Health-related physical fitness in women with polycystic ovary syndrome versus controls: a systematic review and meta-analysis.

INTRODUCTION: Polycystic ovary syndrome (PCOS) is a common endocrinopathy associated with cardiometabolic dysfunction. PURPOSE: (1) To compare HRPF indices, including cardiorespiratory fitness (CRF), muscle strength, and muscle endurance, between women with and without PCOS (i.e., controls). (2) To explore the impact of moderating factors, i.e., insulin sensitivity, androgen levels, physical activity levels, and body mass index, on these indices. METHODS: Articles comparing HRPF between PCOS and control groups were identified until February 27th, 2022. Random-effects meta-analyses were conducted and moderating factors were explored with subgroup and meta-regression analyses. RESULTS: Twenty studies were included. Compared to controls, CRF was lower in women with PCOS (n = 15, - 0.70 [- 1.35, - 0.05], P = 0.03, I2 = 95%). Meta-regression analyses demonstrated that fasting insulin (P = 0.004) and homeostatic model assessment of insulin resistance (P = 0.006) were negatively associated with CRF, while sex-hormone binding globulin levels (P = 0.003) were positively associated. Absolute muscle strength was not different between PCOS and controls (n = 7, 0.17 [- 0.10, 0.45], P = 0.22, I2 = 37%). One study evaluated muscle endurance and reported lower core endurance in PCOS subjects compared to controls. CONCLUSION: These data suggest that PCOS may be associated with impaired CRF. It remains unclear whether muscle strength and endurance differ between women with PCOS and controls. As this data set was limited by a small sample size, potential for bias, and inconsistent findings, additional studies accounting for the heterogeneous presentation of PCOS as well as improved matching between PCOS and controls for characteristics known to affect HRPF would help elucidate the impact of PCOS on indices of HRPF. PROSPERO REGISTRATION NUMBER: CRD42020196380.

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

OBJECTIVE: To understand perceptions on rehabilitation after vertebral fracture, non-pharmacological strategies, and virtual care from the perspective of individuals living with vertebral fractures. DESIGN AND SETTING: We conducted semi-structured interviews online and performed a thematic and content analysis from a post-positivism perspective. PARTICIPANTS: Ten individuals living with osteoporotic vertebral fractures (9F, 1 M, aged 71 ± 8 years). RESULTS: Five themes emerged: pain is the defining limitation of vertebral fracture recovery; delayed diagnosis impacts recovery trajectory; living with fear; being dissatisfied with fracture management; and "getting back into the game of life" using non-pharmacological strategies. CONCLUSION: Participants reported back pain and an inability to perform activities of daily living, affecting psychological and social well-being. Physiotherapy, education, and exercise were considered helpful and important to patients; however, issues with fracture identification and referral limited the use of these options. Participants believed that virtual rehabilitation was a feasible and effective alternative to in-person care, but perceived experience with technology, cost, and individualization of programs as barriers.

Selecting implementation models, theories, and frameworks in which to integrate intersectional approaches.

BACKGROUND: Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective. METHODS: We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights. RESULTS: We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the 'Identify the problem' phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the 'Assess barriers/facilitators to knowledge use' phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the 'Select, tailor, implement interventions' phase (mean = 6.36, SD = 1.08). CONCLUSIONS: Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future. TRIAL REGISTRATION: Open Science Framework Registration: osf.io/qgh64.

Development and usability testing of tools to facilitate incorporating intersectionality in knowledge translation.

BACKGROUND: The field of knowledge translation (KT) has been criticized for neglecting contextual and social considerations that influence health equity. Intersectionality, a concept introduced by Black feminist scholars, emphasizes how human experience is shaped by combinations of social factors (e.g., ethnicity, gender) embedded in systemic power structures. Its use has the potential to advance equity considerations in KT. Our objective was to develop and conduct usability testing of tools to support integrating intersectionality in KT through three key phases of KT: identifying the gap; assessing barriers to knowledge use; and selecting, tailoring, and implementing interventions. METHODS: We used an integrated KT approach and assembled an interdisciplinary development committee who drafted tools. We used a mixed methods approach for usability testing with KT intervention developers that included semi-structured interviews and the System Usability Scale (SUS). We calculated an average SUS score for each tool. We coded interview data using the framework method focusing on actionable feedback. The development committee used the feedback to revise tools, which were formatted by a graphic designer. RESULTS: Nine people working in Canada joined the development committee. They drafted an intersectionality primer and one tool that included recommendations, activities, reflection prompts, and resources for each of the three implementation phases. Thirty-one KT intervention developers from three countries participated in usability testing. They suggested the tools to be shorter, contain more visualizations, and use less jargon. Average SUS scores of the draft tools ranged between 60 and 78/100. The development committee revised and shortened all tools, and added two, one-page summary documents. The final toolkit included six documents. CONCLUSIONS: We developed and evaluated tools to help embed intersectionality considerations in KT. These tools go beyond recommending the use of intersectionality to providing practical guidance on how to do this. Future work should develop guidance for enhancing social justice in intersectionality-enhanced KT.

Exploring Fear of Falling and Exercise Self-Efficacy in Older Women With Vertebral Fractures.

Fear of falling is a common issue among older adults, which decreases quality of life and leads to an avoidance of activities they are still able to do. The goal of this secondary data analysis was to explore the relationship between fear of falling and exercise self-efficacy in 141 women with at least one nontraumatic Genant Grade 2 vertebral fracture. Fear of falling, exercise self-efficacy, history of falling, the number of falls, the use of assisting devices, and pain at rest or during movement were obtained using medical history and health status questionnaires. There was a negative association between fear of falling and exercise self-efficacy (pseudo R2 = .253; p = .004), which persisted when the analysis was adjusted for history and number of falls, use of assistive devices, and pain at rest (pseudo R2 = .329; p < .0001) or during movement (pseudo R2 = .321; p < .0001). Fear of falling may be negatively associated with exercise self-efficacy in older women with vertebral fracture.

Meeting the Canadian strength training recommendations: Implications for the cardiometabolic, psychological and musculoskeletal health of nurses.

AIM: To examine the proportion of nurses meeting the strength training recommendation and its associated cardiometabolic, psychological and musculoskeletal benefits. BACKGROUND: Strength training targets poor physical and mental health often reported by nurses; however, it is unknown whether nurses are meeting the strength training guidelines. METHODS: Nurses from 14 hospitals completed a 7-day physical activity log. Nurses were considered meeting the recommendation if they reported ≥2 strength training sessions per week. Cardiometabolic, psychological and musculoskeletal health, and levels of motivation were compared between nurses meeting and not meeting the guidelines. RESULTS: Of the 307 nurses (94% female; age: 43 ± 12 years), 29 (9.4%) met the strength training recommendation. These nurses had lower body mass index (24.1 ± 2.6 vs. 27.3 ± 5.5 kg/m2 , p = .007) and waist circumference (73.8 ± 8.3 vs. 81.1 ± 11.7 cm, p = .017); and higher vigour-activity (18.0 ± 5.8 vs. 15.6 ± 6.5 points, p = .046) and self-determined motivation (relative autonomic index: 54.9 ± 20.3 vs. 45.0 ± 23.8 points, p = .042) scores than nurses not meeting the recommendation. CONCLUSION: While the proportion of nurses meeting the strength training recommendation was small (<10%), they had lower body mass and waist circumference, and higher vigour-activity. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies to increase the strength training engagement may improve the cardiometabolic health and increase vigour among nurses.

Exercise for improving outcomes after osteoporotic vertebral fracture.

BACKGROUND: Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. This is an update of a Cochrane Review first published in 2013. OBJECTIVES: To assess the effects (benefits and harms) of exercise intervention of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo among adults with a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. Our secondary objectives were to evaluate the effects of exercise on the following outcomes: falls, pain, physical performance, health-related quality of life (disease-specific and generic), and adverse events. SEARCH METHODS: We searched the following databases until November 2017: the Cochrane Library (Issue 11 of 12), MEDLINE (from 2005), Embase (from 1988), CINAHL (Cumulative Index to Nursing and Allied Health Literature, from 1982), AMED (from 1985), and PEDro (Physiotherapy Evidence Database, from 1929). Ongoing/recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. For this update, the search results were limited from 2011 onward. SELECTION CRITERIA: We included all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials and extracted data using a pre-tested data extraction form. Disagreements were resolved by consensus, or third-party adjudication. We used Cochrane's tool for assessing risk of bias to evaluate each study. Studies were grouped according to duration of follow-up (i.e. a) 4-12 weeks; b) 16-24 weeks; c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For dichotomous data, we reported risk ratios (RR) and corresponding 95% confidence intervals (95% CI). For continuous data, we reported mean differences (MD) of the change from baseline and 95% CI. Data were pooled for Timed Up and Go test, self-reported physical function measured by the QUALEFFO-41 physical function subscale score (scale of zero to 100; lower scores indicate better self-reported physical function), and disease-specific quality of life measured by the QUALEFFO-41 total score (scale of zero to 100; lower scores indicate better quality of life) at 12 weeks using a fixed-effect model. MAIN RESULTS: Nine trials (n = 749, 68 male participants; two new trials in this review update) were included. Substantial variability across the trials prevented any meaningful pooling of data for most outcomes. Risk of bias across all studies was variable; low risk across most domains in four studies, and unclear/high risk in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias.One trial reported no between-group difference in favor of the effect of exercise on incident fragility fractures after 52 weeks (RR 0.54, 95% CI 0.17 to 1.71; very low-quality evidence with control: 184 per 1000 and exercise: 100 per 1000, 95% CI 31 to 315; absolute difference: 8%, 95% CI 2 to 30). One trial reported no between-group difference in favor of the effect of exercise on incident falls after 52 weeks (RR 1.06, 95% CI 0.53 to 2.10; very low-quality evidence with control: 262 per 1000 and exercise: 277 per 1000; 95% CI 139 to 550; absolute difference: 2%, 95% CI -12 to 29). These findings should be interpreted with caution because of the very serious risk of bias in these studies and the small sample sizes resulting in imprecise estimates.We are uncertain that exercise could improve pain, self-reported physical function, and disease-specific quality of life, because certain studies showed no evidence of clinically important differences for these outcomes. Pooled analyses revealed a small between-group difference in favor of exercise for Timed Up and Go (MD -1.13 seconds, 95% CI -1.85 to -0.42; studies = 2), which did not change following a sensitivity analysis (MD -1.09 seconds, 95% CI -1.78 to -0.40; studies = 3; moderate-quality evidence). Exercise improved QUALEFFO-41 physical function score (MD -2.84 points, 95% CI -5.57 to -0.11; studies = 2; very low-quality evidence) and QUALEFFO-41 total score (MD -3.24 points, 95% CI -6.05 to -0.43; studies = 2; very low-quality evidence), yet it is unlikely that we observed any clinically important differences. Three trials reported four adverse events related to the exercise intervention (costal cartilage fracture, rib fracture, knee pain, irritation to tape, very low-quality evidence). AUTHORS' CONCLUSIONS: In conclusion, we do not have sufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events. Our updated review found moderate-quality evidence that exercise probably improves physical performance, specifically Timed Up and Go test, in individuals with vertebral fracture (downgraded due to study limitations). However, a one-second improvement in Timed Up and Go is not a clinically important improvement. Although individual trials did report benefits for some pain and disease-specific quality of life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution given the very low-quality evidence due to inconsistent findings, study limitations and imprecise estimates. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture in men is scarce. A high-quality randomized trial is needed to inform safety and effectiveness of exercise to lower incidence of fracture and falls and to improve patient-centered outcomes (pain, function) for individuals with vertebral fractures (minimal sample size required is approximately 2500 untreated participants or 4400 participants if taking anti-osteoporosis therapy).

Measuring Marrow Density and Area Using Peripheral Quantitative Computed Tomography at the Tibia: Precision in Young and Older Adults and Individuals With Spinal Cord Injury.

The objective of this study was to compare the test-retest precision error for peripheral quantitative computed tomography (pQCT)-derived marrow density and marrow area segmentation at the tibia using 3 software packages. A secondary analysis of pQCT data in young adults (n = 18, mean ± standard deviation 25.4 ± 3.2 yr), older adults (n = 47, 71.8 ± 8.2 yr), and individuals with spinal cord injury (C1-T12 American Spinal Injury Association Impairment Scale, classes A-C; n = 19, 43.5 ± 8.6 yr) was conducted. Repeat scans of the tibial shaft (66%) were performed using pQCT (Stratec XCT2000). Test-retest precision errors (root mean square standard deviation and root mean square coefficient of variation [RMSCV%]) for marrow density (mg/cm3) and marrow area (mm2) were reported for the watershed-guided manual segmentation method (SliceOmatic version 4.3 [Sliceo-WS]) and the 2 threshold-based edge detection methods (Stratec version 6.0 [Stratec-TB] and BoneJ version 1.3.14 [BoneJ-TB]). Bland-Altman plots and 95% limits of agreement were computed to evaluate test-retest discrepancies within and between methods of analysis and subgroups. RMSCV% for marrow density segmentation was >5% for all methods across subgroups (Stratec-TB: 12.2%-28.5%, BoneJ-TB: 14.5%-25.2%, and Sliceo-WS: 10.9%-23.0%). RMSCV% for marrow area segmentation was within 5% for all methods across subgroups (Stratec-TB: 1.9%-4.4%, BoneJ-TB: 2.6%-5.1%, and Sliceo-WS: 2.4%-4.5%), except using BoneJ-TB in older adults. Intermethod discrepancies in marrow density appeared to be present across the range of marrow density values and did not differ by subgroup. Intermethod discrepancies varied to a greater extent for marrow area and were found to be more frequently at mid- to higher-range values for those with spinal cord injury. Precision error for pQCT-derived marrow density segmentation exceeded 5% for all methods of analysis across a range of bone mineral densities and fat infiltration, whereas precision error for marrow area segmentation ranged from 2% to 5%. Further investigation is necessary to determine alternative acquisition and analysis methods for pQCT-derived marrow segmentation.

Low energy availability in exercising men is associated with reduced leptin and insulin but not with changes in other metabolic hormones.

Low energy availability, defined as low caloric intake relative to exercise energy expenditure, has been linked to endocrine alterations frequently observed in chronically energy-deficient exercising women. Our goal was to determine the endocrine effects of low energy availability in exercising men. Six exercising men (VO2peak: 49.3 ± 2.4 ml · kg(-1) · min(-1)) underwent two conditions of low energy availability (15 kcal · kg(-1) fat-free mass [FFM] · day(-1)) and two energy-balanced conditions (40 kcal · kg(-1) FFM · day(-1)) in randomised order. During one low energy availability and one balanced condition, participants exercised to expend 15 kcal · kg(-1) FFM · day(-1); no exercise was conducted during the other two conditions. Metabolic hormones were assessed before and after each 4-day period. Following both low energy availability conditions, leptin (-53% to -56%) and insulin (-34% to -38%) were reduced (P < 0.05). Reductions in leptin and insulin were independent of whether low energy availability was attained with or without exercise (P > 0.80). Low energy availability did not significantly impact ghrelin, triiodothyronine, testosterone and IGF-1 (all P > 0.05). The observed reductions in leptin and insulin were in the same magnitude as changes previously reported in sedentary women. Further research is needed to understand why other metabolic hormones are more robust against low energy availability in exercising men than those in sedentary and exercising women.

2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013.

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013.

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad.

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Evaluation of sex-based differences in resistance exercise training-induced changes in muscle mass, strength, and physical performance in healthy older (≥60 y) adults: A systematic review and meta-analysis.

The objective of this systematic review and meta-analysis was to determine if there are sex-based differences in adaptations to resistance exercise training in healthy older adults. Following the screening process, data from 36 studies comparing older males and females (602 males; 703 females; ≥60 years of age) for changes in skeletal muscle size, muscle strength, and/or physical performance following the same resistance exercise training intervention were extracted. Mean study quality was 16/29 (modified Downs and Black checklist), considered moderate quality. Changes in absolute upper-body (Effect Size [ES] = 0.81 [95% CI 0.54, 1.09], P < 0.001), and lower-body (ES = 0.40 [95% CI 0.24, 0.56], P < 0.001) strength were greater in older males than females. Alternatively, changes in relative upper-body (ES = -0.46 [95% CI -0.77, -0.14], P < 0.01), and lower-body (ES = -0.24 [95% CI -0.42, -0.06], P < 0.01) strength were greater in older females than males. Changes in absolute, but not relative, whole-body fat-free mass (ES = 0.18 [95% CI 0.04, 0.33], P < 0.05) were greater in older males than females. There were no sex-based differences for absolute or relative changes in limb muscle size, muscle fiber size, or physical performance.

Rehabilitation interventions to modify endocrine-metabolic disease risk in individuals with chronic spinal cord injury living in the community (RIISC): A systematic search and review of prospective cohort and case-control studies.

CONTEXT: Endocrine-metabolic disease (EMD) is associated with functional disability, social isolation, hospitalization and even death in individuals living with a chronic spinal cord injury (SCI). There is currently very low-quality evidence that rehabilitation interventions can reduce EMD risk during chronic SCI. Non-randomized trials and alternative study designs are excluded from traditional knowledge synthesis. OBJECTIVE: To characterize evidence from level 3-4 studies evaluating rehabilitation interventions for their effectiveness to improve EMD risk in community-dwelling adults with chronic SCI. METHODS: Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, Cochrane Database of Systematic Reviews, and PsychInfo were completed. All longitudinal trials, prospective cohort, case-control studies, and case series evaluating the effectiveness of rehabilitation/therapeutic interventions to modify/associate with EMD outcomes in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean changes from baseline were reported for EMD outcomes. The Downs and Black Checklist was used to rate evidence quality. RESULTS: Of 489 articles identified, 44 articles (N = 842) were eligible for inclusion. Individual studies reported statistically significant effects of electrical stimulation-assisted training on lower-extremity bone outcomes, and the combined effects of exercise and dietary interventions to improve body composition and cardiometabolic biomarkers (lipid profiles, glucose regulation). In contrast, there were also reports of no clinically important changes in EMD outcomes, suggesting lower quality evidence (study bias, inconsistent findings). CONCLUSION: Longitudinal multicentre pragmatic studies involving longer-term exercise and dietary intervention and follow-up periods are needed to fully understand the impact of these rehabilitation approaches to mitigate EMD risk. Our broad evaluation of prospective cohort and case-control studies provides new perspectives on alternative study designs, a multi-impairment paradigm approach of studying EMD outcomes, and knowledge gaps related to SCI rehabilitation.

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

PURPOSE: To understand experiences and perceptions on non-pharmacological treatment of vertebral fractures and virtual-care from the perspective of care professionals' (HCPs). DESIGN AND SETTING: We conducted semi-structured interviews with 13 HCPs within Canada (7 F, 6 M, aged 46 ± 12 years) and performed a thematic and content analysis from a post-positivism perspective. RESULTS: Two themes were identified: acuity matters when selecting appropriate interventions; and roadblocks to receiving non-pharmacological interventions. We found that treatment options were dependent on the acuity/stability of fracture and were individualized accordingly. Pain medication was perceived as important, but non-pharmacological strategies were also considered helpful in supporting recovery. Participants discussed barriers related to the timely identification of fracture, referral to physiotherapy, and lack of knowledge among HCPs on how to manage osteoporosis and vertebral fractures. HCPs reported positive use of virtual-care, but had concerns related to patient access, cost, and comprehensive assessments. CONCLUSION: HCPs used and perceived non-pharmacological interventions as helpful and selected specific treatments based on the recency of fracture and patient symptoms. HCPs' also believed that virtual-care that included an educational component, an assessment by a physiotherapist, and an exercise group was a feasible alternative, but concerns exist and may require further evaluation.Implications for RehabilitationNon-pharmacological strategies in combination with pain medication may be a more effective strategy to support recovery than pain medication alone but should be informed by fracture acuity and patient symptoms.To improve access to physiotherapy and other non-pharmacological treatment options during the acute or chronic management of vertebral fractures, it may be worthwhile to explore the effectiveness and feasibility of virtual-care.

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

OBJECTIVE: This project aimed to develop a virtual intervention for vertebral fractures (VIVA) to implement the international recommendations for the nonpharmacological management of osteoporotic vertebral fractures and to test its acceptability and usability. METHODS: VIVA was developed in accordance with integrated knowledge translation principles and was informed by the Behavioral Change Wheel, the Theoretical Domains Framework, and the affordability, practicability, effectiveness and cost-effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria. The development of the prototype of VIVA involved 3 steps: understanding target behaviors, identifying intervention options, and identifying content and implementation options. The VIVA prototype was delivered to 9 participants to assess its acceptability and usability. RESULTS: VIVA includes 7 1-on-1 virtual sessions delivered by a physical therapist over 5 weeks. Each session lasts 45 minutes and is divided in 3 parts: education, training, and behavioral support/goal setting. Four main themes emerged from the acceptability evaluation: perceived improvements in pain, increased self-confidence, satisfaction with 1-on-1 sessions and resources, and ease of use. All of the participants believed that VIVA was very useful and were very satisfied with the 1-on-1 sessions. Four participants found the information received very easy to practice, 4 found it easy to practice, and 1 found it somewhat difficult to practice. Five participants were satisfied with the supporting resources, and 4 were very satisfied. Potential for statistically significant improvements was observed in participants' ability to make concrete plans about when, how, where, and how often to exercise. CONCLUSION: VIVA was acceptable and usable to the participants, who perceived improvements in pain and self-confidence. IMPACT: The virtual implementation of the recommendations for the nonpharmacological management of vertebral fractures showed high acceptability and usability. Future trials will implement the recommendations on a larger scale to evaluate their effectiveness.

Bone mineral density in response to increased energy intake in exercising women with oligomenorrhea/amenorrhea: the REFUEL randomized controlled trial.

BACKGROUND: Energy deficiency can result in menstrual disturbances and compromised bone health in women, a condition known as the Female Athlete Triad. OBJECTIVES: The REFUEL randomized controlled trial assessed the impact of increased energy intake on bone health and menstrual function in exercising women with menstrual disturbances. METHODS: Exercising women with oligomenorrhea/amenorrhea (Oligo/Amen) were randomly assigned to an intervention group (Oligo/Amen + Cal, n = 40, mean ± SEM age: 21.3 ± 0.5 y; weight: 55.0 ± 1.0 kg; BMI: 20.4 ± 0.3 kg/m2) who increased energy intake 20%-40% above baseline energy needs for 12 mo or a control group (Oligo/Amen Control, n = 36; mean ± SEM age: 20.7 ± 0.5 y; weight: 59.1 ± 1.3 kg; BMI: 21.3 ± 0.4 kg/m2). Energy intake and expenditure, metabolic and reproductive hormones, body composition, and areal bone mineral density (aBMD) were assessed. RESULTS: Oligo/Amen + Cal improved energy status [increased body mass (2.6 ± 0.4 kg), BMI (0.9 ± 0.2 kg/m2), fat mass (2.0 ± 0.3 kg), body fat percentage (2.7% ± 0.4%), and insulin-like growth factor 1 (37.4 ± 14.6 ng/mL)] compared with Oligo/Amen Control and experienced a greater likelihood of menses (P < 0.05). Total body and spine aBMD remained unchanged (P > 0.05). Both groups demonstrated decreased femoral neck aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.0002 g/cm2 ; time main effect P = 0.043) and month 12 (-0.011 g/cm2; 95% CI: -0.021, -0.001 g/cm2; time main effect P = 0.023). Both groups demonstrated a decrease in total hip aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.002 g/cm2; time main effect P = 0.004). CONCLUSIONS: Although higher dietary energy intake increased weight, body fat, and menstrual frequency, bone mineral density was not improved, compared with the control group. The 12-mo intervention may have been too short and the increase in energy intake (∼352 kcal/d), although sufficient to increase menstrual frequency, was insufficient to increase estrogen or improve aBMD. Future research should refine the optimal nutritional and/or pharmacological interventions for the recovery of bone health in athletes and exercising women with Oligo/Amen.This trial was registered at clinicaltrials.gov as NCT00392873.

Exploring the Association between Pain and Fracture Characteristics in Women with Osteoporotic Vertebral Fractures.

Purpose: The purpose of this study was to estimate the association between pain and the number, severity, and location of fractures in women with osteoporotic vertebral fractures. Method: We used an 11-point numeric pain rating scale to assess pain during movement in the preceding week and lateral spinal radiographs to confirm number, location, and severity of vertebral fractures. In model 1, we assessed the association between pain during movement and the number, severity, and location of fractures. We adjusted model 2 for pain medication use and age. Results: The mean age of participants was 76.4 (SD 6.9) years. We found no statistically significant associations between pain and fracture number (estimated ß = 0.23, 95% CI: -0.27, 0.68), fracture severity (estimated ß = -0.46, 95% CI: -1.38, 0.49), or fracture location at T4-T8 (estimated ß = 0.06, 95% CI: -1.26, 1.34), T9-L1 (estimated ß = 0.35, 95% CI: -1.17, 1.74), or L2-L4 (estimated ß = 0.40, 95% CI: -1.01, 1.75). Age and pain medication use were not significantly associated with pain. Model 1 accounted for 4.7% and model 2 for 7.2% of the variance in self-reported pain. Conclusion: The number, location, and severity of fractures do not appear to be the primary explanation for pain in women with vertebral fractures. Clinicians must consider other factors contributing to pain.

Objectif : estimer le lien entre la douleur et le nombre, la gravité et le foyer des fractures chez les femmes atteintes de fractures vertébrales ostéoporotiques. Méthodologie : utilisation d'une échelle d'évaluation numérique de la douleur en 11 points pour établir la douleur pendant le mouvement au cours de la semaine précédente et de radiographies vertébrales latérales pour confirmer le nombre, le foyer et la gravité des fractures vertébrales. Dans le modèle 1, les chercheurs ont évalué l'association entre la douleur pendant le mouvement et le nombre, la gravité et le foyer des fractures. Ils ont rajusté le modèle 2 pour tenir compte de la médication contre la douleur et de l'âge. Résultats : les participants avaient un âge moyen de 76,4 ans (ÉT 6,9). Les chercheurs n'ont pas trouvé d'associations importantes entre la douleur et le nombre de fractures (ß estimatif = 0,23, IC à 95 % : ­0,27, 0,68), la gravité des fractures (ß estimatif = ­0,46, IC à 95 % : ­1,38, 0,49) ou le foyer des fractures aux vertèbres T4 à T8 (ß estimatif = 0,06, IC à 95 % : ­1,26, 1,34), aux vertèbres T9 à L1 (b estimatif = 0,35, IC à 95 % : ­1,17, 1,74) ou aux vertèbres L2 à L4 (ß estimatif = 0,40, IC à 95 % : ­1,01, 1,75). L'âge et l'utilisation d'analgésiques n'étaient pas associés à la douleur de manière significative. Le modèle 1 représentait 4,7 % et le modèle 2, 7,2 % des écarts en matière de douleur autodéclarée. Conclusion : Le nombre, le foyer et la gravité des fractures ne semblaient pas être l'explication primaire de la douleur chez les femmes atteintes de fractures vertébrales. Les cliniciens doivent envisager d'autres facteurs qui contribuent à la douleur.

The association of a high drive for thinness with energy deficiency and severe menstrual disturbances: confirmation in a large population of exercising women.

A high drive-for-thinness (DT) score obtained from the Eating Disorder Inventory-2 is associated with surrogate markers of energy deficiency in exercising women. The purposes of this study were to confirm the association between DT and energy deficiency in a larger population of exercising women that was previously published and to compare the distribution of menstrual status in exercising women when categorized as high vs. normal DT. A high DT was defined as a score ≥7, corresponding to the 75th percentile for college-age women. Exercising women age 22.9 ± 4.3 yr with a BMI of 21.2 ± 2.2 kg/m2 were retrospectively grouped as high DT (n = 27) or normal DT (n = 90) to compare psychometric, energetic, and reproductive characteristics. Chi-square analyses were performed to compare the distribution of menstrual disturbances between groups. Measures of resting energy expenditure (REE) (4,949 ± 494 kJ/day vs. 5,406 ± 560 kJ/day, p < .001) and adjusted REE (123 ± 16 kJ/LBM vs. 130 ± 9 kJ/LBM, p = .027) were suppressed in exercising women with high DT vs. normal DT, respectively. Ratio of measured REE to predicted REE (pREE) in the high-DT group was 0.85 ± 0.10, meeting the authors' operational definition for an energy deficiency (REE:pREE <0.90). A greater prevalence of severe menstrual disturbances such as amenorrhea and oligomenorrhea was observed in the high-DT group (χ2 = 9.3, p = .003) than in the normal-DT group. The current study confirms the association between a high DT score and energy deficiency in exercising women and demonstrates a greater prevalence of severe menstrual disturbances in exercising women with high DT.

Association between obesity and risk of fracture, bone mineral density and bone quality in adults: A systematic review and meta-analysis.

BACKGROUND: The association between obesity and fracture risk may be skeletal site- and sex-specific but results among studies are inconsistent. Whilst several studies reported higher bone mineral density (BMD) in patients with obesity, altered bone quality could be a major determinant of bone fragility in this population. OBJECTIVES: This systematic review and meta-analysis aimed to compare, in men, premenopausal women and postmenopausal women with obesity vs. individuals without obesity: 1) the incidence of fractures overall and by site; 2) BMD; and 3) bone quality parameters (circulating bone turnover markers and bone microarchitecture and strength by advanced imaging techniques). DATA SOURCES: PubMed (MEDLINE), EMBASE, Cochrane Library and Web of Science were searched from inception of databases until the 13th of January 2021. DATA SYNTHESIS: Each outcome was stratified by sex and menopausal status in women. The meta-analysis was performed using a random-effect model with inverse-variance method. The risks of hip and wrist fracture were reduced by 25% (n = 8: RR = 0.75, 95% CI: 0.62, 0.91, P = 0.003, I2 = 95%) and 15% (n = 2 studies: RR = 0.85, 95% CI: 0.81, 0.88), respectively, while ankle fracture risk was increased by 60% (n = 2 studies: RR = 1.60, 95% CI: 1.52, 1.68) in postmenopausal women with obesity compared with those without obesity. In men with obesity, hip fracture risk was decreased by 41% (n = 5 studies: RR = 0.59, 95% CI: 0.44, 0.79). Obesity was associated with increased BMD, better bone microarchitecture and strength, and generally lower or unchanged circulating bone resorption, formation and osteocyte markers. However, heterogeneity among studies was high for most outcomes, and overall quality of evidence was very low to low for all outcomes. CONCLUSIONS: This meta-analysis highlights areas for future research including the need for site-specific fracture studies, especially in men and premenopausal women, and studies comparing bone microarchitecture between individuals with and without obesity. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42020159189.