research-based knowledge into clinical application using clinical vignettes. Results: Body functions and structures, activities and participation, environmental factors and personal factors are described, and the inter-connection among these factors is explored. The vignettes highlight the importance of different components of the ICF framework and to demonstrate how the ICF framework can capture individual differences in how disability can be experienced in OP. Conclusion: The ICF conceptual framework provides a holistic representation of disability by facilitating a critical appraisal of the health status of people with OP. The framework creates an awareness of the broad and multidimensional nature of OP on the health of individual patients, integrates dimensions of functioning, and highlights the complexity of the evaluation and management of OP.

Associated factors with adherence to standard exercise therapy and health-related quality of life in Chinese patients with ankylosing spondylitis

Objectives: The aim of this study is to assess the current situations of standard exercise treatment and predictors of non-standard exercise in Chinese patients with ankylosing spondylitis (AS). An analysis of the effect of standard exercise on health-related quality of life (HR-QoL) was also conducted.Methods: In the cross-sectional study, a total of 259 AS patients were constantly invited to participate in this study and complete the questionnaire under the researchers' supervision in a clinical setting including sociodemographic variables, clinical variables, psychological variables, and HR-QoL. Data were analyzed by Mann-Whitney U test, Chi-square test as well as multivariable analysis of Binary Stepwise Logistic Regression.Results: The data showed that just 20.5% of them could complete the standard exercise. Exercise adherence was associated with employment, educational level, marital status, place of residence, treatment of Tumor Necrosis Factor-α inhibitor, knowledge about exercise, disease duration, clinical variables, and anxiety. The HR-QoL in the group of standard exercise was better than that in the non-standard exercise group. Logistic Regression Analysis showed that lower educational level, less knowledge about benefits of exercise treatment and higher score of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were the independent risk factors of exercise treatment non-adherence.Conclusion: AS patients educated less than 9 years or with higher BASDAI score were more likely not to adhere to standard exercise treatment. Non-adherence to exercise treatment among AS patients is exceedingly common, particularly in patients without knowledge about benefits of exercise treatment. Standard exercise treatment can also improve HR-QoL of AS patients.

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

We pilot-tested a trial of home exercise on individuals with osteoporosis and spine fracture. Our target enrollment was met, though it took longer than expected. Participants stayed in the study and completed the exercise program with no safety concerns. Future trials should expand the inclusion criteria and consider other changes.

PURPOSE

Osteoporotic fragility fractures create a substantial human and economic burden. There have been calls for a large randomized controlled trial examining the effect of exercise on fracture incidence. The B3E pilot trial was designed to evaluate the feasibility of a large trial examining the effects of home exercise on individuals at high risk of fracture.

METHODS

Community-dwelling women ≥ 65 years with radiographically confirmed vertebral compression fractures were recruited at seven sites in Canada and Australia. We randomized participants in a 1:1 ratio to a 12-month home exercise program or equal attention control group, both delivered by a physiotherapist (PT). Participants received six PT home visits in addition to monthly phone calls from the PT and a blinded research assistant. The primary feasibility outcomes of the study were recruitment rate (20 per site in 1 year), retention rate (75% completion), and intervention adherence rate (60% of weeks meeting exercise goals). Secondary outcomes included falls, fractures and adverse events.

RESULTS

One hundred forty-one participants were recruited; an average of 20 per site, though most sites took longer than anticipated. Retention and adherence met the criteria for success: 92% of participants completed the study; average adherence was 66%. The intervention group did not differ significantly in the number of falls (IRR 0.97, 95% CI 0.58 to 1.63) or fragility fractures (OR 1.11, 95% CI 0.60 to 2.05) compared to the control group. There were 18 serious adverse events in the intervention group and 12 in the control group.

CONCLUSION

An RCT of home exercise in women with vertebral fractures is feasible but recruitment was a challenge. Suggestions are made for the conduct of future trials.

Facilitators and barriers to green exercise in chronic pain

BACKGROUND

Green exercise, defined as exercising in nature, demonstrates mental and physical health benefits. There is limited literature on green exercise as part of the treatment for chronic pain. Our objective was to investigate chronic pain patients' perceptions of green exercise and the possible barriers that may arise in employing it as part of their treatment regimes.

METHODS

After institutional ethics committee approval, a convenience sample of 113 adult patients, who attended a chronic pain clinic, were included. Participants completed a questionnaire that included a variety of questions with responses reported using a Likert scale.

RESULTS

The most frequent patient age was 50-70 years in 49% of respondents and the most frequent pain complaint was back pain (62%). Ninety-four percent of participants reported that nature improves their mood. Seventy percent of participants reported that green spaces were easily accessible to them on a regular basis. However, up to 38% reported that they would not be able to commit to three times a week of a green exercise regime. The majority (62% of participants) reported that they would like healthcare practitioners to discuss green exercise with them.

CONCLUSION

Patients who suffer from chronic pain may be interested in green exercise as part of their treatment regime. Barriers that were identified included proximity to outdoor locations, time availability, and personal appraisal of the benefits of exercise for their condition. Green exercise should be considered as a part of a chronic pain treatment plan, and future studies should be directed to evaluating its efficacy in chronic pain.

Efficacy and Safety of Low Frequency Whole-Body Electromyostimulation (WB-EMS) to Improve Health-Related Outcomes in Non-athletic Adults. A Systematic Review

Exercise positively affects most risk factors, diseases and disabling conditions of middle to advanced age, however the majority of middle-aged to older people fall short of the exercise doses recommended for positively affecting cardio-metabolic, musculoskeletal and neurophysiological fitness or disabling conditions. Whole-Body Electromyostimulation (WB-EMS) may be a promising exercise technology for people unable or unmotivated to exercise conventionally. However, until recently there has been a dearth of evidence with respect to WB-EMS-induced effects on health-related outcomes. The aim of this systematic review is to summarize the effects, limitations and risks of WB-EMS as a preventive or therapeutic tool for non-athletic adults. Electronic searches in PubMed, Scopus, Web of Science, PsycINFO, Cochrane and Eric were run to identify randomized controlled trials, non-randomized controlled trials, meta-analyses of individual patient data and peer reviewed scientific theses that examined (1) WB-EMS-induced changes of musculoskeletal risk factors and diseases (2) WB-EMS-induced changes of functional capacity and physical fitness (3) WB-EMS-induced changes of cardio-metabolic risk factors and diseases (4) Risk factors of WB-EMS application and adverse effects during WB-EMS interventions. Two researchers independently reviewed articles for eligibility and methodological quality. Twenty-three eligible research articles generated by fourteen research projects were finally included. In summary, thirteen projects were WB-EMS trials and one study was a meta-analysis of individual patient data. WB-EMS significantly improves muscle mass and function while reducing fat mass and low back pain. Although there is some evidence of a positive effect of WB-EMS on cardio-metabolic risk factors, this aspect requires further detailed study. Properly applied and supervised, WB-EMS appears to be a safe training technology. In summary, WB-EMS represents a safe and reasonable option for cohorts unable or unwilling to join conventional exercise programs. However, much like all other types of exercise, WB-EMS does not affect every aspect of physical performance and health.

"Left to my own devices, I don't know": using theory and patient-reported barriers to move from physical activity recommendations to practice

Knowledge exchange with community-dwelling individuals across Ontario revealed barriers to implementation of physical activity recommendations that reflected capability, opportunity, and motivation; barriers unique to individuals with osteoporosis include fear of fracturing, trust in providers, and knowledge of exercise terminology. Using the Behaviour Change Wheel, we identified interventions (training, education, modeling) and policy categories (communication/marketing, guidelines, service provision).

INTRODUCTION

Physical activity recommendations exist for individuals with osteoporosis; however, to change behavior, we must address barriers and facilitators to their implementation. The purposes of this project are (1) to identify barriers to and facilitators of uptake of disease-specific physical activity recommendations (2) to use the findings to identify behavior change strategies using the Behaviour Change Wheel (BCW).

METHODS

Focus groups and semi-structured interviews were conducted with community-dwelling individuals attending osteoporosis-related programs or education sessions in Ontario. They were stratified by geographic area, urban/rural, and gender, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and interventions were identified.

RESULTS

Two hundred forty community-dwelling individuals across Ontario participated (mean ± SD age = 72 ± 8.28). Barriers were as follows: capability: disease-related symptoms hinder exercise and physical activity participation, lack of exercise-related knowledge, low exercise self-efficacy; opportunity: access to exercise programs that meet needs and preferences, limited resources and time, physical activity norms and preferences; motivation: incentives to exercise, fear of fracturing, trust in exercise providers. Interventions selected were training, education, and modeling. Policy categories selected were communication/marketing, guidelines, and service provision.

CONCLUSIONS

Barriers unique to individuals with osteoporosis included the following: lack of knowledge on key exercise concepts, fear of fracturing, and trust in providers. Behavior change techniques may need tailoring to gender, age, or presence of comorbid conditions.

Patient Adherence to Dysphagia Recommendations: A Systematic Review

Patient adherence to treatment recommendations is an important issue for healthcare providers, in a multitude of specialties, and is critical when assessing the efficacy and effectiveness of a particular treatment approach. Patients who have swallowing impairment often require complex and specific interventions requiring altered daily patterns of behavior. Patients with dysphagia who do not follow recommendations or prescribed exercises may not receive maximum benefit of an intervention. Poor adherence also makes it more difficult to evaluate efficacy of a treatment both clinically and in experimental settings. Further, swallow safety can be compromised if certain recommendations are not followed. Our purpose was to systematically review the literature to understand what is known about adherence within the field of dysphagia treatment. We systematically identified 12 studies that tracked and reported patient-specific adherence. In this review, we found that the average adherence rate from these studies ranges between 21.9 and 51.9%. Adherence to prophylactic treatment recommendations for patients with head and neck cancer was the focus in 9/12 studies. The findings of this review identify a large gap in knowledge regarding adherence to dysphagia treatment. Few studies account for adherence within their study designs. When planning dysphagia treatment studies, it is imperative that investigators include information regarding patient adherence to accurately interpret findings. Given the variable adherence rates found in this review, factors influencing patient adherence with dysphagia treatments should be identified to increase adherence in future trials.

High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial

Optimal osteogenic mechanical loading requires the application of high-magnitude strains at high rates. High-intensity resistance and impact training (HiRIT) applies such loads but is not traditionally recommended for individuals with osteoporosis because of a perceived high risk of fracture. The purpose of the LIFTMOR trial was to determine the efficacy and to monitor adverse events of HiRIT to reduce parameters of risk for fracture in postmenopausal women with low bone mass. Postmenopausal women with low bone mass (T-score < -1.0, screened for conditions and medications that influence bone and physical function) were recruited and randomized to either 8 months of twice-weekly, 30-minute, supervised HiRIT (5 sets of 5 repetitions, >85% 1 repetition maximum) or a home-based, low-intensity exercise program (CON). Pre- and post-intervention testing included lumbar spine and proximal femur bone mineral density (BMD) and measures of functional performance (timed up-and-go, functional reach, 5 times sit-to-stand, back and leg strength). A total of 101 women (aged 65 ± 5 years, 161.8 ± 5.9 cm, 63.1 ± 10.4 kg) participated in the trial. HiRIT (n = 49) effects were superior to CON (n = 52) for lumbar spine (LS) BMD (2.9 ± 2.8% versus -1.2 ± 2.8%, p < 0.001), femoral neck (FN) BMD (0.3 ± 2.6% versus -1.9 ± 2.6%, p = 0.004), FN cortical thickness (13.6 ± 16.6% versus 6.3 ± 16.6%, p = 0.014), height (0.2 ± 0.5 cm versus -0.2 ± 0.5 cm, p = 0.004), and all functional performance measures (p < 0.001). Compliance was high (HiRIT 92 ± 11%; CON 85 ± 24%) in both groups, with only one adverse event reported (HiRIT: minor lower back spasm, 2/70 missed training sessions). Our novel, brief HiRIT program enhances indices of bone strength and functional performance in postmenopausal women with low bone mass. Contrary to current opinion, HiRIT was efficacious and induced no adverse events under highly supervised conditions for our sample of otherwise healthy postmenopausal women with low to very low bone mass. © 2017 American Society for Bone and Mineral Research.

Exercise to improve functional outcomes in persons with osteoporosis: a systematic review and meta-analysis

Osteoporosis affects many aspects of daily life. The aim of this systematic review was to assess the effects of exercise interventions on functional outcomes in persons with osteoporosis, in comparison with controls.

METHODS

Four databases were searched and yielded 1587 citations. Two reviewers independently determined study eligibility, rated risk of bias, appraised methodological quality of studies, and resolved discordance by consensus.

RESULTS

A total of 28 studies examining 2113 participants met inclusion criteria; 25 studies were suitable for meta-analyses. Four categories of exercise were identified using the ProFaNE taxonomy. After removing studies with high risk of bias and sorting them into intervention sub-types, we were able to sufficiently reduce the heterogeneity. The standardized mean difference (SMD) favored multicomponent exercise for mobility (- 0.56, 95% CI [- 0.81, - 0.32], p = 0.06, I² = 51%); balance (0.50, 95% CI [0.27, 0.74], p = 0.28, I² = 21%); and self-reported measures of functioning (- 0.69, 95% CI [- 1.04, - 0.34], p = 0.02, I² = 61%). Trials were judged at low or unclear risk of selection bias, indicating inadequate reporting and at high risk of performance bias due to lack of participant blinding. The mean methodological quality rating of the studies was 63.5% indicating moderate quality.

CONCLUSIONS

A multicomponent exercise program of high-speed training combined with simulated functional tasks is promising to enhance functional outcomes. Due to substantial clinical heterogeneity of the target groups and specific demands of exercise modes, it is unclear which exercise program is optimal.

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.

Prescribing Physical Activity for the Prevention and Treatment of Osteoporosis in Older Adults

Osteoporosis is an age-related disease, characterised by low bone mineral density (BMD) and compromised bone geometry and microarchitecture, leading to reduced bone strength. Physical activity (PA) has potential as a therapy for osteoporosis, yet different modalities of PA have varying influences on bone health. This review explores current evidence for the benefits of PA, and targeted exercise regimes for the prevention and treatment of osteoporosis in older adults. In particular, the outcomes of interventions involving resistance training, low- and high-impact weight bearing activities, and whole-body vibration therapy are discussed. Finally, we present recommendations for future research that may maximise the potential of exercise in primary and secondary prevention of osteoporosis in the ageing population.

Whole-body electromyostimulation and protein supplementation favorably affect sarcopenic obesity in community-dwelling older men at risk: the randomized controlled FranSO study

BACKGROUND

Sarcopenic obesity (SO) is a geriatric syndrome characterized by the disproportion between the amount of lean mass and fat mass. Exercise decreases fat and maintains muscle mass; however, older people fail to exercise at doses sufficient to affect musculoskeletal and cardiometabolic risk factors. The aim of this study was to evaluate the effect of whole-body electromyostimulation (WB-EMS), a time-efficient, joint-friendly and highly individualized exercise technology, on sarcopenia and SO in older men.

MATERIALS AND METHODS

A total of 100 community-dwelling northern Bavarian men aged ≥70 years with sarcopenia and obesity were randomly (1-1-1) assigned to either 16 weeks of 1) WB-EMS and protein supplementation (WB-EMS&P), 2) isolated protein supplementation or 3) nonintervention control. WB-EMS consisted of 1.5×20 min (85 Hz, 350 µs, 4 s of strain to 4 s of rest) applied with moderate-to-high intensity while moving. We further generated a daily protein intake of 1.7-1.8 g/kg/body mass per day. The primary study end point was Sarcopenia Z-Score, and the secondary study end points were body fat rate (%), skeletal muscle mass index (SMI) and handgrip strength.

RESULTS

Intention-to-treat analysis determined a significantly favorable effect of WB-EMS&P (P<0.001) and protein (P=0.007) vs control. Both groups significantly (P<0.001) lost body fat (WB-EMS&P: 2.1%; protein: 1.1%) and differed significantly (P≤0.004) from control (0.3%). Differences between WB-EMS&P and protein were significant for the Sarcopenia Z-Score (P=0.39) and borderline nonsignificant (P=0.051) for body fat. SMI increased significantly in both groups (P<0.001 and P=0.043) and decreased significantly in the control group (CG; P=0.033); differences between the verum groups and control were significant (P≤0.009). Handgrip strength increased in the WB-EMS group (1.90 kg; P<0.001; P=0.050 vs control) only. No adverse effects of WB-EMS or protein supplementation were recorded.

CONCLUSION

WB-EMS&P is a safe and efficient method for tackling sarcopenia and SO in older men. However, the suboptimum effect on functional parameters should be addressed by increased voluntary activation during WB-EMS application.