Nonpharmacological interventions for osteoporosis treatment: Systematic review of clinical practice guidelines

Effect of a Multicomponent Intervention with Tele-Rehabilitation and the Vivifrail© Exercise Programme on Functional Capacity after Hip Fracture: Study Protocol for the ActiveFLS Randomized Controlled Trial

INTRODUCTION

Hip fractures are the most common fracture leading to hospitalization and are associated with high costs, mortality rates and functional decline. Although several guidelines exist for preventing new fractures and promoting functional recovery, they tend to focus on osteoporosis treatment and do not take into account the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. Moreover, most health systems are fragmented and are incapable of providing appropriate management for frail and vulnerable individuals who are at risk of experiencing fragility fractures. Multicomponent interventions and physical exercise using tele-rehabilitation could play a role in the management of hip fracture recovery. However, the effectiveness of exercise prescription and its combination with a comprehensive geriatric assessment (CGA) is still unclear.

METHODS

This randomized clinical trial will be conducted at the Hospital Universitario de Navarra (Pamplona, Spain). A total of 174 older adults who have suffered a hip fracture and fulfil the criteria for inclusion will be randomly allocated to either the intervention group or the control group. The intervention group will receive a multicomponent intervention consisting of individualized home-based exercise using the @ctive hip app for three months, followed by nine months of exercise using Vivifrail. Additionally, the intervention group will receive nutrition intervention, osteoporosis treatment, polypharmacy adjustment and evaluation of patient mood, cognitive impairment and fear of falling. The control group will receive standard outpatient care according to local guidelines. This research aims to evaluate the impact of the intervention on primary outcome measures, which include changes in functional status during the study period based on the Short Physical Performance Battery.

DISCUSSION

The findings of this study will offer valuable insights into the efficacy of a comprehensive approach that considers the complexity of frailty in older adults and geriatric syndromes, which are important factors in individuals at risk of suffering from frailty fractures. This study's findings will contribute to the creation of more effective strategies tailored to the requirements of these at-risk groups.

Pharmacological and Non-Pharmacological Agents versus Bovine Colostrum Supplementation for the Management of Bone Health Using an Osteoporosis-Induced Rat Model

Osteoporosis is defined by loss of bone mass and deteriorated bone microarchitecture. The present study compared the effects of available pharmacological and non-pharmacological agents for osteoporosis [alendronate (ALE) and concomitant supplementation of vitamin D (VD) and calcium (Ca)] with the effects of bovine colostrum (BC) supplementation in ovariectomized (OVX) and orchidectomized (ORX) rats. Seven-month-old rats were randomly allocated to: (1) placebo-control, (2) ALE group (7.5 μg/kg of body weight/day/5 times per week), (3) VD/Ca group (VD: 35 μg/kg of body weight/day/5 times per week; Ca: 13 mg/kg of body weight/day/3 times per week), and (4) BC supplementation (OVX: 1.5 g/day/5 times per week; ORX: 2 g/day/5 times per week). Following four months of supplementation, bone microarchitecture, strength and bone markers were evaluated. ALE group demonstrated significantly higher Ct.OV, Ct.BMC, Tb.Th, Tb.OV and Tb.BMC and significantly lower Ct.Pr, Tb.Pr, Tb.Sp, Ct.BMD and Tb.BMD, compared to placebo (p < 0.05). BC presented significantly higher Ct.Pr, Ct.BMD, Tb.Pr, Tb.Sp, and Tb.BMD and significantly lower Ct.OV, Ct.BMC, Tb.Th, Tb.OV and Tb.BMC compared to ALE in OVX rats (p < 0.05). OVX rats receiving BC experienced a significant increase in serum ALP and OC levels post-supplementation (p < 0.05). BC supplementation may induce positive effects on bone metabolism by stimulating bone formation, but appear not to be as effective as ALE.

Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures.

INTRODUCTION

The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture.

METHODS

The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized.

RESULTS AND CONCLUSION

The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

Effect of Strength Training Protocol on Bone Mineral Density for Postmenopausal Women with Osteopenia/Osteoporosis Assessed by Dual-Energy X-ray Absorptiometry (DEXA)

This study aims to introduce a resistance training protocol (6 repetitions × 70% of 1 maximum repetition (1RM), followed by 6 repetitions × 50% of 1RM within the same set) specifically designed for postmenopausal women with osteopenia/osteoporosis and monitor the effect of the protocol on bone mineral density (BMD) in the lumbar spine, assessed by dual-energy X-ray absorptiometry (DEXA). The subjects included in the study were 29 postmenopausal women (56.5 ± 2.8 years) with osteopenia or osteoporosis; they were separated into two groups: the experimental group (n = 15), in which the subjects participated in the strength training protocol for a period of 6 months; and the control group (n = 14), in which the subjects did not take part in any physical activity. BMD in the lumbar spine was measured by DEXA. The measurements were performed at the beginning and end of the study. A statistically significant increase (Δ% = 1.82%) in BMD was observed at the end of the study for the exercise group (0.778 ± 0.042 at baseline vs. 0.792 ± 0.046 after 6 months, p = 0.018, 95% CI [-0.025, -0.003]); while an increase was observed for the control group (Δ% = 0.14%), the difference was not statistically significant (0.762 ± 0.057 at baseline vs. 0.763 ± 0.059, p = 0.85, 95% CI [-0.013, 0.011]). In conclusion, our strength training protocol seems to be effective in increasing BMD among women with osteopenia/osteoporosis and represents an affordable strategy for preventing future bone loss.

LncRNA MALAT1 promotes osteogenic differentiation of BMSCs and inhibits osteoclastic differentiation of Mø in osteoporosis via the miR-124-3p/IGF2BP1/Wnt/β-catenin axis

Osteoporosis is defined as a skeletal disorder characterized by impairment in bone strength. The potential application of lncRNAs as therapeutic targets for osteoporosis has been unveiled. This study investigated the regulatory mechanism of lncRNA MALAT1 in the differentiation of bone marrow stem cells (BMSCs) and macrophages (Mø) in osteoporosis. MALAT1 expression in peripheral blood of elderly osteoporosis patients and healthy volunteers was detected. BMSCs and mononuclear Mø were isolated and cultured. Osteogenic differentiation of BMSCs and osteoclastic differentiation of Mø were induced. BMSCs and Mø were transfected with si-MALAT1, miR-124-3p mimics, miR-124-3p inhibitor, or pcDNA IGF2BP1, followed by detection of cell differentiation. The target microRNAs (miRs) and downstream genes and signaling pathways of MALAT1 were examined. The ovariectomy-induced mouse model of osteoporosis was established, and the mice were injected with pcDNA-MALAT1. MALAT1 was downregulated in osteoporosis patients, increased in BMSCs after osteogenic differentiation, and diminished in Mø after osteoclastic differentiation. Downregulation of MALAT1 repressed osteogenic differentiation of BMSCs and facilitated osteoclastic differentiation of Mø. MALAT1 upregulated IGF2BP1 expression by competitively binding to miR-124-3p. miR-124-3p silencing reversed the effect of si-MALAT1 on BMSCs and Mø differentiation, and IGF2BP1 upregulation averted the effect of overexpressed-miR-124-3p by activating the Wnt/β-catenin pathway. Upregulation of MALAT1 activated the Wnt/β-catenin pathway and attenuated bone injury in mice. In conclusion, lncRNA MALAT1 promoted the osteogenic differentiation of BMSCs and inhibited osteoclastic differentiation of Mø in osteoporosis via the miR-124-3p/IGF2BP1/Wnt/β-catenin axis. This article is protected by copyright. All rights reserved.

Postmenopausal osteoporosis: risk evaluation and treatment options

Postmenopausal osteoporosis is a chronic progressive condition characterized by reduced bone mass and impaired bone quality, leading to an increased risk of fragility fractures. Osteoporotic fractures reduce quality of life and are associated with high morbidity, mortality and economic burden. Primary and secondary prevention interventions are always recommended starting from the premenopausal age, in women after menopause, however, it is essential to develop a long-term intervention strategy that allows to identify patients at high risk of fracture and the choice of therapy based on the estimated risk. This narrative review described the tools for layering the management approach in relation to low, high and very high fracture risk. Several medications are now available for the treatment of osteoporosis and the prevention of fractures; the knowledge of the efficacy, safety and additional benefits profile of the individual preparations allows an appropriate choice between the different drugs available and the possibility of adapting the prescription to the lifetime fracture risk spectrum. From the literature it emerges that menopausal hormone therapy (MHT), TSEC combination and SERMs can be drugs of choice to counteract postmenopausal bone loss in younger women or at low risk of fracture, while bisphosphonates and denosumab are appropriate for women with high risk or at an older age. Therapy with denosumab and anabolic agents such as teriparatide and romosozumab is particularly indicated for subjects with very high risk of fracture.

Bovine Colostrum Supplementation Improves Bone Metabolism in an Osteoporosis-Induced Animal Model

Osteoporosis is characterized by bone loss. The present study aims to investigate the effects of bovine colostrum (BC) on bone metabolism using ovariectomized (OVX) and orchidectomized (ORX) rat models. Twenty-seven-week-old Wistar Han rats were randomly assigned as: (1) placebo control, (2) BC supplementation dose 1 (BC1: 0.5 g/day/OVX, 1 g/day/ORX), (3) BC supplementation dose 2 (BC2: 1 g/day/OVX, 1.5 g/day/ORX) and (4) BC supplementation dose 3 (BC3: 1.5 g/day/OVX, 2 g/day/ORX). Bone microarchitecture, strength, gene expression of VEGFA, FGF2, RANKL, RANK and OPG, and bone resorption/formation markers were assessed after four months of BC supplementation. Compared to the placebo, OVX rats in the BC1 group exhibited significantly higher cortical bone mineral content and trabecular bone mineral content (p < 0.01), while OVX rats in the BC3 group showed significantly higher trabecular bone mineral content (p < 0.05). ORX rats receiving BC dose 2 demonstrated significantly higher levels of trabecular bone mineral content (p < 0.05). Serum osteocalcin in the ORX was pointedly higher in all BC supplementation groups than the placebo (BC1: p < 0.05; BC2, BC3: p < 0.001). Higher doses of BC induced significantly higher relative mRNA expression of OPG, VEGFA, FGF2 and RANKL (p < 0.05). BC supplementation improves bone metabolism of OVX and ORX rats, which might be associated with the activation of the VEGFA, FGF2 and RANKL/RANK/OPG pathways.

What Determines the Quality of Rehabilitation Clinical Practice Guidelines?: An Overview Study

OBJECTIVE

The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines.

DESIGN

Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations.

RESULTS

All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53).

CONCLUSIONS

Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.

Bone Health in Idiopathic Inflammatory Myopathies: Diagnosis and Management

PURPOSE OF REVIEW

This article provides an update on the most recent advances in epidemiology, pathogenesis, diagnostic procedures, and therapeutic approaches for myositis-associated bone diseases, such as osteoporosis and bone fractures.

RECENT FINDINGS

In the recent years, several studies showed that osteoporosis and consequent fractures are a common and frequently underestimated complication in patients with idiopathic inflammatory myopathies (IIM). In younger patients, asymptomatic fractures might present in the early phase of the disease which could increase the risk of development of further fractures. High-risk patients could be selected with early application of combined diagnostic procedures, such as fracture risk scores with steroid dose adjustments and imaging. Recent advances might help clinicians from different fields of medicine in the early recognition and management of myositis-associated osteoporosis, which will potentially improve the quality of life of patients with IIM.

Effects of Nonpharmacological Interventions on Balance Function in Patients with Osteoporosis or Osteopenia: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the clinical efficacy of nonpharmacological interventions in improving balance function of patients with osteoporosis or osteopenia using network meta-analysis (NMA).

METHODS

We searched seven databases (PubMed, the Cochrane Library, Embase, CKNI, Wanfang Data, VIP, and CBM) for relevant randomized controlled trials (RCTs) up to August 31, 2020. Berg Balance Scale (BBS) and Time Up and Go Test (TUGT) were used as outcome measures. Two researchers independently screened studies, collected data from the studies, and estimated risk of study bias. Divergence in the evaluation process was settled by consulting a third researcher. We used Stata 15.1 software for network meta-analysis (NMA).

RESULTS

We identified 10 eligible RCTs, with a total of 737 patients and four intervention methods, including traditional Chinese medicine (TCM) exercises, pulsed electromagnetic fields (PEMFs), strength training, and balance and strength training. The results revealed that all nonpharmacological interventions could improve balance function, but the effect of balance and strength training was better than other interventions.

CONCLUSION

Exercise can significantly improve the balance function of patients with osteoporosis and osteopenia, and balance combined with strength training has the best effect, followed by TCM exercises.

Cancer Treatment-Induced Bone Loss (CTIBL): State of the Art and Proper Management in Breast Cancer Patients on Endocrine Therapy

OPINION STATEMENT

About 70-80% of early breast cancer (BC) patients receive adjuvant endocrine therapy (ET) for at least 5 years. ET includes in the majority of cases the use of aromatase inhibitors, as upfront or switch strategy, that lead to impaired bone health. Given the high incidence and also the high prevalence of BC, cancer treatment-induced bone loss (CTIBL) represents the most common long-term adverse event experimented by patients with hormone receptor positive tumours. CTIBL is responsible for osteoporosis occurrence and, as a consequence, fragility fractures that may negatively affect quality of life and survival expectancy. As recommended by main international guidelines, BC women on aromatase inhibitors should be carefully assessed for their fracture risk at baseline and periodically reassessed during adjuvant ET in order to early detect significant worsening in terms of bone health. Antiresorptive agents, together with adequate intake of calcium and vitamin D, should be administered in BC patients during all course of ET, especially in those at high risk of osteoporotic fractures, as calculated by tools available for clinicians. Bisphosphonates, such as zoledronate or pamidronate, and anti-RANKL antibody, denosumab, are the two classes of antiresorptive drugs used in clinical practice with similar efficacy in preventing bone loss induced by aromatase inhibitor therapy. The choice between them, in the absence of direct comparison, should be based on patients' preference and compliance; the different safety profile is mainly related to the route of administration, although both types of drugs are manageable with due care, since most of the adverse events are predictable and preventable. Despite advances in management of CTIBL, several issues such as the optimal time of starting antiresorptive agents and the duration of treatment remain unanswered. Future clinical trials as well as increased awareness of bone health are needed to improve prevention, assessment and treatment of CTIBL in these long-term survivor patients.

Adaptation of clinical practice guidelines for osteoporosis in a Mexican context. Experience using methodologies ADAPTE, GRADE-ADOLOPMENT, and RAND/UCLA

High quality guidelines are required to enhance clinical practice, but its development is time consuming and a complex process. Adaptation might shorten development time and prevent double effort adjusting recommendations for a local context.

BACKGROUND AND OBJECTIVE

The aim of this article is to present our experience in a process in which we combined two methodologies for the adaptation of high quality osteoporosis CPGs for a primary health care context, with the inclusion of a formal consensus.

METHODS

We began an adaptation process with ADAPTE, and required to migrate to GRADE-ADOLOPMENT methodology, based on GIN-McMaster Guideline Development Checklist. To identify high quality clinical practice guidelines, we performed a systematic review as per the PRISMA-statement methodology (PROSPERO: CRD42019138548, August 19th, 2019); methodological quality was assessed using the Appraisal of Guidelines for Research & Evaluation version II system. We developed a RAND/UCLA consensus to support the inclusion of good practice statements and feasibility of selected recommendations.

RESULTS

Thirteen clinical questions were integrated, and fracture risk was selected as the main outcome for intervention recommendations analysis. Six high quality guidelines were selected. We prepared final recommendations from selected guides in an evidence synthesis framework. After the consensus, we integrated 50 recommendations.

CONCLUSION

By starting the adaptation process with ADAPTE, we experienced a time consuming process, which we could overcome when migrating to GRADE-Adolopment in combination with a consensus panel.

Health behaviors in major chronic diseases patients: trends and regional variations analysis, 2008-2017, Korea

Background

Improving the health behaviors of those with chronic diseases such as hypertension and diabetes is important for disease management. Few in-depth studies have been conducted in Korea on the health behaviors of chronic disease patients. This study examined the health behaviors of chronic disease patients over time and compared them with those of the general population.

Methods

Cross-sectional time-series data obtained from the Korea Community Health Survey from 2008 to 2017 were analyzed. Thirteen diseases were included in this analysis, namely, hypertension, diabetes, dyslipidemia, stroke, myocardial infarction, angina, osteoarthritis, osteoporosis, asthma, allergic rhinitis, atopic dermatitis, cataract, and depression. The current smoking rate, drinking rate, and the walking rate, which are leading health behaviors necessary for preventing chronic diseases, were analyzed by disease type. We compared patients’ health behaviors with those of the general population and identified regional variations.

Results

Although the current overall smoking rate was seemingly declining, the overall monthly drinking and high-risk drinking rates were increasing. In 2017, patients experiencing depression symptoms had a higher smoking rate than did the general population; hypertension and diabetes patients had a higher risk-drinking rate than did the latter. The general population’s walking rate was highest. There were considerable variations by region among chronic disease patients.

Conclusions

Chronic disease patients displayed worse health behaviors than those of the general population, in some instances. Rather than focusing only on chronic disease patients’ medication adherence, strategies must be devised to increase their smoking cessation rate, decrease their drinking rate, and increase their walking rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09940-7.

Idiopathic Osteoporosis and Nephrolithiasis: Two Sides of the Same Coin?

Idiopathic osteoporosis and nephrolithiasis are formidable health problems showing a progressive increase in their incidence and prevalence in the last decades. These temporal trends were observed in both pediatric and adult populations worldwide. Epidemiological and experimental studies indicate that both disorders show several common pathogenic environmental and genetic factors. In this review, we analyzed the clinical characteristics common to the two disorders and the state-of-the-art knowledge regarding the genetic predisposition and the environmental factors recognized as triggers in adult and pediatric ages. As a result of this work, we propose to consider idiopathic nephrolithiasis and osteoporosis as two possible expressions of a unique clinical syndrome. Accordingly, the clinical approach to both disorders should be modified in order to program an efficient primary and secondary prevention strategy.

Targeting autophagy in osteoporosis: From pathophysiology to potential therapy

Osteoporosis is a highly prevalent disorder characterized by the loss of bone mass and microarchitecture deterioration of bone tissue, attributed to various factors, including menopause (primary), aging (primary) and adverse effects of relevant medications (secondary). In recent decades, knowledge regarding the etiological mechanisms underpinning osteoporosis emphasizes that bone cellular homeostasis, including the maintenance of cell functions, differentiation, and the response to stress, is tightly regulated by autophagy, which is a cell survival mechanism for eliminating and recycling damaged proteins and organelles. With the important roles in the maintenance of cellular homeostasis and organ function, autophagy has emerged as a potential target for the prevention and treatment of osteoporosis. In this review, we update and discuss the pathophysiology of autophagy in normal bone cell life cycle and metabolism. Then, the alternations of autophagy in primary and secondary osteoporosis, and the accompanied pathological process are discussed. Finally, we discuss current strategies, limitations, and challenges involved in targeting relevant pathways and propose strategies by which such hurdles may be circumvented in the future for their translation into clinical validations and applications for the prevention and treatment of osteoporosis.

Osteoporosis: Pathophysiology and therapeutic options

Osteoporosis is a metabolic bone disease that, on a cellular level, results from osteoclastic bone resorption not compensated by osteoblastic bone formation. This causes bones to become weak and fragile, thus increasing the risk of fractures. Traditional pathophysiological concepts of osteoporosis focused on endocrine mechanisms such as estrogen or vitamin D deficiency as well as secondary hyperparathyroidism. However, research over the last decades provided exiting new insights into mechanisms contributing to the onset of osteoporosis, which go far beyond this. Selected mechanisms such as interactions between bone and the immune system, the gut microbiome, and cellular senescence are reviewed in this article. Furthermore, an overview on currently available osteoporosis medications including antiresorptive and bone forming drugs is provided and an outlook on potential future treatment options is given.