Meta-analysis of walking for preservation of bone mineral density in postmenopausal women

Outdoor walking, genetic predisposition, and the risk of incident osteoporosis among older adults: A prospective large population-based cohort study

This large-scale prospective study showed that a significant association between longer duration of daily outdoor walking and reduced osteoporosis risk was found among older adults, particularly among those with a low genetic predisposition to osteoporosis, which highlighted the importance of outdoor walking as a simple, cost-effective adjunct for preventing osteoporosis.

PURPOSE

The available cross-sectional data and small-scale studies indicate that outdoor walking benefits bone metabolism. Nevertheless, there is a scarcity of comprehensive prospective research investigating the enduring correlation between outdoor walking and osteoporosis. This study aims to conduct a prospective analysis of the correlation between outdoor walking and osteoporosis while also examining potential variations influenced by genetic susceptibility to osteoporosis.

METHODS

24,700 older adults without osteoporosis at baseline were enrolled. These individuals were followed up until December 31, 2021, during which data on outdoor walking was gathered. The genetic risk score for osteoporosis was comprised of 14 single-nucleotide polymorphisms.

RESULTS

4,586 cases of osteoporosis were identified throughout a median follow-up period of 37.3 months. Those who walked outside for > 30 but ≤ 60 min per day had a hazard ratio (HR) of 0.83 (95% confidence interval (CI): 0.72-0.95) for incident osteoporosis, whereas those who walked outside for > 60 min per day had an HR of 0.60 (95% CI: 0.39-0.92). We found that osteoporosis risk exhibited a declining trend in individuals with low genetic risk. Individuals walking outside for > 60 min per day tended to have the lowest overall osteoporosis risk among those with high genetic risk.

CONCLUSIONS

A significant negative correlation exists between an extended period of daily outdoor walking and osteoporosis incidence risk. This correlation is particularly pronounced among individuals with low genetic risk. The results above underscore the significance of outdoor walking as a simple and economical adjunct to public health programs to prevent osteoporosis.

Gamified Exercise with Kinect: Can Kinect-Based Virtual Reality Training Improve Physical Performance and Quality of Life in Postmenopausal Women with Osteopenia? A Randomized Controlled Trial

BACKGROUND

Osteopenia, caused by estrogen deficiency in postmenopausal women (PMW), lowers Bone Mineral Density (BMD) and increases bone fragility. It affects about half of older women's social and physical health. PMW experience pain and disability, impacting their health-related Quality of Life (QoL) and function. This study aimed to determine the effects of Kinect-based Virtual Reality Training (VRT) on physical performance and QoL in PMW with osteopenia.

METHODOLOGY

The study was a prospective, two-arm, parallel-design, randomized controlled trial. Fifty-two participants were recruited in the trial, with 26 randomly assigned to each group. The experimental group received Kinect-based VRT thrice a week for 24 weeks, each lasting 45 min. Both groups were directed to participate in a 30-min walk outside every day. Physical performance was measured by the Time Up and Go Test (TUG), Functional Reach Test (FRT), Five Times Sit to Stand Test (FTSST), Modified Sit and Reach Test (MSRT), Dynamic Hand Grip Strength (DHGS), Non-Dynamic Hand Grip Strength (NDHGS), BORG Score and Dyspnea Index. Escala de Calidad de vida Osteoporosis (ECOS-16) questionnaire measured QoL. Both physical performance and QoL measures were assessed at baseline, after 12 weeks, and after 24 weeks. Data were analyzed on SPSS 25.

RESULTS

The mean age of the PMW participants was 58.00 ± 5.52 years. In within-group comparison, all outcome variables (TUG, FRT, FTSST, MSRT, DHGS, NDHGS, BORG Score, Dyspnea, and ECOS-16) showed significant improvements (p < 0.001) from baseline at both the 12th and 24th weeks and between baseline and the 24th week in the experimental group. In the control group, all outcome variables except FRT (12th week to 24th week) showed statistically significant improvements (p < 0.001) from baseline at both the 12th and 24th weeks and between baseline and the 24th week. In between-group comparison, the experimental group demonstrated more significant improvements in most outcome variables at all points than the control group (p < 0.001), indicating the positive additional effects of Kinect-based VRT.

CONCLUSION

The study concludes that physical performance and QoL measures were improved in both the experimental and control groups. However, in the group comparison, these variables showed better results in the experimental group. Thus, Kinect-based VRT is an alternative and feasible intervention to improve physical performance and QoL in PMW with osteopenia. This novel approach may be widely applicable in upcoming studies, considering the increasing interest in virtual reality-based therapy for rehabilitation.

Association between physical performance and bone mass in community-dwelling postmenopausal Japanese women: The Unzen study

BACKGROUND

Low bone mass is an independent risk factor for osteoporotic fractures. We examined the association between physical performance and bone mass using quantitative ultrasound in community-dwelling postmenopausal Japanese women.

METHODS

We conducted a cross-sectional study on 524 community-dwelling postmenopausal Japanese women who were not being administered osteoporosis medications. Physical performance was assessed on the basis of grip strength, chair stand time, and functional reach. The stiffness index was measured as a quantitative ultrasound parameter for heel bone mass.

RESULTS

Physical performance, assessed by grip strength, chair stand time, and functional reach, and the stiffness index significantly decreased with age (both p<0.001). The multiple linear regression analysis showed that grip strength (p = 0.001), chair stand time (p = 0.004), and functional reach (p = 0.048) were significantly associated with the stiffness index after adjusting for age, body mass index, smoking, drinking, and exercise.

CONCLUSIONS

Physical performance was significantly associated with heel bone mass in community-dwelling postmenopausal Japanese women.

The multifaceted benefits of walking for healthy aging: from Blue Zones to molecular mechanisms

Physical activity, including walking, has numerous health benefits in older adults, supported by a plethora of observational and interventional studies. Walking decreases the risk or severity of various health outcomes such as cardiovascular and cerebrovascular diseases, type 2 diabetes mellitus, cognitive impairment and dementia, while also improving mental well-being, sleep, and longevity. Dose-response relationships for walking duration and intensity are established for adverse cardiovascular outcomes. Walking's favorable effects on cardiovascular risk factors are attributed to its impact on circulatory, cardiopulmonary, and immune function. Meeting current physical activity guidelines by walking briskly for 30 min per day for 5 days can reduce the risk of several age-associated diseases. Additionally, low-intensity physical exercise, including walking, exerts anti-aging effects and helps prevent age-related diseases, making it a powerful tool for promoting healthy aging. This is exemplified by the lifestyles of individuals in Blue Zones, regions of the world with the highest concentration of centenarians. Walking and other low-intensity physical activities contribute significantly to the longevity of individuals in these regions, with walking being an integral part of their daily lives. Thus, incorporating walking into daily routines and encouraging walking-based physical activity interventions can be an effective strategy for promoting healthy aging and improving health outcomes in all populations. The goal of this review is to provide an overview of the vast and consistent evidence supporting the health benefits of physical activity, with a specific focus on walking, and to discuss the impact of walking on various health outcomes, including the prevention of age-related diseases. Furthermore, this review will delve into the evidence on the impact of walking and low-intensity physical activity on specific molecular and cellular mechanisms of aging, providing insights into the underlying biological mechanisms through which walking exerts its beneficial anti-aging effects.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

Detrimental Changes in Health during Menopause: The Role of Physical Activity

Midlife women experience changes in cardiometabolic, physical, and psychosocial health during menopause that negatively impacts their overall quality of life. Factors that contribute to these increases in cardiometabolic risk include weight gain as well as increases in fat mass (particularly abdominal adiposity), insulin resistance, and vascular dysfunction. Other deleterious changes in physical health (e. g. reduced sleep health, bone density, and balance) as well as changes in psychosocial health (e. g. mood, anxiety, and depression) often coincide and are linked to these increases in cardiometabolic risk. Physical activity and exercise are important lifestyle components that have been demonstrated to improve cardiometabolic, physical, and psychosocial health, yet physical activity and exercise is known to decline during perimenopause and into the postmenopausal years. In this narrative review, we summarize these changes in overall health during menopause as well as how declining physical activity contributes to these changes. Additionally, we discuss how incorporating physical activity and exercise during menopause can potentially ameliorate health declines. We conclude that there exists a significant, positive impact of physical activity on cardiometabolic, physical, and psychological health among midlife women, particularly if undertaken during the perimenopausal and postmenopausal years.

Molecular mechanisms of exercise contributing to tissue regeneration

Physical activity has been known as an essential element to promote human health for centuries. Thus, exercise intervention is encouraged to battle against sedentary lifestyle. Recent rapid advances in molecular biotechnology have demonstrated that both endurance and resistance exercise training, two traditional types of exercise, trigger a series of physiological responses, unraveling the mechanisms of exercise regulating on the human body. Therefore, exercise has been expected as a candidate approach of alleviating a wide range of diseases, such as metabolic diseases, neurodegenerative disorders, tumors, and cardiovascular diseases. In particular, the capacity of exercise to promote tissue regeneration has attracted the attention of many researchers in recent decades. Since most adult human organs have a weak regenerative capacity, it is currently a key challenge in regenerative medicine to improve the efficiency of tissue regeneration. As research progresses, exercise-induced tissue regeneration seems to provide a novel approach for fighting against injury or senescence, establishing strong theoretical basis for more and more "exercise mimetics." These drugs are acting as the pharmaceutical alternatives of those individuals who cannot experience the benefits of exercise. Here, we comprehensively provide a description of the benefits of exercise on tissue regeneration in diverse organs, mainly focusing on musculoskeletal system, cardiovascular system, and nervous system. We also discuss the underlying molecular mechanisms associated with the regenerative effects of exercise and emerging therapeutic exercise mimetics for regeneration, as well as the associated opportunities and challenges. We aim to describe an integrated perspective on the current advances of distinct physiological mechanisms associated with exercise-induced tissue regeneration on various organs and facilitate the development of drugs that mimics the benefits of exercise.

Potential of Neuromuscular Electrical Stimulation as a Bone Loss Countermeasure in Microgravity

INTRODUCTION: For future long-duration spaceflight missions, additional methods of loading the skeleton may be required to supplement exercise to minimize bone loss. Neuromuscular electrical stimulation (NMES) can elicit muscular contractions that create strain on bone. However, the potential effectiveness of NMES on the proximal femur during disuse is not known.METHODS: We measured the maximum isometric force of NMES-induced contractions of the rectus femoris and the hamstrings of 10 subjects (5 male, 5 female), sitting with the hips and knees at 90 degrees of flexion. We employed 2-D biomechanical models of the knee and hip to estimate the hip joint reaction forces, applied these forces to a generic femur finite element analysis model, and qualitatively compared the peak principal strains of the proximal femoral neck to the peak strains modeled in previous studies for other forms of exercise.RESULTS: The average peak tensile/compressive strains were 1380 ± 719 µε/-2179 ± 1130 µε and 573 ± 345 µε/-900 ± 543 µε for the male and female subjects, respectively. While results varied between studies, the strains achieved during NMES generally were comparable to those achieved during walking or stairs, with some individuals matching higher intensity activities.DISCUSSION: This study demonstrated that isometric NMES contractions of the thigh muscles can create strain in the proximal femoral neck similar to that achieved during low impact activities. While NMES alone will unlikely create a sufficient daily strain stimulus to prevent bone loss, it will likely improve the current spaceflight countermeasures by adding more frequent loading throughout the day.Abitante TJ, Bouxsein ML, Duda KR, Newman DJ. Potential of neuromuscular electrical stimulation as a bone loss countermeasure in microgravity. Aerosp Med Hum Perform. 2022; 93(11):774–782.

Synergistic multi-joint kinematic strategies to reduce tripping risks during obstacle-crossing in older long-term Tai-Chi Chuan practitioners

Introduction

Losing balance or tripping over obstacles is considered one of the most common causes of falls in the elderly. Tai-Chi Chuan (TCC) has been shown to improve muscle strength, inter-joint coordination and balance control in the elderly. This study aimed to determine whether older long-term TCC practitioners would show multi-joint kinematic strategies that would reduce the risk of tripping during obstacle-crossing compared to peers without TCC experience.

Methods

Three-dimensional motions of the pelvis and lower extremities were measured using a motion capture system in fifteen older long-term TCC practitioners (TCC group) and 15 healthy controls without TCC experience during walking and crossing obstacles of three different heights. Crossing angles of the pelvis and lower limbs and toe-obstacle clearances were obtained and analyzed using two-way analyses of variance to study the between-subject (group) and within-subject (height) effects. A multi-link system approach was used to reveal the relationship between joint angular changes and toe-obstacle clearances.

Results

Compared to the controls, the TCC group showed increased leading and trailing toe-obstacle clearances (p < 0.05) with increased pelvic hiking and hip flexion but decreased hip adduction on the swing side and decreased knee flexion on the stance side during leading-limb crossing (p < 0.05), and increased pelvic hiking and anterior tilt but decreased hip adduction on the swing side, and decreased knee flexion on the stance side during trailing limb crossing (p < 0.05). All significant joint angular changes contributed to the increases in the toe-obstacle clearances.

Conclusion

The current study identified the kinematic changes of the pelvis and the lower limb joints and revealed a specific synergistic multi-joint kinematic strategy to reduce tripping risks during obstacle-crossing in older long-term TCC practitioners as compared to non-TCC controls. The observed multi-joint kinematic strategies and the associated increases in toe-obstacle clearances appeared to be related to the training characteristics of TCC movements. Long-term TCC practice may be helpful for older people in reducing the risk of tripping and the subsequent loss of balance.

Postmenopausal Osteoporosis: A Literature Review

A substantial proportion of the population of females in India falls in the perimenopausal and postmenopausal age groups. One of the complications associated with older age in women is the weakening of bones and the fall in bone mineral density (BMD). This has a severe debilitating consequence in a woman’s life and leads to reduced quality of life along with a greater incidence of fractures. If the fracture involves the hip or the vertebrae, it can cause immobility and be devastating. Postmenopausal osteoporosis is linked with the deficiency of estrogen that occurs with the cessation of the function of the ovaries as age progresses. The function of estrogen in the bone remodeling process is very well understood after years of research; estrogen plays a part in both the formation of bone as well as the prevention of the resorption of bone. A diagnosis can be made by dual-energy X-ray absorptiometry (DEXA). It is the gold standard and can spot low bone density at particular sites. The treatment options are selected according to the severity and rate of progression and factors pertaining to each patient. All postmenopausal women should be made aware of this disorder, and they should be encouraged to cultivate a healthy lifestyle through the implementation of a proper diet and inculcation of a regular exercise routine. Smoking and drinking alcohol should be limited, and calcium and vitamin D supplementation should be started in all women of the postmenopausal age group with or without osteoporosis. In patients who have been diagnosed with the disorder, pharmacological intervention is done. Drugs should be selected based on their side effects and contradictions. Follow-up is essential, and patient compliance should be carefully monitored. This article attempts to review the existing literature on this very prevalent disorder to spread awareness about it so that all postmenopausal women can take the necessary steps to prevent the weakening of their bones, and deal with its progression.

The effects of combined amplitude and high-frequency vibration on physically inactive osteopenic postmenopausal women

Purpose: To evaluate whole-body vibration (WBV) osteogenic potential in physically inactive postmenopausal women using high-frequency and combined amplitude stimuli.

Methods: Two-hundred fifty-five physically inactive postmenopausal women (55–75 years) with 10-year major osteoporotic fracture risk (3%–35%) participated in this 18-month study. For the first 12 months, the vibration group experienced progressive 20-min WBV sessions (up to 3 sessions/week) with rest periods (30–60 s) between exercises. Frequencies (30–50 Hz), with low (0.2–0.4 mm) and high (0.6–0.8 mm) amplitude stimuli were delivered via PowerPlate Pro5 platforms producing accelerations of (0.75–7.04 g). The last 6 months for the treatment group were a follow-up period similar to control. Serum bone remodelling markers [C-terminal crosslinked telopeptide of type-1 collagen (CTX), procollagen type-1 N-terminal propeptide (P1NP), bone alkaline phosphatase (BAP) and sclerostin] were measured at fasting. CTX and P1NP were determined by automated chemiluminescence immunoassay, bone alkaline phosphatase (BAP) by automated spectrophotometric immunoassay, and sclerostin by an enzyme-immunoassay. Bone mineral density (BMD) of the whole-body, proximal femur and lumbar vertebrae was measured by dual-energy X-ray absorptiometry (DXA). Bone microarchitecture of the distal non-dominant radius and tibia was measured by high-resolution peripheral quantitative computed tomography (HR-pQCT).

Results: Femoral neck (p = 0.520) and spine BMD (p = 0.444) failed to improve after 12 months of WBV. Bone macro and microstructural parameters were not impacted by WBV, as well as estimated failure load at the distal radius (p = 0.354) and tibia (p = 0.813). As expected, most DXA and HR-pQCT parameters displayed age-related degradation in this postmenopausal population. BAP and CTX increased over time in both groups, with CTX more marginally elevated in the vibration group when comparing baseline changes to month-12 (480.80 pmol/L; p = 0.039) and month-18 (492.78 pmol/L; p = 0.075). However, no differences were found when comparing group concentrations only at month-12 (506.35 pmol/L; p = 0.415) and month-18 (518.33 pmol/L; p = 0.480), indicating differences below the threshold of clinical significance. Overall, HR-pQCT, DXA bone parameters and bone turnover markers remained unaffected.

Conclusion: Combined amplitude and high-frequency training for one year had no ameliorating effect on DXA and HR-pQCT bone parameters in physically inactive postmenopausal women. Serum analysis did not display any significant improvement in formation and resorption markers and also failed to alter sclerostin concentrations between groups.

Is Regular Weight-Bearing Physical Activity Throughout the Lifecourse Associated with Better Bone Health in Late Adulthood?

We considered how weight-bearing physical activity (WBPA) through the lifecourse related to bone health in late adulthood in the Hertfordshire Cohort Study (HCS), a cohort of community dwelling adults born 1931-9, to identify sex-specific differences and periods critical for optimal bone health. Available questionnaire data from 258 participants (128 men and 130 women) included current reported lifestyle factors (including physical activity) and WBPA, coded as participation in WBPA aged < 18 years; aged 18-29 years; aged 30-49 years and aged ≥ 50 years. Responses were recorded as none/once a month/once a week/> once a week. Hip bone mineral density (BMD) was measured using a Lunar Prodigy DXA scanner. The mean age was 75.4 (SD 2.5) years in men and 75.7 (SD 2.6) years in women. Men reported significantly higher levels of past WBPA aged < 18 years (p = 0.006) and aged 18-29 years than women (p < 0.001). We observed greater BMD at total hip in women who reported regular WBPA at ages 18-29 years (p = 0.02) and 30-49 years (p = 0.02) compared with those who reported no WBPA (p = 0.019), after adjustment for confounders including current activity levels. In this cohort of older adults, recalled regular WBPA around the time of peak bone mass acquisition was less common in women than men, but associated with higher hip BMD in women in late adulthood.

Bone Tissue Engineering in the Treatment of Bone Defects

Bones play an important role in maintaining exercise and protecting organs. Bone defect, as a common orthopedic disease in clinics, can cause tremendous damage with long treatment cycles. Therefore, the treatment of bone defect remains as one of the main challenges in clinical practice. Today, with increased incidence of bone disease in the aging population, demand for bone repair material is high. At present, the method of clinical treatment for bone defects including non-invasive therapy and invasive therapy. Surgical treatment is the most effective way to treat bone defects, such as using bone grafts, Masquelet technique, Ilizarov technique etc. In recent years, the rapid development of tissue engineering technology provides a new treatment strategy for bone repair. This review paper introduces the current situation and challenges of clinical treatment of bone defect repair in detail. The advantages and disadvantages of bone tissue engineering scaffolds are comprehensively discussed from the aspect of material, preparation technology, and function of bone tissue engineering scaffolds. This paper also summarizes the 3D printing technology based on computer technology, aiming at designing personalized artificial scaffolds that can accurately fit bone defects.

Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis

Exercise and physical activity can improve bone strength and the risk of falls, which may offer benefits in the prevention and management of osteoporosis. However, uncertainty about the types of exercise that are safe and effective instigates lack of confidence in people with osteoporosis and health professionals. Existing guidelines leave some questions unresolved. This consensus statement aimed to determine the physical activity and exercise needed to optimise bone strength, reduce fall and fracture risk, improve posture and manage vertebral fracture symptoms, while minimising potential risks in people with osteoporosis. The scope of this statement was developed following stakeholder consultation. Meta-analyses were reviewed and where evidence was lacking, individual studies or expert opinion were used to develop recommendations. A multidisciplinary expert group reviewed evidence to make recommendations, by consensus when evidence was not available. Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. For safety, we recommend avoiding postures involving a high degree of spinal flexion during exercise or daily life. People with vertebral fracture or multiple low trauma fractures should usually exercise only up to an impact equivalent to brisk walking. Those at risk of falls should start with targeted strength and balance training. Vertebral fracture symptoms may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with specialist advice to encourage return to normal activities. Everyone with osteoporosis may benefit from guidance on adapting postures and movements. There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks.

Effect of fall direction on the lower hip fracture risk in athletes with different loading histories: A finite element modeling study in multiple sideways fall configurations

Physical loading makes bones stronger through structural adaptation. Finding effective modes of exercise to improve proximal femur strength has the potential to decrease hip fracture risk. Previous proximal femur finite element (FE) modeling studies have indicated that the loading history comprising impact exercises is associated with substantially higher fracture load. However, those results were limited only to one specified fall direction. It remains thus unclear whether exercise-induced higher fracture load depends on the fall direction. To address this, using magnetic resonance images of proximal femora from 91 female athletes (mean age 24.7 years with >8 years competitive career) and their 20 non-athletic but physically active controls (mean age 23.7 years), proximal femur FE models were created in 12 different sideways fall configurations. The athletes were divided into five groups by typical loading patterns of their sports: high-impact (H-I: 9 triple- and 10 high-jumpers), odd-impact (O-I: 9 soccer and 10 squash players), high-magnitude (H-M: 17 powerlifters), repetitive-impact (R-I: 18 endurance runners), and repetitive non-impact (R-NI: 18 swimmers). Compared to the controls, the FE models showed that the H-I and R-I groups had significantly (p < 0.05) higher fracture loads, 11-17% and 22-28% respectively, in all fall directions while the O-I group had significantly 10-11% higher fracture loads in four fall directions. The H-M and R-NI groups did not show significant benefit in any direction. Also, the analyses of the minimum fall strength (MFS) among these multiple fall configurations confirmed significantly 15%, 11%, and 14% higher MFSs in these impact groups, respectively, compared to the controls. These results suggest that the lower hip fracture risk indicated by higher fracture loads in athletes engaged in high impact or repetitive impact sports is independent of fall direction whereas the lower fracture risk attributed to odd-impact exercise is more modest and specific to the fall direction. Moreover, in concordance with the literature, the present study also confirmed that the fracture risk increases if the impact is imposed on the more posterolateral aspect of the hip. The present results highlight the importance of engaging in the impact exercises to prevent hip fractures and call for retrospective studies to investigate whether specific impact exercise history in adolescence and young adulthood is also associated with lower incidence of hip fractures in later life.

Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy

A clinical practice guideline on physical therapist management of patients with suspected or confirmed osteoporosis was developed by a volunteer guideline development group (GDG) that was appointed by the Academy of Geriatric Physical Therapy (APTA Geriatrics). The GDG consisted of an exercise physiologist and 6 physical therapists with clinical and methodological expertise. The guideline was based on a systematic review of existing clinical practice guidelines, followed by application of the ADAPTE methodological process described by Guidelines International Network for adapting guidelines for cultural and professional utility. The recommendations contained in this guideline are derived from the 2021 Scottish Intercollegiate Guideline Network (SIGN) document: Management of Osteoporosis and the Prevention of Fragility Fractures. These guidelines are intended to assist physical therapists practicing in the United States, and implementation in the context of the US health care system is discussed.

Distribution of hounsfield unit values in the pelvic bones: a comparison between young men and women with traumatic fractures and older men and women with fragility fractures: a retrospective cohort study

Background

The fixation strength of bone screws depends on bone mineral density (BMD), so it is important to evaluate bone strength at fracture sites. Few studies have investigated BMD in the pelvis. The aims of this study were to measure the regional Hounsfield unit (HU) values in the cancellous bone of the acetabulum and pelvic ring and to compare these values between young and older patients.

Methods

This study enrolled young patients with high-energy trauma (aged 20–44 years; young group) and older patients with low-energy trauma (aged 65–89 years; older group). Patients without pelvic computed tomography (CT) scans, those with pelvic bone implants, and those who died were excluded. The HU values on the contralateral (non-fractured) side of the pelvis were measured on CT scans. The CT data were divided into 7 areas: the pubic bone, the anterior and posterior walls and roof of the acetabulum, the ischial tuberosity, the body of the ilium, and the third lumbar vertebra. The HU values in each area were compared between the young and older groups.

Results

Sixty-one young patients and 154 older patients were included in the study. The highest HU value was in the roof of the acetabulum regardless of age and sex. HU values were significantly higher in the ischial tuberosity and body of the ilium and lower in the pubic bone and anterior wall. The HU values in all pelvic areas were significantly lower in the older group than in the young group, especially in the anterior area.

Conclusions

HU values in the 6 pelvic areas were not uniform and were strongly related to load distribution. The HU distribution and age-related differences could explain the characteristic causes and patterns of acetabular fractures in the older and may help in surgical treatment.

Exercise to Mend Aged-tissue Crosstalk in Bone Targeting Osteoporosis & Osteoarthritis

Aging induces alterations in bone structure and strength through a multitude of processes, exacerbating common aging- related diseases like osteoporosis and osteoarthritis. Cellular hallmarks of aging are examined, as related to bone and the marrow microenvironment, and ways in which these might contribute to a variety of age-related perturbations in osteoblasts, osteocytes, marrow adipocytes, chondrocytes, osteoclasts, and their respective progenitors. Cellular senescence, stem cell exhaustion, mitochondrial dysfunction, epigenetic and intracellular communication changes are central pathways and recognized as associated and potentially causal in aging. We focus on these in musculoskeletal system and highlight knowledge gaps in the literature regarding cellular and tissue crosstalk in bone, cartilage, and the bone marrow niche. While senolytics have been utilized to target aging pathways, here we propose non-pharmacologic, exercise-based interventions as prospective "senolytics" against aging effects on the skeleton. Increased bone mass and delayed onset or progression of osteoporosis and osteoarthritis are some of the recognized benefits of regular exercise across the lifespan. Further investigation is needed to delineate how cellular indicators of aging manifest in bone and the marrow niche and how altered cellular and tissue crosstalk impact disease progression, as well as consideration of exercise as a therapeutic modality, as a means to enhance discovery of bone-targeted therapies.

The effects of exercise on body composition of prostate cancer patients receiving androgen deprivation therapy: An update systematic review and meta-analysis

Androgen deprivation therapy is a common treatment for prostate cancer. However, this therapy is associated with various adverse effects, such as increased body fat and decreased bone mineral density. Exercise may be useful for ameliorating these adverse effects, although it is not completely effective. This review aimed to clarify how exercise interventions influenced body composition and bone mineral density and to explore the most effective exercise program among prostate cancer patients who received androgen deprivation therapy. We searched the PubMed, EMBASE, Web of Science, EBSCO, and Cochrane Library databases for reports of randomised controlled trials that were published until October 2021. All studies involved prostate cancer patients who received androgen deprivation therapy and completed aerobic exercise, resistance exercise, and/or impact exercise training. Outcomes were defined as lean body mass, body fat mass, body fat rate, regional and whole-body bone mineral density. Thirteen reports regarding 12 randomised clinical trials (715 participants) were included. Relative to the control group, exercise intervention provided a higher lean body mass (mean difference: 0.88, 95% confidence interval: 0.40 to 1.36, P<0.01), a lower body fat mass (mean difference: -0.60, 95% confidence interval: -1.10 to -0.10, P<0.05), and a lower body fat rate (mean difference: -0.93, 95% confidence interval: -1.39 to -0.47, P<0.01). Subgroup analyses revealed greater efficacy for exercise duration of ≥6 months (vs. <6 months) and exercise immediately after the therapy (vs. delayed exercise). No significant differences were observed in the bone mineral density outcomes. Exercise can help ameliorate the adverse effects of androgen deprivation therapy in body composition, with combination exercises including resistance exercise, 8–12 repetition maximum of resistance exercise intensity, prolonged exercise duration, and performing exercise immediately after therapy providing better amelioration. And the combination of resistance and impact exercise appears to be the best mode for improving the bone mineral density.

Exercise Effects on Bone Mineral Density in Men

In contrast to postmenopausal women, evidence for a favorable effect of exercise on Bone Mineral Density (BMD) is still limited for men. This might be due to the paucity of studies, but also to the great variety of participants and study characteristics that may dilute study results. The aim of the present systematic review and meta-analysis was to evaluate the effect of exercise on BMD changes with rational eligibility criteria. A comprehensive search of six electronic databases up to 15 March 2021 was conducted. Briefly, controlled trials ≥6 months that determined changes in areal BMD in men >18 years old, with no apparent diseases or pharmacological therapy that relevantly affect bone metabolism, were included. BMD changes (standardized mean differences: SMD) of the lumbar spine (LS) and femoral neck (FN) were considered as outcomes. Twelve studies with 16 exercise and 12 control groups were identified. The pooled estimate of random-effect analysis was SMD = 0.38, 95%-CI: 0.14–0.61 and SMD = 0.25, 95%-CI: 0.00–0.49, for LS and FN, respectively. Heterogeneity between the trials was low–moderate. Funnel plots and rank and regression correlation tests indicate evidence for small study publication bias for LS but not FN-BMD. Subgroup analyses that focus on study length, type of exercise and methodologic quality revealed no significant difference between each of the three categories. In summary, we provided further evidence for a low but significant effect of exercise on BMD in men. However, we are currently unable to give even rough exercise recommendations for male cohorts.

Handgrip strength, dynapenia, and related factors in postmenopausal women

OBJECTIVE

This study aimed to evaluate the prevalence of dynapenia and factors related to low dominant handgrip strength (HGS) in postmenopausal women.

METHODS

A cross-sectional study was performed on 249 postmenopausal women aged 50 to 84 years. The following variables were recorded: age, age at menopause, smoking status, and the HGS measured with a digital dynamometer, body mass index, and adiposity assessed by bioelectric impedance. The physical activity level was evaluated by using the International Physical Activity Questionnaire. Bone mineral density was reported as T-scores, and blood biochemical parameters (calcium, phosphorus, vitamin D, and parathormone levels) were measured.

RESULTS

31.3% of women had dynapenia, and those aged ≥65 years had lower HGS (P < 0.001). Age at menopause was also associated with HGS, with those with menopause < 51 showing lower HGS (P = 0.005). Likewise, fat content ≥ 40%, and osteopenia/osteoporosis were also related to lower strength (P < 0.001). There was no statistically significant difference among HGS with respect to body mass index, smoking status, and plasma levels of vitamin D. A logistic regression model with lower Akaine Information Criterion showed that for every year in age and for each 1% of adiposity, women were more likely to have dynapenia with odd ratio (OR): 1.09; 95% and confidence interval (CI): 1.04 to 1.14 and OR: 1.06; 95% CI: 1.00 to 1.13, respectively. Conversely, women with higher femoral neck T-score were less likely to have dynapenia (OR: 0.53; 95% CI: 0.35-0.78).

CONCLUSIONS

HGS was associated with age at menopause, bone mineral density, and adiposity adjusted by age. The age and adiposity were significantly associated with a higher risk of dynapenia, whereas women with higher femoral neck T-score were less likely to have dynapenia.

The effect of magnetic therapy and moderate aerobic exercise on osteoporotic patients: A randomized clinical study

BACKGROUND

Osteoporosis is a frequent musculoskeletal condition with significant complications that would be a global health problem and one of the major causes of mortality and morbidity.

OBJECTIVES

The current study aimed to ascertain the impact of pulsed magnetic therapy, aerobic exercise, and a combination of both modalities on osteoporotic female patients postthyroidectomy.

METHODS

Between May 2018 and September 2019, 45 female patients with osteoporosis were included in the randomized clinical study, their age ranged from 40 to 50 years, had thyroidectomy for at least 6 months ago, and had an inactive lifestyle for at least the previous 6 months. Patients were assigned randomly into 3 equal groups. Group A (magnetic therapy group): received routine medical treatment (bisphosphonates, calcium, and vitamin D) in addition to pulsed magnetic therapy on the hip region for 12 weeks (3 sessions/week). Group B (exercise group): received routine medical treatment plus moderate-intensity aerobic exercise for 12 weeks (3 sessions/week). Group C (combined magnetic therapy and exercise therapy group): received routine medical treatment plus pulsed magnetic therapy and moderate-intensity aerobic exercise for 12 weeks (3 sessions/week). The 3 groups were assessed for bone mineral density (BMD) at baseline by dual-energy x-ray absorptiometry and after 12 weeks of treatment.

RESULTS

The results showed that within-group analysis a statistically significant increase was reveled (P < .05) for BMD in the 3 studied groups. Comparing the results among the 3 tested groups revealed a significant increase (P < .05) in posttesting mean values of BMD in group (C) compared to group (A) and group (B). No significant statistical difference in BMD means values between the 2 groups (A) and (B) after testing was detected.

CONCLUSION

Combination of both pulsed magnetic therapy and moderate-intensity aerobic exercise showed significant improvement in BMD at the hip region than using any of the 2 modalities alone.

Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1

PURPOSE

To provide updated evidence-based recommendations for the prevention, screening, and diagnosis of postmenopausal osteoporosis.

TARGET POPULATION

Postmenopausal patients without identified risk factors for fracture, low bone mineral density, or secondary osteoporosis related to medication or a medical condition.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within the Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team on the basis of standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations, Assessment, Development and Evaluations) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes updated recommendations on the role of exercise, calcium, and vitamin D in osteoporosis prevention; osteoporosis screening and diagnosis; rescreening intervals; and interventions to prevent falls. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Exercise attenuates bone mineral density loss during diet-induced weight loss in adults with overweight and obesity: A systematic review and meta-analysis

BACKGROUND

Weight-loss-induced fat loss improves cardiometabolic health in individuals with overweight and obesity; however, weight loss can also result in bone loss and increased fracture risk. Weight-loss-induced bone loss may be attenuated with exercise. Our aim was to compare changes in bone mineral density (BMD) in adults with overweight and obesity who undertook diet-induced weight loss alone or in combination with exercise.

METHODS

We included randomized controlled trials (RCTs) in adults with overweight or obesity (aged ≥18 years; body mass index ≥25 kg/m2) that prescribed diet-induced weight loss alone or in combination with supervised exercise, and measured any bone structural parameters. Risk of bias was assessed using the Cochrane Risk of Bias tool. Random-effects meta-analyses determined mean changes and net mean differences (95% confidence intervals (95%CIs)) in the percentage of areal BMD (aBMD) change between groups.

RESULTS

We included 9 RCTs. Diet-induced weight loss led to significant losses in femoral neck aBMD (mean change: -1.73% (95%CI: -2.39% to -1.07%), p < 0.001) and total hip aBMD (-2.19% (95%CI: -3.84% to -0.54%), p = 0.009). Femoral neck aBMD losses were significantly greater in the diet-induced weight loss group compared to the exercise plus diet-induced weight loss group (net difference: -0.88% (95%CI: -1.73% to -0.03%)); however, there were no differences in aBMD changes at any other skeletal site: total hip (-1.96% (95%CI: -4.59% to 0.68%)) and lumbar spine (-0.48% (95%CI: -1.81% to 0.86%)). aBMD changes did not differ significantly according to exercise modality (resistance exercise, aerobic exercise, or a combination of the two) during diet-induced weight loss.

CONCLUSION

Diet-induced weight loss led to greater femoral neck bone loss compared to diet-induced weight loss plus exercise. Bone loss at the total hip and lumbar spine was not attenuated by exercise during diet-induced weight loss. The lack of consistent skeletal benefits may be due to the insufficient duration and/or training intensities of most exercise interventions. Additional RCTs with appropriate, targeted exercise interventions should be conducted.

Bone Mineral Density Changes during Weight Regain following Weight Loss with and without Exercise

The purpose of this study was to compare changes in bone mineral density (BMD) over a 6 month follow up (period of weight regain) in overweight, postmenopausal women having previously completed a 6 month weight loss (WL) intervention with and without aerobic exercise (AEX). Women (BMI > 25 kg/m²) underwent VO₂max and DEXA scans at baseline, after 6 months of WL or AEX + WL, and at 12 months ad libitum follow up. Both groups lost ~9% body weight from 0 to 6 months and regained ~2% from 6 to 12 months, while losing ~4% of appendicular lean mass (ALM) across the 12-month study duration. VO₂max increased 10% from 0 to 6 months and declined 12% from 6 to 12 months for AEX + WL, with no changes for WL. Total body (p < 0.01) and total femur (p = 0.03) BMD decreased similar between groups across time (combined groups: 0-6 months: total body: -1.2% and total femur: -1.2%; 6-12 months: total body: -0.26% and total femur: -0.09%). Less ALM loss and greater VO₂max increases during the WL phase were associated with attenuated BMD loss at various anatomical sites during periods of weight regain (6-12 months) p's < 0.05). Results suggest that BMD loss may continue following WL, despite weight regain. Further, this study adds to the literature by suggesting that preventing declines in muscle quality and function during WL may attenuate the loss of BMD during weight regain. Future studies are needed to identify mechanisms underlying WL-induced bone loss so that effective practices can be designed to minimize the loss of BMD during WL and weight maintenance in older women.

Risk Factors for New Vertebral Fracture After Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures

Purpose

To analyze the risk factors for new vertebral fractures after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs).

Patients and Methods

We retrospectively reviewed the records of patients with symptomatic OVCFs who underwent PVP in our hospital, from January 2014 to January 2019. Demographic and lifestyle data on the presence of underlying chronic disease, preoperative bone mineral density, details of vertebral fractures, postoperative osteoporosis treatment, and new fracture development were collected. Patients were divided into postoperative fracture and non-fracture groups. To identify the independent risk factors for new vertebral fracture development, variables significant on univariate analysis were included in a multivariate regression model.

Results

Of the 2202 patients treated with PVP, 362 (16.43%) had a new postoperative vertebral fracture. All patients were followed up for >12 months (mean 14.7 months). Univariate analysis revealed no significant difference in height; body weight; preoperative bone mineral density; number of fractured vertebrae; injection volume of bone cement in a single vertebra; leakage rate of bone cement; or presence of hypertension, coronary heart disease, and chronic obstructive pulmonary disease between the fracture and non-fracture groups (P>0.05). Age, sex, smoking, alcohol consumption, diabetes mellitus, postoperative exercise, and postoperative osteoporosis treatment were associated with new vertebral fractures (all P<0.05). A multivariate analysis showed that age (odds ratio [OR]=1.212, P<0.0001), female sex (OR=1.917, P<0.0001), smoking (OR=1.538, P=0.026), and diabetes (OR=1.915, P<0.0001) were positively correlated with new vertebral fracture development, whereas postoperative exercise (OR=0.220, P<0.0001) and osteoporosis treatment (OR=0.413, P<0.0001) were negatively correlated.

Conclusion

Elderly patients, females, and those with a history of smoking and diabetes are at high risk of new vertebral fracture after PVP. Patients should be encouraged to stop smoking and consuming alcohol, control blood glucose level, participate in sufficient physical activity, and adhere to osteoporosis treatment to prevent new vertebral fractures.

High-Intensity Physical Activity with High Serum Vitamin D Levels is Associated with a Low Prevalence of Osteopenia and Osteoporosis: A Population-Based Study

We found that combination of high-intensity PA and high 25(OH)D levels was associated with low prevalence of osteoporosis/osteopenia. In addition, the prevalence of osteoporosis was lower in the low PA with high 25(OH)D levels than in the moderate or high PA with low 25(OH)D levels.

INTRODUCTION

The aim of this study was to explore the association of physical activity (PA) and serum 25-hydroxyvitamin D (25[OH]D) levels with osteopenia/osteoporosis.

METHODS

The Korean National Health and Nutrition Examination Survey data from 2008 to 2011 were used in this study. Data from 6868 individuals were selected. Each individual's level of PA was classified as 'low', 'moderate', or 'high'. Serum 25(OH)D levels were classified as 'low' or 'high'. Accordingly, the combined PA and 25(OH)D groups were divided into 6 groups. Bone mineral density (BMD) was classified as 'normal (T score ≥ - 1.0)', 'osteopenia (- 2.5 < T score < - 1.0)' or 'osteoporosis (T score ≤ - 2.5)'. Crude and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated using multinomial logistic regression models.

RESULTS

The AORs (95% CIs) for osteopenia were 0.64 (0.50-0.83) in the high PA with high 25(OH)D group and 0.69 (0.53-0.88) in the moderate PA with high 25(OH)D group. The AORs (95% CIs) for osteoporosis were increased in the groups in ascending order as follows: high PA with high 25(OH)D (0.40 [0.28-0.57]) < moderate PA with high 25(OH)D (0.47 [0.33-0.66]) < low PA with high 25(OH)D (0.59 [0.42-0.83]) < high PA with low 25(OH)D (0.70 [0.49-1.00]) < moderate PA with low 25(OH)D (0.76 [0.53-1.07]) < low PA with low 25(OH)D. This result was consistent in males but not evident in females.

CONCLUSION

We suggest that the combination of high-intensity PA and high 25(OH)D levels is positively associated with high BMD.

The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care

Global health organizations have provided recommendations regarding exercise for the general population. Strength training has been included in several position statements due to its multi-systemic benefits. In this narrative review, we examine the available literature, first explaining how specific mechanical loading is converted into positive cellular responses. Secondly, benefits related to specific musculoskeletal tissues are discussed, with practical applications and training programmes clearly outlined for both common musculoskeletal disorders and primary prevention strategies.

The effects of acute exercise on bone turnover markers in middle-aged and older adults: A systematic review

BACKGROUND

Bone turnover is the cellular machinery responsible for bone integrity and strength and, in the clinical setting, it is assessed using bone turnover markers (BTMs). Acute exercise can induce mechanical stress on bone which is needed for bone remodelling, but to date, there are conflicting results in regards to the effects of varying mechanical stimuli on BTMs.

OBJECTIVES

This systematic review examines the effects of acute aerobic, resistance and impact exercises on BTMs in middle and older-aged adults and examines whether the responses are determined by the exercise mode, intensity, age and sex.

METHODS

We searched PubMed, SCOPUS, Web of Science and EMBASE up to 22nd April 2020. Eligibility criteria included randomised controlled trials (RCTs) and single-arm studies that included middle-aged (50 to 65 years) and older adults (>65 years) and, a single-bout, acute-exercise (aerobic, resistance, impact) intervention with measurement of BTMs. PROSPERO registration number CRD42020145359.

RESULTS

Thirteen studies were included; 8 in middle-aged (n = 275, 212 women/63 men, mean age = 57.9 ± 1.5 years) and 5 in older adults (n = 93, 50 women/43 men, mean age = 68.2 ± 2.2 years). Eleven studies included aerobic exercise (AE, 7 middle-aged/4 older adults), and two included resistance exercise (RE, both middle-aged). AE significantly increased C-terminal telopeptide (CTX), alkaline phosphatase (ALP) and bone-ALP in middle-aged and older adults. AE also significantly increased total osteocalcin (tOC) in middle-aged men and Procollagen I Carboxyterminal Propeptide and Cross-Linked Carboxyterminal Telopeptide of Type I Collagen in older women. RE alone decreased ALP in older adults. In middle-aged adults, RE with impact had no effect on tOC or BALP, but significantly decreased CTX. Impact (jumping) exercise alone increased Procollagen Type 1 N Propeptide and tOC in middle-aged women.

CONCLUSION

Acute exercise is an effective tool to modify BTMs, however, the response appears to be exercise modality-, intensity-, age- and sex-specific. There is further need for higher quality and larger RCTs in this area.

The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis

BACKGROUND

Previous reviews have concluded that exercise has only modest effects on bone mineral density (BMD) in postmenopausal women. Despite the well-recognized strong positive relationship between load magnitude and bone response observed from animal research, the majority of human trials have examined the effects of only low to moderate intensity exercise on bone. We speculated that meta-analysing according to intensity may reveal a more potent exercise effect at higher intensity.

OBJECTIVES

To determine the effects of low, moderate and high intensity exercise on BMD at the spine and hip in postmenopausal women.

METHODS

Electronic databases and reference lists were searched for RCTs that examined the effect of exercise compared to control on DXA-derived lumbar spine, femoral neck or total hip BMD in healthy postmenopausal women. Interventions were classified as low, moderate or high intensity and pooled based on classification. Mean differences (MD) were calculated using random effects models and a risk of bias analysis was undertaken. To determine the effect of different exercise types (resistance and impact training) on BMD outcomes, subgroup analyses for all intensity categories and outcomes were conducted. Separate meta-analyses were undertaken to examine the influence of adding exercise to a bone medication intervention and to examine exercise effects on fracture risk.

RESULTS

Fifty-three trials, testing 63 interventions (19 low, 40 moderate, 4 high intensity) were included. At the lumbar spine, high intensity exercise yielded greater BMD effects (MD = 0.031 g/cm² 95% CI [0.012, 0.049], p = 0.002) than moderate (MD = 0.012 g/cm² 95% CI [0.008, 0.017], p < 0.001) and low intensity (MD = 0.010 g/cm² 95% CI [0.005, 0.015], p < 0.001). Low and moderate intensity exercise was equally effective at the femoral neck (low: 0.011 g/cm² 95% CI [0.006, 0.016], p < 0.001; moderate: 0.011 g/cm² 95% CI [0.007, 0.015], p < 0.001), but no effect of high-intensity exercise was observed. Moderate intensity exercise increased total hip BMD (0.008 g/cm² 95% CI [0.004, 0.012], p < 0.001), but low intensity did not. There were insufficient data to meta-analyse the effect of high intensity exercise at the total hip. Resistance training, potentially in combination with impact training, appears to be the most effective osteogenic stimulus at the spine and hip. Findings from meta-regression analyses were not informative and no influence of exercise on medication efficacy was observed. Risk of bias was mainly low or unclear due to insufficient information reported.

CONCLUSION

High intensity exercise is a more effective stimulus for lumbar spine BMD than low or moderate intensity, but not femoral neck BMD, however, the latter finding may be due to lack of power. While data from high-intensity exercise interventions are limited, the current comprehensive meta-analysis demonstrates the same positive relationship between load magnitude and bone response in humans that is observed in animal research. Findings have implications for optimal exercise prescription for osteoporosis in postmenopausal women.

STUDY REGISTRATION

Registered on PROSPERO (CRD42018117254).

The effect of exercise intensity on bone in postmenopausal women (part 1): A systematic review

BACKGROUND

Previous systematic reviews and meta-analyses of exercise effects on bone have reported null or modest effect sizes. While animal research has determined that a strong positive relationship exists between load magnitude/intensity and bone adaptation, nevertheless many human exercise interventions have been applied at low intensity. Meta-analytic pooling of exercise interventions irrespective of intensity dilutes the ability to detect efficacy of any one training regimen. Parsing out efficacy of low, moderate and high intensity exercise interventions will assist the determination of optimal exercise prescription for bone.

OBJECTIVES

First, to summarise and critically evaluate existing evidence of exercise effect on bone mass, bone structure and bone turnover markers (BTMs) in healthy postmenopausal women. Second, to examine the influence of intensity on bone response to exercise.

METHODS

Electronic databases (Embase, Scopus, CINAHL Plus, SPORTDiscus), database platforms (PubMed, Cochrane CENTRAL, ProQuest Central, Web of Science) and reference lists of included studies were searched for controlled trials and randomised controlled trials that described the effect of any exercise intervention compared to control on bone mass, bone structure or BTMs in healthy postmenopausal women. Fracture incidence was included as an exploratory endpoint. Data was extracted and weighed against the results of a comprehensive risk of bias analysis.

RESULTS

One hundred trials were included, investigating a total of 120 exercise interventions. Of those, 57 interventions were low intensity, 57 were moderate, and six were high intensity. On balance, low intensity exercise was not an effective stimulus to increase bone mass. Higher quality evidence suggests moderate to high intensity interventions, particularly those that combined high intensity resistance and impact training, were most beneficial for bone mass. Only high intensity exercise appears to improve structural parameters of bone strength, however, data are limited. Only low and moderate intensity interventions have measured BTMs and no notable benefits have been observed. The quality of trials varied greatly, and risk of bias determinations were frequently limited by insufficiently reported detail.

CONCLUSION

Heterogeneity in both study quality and outcomes limits the ability to draw strong conclusions from this comprehensive systematic review of RCT and CT reports. Nevertheless, there is a tendency in the higher quality data to indicate exercise intensity is positively related to the adaptive bone response. Part 2 of this review series reports a meta-analysis of the RCT data in order to draw quantitative conclusions from the higher quality trials.

STUDY REGISTRATION

Registered on PROSPERO (CRD42018117254).

Effect of an intensive intervention on the increase of physical activity and the decrease of sedentary lifestyle in inactive postmenopausal

BACKGROUND

During the transition to menopause, women experience different psychological, hormonal, and physical alterations that can affect their health. Physical activity is considered an important strategy in the prevention and control of such changes.

AIM

To evaluate the short-term effect of an intensive intervention, based on a combined exercise programme using a Smartband, on the increase of physical activity and the decrease of sedentary lifestyle in postmenopausal and inactive women.

DESIGN

Randomized clinical trial with two parallel groups.

METHODS

In total, 100 postmenopausal and inactive women aged 45-70 years will be randomized to a control group or an intervention group. Both groups will be given a standardized advice about physical activity. The intervention group will carry out a supervised 12-week programme of aerobic and muscle strengthening exercise; moreover, the women in this group will receive a Smartband to assist them in the intervention. The main result will be the increase of physical activity and the decrease of sedentary lifestyle, measured with an accelerometer for 1 week. This programme will be conducted by a nurse and a physiotherapist of the health centre. The study was approved by the Drug Research Ethics Committee of the Salamanca Health Service on 15 February 2019. The project was funded by the Autonomous Government of Castile and Leon and by the Carlos III Health Institute.

DISCUSSION

Physical activity is an important strategy to consider when addressing the changes caused by menopause, although the current evidence shows that further studies should be carried out with longer intervention periods and new technologies.

IMPACT

This study will allow determining the effectiveness of the intensive intervention based on a combined programme of physical activity using a Smartband in postmenopausal and inactive women.

TRIALS REGISTRATION

ClinicalTrials.gov with identifying code NCT03872258.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between self-reported walking speed and calcaneal stiffness index in postmenopausal Japanese women

BACKGROUND

Osteoporosis and related fractures, a worldwide public health issue of growing concern, is characterized by compromised bone strength and an increased risk of fracture. Here we show an association between self-reported walking speed and bone mass among community-dwelling postmenopausal Japanese women aged 50 years and older. DESIGN; CROSS-SECTIONAL STUDY: Setting and Participants; The survey population included 1008 postmenopausal women 50-92 years of age residing in rural communities.

METHODS

Self-reported walking speed was ascertained by asking the participants: "Is your walking speed faster than others of the same age and sex?" to which participants responded "yes (faster)" or "no (moderate/slower)." Calcaneal stiffness index was measured.

RESULTS

Women with a faster self-reported walking speed were younger and had a lower BMI, higher stiffness index, and higher grip strength than women with a slower walking speed. Multiple linear regression analysis adjusted for age, BMI, grip strength, comorbidity, current smoking, and alcohol drinking status showed a significant association between faster self-reported walking speed and higher calcaneal stiffness index (p <  0.001).

CONCLUSIONS

Our findings suggest that questionnaires of walking speed may be useful for predicting bone mass and that a fast self-reported walking may benefit bone health in postmenopausal women.

Effects of Different Types of Exercise on Bone Mineral Density in Postmenopausal Women: A Systematic Review and Meta-analysis

In this sub-analysis of a comprehensive meta-analysis, we aimed to determine the effect of different types of exercise on (areal) bone mineral density (BMD) in postmenopausal women. A systematic review of the literature according to the PRISMA statement included (a) controlled trials, (b) with at least one exercise and one control group, (c) intervention ≥ 6 months, (d) BMD assessments at lumbar spine (LS), femoral neck (FN) or total hip (TH), (e) in postmenopausal women. Eight electronic databases were scanned without language restrictions up to March 2019. The present subgroup analysis was conducted as a mixed-effect meta-analysis with "type of exercise" as the moderator. The 84 eligible exercise groups were classified into (a) weight bearing (WB, n = 30) exercise, (b) (dynamic) resistance exercise (DRT, n = 18), (c) mixed WB&DRT interventions (n = 36). Outcome measures were standardized mean differences (SMD) for BMD-changes at LS, FN and TH. All types of exercise significantly affect BMD at LS, FN and TH. SMD for LS average 0.40 (95% CI 0.15-0.65) for DRT, SMD 0.26 (0.03-0.49) for WB and SMD 0.42 (0.23-0.61) for WB&DRT. SMD for FN were 0.27 (0.09-0.45) for DRT, 0.37 (0.12-0.62) for WB and 0.35 (0.19-0.51) for WB&DRT. Lastly, SMD for TH changes were 0.51 (0.28-0.74) for DRT, 0.40 (0.21-0.58) for WB and 0.34 (0.14-0.53) for WB&DRT. In summary, we provided further evidence for the favorable effect of exercise on BMD largely independent of the type of exercise. However, in order to generate dedicated exercise recommendations or exercise guideline, meta-analyses might be a too rough tool.

[Physical rehabilitation of patients with osteoporosis]

Osteoporosis is one of the most common diseases, which along with cardiovascular pathology, diabetes mellitus and oncological diseases has a leading place in the structure of morbidity and mortality of the population. The combination of pharmacological and non-pharmacological methods is fundamental for the treatment and prevention of osteopenia and osteoporosis. This article presents rehabilitation methods that are of great importance for improving the functioning of the musculoskeletal system, the quality of life of patients with osteoporosis. Physical rehabilitation is aimed at stopping the destruction of bone tissue, strengthening it, eliminating pain, reducing stress from the affected areas and restoring the normal function of joints and bones. The proposed types of physical activity not only increase bone strength and strengthen muscle mass, but also reduce the risk of falling - a leading cause of osteoporotic fractures. Exercise programs designed for patients with osteoporosis should include strength and exercise exercises, as well as exercises for flexibility, posture correction, coordination of movements and balance. Training should be regular, varied and of a certain duration. The article considers the advantages and disadvantages of each type of activity.

Sports and Metabolic Bone Disease

Physical activity (PA) increases bone mass and bone strength through different mechanisms and also reduces the risk of falls in the elderly, through proprioception and balance training. The benefits seen in adolescence continue into adulthood. Exercise delays and attenuates the effects of osteoporosis, and particular sports activities may be recommended to improve bone mineral density (BMD) of the spine or regional BMD, improve balance, and prevent falls. Stress injuries related to exercise are more common in osteopenic and osteoporotic individuals.Sports activity may in some cases be detrimental for bone health, with nutrition restriction a frequent cause for negative effects of the practice of PA on bone. The examples are the so-called female athlete triad of menstrual dysfunction resulting in reduced estrogen levels, low energy due to malnutrition, and decreased BMD. A similar triad is described in male athletes. This review analyzes the effects of sport on bone metabolism and in particular its relationship with metabolic bone disease.

Impact of physical activity and exercise on bone health in patients with chronic kidney disease: a systematic review of observational and experimental studies

Background

Chronic Kidney Disease (CKD) patients frequently develop life-impairing bone mineral disorders. Despite the reported impact of exercise on bone health, systematic reviews of the evidence are lacking. This review examines the association of both physical activity (PA) and the effects of different exercise interventions with bone outcomes in CKD.

Methods

English-language publications in EBSCO, Web of Science and Scopus were searched up to May 2019, from which observational and experimental studies examining the relation between PA and the effect of regular exercise on bone-imaging or -outcomes in CKD stage 3–5 adults were included. All data were extracted and recorded using a spreadsheet by two review authors. The evidence quality was rated using the Cochrane risk of bias tool and a modified Newcastle-Ottawa scale.

Results

Six observational (4 cross-sectional, 2 longitudinal) and seven experimental (2 aerobic-, 5 resistance-exercise trials) studies were included, with an overall sample size of 367 and 215 patients, respectively. Judged risk of bias was low and unclear in most observational and experimental studies, respectively. PA was positively associated with bone mineral density at lumbar spine, femoral neck and total body, but not with bone biomarkers. Resistance exercise seems to improve bone mass at femoral neck and proximal femur, with improved bone formation and inhibited bone resorption observed, despite the inconsistency of results amongst different studies.

Conclusions

There is partial evidence supporting (i) a positive relation of PA and bone outcomes, and (ii) positive effects of resistance exercise on bone health in CKD. Prospective population studies and long-term RCT trials exploring different exercise modalities measuring bone-related parameters as endpoint are currently lacking.

Muscle and bone mass in middle-aged women: role of menopausal status and physical activity

BACKGROUND

Women experience drastic hormonal changes during midlife due to the menopausal transition. Menopausal hormonal changes are known to lead to bone loss and potentially also to loss of lean mass. The loss of muscle and bone tissue coincide due to the functional relationship and interaction between these tissues. If and how physical activity counteracts deterioration in muscle and bone during the menopausal transition remains partly unresolved. This study investigated differences between premenopausal, early perimenopausal, late perimenopausal, and postmenopausal women in appendicular lean mass (ALM), appendicular lean mass index (ALMI), femoral neck bone mineral density (BMD) and T score. Furthermore, we investigated the simultaneous associations of ALM and BMD with physical activity in the above-mentioned menopausal groups.

METHODS

Data from the Estrogen Regulation of Muscle Apoptosis study were utilized. In total, 1393 women aged 47-55 years were assigned to premenopausal, early perimenopausal, late perimenopausal, and postmenopausal groups based on follicle-stimulating hormone concentration and bleeding diaries. Of them, 897 were scanned for ALM and femoral neck BMD by dual-energy X-ray absorptiometry and ALMI (ALM/height² ) and neck T scores calculated. Current level of leisure-time physical activity was estimated by a validated self-report questionnaire and categorized as sedentary, low, medium, and high.

RESULTS

Appendicular lean mass, appendicular lean mass index, femoral neck bone mineral density, and and T score showed a significant linear declining trend across all four menopausal groups. Compared with the postmenopausal women, the premenopausal women showed greater ALM (18.2, SD 2.2 vs. 17.8, SD 2.1, P < 0.001), ALMI (6.73, SD 0.64 vs. 6.52, SD 0.62, P < 0.001), neck BMD (0.969, SD 0.117 vs. 0.925, SD 0.108, P < 0.001), and T score (-0.093, SD 0.977 vs -0.459, SD 0.902, P < 0.001). After adjusting for potential confounding pathways, a higher level of physical activity was associated with greater ALM among the premenopausal [β = 0.171; confidence interval (CI) 95% 0.063-0.280], late perimenopausal (β = 0.289; CI 95% 0.174-0.403), and postmenopausal (β=0.278; CI 95% 0.179-0.376) women. The positive association between femoral neck BMD and level of physical activity was significant only among the late perimenopausal women (β = 0.227; CI 95% 0.097-0.356).

CONCLUSIONS

Skeletal muscle and bone losses were associated with the menopausal transition. A higher level of physical activity during the different menopausal phases was beneficial, especially for skeletal muscle. Menopause-related hormonal changes predispose women to sarcopenia and osteoporosis and further to mobility disability and fall-related fractures in later life. New strategies are needed to promote physical activity among middle-aged women. Longitudinal studies are needed to confirm these results.

The Relationship Between Non-elite Sporting Activity and Calcaneal Bone Density in Adolescents and Young Adults: A Narrative Systematic Review

Introduction: Osteoporotic fractures represent a major public health burden. The risk of fragility fractures in late adulthood is strongly impacted by peak bone mass acquisition by the third decade. Weight-bearing sporting activity may be beneficial to peak bone mass accrual, but previous studies have focused on elite sporting activity and have used dual energy X-ray absorptiometry as a measure of bone density. The authors performed a narrative systematic review of individual sports (performed non-competitively or at local level) and calcaneal quantitative ultrasound (cQUS) bone measures in young people.

Methods: Multiple databases were systematically searched up until the 31st of March 2019. The authors included studies of participants' mean age (11–35 years), reporting any level of recreational sporting activity and cQUS measures as well as excluding elite/professional sporting physical activity. Studies (title and abstract) were screened independently by two reviewers, and a third reviewer resolved any discrepancies. STROBE guidelines were used to check the reporting of observational studies. The Newcastle–Ottawa Scale was used to assess the risk of bias of the studies included in the review. The systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO).

Results: A search yielded 29,512 articles that considered relationships between bone density assessed by any technique and sporting activity. Duplicate and out of scope abstracts were removed. This left 424 papers that were screened by two reviewers; of these, six met the inclusion criteria, including assessment by cQUS. The authors identified papers where sports were considered, included soccer (football), swimming, cycling, gymnastics, dancing, badminton, basketball, fencing, wrestling, and judokas. Although study heterogeneity prohibited meta-analysis, all six included studies reported significant benefits of weight-bearing non-elite sports on cQUS outcomes.

Conclusion: Our study found beneficial effects of non-elite sports participation on cQUS in adolescence and young adulthood, although further work is now indicated.

Bilateral multidirectional jumps with reactive jump-landings achieve osteogenic thresholds with and without instruction in premenopausal women

BACKGROUND

Currently jump-landing ground reaction forces have only been quantified in the vertical direction as a stimulus for bone development. This study quantified the full-spectrum of jump-landing force magnitudes (body weight's) and rates of strain (body weights per second) of bilateral multidirectional jumps (star jump and stride jump) with reactive jump-landings (i.e. jumping immediately after initial jump-landing) among premenopausal women. It was also of interest to quantify the influence of instruction on the magnitude and rate of the jump-landing ground reaction forces.

METHODS

Twenty-one women [Mean (SD): 43.3(5.9)yr; 69.4(9.6)kg; 167(5.5)cm; 27.5(8.7)% body fat] performed a jump testing session 'with instruction' followed by a jump testing session performed one week later with 'instruction withdrawn'.

FINDINGS

The resultant magnitudes (3.90 to 5.38, body weights) and rates of strain (192 to 329, body weights per second) for the jump-landings, performed on a force plate, exceeded previously determined osteogenic thresholds (>3body weight's and >43body weights per second, respectively). An instruction effect was observed for resultant (↑8% and ↑12%; P ≤ .01) and vertical (↑8% and ↑7%; P ≤ .01) ground reaction force's (Newtons and body weight, respectively) indicating learning/practice effects for these exercises. A jump-landing effect was observed, with larger peak rates of strain (↑29%; P < .0001, body weight per second) and peak forces (↑12% to ↑48%; P ≤ .01, body weights) for the second jump-landing (post-reactive jump).

INTERPRETATION

These multidirectional bilateral jumps represent a unique training stimulus for premenopausal women and achieve osteogenic thresholds thought pre-requisite for bone growth and could be utilized in the development of osteogenic exercise programs.

Aspirin and fracture risk: a systematic review and exploratory meta-analysis of observational studies

OBJECTIVES

This review provides insights into the potential for aspirin to preserve bone mineral density (BMD) and reduce fracture risk, building knowledge of the risk-benefit profile of aspirin.

METHODS

We conducted a systematic review and exploratory meta-analysis of observational studies. Electronic searches of MEDLINE and Embase, and a manual search of bibliographies was undertaken for studies published to 28 March 2018. Studies were included if: participants were men or women aged ≥18 years; the exposure of interest was aspirin; and relative risks, ORs and 95% CIs for the risk of fracture or difference (percentage or absolute) in BMD (measured by dual energy X-ray absorptiometry) between aspirin users and non-users were presented. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists for observational studies. Pooled ORs for any fracture and standardised mean differences (SMDs) for BMD outcomes were calculated using random-effects models.

RESULTS

Twelve studies met the inclusion criteria and were included in the meta-analysis. Aspirin use was associated with a 17% lower odds for any fracture (OR 0.83, 95% CI 0.70 to 0.99; I²=71%; six studies; n=511 390). Aspirin was associated with a higher total hip BMD for women (SMD 0.03, 95% CI -0.02 to 0.07; I²=0%; three studies; n=9686) and men (SMD 0.06, 95% CI -0.02 to 0.13, I²=0%; two studies; n=4137) although these associations were not significant. Similar results were observed for lumbar spine BMD in women (SMD 0.03, 95% CI -0.03 to 0.09; I²=34%; four studies; n=11 330) and men (SMD 0.08; 95% CI -0.01 to 0.18; one study; n=432).

CONCLUSIONS

While the benefits of reduced fracture risk and higher BMD from aspirin use may be modest for individuals, if confirmed in prospective controlled trials, they may confer a large population benefit given the common use of aspirin in older people.

A High-Intensity Exercise Intervention Improves Older Women Lumbar Spine and Distal Tibia Bone Microstructure and Function: A 20-Week Randomized Controlled Trial

Introduction: The effects of ageing on bone can be mitigated with different types of physical training, such as power training. However, stimuli that combine increasing external and internal loads concomitantly may improve bone quality. The goal of this study was to assess the efficacy of a combined power and plyometric training on lumbar spine and distal tibia microstructure and function. Methods: 38 sedentary elderly women between 60 and 70 years were randomly allocated in experimental (N = 21) and control group (N = 17). The effects of the 20-week protocol on lumbar spine microstructure and tibia microstructure and function were assessed by trabecular bone score (TBS), high resolution peripheral quantitative computed tomography (HR-pQCT) and microfinite element analysis. Results: when compared to the effects found in the control group, the experimental group showed significant improvements in lumbar spine TBS (Hedges' g = 0.77); and in distal tibia trabecular thickness (g = 0.82) and trabecular bone mineral density (g=0.63). Conclusion: our findings underscore the effectiveness of the proposed intervention, suggesting it as a new strategy to slow down and even reverse the structural and functional losses in the skeletal system due to ageing.

[Multidisciplinary approach to the rehabilitation of patients with osteoporosis]

The article outlines the modern concept of rehabilitation of patients with osteoporosis (OP), the cornerstone of which is the use of a multidisciplinary approach. This approach involves not only the participation of specialists of various specializations and levels in the process of rehabilitation treatment, but the formation of a new functional unit - a multidisciplinary team, whose members actively interact with each other from the first days to the completion of the rehabilitation course at every stage of the course; they together make a rehabilitation diagnosis based on the International Classification of Functioning, Disability and Health (ICF); they formulate rehabilitation goals, evaluate rehabilitation potential, discuss and develop a rehabilitation program and evaluate its effectiveness by using modern scales, tests and questionnaires to assess the change in the condition of the patient"s life at all levels and the quality of life in general. Taking into account the principle of multidisciplinarity, approaches to preparation of rehabilitation programs for patients with OP are described using various methods: those of therapeutic gymnastics, mechanotherapy, physiotherapy, balneotherapy, occupational therapy, psychotherapy, drug treatment and orthosis. Particular attention in the process of rehabilitation of patients with OP is given to physical therapy and orthosis, which are aimed at reducing pain, improving coordination, posture, as well as reducing the risk of falls and fractures. The literature review presented in the article allows us to conclude that the use of a multidisciplinary approach in the rehabilitation of patients with OP makes it possible to significantly improve the quality of life of patients even with severe forms of the disease.

Effect of 2 years of endurance and high-impact training on preventing osteoporosis in postmenopausal women: randomized clinical trial

OBJECTIVE

The aim of the study was to analyze the effects of endurance and high-impact training oriented toward preventing osteoporosis in postmenopausal women with calcium and vitamin D supplementation.

METHODS

This study was a randomized clinical trial. Thirty-six postmenopausal women were randomized to the control and experimental groups. Thirty-four women completed the 2-year interventions. The control group training involved walking at an intense pace. The experimental group conducted high-impact training specifically oriented to prevent osteoporosis. Dual-energy x-ray absorptiometry was used to estimate the T-scores of the lumbar spine and femoral neck.

RESULTS

The fast-walking group showed constant T-scores in the femoral neck and improved T-scores in the lumbar spine. High-impact exercises produced improvements in both anatomical levels. Significant differences were found in the femoral neck (ΔControl = -0.04, ΔExperimental = 0.28). The differences were not significant in the lumbar spine (ΔControl = 0.27, ΔExperimental = 0.47). Cohen's effect size (d = 0.52) suggested a medium practical significance of the trial. The power was 51%.

CONCLUSIONS

Calcium plus vitamin D supplementation combined with specifically oriented exercises had a higher impact in the femoral neck than walking at an intense pace. As there were no differences at the lumbar spine level, the results were, however, inconclusive concerning which type of exercise was the most convenient. Importantly, the fact that the T-scores did not decrease after 2 years supports the belief that both proposed interventions can be conveniently used to prevent osteoporosis in postmenopausal women. A trial with a larger sample size would provide consistency to the findings and is warranted given the possible effects and benefits.

Guidelines for the management of osteoporosis and fragility fractures

The purpose of this document, a result of the harmonisation and revision of Guidelines published separately by the SIMFER, SIOMMMS/SIR, and SIOT associations, is to provide practical indications based on specific levels of evidence and various grades of recommendations, drawn from available literature, for the management of osteoporosis and for the diagnosis, prevention, and treatment of fragility fractures. These indications were discussed and formally approved by the delegates of the Italian Scientific Associations involved in the project (SIE, SIGG, SIMFER, SIMG, SIMI, SIOMMMS, SIR, and SIOT).