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).

Therapist's practice patterns for subsequent fall/osteoporotic fracture prevention for patients with a distal radius fracture.

STUDY DESIGN: Cross-sectional survey. INTRODUCTION: Multifactorial risk factor screening and treatment is needed for subsequent falls/osteoporotic fractures prevention (SFOFP), given the elevated risk among patients with distal radius fracture (DRF). PURPOSE OF THE STUDY: The primary objective was to describe hand therapists' knowledge and clinical practice patterns for assessment, treatment, referral, and education with respect to SFOFP for patients with DRF older than 45 years. Secondary objective was to explore therapist's preferences in content and delivery of knowledge translation tools that would support implementation of SFOFP. METHODS: A cross-sectional multinational (Canada, the United States, and India) survey was conducted among 272 therapists from August to October 2014. Completed surveys were analyzed descriptively. RESULTS: Surveys were completed by 157 therapists. Most respondents were from the United States (59%), certified hand therapists (54%), and females (87%). Although 65%-90% believed that they had knowledge about SFOFP assessment, treatment, and referral options, 55% did not include it in their routine practice for patients with DRF. Most assessed medication history (82%) and never used a Fracture Risk Assessment Tool (90%) or lower extremity muscle strength testing (54%) to identify those at risk of secondary fractures. With respect to treatment, approximately 33% always used upper extremity muscle strengthening exercises. Most reported rarely (sometimes to never) using balance (79%), lower extremity muscle strengthening (85%), bone strengthening (54%), or community-based physical activity (72%) programs. Similarly, when surveyed about patient education, therapists rarely (sometimes to never) advised patients about web-based resources (94%), regular vision testing (92%), diet for good bone health (87%), bone density evaluation (86%), footwear correction (73%), and hazard identification (67%). Most hand therapists were interested to receive more information on SFOFP for patients with DRF. Nearly one-half preferred to have Web sites for patients, and two-fifth were in favor of pamphlets for patients. CONCLUSION: Current practice patterns reveal care gaps and limited implementation with respect to SFOFP for patients with DRF. Future research should focus on web-based educational/knowledge translation strategies to promote implementation of multifactorial fall risk screening and hand therapist's engagement in SFOFP for patients with DRF.

Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.

BACKGROUND: Most conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination or independently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care arises largely from psychotherapy and medicine literature. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines. METHODS: A scoping review of the literature published in English since inception to July 2015 was conducted using Medline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search term strategy was employed using "physiotherapy", "occupational therapy", "therapeutic alliance", and "musculoskeletal" to identify relevant studies. All searches were performed between December 2014 and July 2015 with an updated search on January 2017. Two investigators screened article title, abstract and full text review for articles meeting the inclusion criteria and extracted therapeutic alliance data and details of each study. RESULTS: One hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%), mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trials and systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) were the most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42 subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory (WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patient perspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57% showed some correlation between therapeutic alliance and adherence. Age moderated the relationship between therapeutic alliance and adherence with younger individuals and an autonomy support environment reporting improved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance. CONCLUSION: Therapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflicting frameworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exercise adherence. Several knowledge gaps have been identified with a potential for generating future research priorities for therapeutic alliance in musculoskeletal rehabilitation.

Correction to: Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.

CORRECTION: Following publication of the original article [1], an erratum was initiated in order to include supplementary material that was not updated and not included during the online submission of the authors' corrections. The additional corrections, included below, are to Appendix II. The original article has been corrected.

Epidemiology of distal radius fractures and factors predicting risk and prognosis.

STUDY DESIGN: Literature Review. INTRODUCTION: For optimal Distal Radius Fracture (DRF) rehabilitation and fracture prevention, it is important to understand the epidemiology and factors predictive of injury, chronic pain, chronic disability, and subsequent fracture. PURPOSE: To summarize the literature reporting on DRF epidemiology, risk factors, and prognostic factors. METHODS: Literature synthesis. RESULTS: Although incidence varies globally, DRFs are common across the lifespan and appear to be on the rise. Risk of DRF is determined by personal factors (age, sex/gender, lifestyle, health condition) and environmental factors (population density, climate). For example, age and sex influence risk such that DRF is most common in boys/young men and older women. The most common causes of DRF in the pediatric and young adult age groups include playing/sporting activities and motor vehicle accidents. In contrast, the most common mechanism of injury in older adults is a low-energy trauma because of a fall from a standing height. Poorer health outcomes are associated with older age, being female, poor bone healing (or having an associated fracture of the ulnar styloid), having a compensated injury, and a lower socioeconomic status. CONCLUSIONS: Risk stratification according to predictors of chronic pain and disability enable therapists to identify those patients who will benefit from advocacy for more comprehensive assessment, targeted interventions, and tailored educational strategies. The unique opportunity for secondary prevention of osteoporotic fracture after DRF has yet to be realized by treating therapists in the orthopedic community. LEVEL OF EVIDENCE: V.

Reproducibility: Reliability and agreement of short version of Western Ontario Rotator Cuff Index (Short-WORC) in patients with rotator cuff disorders.

INTRODUCTION: Recently, a shorter version of Western Ontario Rotator Cuff Index (Short-WORC) was proposed as a subset of 7 items from the original 21-item WORC. However, the reproducibility of the Short-WORC has not been established. PURPOSE OF THE STUDY: To determine reproducibility (reliability and agreement) of the Short-WORC among patients with rotator cuff disorders (RCDs). METHODS: Patients (n = 153) diagnosed with RCD completed the WORC at baseline and at 3 months post-operatively (n = 146). The Short-WORC was extracted from the full version of WORC. From this retrospective cohort, 43 patients were retested within 5 weeks, if they remained stable. Cronbach's alpha (α) and intra class correlation coefficients (ICC2,1) were used to assess internal consistency and test-retest reliability respectively. Standard error measurement (SEM), minimal detectable change (MDC90) and Bland Altman (BA) plots were used to assess agreement. RESULTS: No floor and ceiling effects were reported for either the Short-WORC or WORC. Cronbach's α were 0.84 and 0.90 at baseline and 0.89 and 0.95 at 3 month of follow up for Short-WORC and WORC respectively. The ICC2,1 were 0.89 and 0.91 for the Short-WORC and WORC respectively. The agreement parameters for the Short-WORC were: SEMagreement = 8.8, MDC90individual = 20.3, MDC90group = 5.1. We found substantial agreement between the two versions of WORC on BA plots with minimal (mean difference (d) <1) systematic differences between them. The limits of agreement (LOA) between two versions of WORC were similar across sessions and fell within range of -11.7 to 13.2 points at test and -14.7 to 14.7 points at retest. CONCLUSION: Short-WORC and WORC demonstrates strong reproducibility and can be used for group and individual comparison of health-related quality of life (HRQoL) among patients with RCD. Wider LOA may be expected when using the Short-WORC for individual patient assessment. Reproducibility data is essential, but should be supplemented by validation of actual Short-WORC with samples representing the spectrum of RCD. LEVEL OF EVIDENCE: N/A.

Fat Infiltration in the Leg is Associated with Bone Geometry and Physical Function in Healthy Older Women.

The objective of this study was to estimate the associations between muscular fat infiltration, tibia bone mineral quantity and distribution, and physical function in healthy older women. Thirty-five women (aged 60-75 years, mean 70 years) were recruited from the community. Percent intramuscular fat (%IntraMF) within the right leg tibialis anterior, soleus, and gastrocnemius muscles and total intermuscular fat (IMF) were segmented from magnetic resonance imaging scans at the mid-calf. Intramyocellular lipid (IMCL) content in the right tibialis anterior was measured with proton magnetic resonance spectroscopy. Right tibia bone content, area, and strength were measured at the 4, 14, and 66% sites using peripheral quantitative computed tomography. Physical function was assessed by gait speed on the 20 m walking test. After adjusting for age, body size, and activity level, %IntraMF had a negative association with bone content and area at all tibia sites (r = -0.31 to -0.03). Conversely, greater IMF was associated with increased bone content and area (r = 0.04-0.32). Correlation coefficients for the association between IMCL and bone were negative (r = -0.44 to -0.03). All measures of fat infiltration had a negative association with observed physical function (r = -0.42 to -0.04). Our findings suggest that muscular fat infiltration in the leg of healthy postmenopausal women has a compartment-specific relationship with bone status and physical function. Minimizing fat accumulation within and between muscle compartments may prevent bone fragility and functional decline in women.

Age-related differences in the response of leg muscle cross-sectional area and water diffusivity measures to a period of supine rest.

OBJECT: The object was to assess whether cross-sectional area (CSA) and water diffusion properties of leg muscles in young and older women change with increased time spent in supine rest. MATERIALS AND METHODS: Healthy young (n = 9, aged 20-30 years) and older (n = 9, aged 65-75 years) women underwent MRI scanning of the right leg at baseline, 30 and 60 min of supine rest. Muscle CSA was derived from proton density images. Water diffusion properties [apparent diffusion coefficient (ADC) and fractional anisotropy (FA)] of the tibialis anterior and posterior, soleus, and medial and lateral heads of the gastrocnemius were derived from diffusion tensor imaging (DTI). Repeated measures ANOVAs and Bonferroni post hoc tests determined the effects of time and group on each muscle outcome. RESULTS: In both groups, muscle CSA and FA did not significantly change over time, whereas ADC significantly decreased. A greater decline at 30 min for young women was only observed for ADC in the medial gastrocnemius. CONCLUSION: Regardless of age, ADC values decreased with fluid shift associated with time spent supine, whereas CSA and FA were not affected. For leg muscle assessment in young and older women, DTI scanning protocols should consider the amount of time spent in a recumbent position.

A scoping review of the proximal humerus fracture literature.

BACKGROUND: Proximal humerus fractures are a common fragility fracture that significantly affects the independence of older adults. The outcomes of these fractures are frequently disappointing and previous systematic reviews are unable to guide clinical practice. Through an integrated knowledge user collaboration, we sought to map the breadth of literature available to guide the management of proximal humerus fractures. METHODS: We utilized a scoping review technique because of its novel ability to map research activity and identify knowledge gaps in fields with diverse treatments. Through multiple electronic database searches, we identified a comprehensive body of proximal humerus fracture literature that was classified into eight research themes. Meta-data from each study were abstracted and descriptive statistics were used to summarize the results. RESULTS: 1,051 studies met our inclusion criteria with the majority of research being performed in Europe (64%). The included literature consists primarily of surgical treatment studies (67%) and biomechanical fracture models (10%). Nearly half of all clinical studies are uncontrolled case series of a single treatment (48%). Non-randomized comparative studies represented 12% of the literature and only 3% of the studies were randomized controlled trials. Finally, studies with a primary outcome examining the effectiveness of non-operative treatment or using a prognostic study design were also uncommon (4% and 6%, respectively). CONCLUSIONS: The current study provides a comprehensive summary of the existing proximal humerus fracture literature using a thematic framework developed by a multi-disciplinary collaboration. Several knowledge gaps have been identified and have generated a roadmap for future research priorities.

A scoping review of biomechanical testing for proximal humerus fracture implants.

BACKGROUND: Fixation failure is a relatively common sequela of surgical management of proximal humerus fractures (PHF). The purpose of this study is to understand the current state of the literature with regard to the biomechanical testing of proximal humerus fracture implants. METHODS: A scoping review of the proximal humerus fracture literature was performed, and studies testing the mechanical properties of a PHF treatment were included in this review. Descriptive statistics were used to summarize the characteristics and methods of the included studies. RESULTS: 1,051 proximal humerus fracture studies were reviewed; 67 studies met our inclusion criteria. The most common specimen used was cadaver bone (87%), followed by sawbones (7%) and animal bones (4%). A two-part fracture pattern was tested most frequently (68%), followed by three-part (23%), and four-part (8%). Implants tested included locking plates (52%), intramedullary devices (25%), and non-locking plates (25%). Hemi-arthroplasty was tested in 5 studies (7%), with no studies using reverse total shoulder arthroplasty (RTSA) implants. Torque was the most common mode of force applied (51%), followed by axial loading (45%), and cantilever bending (34%). Substantial testing diversity was observed across all studies. CONCLUSIONS: The biomechanical literature was found to be both diverse and heterogeneous. More complex fracture patterns and RTSA implants have not been adequately tested. These gaps in the current literature will need to be addressed to ensure that future biomechanical research is clinically relevant and capable of improving the outcomes of challenging proximal humerus fracture patterns.

Reliability and validity of selected measures associated with increased fall risk in females over the age of 45 years with distal radius fracture - A pilot study.

STUDY DESIGN: Clinical measurement. PURPOSE: This study examined test-retest reliability and convergent/divergent construct validity of selected tests and measures that assess balance impairment, fear of falling (FOF), impaired physical activity (PA), and lower extremity muscle strength (LEMS) in females >45 years of age after the distal radius fracture (DRF) population. METHODS: Twenty one female participants with DRF were assessed on two occasions. Timed Up and Go, Functional Reach, and One Leg Standing tests assessed balance impairment. Shortened Falls Efficacy Scale, Activity-specific Balance Confidence scale, and Fall Risk Perception Questionnaire assessed FOF. International Physical Activity Questionnaire and Rapid Assessment of Physical Activity were administered to assess PA level. Chair stand test and isometric muscle strength testing for hip and knee assessed LEMS. Intraclass correlation coefficients (ICC) examined the test-retest reliability of the measures. Pearson correlation coefficients (r) examined concurrent relationships between the measures. RESULTS: The results demonstrated fair to excellent test-retest reliability (ICC between 0.50 and 0.96) and low to moderate concordance between the measures (low if r ≤ 0.4; moderate if r = 0.4-0.7). DISCUSSION: The results provide preliminary estimates of test-retest reliability and convergent/divergent construct validity of selected measures associated with increased risk for falling in the females >45 years of age after DRF. Further research directions to advance knowledge regarding fall risk assessment in DRF population have been identified.

Self-management interventions for chronic disease: a systematic scoping review.

OBJECTIVE: To investigate the contributions of physiotherapy and occupational therapy to self-management interventions and the theoretical models used to support these interventions in chronic disease. DATA SOURCES: We conducted two literature searches to identify studies that evaluated self-management interventions involving physiotherapists and occupational therapists in MEDLINE, the Cochrane Library, CINAHL, EMBASE, AMED (Allied and Complementary Medicine), SPORTdiscus, and REHABDATA databases. STUDY SELECTION: Four investigator pairs screened article title and abstract, then full text with inclusion criteria. Selected articles (n = 57) included adults who received a chronic disease self-management intervention, developed or delivered by a physiotherapist and/or an occupational therapist compared with a control group. DATA EXTRACTION: Four pairs of investigators performed independent reviews of each article and data extraction included: (a) participant characteristics, (b) the self-management intervention, (c) the comparison intervention, (d) outcome measures, construct measured and results. DATA SYNTHESIS: A total of 47 articles reported the involvement of physiotherapy in self-management compared with 10 occupational therapy articles. The type of chronic condition produced different yields: arthritis n = 21 articles; chronic obstructive pulmonary disease and chronic pain n = 9 articles each. The theoretical frameworks most frequently cited were social cognitive theory and self-efficacy theory. Physical activity was the predominant focus of the self-management interventions. Physiotherapy programmes included disease-specific education, fatigue, posture, and pain management, while occupational therapists concentrated on joint protection, fatigue, and stress management. CONCLUSIONS: Physiotherapists and occupational therapists make moderate contributions to self-management interventions. Most of these interventions are disease-specific and are most frequently based on the principles of behaviour change theories.

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-pharmacologic conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. OBJECTIVES: Our objectives were to evaluate the benefits and harms of exercise interventions of four weeks or greater (alone or as part of a physical therapyintervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo on the incidence of future fractures and adverse events among adults with a history of osteoporotic vertebral fracture(s). We were also examined the effects of exercise on the following secondary outcomes: falls, pain, posture,physical function, balance,mobility, muscle function,quality of life and bone mineral density of the lumbar spine or hip measured using dual-energy X-ray absorptiometry (DXA).We also reported exercise adherence. SEARCH METHODS: We searched the following databases: The Cochrane Library ( Issue 11 of 12, November 2011), MEDLINE (2005 to 2011), EMBASE (1988 to November 23, 2011), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to November 23, 2011), AMED (1985 to November 2011), and PEDro (Physiotherapy Evidence Database, www.pedro.fhs.usyd.edu.au/index.html, 1929 to November 23, 2011. Ongoing and recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform (to December 2009). 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. SELECTION CRITERIA: We considered 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 and evaluating the outcomes of interest. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials and extracted data using a pre-tested data abstraction form. Disagreements were resolved by consensus, or third party adjudication. The Cochrane Collaboration's tool for assessing risk of bias was used to evaluate each study. Studies were grouped according to duration of follow-up (i.e., a) four to 12 weeks; b) 16 to 24 weeks; and c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For continuous data, we report mean differences (MDs) of the change or percentage change from baseline. Data from two studies were pooled for one outcome using a fixed-effect model. MAIN RESULTS: Seven trials (488 participants, four male participants) were included. Substantial variability across the seven trials prevented any meaningful pooling of data for most outcomes. No trials assessed the effect of exercise on incident fractures, adverse events or incident falls. Individual trials reported that exercise could improve pain, performance on the Timed Up and Go test, walking speed, back extensor strength, trunk muscle endurance, and quality of life. However, the findings should be interpreted with caution given that there were also reports of no significant difference between exercise and control groups for pain, Timed Up and Go test performance, trunk extensor muscle strength and quality of life. Pooled analyses from two studies revealed a significant between-group difference in favour of exercise for Timed Up and Go performance (MD -1.13 seconds, 95% confidence interval (CI) -1.85 to -0.42, P = 0.002). Individual studies also reported no significant between-group differences for posture or bone mineral density. Adherence to exercise varied across studies. The risk of bias across all studies was variable; low risk across most domains in four studies, and unclear or high risk in most domains for three studies. AUTHORS' CONCLUSIONS: No definitive conclusions can be made regarding the benefits of exercise for individuals with vertebral fracture. Although individual trials did report benefits for some pain, physical function and quality of life outcomes, the findings should be interpreted with caution given that findings were inconsistent and the quality of evidence was very low. 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, particularly for men, is scarce. A high-quality randomized trial is needed to inform exercise prescription for individuals with vertebral fractures.

Physical therapists in primary care are interested in high quality evidence regarding efficacy of therapeutic ultrasound for knee osteoarthritis: a provincial survey.

Recent high-level evidence favours therapeutic ultrasound (US) for reducing pain in people with knee osteoarthritis (OA). It is unknown how current practice patterns align with current evidence regarding US efficacy and whether physical therapists perceive a need for further high-level evidence. We conducted a descriptive electronic survey to characterize the beliefs and use of US among physical therapists in Ontario treating people with nonsurgical knee OA. Most of the 123 respondents (81%) reported at least some use of US with 45% using it often or sometimes. The main goal for using US was to reduce pain in the surrounding soft tissue (n = 66) and/or the knee joint (n = 43). Almost half (46%) endorsed the belief that US is likely to be beneficial for clients with nonsurgical knee OA. Most respondents (85%) expressed interest in the results of a randomized controlled trial evaluating the effectiveness of US on pain and physical function. Patterns of use reflect the respondents' belief that US is likely to be beneficial for knee OA pain.

Intrarater reliability of dual-energy X-ray absorptiometry-based measures of vertebral height in postmenopausal women.

The primary purpose was to estimate intrarater reliability of vertebral body height (VH) measures in postmenopausal women based on duplicate analyses of vertebral fracture assessment (VFA) images. The secondary purpose was to determine the consistency in classification of vertebral deformity on duplicate analyses. Thirty-two VFA were randomly selected from a database of 464 scans acquired in postmenopausal women using dual-energy X-ray absorptiometry (Discovery A; Hologic Inc., Waltham, MA). Visible endplates were marked on each image on 2 occasions (4 wk apart) by a single rater; the semiautomated software derived measures of anterior, middle, and posterior VH and classified severity of vertebral deformity. Intrarater reliability was assessed using the intraclass correlation coefficient (with 95% confidence interval [CI]) when ≥ 22 VFA could be analyzed. Reliability of grading deformity of 267 vertebrae was assessed using Cohen's unweighted kappa (with 95% CI). Reliability of anterior, middle, and posterior height measures from T8 to L4 was 0.85 and greater except for T8 anterior VH and T9 posterior VH (0.76 [0.43, 0.90] and 0.62 [0.15, 0.83], respectively). Chance-corrected agreement for 4 grades of vertebral deformity was 0.48 (0.30, 0.66) and for 2 categories (normal/mild and moderate/severe) was 0.70 (50, 0.90). Intrarater reliability was acceptable for VH measures from T10 to L4. Reliability in grading severity of deformity was improved by classifying as <25% deformity (nonfracture) and as >25% deformity (fracture).

Effect of low-intensity pulsed ultrasound on the cartilage repair in people with mild to moderate knee osteoarthritis: a double-blinded, randomized, placebo-controlled pilot study.

OBJECTIVE: To determine the feasibility of conducting a randomized controlled trial assessing the effect of low-intensity pulsed ultrasound (US) therapy on cartilage repair in patients with mild to moderate knee osteoarthritis (OA). DESIGN: Pilot, double-blinded, randomized placebo-controlled trial with 2-months follow-up. SETTING: Rehabilitation research facility. PARTICIPANTS: Adults (N=27; ≥45y) with grades 1 or 2 of medial joint space narrowing (Osteoarthritis Research Society International atlas) due to knee OA were randomly allocated to receive active (n=14) or sham (n=13) US therapy. Four participants withdrew for personal reasons. INTERVENTIONS: Twenty-four sessions of active (20% duty cycle, 1MHz, average temporal intensity: 0.2W/cm(2), therapeutic dose: 112.5J/cm(2)) or sham (no sound-head crystal) US therapy. MAIN OUTCOME MEASURES: Success of recruitment and adherence rates were established by a priori criteria. Effect on cartilage repair was assessed by measuring cartilage volume and thickness and scoring cartilage injury, subchondral cyst formation, and bone marrow lesions on magnetic resonance images. RESULTS: Patient recruitment and adherence rates were successful. No significant age-adjusted differences were seen between groups in the cartilage repair outcomes. Age-adjusted analyses, including only subjects who attended 20 sessions or more, showed an increase in medial tibia cartilage thickness in the active US therapy group (90µm; 95% confidence interval, 1-200; P=.05). CONCLUSIONS: Conducting a randomized controlled trial to assess the effects of US therapy on the cartilage repair in people with mild to moderate knee OA is feasible. However, further pilot studies are needed to determine the optimal US dose and application parameters before designing a full trial.

Sensory nerve action potentials and sensory perception in women with arthritis of the hand.

BACKGROUND: Arthritis of the hand can limit a person's ability to perform daily activities. Whether or not sensory deficits contribute to the disability in this population remains unknown. The primary purpose of this study was to determine if women with osteoarthritis (OA) or rheumatoid arthritis (RA) of the hand have sensory impairments. METHODS: Sensory function in the dominant hand of women with hand OA or RA and healthy women was evaluated by measuring sensory nerve action potentials (SNAPs) from the median, ulnar and radial nerves, sensory mapping (SM), and vibratory and current perception thresholds (VPT and CPT, respectively) of the second and fifth digits. RESULTS: All SNAP amplitudes were significantly lower for the hand OA and hand RA groups compared with the healthy group (p < 0.05). No group differences were found for SNAP conduction velocities, SM, VPT, and CPT. DISCUSSION: We propose, based on these findings, that women with hand OA or RA may have axonal loss of sensory fibers in the median, ulnar and radial nerves. Less apparent were losses in conduction speed or sensory perception.

Muscle activation during hand dexterity tasks in women with hand osteoarthritis and control subjects.

STUDY DESIGN: Descriptive cross-sectional study. INTRODUCTION: Hand osteoarthritis (OA) is a condition that results in hand pain and disability. It is important to understand how muscle function impairments contribute to impaired dexterity. PURPOSE OF THE STUDY: To compare muscle activation in women with and without hand OA and determine if the activation relates to measures of impairment and disability. METHODS: Electromyography (EMG) was recorded from four muscles of the hand/forearm while subjects threaded (assembly) and unthreaded (disassembly) a small bolt. The groups were compared on the integrated EMG (IEMG) of four muscles using two-way repeated-measures analyses of covariance for the assembly and disassembly tasks. RESULTS: No differences were found in muscle activation between groups when IEMG values were normalized by time (p>0.05). CONCLUSIONS: Patients with OA have some indicators of altered muscle function. It is unclear whether these are adaptive or predisposing changes. When controlling for the time to perform a task, there were no significant IEMG differences between women with hand OA and control subjects. LEVEL OF EVIDENCE: 2b.

Comparison of pQCT-based measures of radial bone geometry and apparent trabecular bone structure using manufacturer and in-house-developed algorithms.

Peripheral quantitative computed tomography (pQCT) provides noninvasive densitometric and morphometric measures of total, trabecular, and cortical bone compartments. Skeletal changes over time can be determined by repeated measurements. Image thickness of 2.5mm is thought to be advantageous with respect to test-retest reliability through interrogation of a significant tissue volume. However, the error associated with slight shifts in image location is unknown. The primary purpose of this study was to determine the effects of positional variability around the 4% site on radial bone measures. The secondary objective was to compare different software algorithms for estimating the same bone characteristics. Eight left cadaveric forearms (aged 65-88 yr) were imaged at 0.5-mm intervals around the 4% site of the radial bone using pQCT (10 slices; in-plane resolution: 0.2 × 0.2mm; thickness: 2.5mm; Stratec XCT2000L. We used the manufacturer's software (Stratec v6.0B) to determine the total bone mineral density (BD_tot), total bone mineral content (BMC_tot), total bone area (Area_tot), trabecular bone mineral density (BD_trab), trabecular bone mineral content (BMC_trab), and trabecular bone area (Area_trab) from each image. For comparison, in-house-developed software was also used to analyze Area_tot and Area_trab at the 4% site. The in-house software also produced measures of apparent trabecular structure, including number (App.Tb.N), thickness (App.Tb.Th), and spacing (App.Tb.Sp), quantified using 2 different stereological approaches: the parallel-plate method using trabecular perimeter lengths and mean intercept length analysis. The effect of slice position was assessed using a 1-way repeated-measures analysis of variance (ANOVA). Reliability of nonsignificant slice distances around the 4% site was determined using intraclass correlation coefficients (ICCs). One-way repeated-measures ANOVA was used to compare measures of similar bone characteristics at the 4% site. Bland-Altman plots were created to assess the level of agreement between pairs of algorithms quantifying comparable apparent trabecular structure. Area_tot and Area_trab differed significantly at greater than or equal to 1.0mm proximal and greater than or equal to 0.5mm distal to the 4% site. BMC_tot and BMC_trab differ significantly greater than or equal to 1.5mm proximally (for both) and greater than or equal to 2.0 and 1.0mm distally, respectively. BD_tot differed significantly at greater than or equal to 1mm proximal and distal to the 4% site. BD_trab did not differ among the 10 slices. For images acquired at the 4% site, and 0.5mm more proximally, reliability was excellent (ICC=0.98 to 0.99). Although the in-house software yielded a higher value for Area_tot and Area_trab at the 4% site (p<0.05), no systematic bias was observed. The parallel-plate method yielded higher values for App.Tb.N and lower values for App.Tb.Th (p<0.05), with no systematic bias. App.Tb.Sp values were smaller using the parallel-plate method, and the difference in methods increased as App.Tb.Sp values increased. Statistically, tolerance for repositioning around the 4% site of the radial bone is least for measures of bone area and greatest for BD_trab. On repeated measures, a proximal shift of 0.5mm will not influence the results.

Functional risk for fracture by safe functional motion testing: a short version of the safe functional motion test.

BACKGROUND: 'Unsafe' movement strategies used to perform everyday activities were quantified using scores for tasks included in the Short Form Safe Functional Motion test series (SSFM). Baseline scores were independently associated with incident fractures after adjusting for factors known to effect fracture risk. The purpose of the present study is to determine whether the SSFM, a series of tests of habitual motion, is associated with incident fragility fracture at any skeletal sites. METHODS: An osteoporosis clinic database was queried for adults with baseline SSFM scores and corresponding data for prevalent fractures, femoral neck bone mineral density (fnBMD), osteoporosis medication use, and incident fractures at 1-year and 3-year follow ups [n = 1700 (118 incident fractures) and n = 1058 (202 incident fractures), respectively]. Multiple logistic regressions, adjusted for sex, age, fnBMD, osteoporosis medication use, and any prevalent fractures at baseline, were used to determine whether baseline SSFM scores were associated with incident fragility fractures. RESULTS: An Sfm-3 score was a significant independent predictor of any fracture at 1 year [adjusted odds ratio (95% CI) = 1.118 (1.025, 1.219) for each 10-point decrease in Sfm-3; p = 0.012], and 3-year follow up [adjusted odds ratio (95% CI) = 1.183 (1.098, 1.274) for each 10-point decrease in Sfm-3; p < 0.0001]. CONCLUSIONS: Scores on the SSFM predict fracture risk such that for each 10-point drop in score the odds of fracture are increased by up to 18% independent of risk associated with age, bone mineral density, use of bone-sparing medications, and history of a fracture.