FRAX predicts cardiovascular risk in women undergoing osteoporosis screening: the Manitoba bone mineral density registry.

Osteoporosis and cardiovascular disease (CVD) are highly prevalent in older women, with increasing evidence for shared risk factors and pathogenesis. Although FRAX was developed for the assessment of fracture risk, we hypothesized that it might also provide information on CVD risk. To test the ability of the FRAX tool and FRAX-defined risk factors to predict incident CVD in women undergoing osteoporosis screening with DXA, we performed a retrospective prognostic cohort study which included women aged 50 yr or older with a baseline DXA scan in the Manitoba Bone Mineral Density Registry between March 31, 1999 and March 31, 2018. FRAX scores for major osteoporotic fracture (MOF) were calculated on all participants. Incident MOF and major adverse CV events (MACE; hospitalized acute myocardial infarction [AMI], hospitalized non-hemorrhagic cerebrovascular disease [CVA], or all-cause death) were ascertained from linkage to population-based healthcare data. The study population comprised 59 696 women (mean age 65.7 ± 9.4 yr). Over mean 8.7 yr of observation, 6021 (10.1%) had MOF, 12 277 women (20.6%) had MACE, 2274 (3.8%) had AMI, 2061 (3.5%) had CVA, and 10 253 (17.2%) died. MACE rates per 1000 person-years by FRAX risk categories low (10-yr predicted MOF <10%), moderate (10%-19.9%) and high (≥20%) were 13.5, 34.0, and 64.6, respectively. Although weaker than the association with incident MOF, increasing FRAX quintile was associated with increasing risk for MACE (all P-trend <.001), even after excluding prior CVD and adjusting for age. HR for MACE per SD increase in FRAX was 1.99 (95%CI, 1.96-2.02). All FRAX-defined risk factors (except parental hip fracture and lower BMI) were independently associated with higher non-death CV events. Although FRAX is intended for fracture risk prediction, it has predictive value for cardiovascular risk.

Sedentary behavior does not predict low BMD nor fracture-population-based Canadian Multicentre Osteoporosis Study.

Sedentary behavior (SB) or sitting is associated with multiple unfavorable health outcomes. Bone tissue responds to imposed gravitational and muscular strain with there being some evidence suggesting a causal link between SB and poor bone health. However, there are no population-based data on the longitudinal relationship between SB, bone change, and incidence of fragility fractures. This study aimed to examine the associations of sitting/SB (defined as daily sitting time), areal BMD (by DXA), and incident low trauma (fragility) osteoporotic fractures (excluding hands, feet, face, and head). We measured baseline (1995-7) and 10-yr self-reported SB, femoral neck (FN), total hip (TH), and lumbar spine (L1-L4) BMD in 5708 women and 2564 men aged 25 to 80+ yr from the population-based, nationwide, 9-center Canadian Multicentre Osteoporosis Study. Incident 10-yr fragility fracture data were obtained from 4624 participants; >80% of fractures were objectively confirmed by medical records or radiology reports. Vertebral fractures were confirmed by qualitative morphological methods. All analyses were stratified by sex. Multivariable regression models assessed SB-BMD relationships; Cox proportional models were fit for fracture risk. Models were adjusted for age, height, BMI, physical activity, and sex-specific covariates. Women in third/fourth quartiles had lower adjusted FN BMD versus women with the least SB (first quartile); women in the SB third quartile had lower adjusted TH BMD. Men in the SB third quartile had lower adjusted FN BMD than those in SB first quartile. Neither baseline nor stable 10-yr SB was related to BMD change nor to incident fragility fractures. Increased sitting (SB) in this large, population-based cohort was associated with lower baseline FN BMD. Stable SB was not associated with 10-yr BMD loss nor increased fragility fracture. In conclusion, habitual adult SB was not associated with subsequent loss of BMD nor increased risk of fracture.

The number of hours of sitting in a day (often called "sedentary behavior") is currently understood to be "bad for bone health" both because of increased bone loss and a higher risk for fractures. Very few studies in randomly sampled men and women from a whole population have consistently asked about hours of sitting and examined baseline bone density. Fewer still have compared hours of sitting and its changes over 10 yr with changes in bone density and the number of new fractures that occurred. The Canadian Multicentre Osteoporosis Study obtained sitting hours from 5708 women and 2564 men aged 25 to 80+ yr and compared it with the spine, total hip (TH), and femoral neck (FN) bone density values. The average sitting at 7.4 h in men was associated with slightly lower adjusted femoral neck bone density; in women, sitting 6.7 h/d was associated with slightly lower adjusted FN and TH bone density. Ten-year follow-up data (now in about 5000 people) showed no relationship between the slightly longer sitting (an increase of 18% in men and 22% in women) and bone loss or new bone fractures. In this large country-wide population-based study, hours of sitting each day were not associated with 10-yr BMD loss in women or men nor did sitting more associate with new bone fractures. These data are reassuring; women and men who walk regularly and have some moderate-vigorous physical activity each day, despite more sitting, do not seem to be at greater risk for osteoporosis.

Advanced glycation end products are not associated with bone mineral density, trabecular bone score, and bone turnover markers in adults with and without type 1 diabetes: a cross-sectional study.

It is unclear if AGEs are involved in the bone fragility of type 1 diabetes (T1D). We evaluated whether skin AGEs by skin autofluorescence and serum AGEs (pentosidine, carboxymethyl-lysine [CML]) are independently associated with BMD by DXA (lumbar spine, hip, distal radius), trabecular bone score (TBS), serum bone turnover markers (BTMs: CTX; P1NP; osteocalcin), and sclerostin in participants with and without T1D. Linear regression models were used, with interaction terms to test effect modification by T1D status. In participants with T1D, correlations between skin and serum AGEs as well as between AGEs and 3-year HbA1C were evaluated using Spearman's correlations. Data are mean ± SD or median (interquartile range). We included individuals who participated in a cross-sectional study and had BMD and TBS assessment (106 T1D/65 controls, 53.2% women, age 43 ± 15 yr, BMI 26.6 ± 5.5 kg/m2). Participants with T1D had diabetes for 27.6 ± 12.3 yr, a mean 3-yr HbA1C of 7.5 ± 0.9% and skin AGEs of 2.15 ± 0.54 arbitrary units. A subgroup of 65 T1D/57 controls had BTMs and sclerostin measurements, and those with T1D also had serum pentosidine (16.8[8.2-32.0] ng/mL) and CML [48.0 ± 16.8] ng/mL) measured. Femoral neck BMD, TBS, and BTMs were lower, while sclerostin levels were similar in participants with T1D vs controls. T1D status did not modify the associations between AGEs and bone outcomes. Skin AGEs were significantly associated with total hip and femoral neck BMD, TBS, BTMs, and sclerostin before, but not after, adjustment for confounders. Serum AGEs were not associated with any bone outcome. There were no significant correlations between skin and serum AGEs or between AGEs and 3-yr HbA1C. In conclusion, skin and serum AGEs are not independently associated with BMD, TBS, BTMs, and sclerostin in participants with relatively well-controlled T1D and participants without diabetes.

Perspectives of wheelchair users with chronic spinal cord injury following a walking program using a wearable robotic exoskeleton.

PURPOSE: To examine the perspectives of wheelchair users with spinal cord injury (WUSCI) regarding their participation in a 16-week walking program using a wearable robotic exoskeleton (WRE); and explore concerns and expectations regarding potential use of this device and intervention in the context of a home or community-based adapted physical activity program. METHOD: Semi-structured interviews were conducted using a narrative research, 3 weeks post-intervention. Thematic analysis resulted in 6 themes and 21 subthemes. RESULTS: Seven men and 4 women aged between 32 and 72 years were interviewed; 8 of them had a complete SCI. After the walking program, WUSCI reported positive psychological aspects (having fun and motivation) and experiencing improvements in physical aspects (strength, endurance, balance and flexibility, blood circulation and intestinal transit). The structural aspects of the WRE device were acceptable in a lab with research personnel (appearance, size, weight, and comfort). Participants had concerns about safety on uneven surfaces, and possibility of falling. They expressed the desire to use the WRE for more life habits than just walking. CONCLUSION: This is the first study in which WUSCI report that the WRE should be implemented in initial rehabilitation. Lack of availability for community use after rehabilitation remains a concern.

Participation in a walking training program using a wearable robotic exoskeleton, 1-3 times weekly over several weeks, may be well tolerated and provide physical and psychological benefits for wheelchair users with spinal cord injuries.Using a robotic exoskeleton during initial rehabilitation may be well received and help with regaining strength, endurance, balance, and flexibility as well as promoting blood circulation and intestinal transit.The use of the wearable robotic exoskeleton always needs supervision of a clinician for walking and can't be used independently by wheelchair users; there is no possibility for hands free for household tasks (e.g., washing floors, accessing cupboards or reaching shelves, using stairs), and for recreation (e.g., exercising, taking walks, cultural activities, concerts).

Potential Effects of an Exoskeleton-Assisted Overground Walking Program for Individuals With Spinal Cord Injury Who Uses a Wheelchair on Imaging and Serum Markers of Bone Strength: Pre-Post Study.

BACKGROUND: As many as 60% of individuals use a wheelchair long term after a spinal cord injury (SCI). This mode of locomotion leads to chronic decline in lower-extremity weight-bearing activities and contributes to the development of severe sublesional osteoporosis and high rates of fragility fracture. Overground exoskeleton-assisted walking programs provide a novel opportunity to increase lower-extremity weight bearing, with the potential to improve bone health. OBJECTIVE: The aim of the study is to measure the potential effects of an exoskeleton-assisted walking program on lower-extremity bone strength and bone remodeling biomarkers in individuals with chronic (≥18 months) SCI who use a wheelchair. METHODS: In total, 10 participants completed a 16-week exoskeleton-assisted walking program (34 individualized 1-hour sessions, progressing from 1 to 3 per week). Bone mineral density and bone strength markers (dual-energy x-ray absorptiometry: total body, left arm, leg, total hip, and femoral neck and peripheral quantitative computed tomography: 25% of left femur and 66% of left tibia) as well as bone remodeling biomarkers (formation=osteocalcin and resorption=C-telopeptide) were measured before and after intervention and compared using nonparametric tests. Changes were considered significant and meaningful if the following criteria were met: P<0.1, effect size ≥0.5, and relative variation >5%. RESULTS: Significant and meaningful increases were observed at the femur (femoral neck bone mineral content, bone strength index, and stress-strain index) and tibia (cortical cross-sectional area and polar moment of inertia) after the intervention (all P<.10). We also noted a decrease in estimated femoral cortical thickness. However, no changes in bone remodeling biomarkers were found. CONCLUSIONS: These initial results suggest promising improvements in bone strength markers after a 16-week exoskeleton-assisted walking program in individuals with chronic SCI. Additional research with larger sample sizes, longer interventions (possibly of greater loading intensity), and combined modalities (eg, pharmacotherapy or functional electrical stimulation) are warranted to strengthen current evidence. TRIAL REGISTRATION: ClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/19251.

Opportunistic Screening of Low Bone Mineral Density From Standard X-Rays.

BACKGROUND: Osteoporosis, characterized by loss of bone mineral density (BMD), is underscreened. Osteoporosis and low bone mass are diagnosed by a BMD T-score ≤ -2.5, and between -1.0 and -2.5, respectively, at the femoral neck or lumbar vertebrae (L1-4), using dual energy x-ray absorptiometry (DXA). The ability to estimate BMD at those anatomic sites from standard radiographs would enable opportunistic screening of low BMD (T-score < -1) in individuals undergoing x-ray for any clinical indication. METHODS: Radiographs of the lumbar spine, thoracic spine, chest, pelvis, hand, and knee, with a paired DXA acquired within 1 year, were obtained from community imaging centers (62,023 x-ray-DXA pairs of patients). A software program called Rho was developed that uses x-ray, age, and sex as inputs, and outputs a score of 1 to 10 that corresponds with the likelihood of low BMD. The program's performance was assessed using receiver-operating characteristic analyses in three independent test sets, as follows: patients from community imaging centers (n = 3,729; 83% female); patients in the Canadian Multicentre Osteoporosis Study (n = 1,780; 71% female); and patients in the Osteoarthritis Initiative (n = 591; 50% female). RESULTS: The areas under the receiver-operating characteristic curves were 0.89 (0.87-0.90), 0.87 (0.85-0.88), and 0.82 (0.79-0.85), respectively, and subset analyses showed similar results for each sex, body part, and race. CONCLUSION: Rho can opportunistically screen patients at risk of low BMD (at femoral neck or L1-4) from radiographs of the lumbar spine, thoracic spine, chest, pelvis, hand, or knee.

Patients' preferences for fracture risk communication: the Risk Communication in Osteoporosis (RICO) study.

The RICO study indicated that most patients would like to receive information regarding their fracture risk but that only a small majority have actually received it. Patients globally preferred a visual presentation of fracture risk and were interested in an online tool showing the risk. PURPOSE: The aim of the Risk Communication in Osteoporosis (RICO) study was to assess patients' preferences regarding fracture risk communication. METHODS: To assess patients' preferences for fracture risk communication, structured interviews with women with osteoporosis or who were at risk for fracture were conducted in 11 sites around the world, namely in Argentina, Belgium, Canada at Hamilton and with participants from the Osteoporosis Canada Canadian Osteoporosis Patient Network (COPN), Japan, Mexico, Spain, the Netherlands, the UK, and the USA in California and Washington state. The interviews used to collect data were designed on the basis of a systematic review and a qualitative pilot study involving 26 participants at risk of fracture. RESULTS: A total of 332 women (mean age 67.5 ± 8.0 years, 48% with a history of fracture) were included in the study. Although the participants considered it important to receive information about their fracture risk (mean importance of 6.2 ± 1.4 on a 7-point Likert scale), only 56% (i.e. 185/332) had already received such information. Globally, participants preferred a visual presentation with a traffic-light type of coloured graph of their FRAX® fracture risk probability, compared to a verbal or written presentation. Almost all participants considered it important to discuss their fracture risk and the consequences of fractures with their healthcare professionals in addition to receiving information in a printed format or access to an online website showing their fracture risk. CONCLUSIONS: There is a significant communication gap between healthcare professionals and patients when discussing osteoporosis fracture risk. The RICO study provides insight into preferred approaches to rectify this communication gap.

Actualisation 2023 des lignes directrices de pratique clinique pour la prise en charge de l'ostéoporose et la prévention des fractures au Canada.

CONTEXTE: Au Canada, plus de 2 millions de personnes vivent avec l'ostéoporose, une maladie qui accroît le risque de fracture, ce qui fait augmenter la morbidité et la mortalité, et entraîne une perte de qualité de vie et d'autonomie. La présente actualisation des lignes directrices vise à accompagner les professionnelles et professionnels de la santé au Canada dans la prestation de soins visant à optimiser la santé osseuse et à prévenir les fractures chez les femmes ménopausées et les hommes de 50 ans et plus. MÉTHODES: Le présent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d'Ostéoporose Canada sur le diagnostic et la prise en charge de l'ostéoporose au pays. Nous avons utilisé l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectué l'assurance de la qualité conformément aux normes de qualité et de présentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les médecins de premier recours et les patientes et patients partenaires ont été représentés à tous les niveaux des comités et des groupes ayant participé à l'élaboration des lignes directrices, et ont participé à toutes les étapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des intérêts concurrents a été entamé avant l'élaboration des lignes directrices et s'est poursuivi sur toute sa durée, selon les principes du Réseau international en matière de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et préférences de la patientèle, des ressources, de l'équité, de l'acceptabilité et de la faisabilité; la force de chacune des recommandations a été déterminée en fonction du cadre GRADE. RECOMMANDATIONS: Les 25 recommandations et les 10 énoncés de bonne pratique sont répartis en sections : activité physique, alimentation, évaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, durée et séquence du traitement, et monitorage. La prise en charge de l'ostéoporose devrait se fonder sur le risque de fracture, établi au moyen d'une évaluation clinique réalisée avec un outil d'évaluation du risque de fracture validé. L'activité physique, l'alimentation et la pharmacothérapie sont des éléments essentiels à la stratégie de prévention des fractures, qui devraient être personnalisés. INTERPRÉTATION: Les présentes lignes directrices ont pour but d'outiller les professionnelles et professionnels de la santé et la patientèle afin qu'ensemble ils puissent parler de l'importance de la santé osseuse et du risque de fracture tout au long de la vie adulte avancée. La détection et la prise en charge efficace de la fragilité osseuse peuvent contribuer à réduire les fractures et à préserver la mobilité, l'autonomie et la qualité de vie.

Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update.

BACKGROUND: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older. METHODS: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework. RECOMMENDATIONS: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized. INTERPRETATION: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life.

What Do Older Canadians Think They Need to Walk Well?

Purpose: To identify older Canadians' perception of the importance of expert-generated elements of walking quality, and the contributors to and consequences of perceived walking quality. Method: Cross-sectional survey of 649 adults was conducted through a commercial participant panel, Hosted in Canada Surveys. Results: Of the 649 respondents, 75% were between 65 and 74 years old (25% ≥ 75) and 49% were women. The most important elements were foot, ankle, hip, and knee mobility with little difference in ranks across walking perception (Fr χ12 = 5.0, p > 0.05). People who were older by a decade were more likely to report poorer walking (POR: 1.4; 95% CI: 1.0, 1.7), as were women compared to men, and people who used a walking aid compared to none. Lung disease showed the highest association with a perception of not walking well (POR: 7.2; 95% CI: 3.7, 14.2). The odds of being willing to pay more for a technology to improve walking were always greater for those with a lower perception of their walking quality. Conclusions: People who perceived their walking quality as poor were more likely to report poorer health and were willing to pay more for a technology to improve walking. This supports the opportunity of leveraging wearable technologies to improve walking.

Objectif : déterminer la perception des Canadiens âgés à l'égard de l'importance des éléments relatifs à la qualité de la marche produits par des experts et établir les incitatifs à la perception de la qualité de la marche, de même que les conséquences s'y rapportant. Méthodologie : sondage transversal auprès de 649 adultes au moyen de Hosted in Canada Surveys, un groupe commercial de participants. Résultats : sur les 649 répondants, 75 % étaient âgés de 65 à 74 ans (25 % ≥ 75 ans), et 49 % étaient des femmes. La mobilité du pied, de la cheville, de la hanche et du genou constituait les éléments les plus importants, et le niveau hiérarchique de chacun différait peu en matière de perceptions de la marche (test de Friedman [Fr] χ2 = 5,0, degré de liberté [ddl] 12, p > 0,05). Les personnes âgées d'une décennie de plus risquaient davantage de déclarer moins bien marcher (rapport de cotes proportionnel [RCP] : 1,4; IC à 95 % : 1,0 à 1,7), tout comme les femmes et les personnes qui utilisaient une aide à la marche. La maladie pulmonaire était la plus liée à la perception de moins bien marcher (RCP : 7,2; IC à 95 % : 3,7, 14,2). La probabilité d'être prêt à payer plus cher pour disposer d'une technologie destinée à améliorer la marche était toujours plus forte chez les personnes qui avaient une moins bonne perception de leur qualité de marche. Conclusion : les personnes qui avaient une moins bonne perception de leur qualité de marche étaient plus susceptibles de se déclarer en moins bonne santé et étaient prêtes à payer plus cher pour disposer d'une technologie destinée à améliorer la marche. Cette constatation confirme la possibilité de mettre à profit des technologies portables pour améliorer la marche.

Adjusting FRAX Estimates of Fracture Probability Based on a Positive Vertebral Fracture Assessment.

Importance: FRAX is the most widely used and validated fracture risk prediction tool worldwide. Vertebral fractures, which are an indicator of subsequent osteoporotic fractures, can be identified using dual-energy x-ray absorptiometry (DXA) vertebral fracture assessment (VFA). Objective: To assess the calibration of FRAX and develop a simple method for improving FRAX-predicted fracture probability in the presence of VFA-identified fracture. Design, Setting, and Participants: This prognostic study analyzed the DXA and VFA results of all individuals who underwent a VFA between March 31, 2010, and March 31, 2018, who were included in the Manitoba Bone Mineral Density Registry. These individuals were randomly assigned to either the development cohort or validation cohort. A modified algorithm-based qualitative approach was used by expert readers to code VFAs as positive (≥1 vertebral fractures detected) or negative (0 vertebral fracture detected). Statistical analysis was conducted from August 7, 2022, to May 22, 2023. Exposures: FRAX scores for major osteoporotic fracture (MOF) and hip fracture were calculated with or without VFA results. Main Outcomes and Measures: Incident fractures and death were ascertained using linked population-based health care provincial data. Cumulative incidence curves for MOF and hip fracture were constructed, including competing mortality, to predict the 10-year observed risk of fracture. The observed probability was compared with FRAX-predicted fracture probability with and without VFA results and recalibrated FRAX from derived multipliers. Results: The full cohort of 11 766 individuals was randomly allocated to the development cohort (n = 7854; 7349 females [93.6%]; mean [SD] age, 75.7 [6.8] years) or the validation cohort (n = 3912; 3713 females [94.9%]; mean [SD] age, 75.5 [6.9] years). Over a mean (SD) observation time of 3.8 (2.3) years, with the longest observation at 7.5 years, FRAX was well calibrated in subgroups with negative VFA results. For individuals without a prior clinical fracture but with a positive VFA result, the 10-year FRAX-predicted MOF probability was 16.3% (95% CI, 15.7%-16.8%) without VFA information and 23.4% (95% CI, 22.7%-24.1%) with VFA information. The observed 10-year probabilities were 26.9% (95% CI, 26.0%-27.8%) and 11.2% (95% CI, 10.3%-12.1%), respectively, resulting in recalibration multipliers of 1.15 (95% CI, 0.87-1.43) for MOF and 1.31 (95% CI, 0.75-1.87) for hip fracture. For individuals with a prior clinical fracture and a positive VFA result, the 10-year FRAX-predicted probabilities were 25.0% (95% CI, 24.2%-25.7%) for MOF and 9.3% (95% CI, 8.7%-10.0%) for hip fracture. The observed 10-year probabilities were 38.1% (95% CI, 37.0%-39.1%) for MOF and 16.4% (95% CI, 15.4%-17.4%) for hip fracture, resulting in a recalibration multiplier of 1.53 (95% CI, 1.10-1.96) for MOF and 1.76 (95% CI, 1.17-2.35) for hip fracture. Good calibration (>0.90) was confirmed using the derived multipliers in the validation cohort. Conclusions and Relevance: Results of this prognostic study suggest that FRAX underestimated fracture risk in patients with VFA-identified fractures. Simple multipliers could recover FRAX calibration in individuals with VFA-identified fractures.

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.

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.

A Population-Based Registry Study of Extended Bisphosphonate Use: Minimal Shift After Landmark Publications About Shorter Treatment Duration.

Optimal duration of bisphosphonate therapy was unknown until the FLEX study was published in 2006 showing a 5-year course to be adequate for most women. In 2008, a link between long-term bisphosphonate and atypical femoral fractures was reported and confirmed in later studies. We hypothesized these landmark observations should have led to a decrease in use of bisphosphonates for >5 or 10 years, from 2010 onward. The Manitoba Bone Mineral Density (BMD) Registry with linkage to provincial pharmacy data was used to determine the percentage of long- and very long-term bisphosphonate users from therapy start. The cohort comprised women aged >50 years with BMD between 1995 and 2018 with oral bisphosphonate first prescribed for >90 days with adherence >75% in the first year. For each calendar year of continued therapy, the percentage of patients and medication possession rate was tabulated. The percentage of users beyond 5 years was compared among patients who started therapy in 1998-2004 (those taking 5 years of therapy still finish before 2010) versus 2005-2012 (all new therapy starts overlap 2010 in those taking ≥5 years of treatment). The cohort included 2991 women with mean follow-up 8.8 (1.3) years, 64.9% of whom took continuous oral bisphosphonate for >5 years and 41.9% for >10 years. In the earlier versus later era, there were 74.4% versus 70.2% who completed 5 years. With respect to longer treatment, there were 68.0% and 60.5% of patients treated for 6 or more years (p < 0.0001) and 46.6% versus 33.5% treated for >10 years (p = 0.08). Medication possession rate was >79% in every year of therapy. Landmark studies leading to more limited bisphosphonate courses may have slightly reduced longer-term treatment, but up to one-third of adherent patients in the modern era still receive continuous bisphosphonate therapy for >10 years. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Added value of waist circumference to body mass index for predicting fracture risk in obesity: a prospective study from the CARTaGENE cohort.

Larger waist circumference is significantly associated with an increased risk of distal lower limb fractures in individuals aged 40-70 years with a body mass index within the normal or overweight category. Therefore, waist circumference provides additive information to body mass index for the identification of individuals at risk of obesity-related fractures. INTRODUCTION: Waist circumference (WC) is a stronger risk factor of metabolic disorders than body mass index (BMI), but whether it holds true for fracture risk prediction remains unclear. We aimed to evaluate relationships between WC and fracture incidence within BMI categories and evaluate whether BMI modifies these relationships. METHODS: Men and women aged 40-70 years from the CARTaGENE cohort were divided by BMI category at baseline: normal weight, overweight, and obesity. Incident fractures were identified over 7 years via linkage with healthcare administrative databases. Cox proportional hazard models estimated the relationships between WC and incident fractures at any site and by skeletal site within each BMI category. Results are reported as adjusted hazard ratios (95% confidence intervals) per 10 cm increase in WC. Effect modification was evaluated qualitatively by comparing relationships between BMI categories. RESULTS: Of the 18 236 individuals included, 754 sustained a fracture. Significant relationships were found between WC and distal lower limb fractures in the normal (1.25 [1.08, 1.45]) and overweight (1.28 [1.07, 1.52]) BMI categories, but not in the obesity category. In the overweight category, we found an increased risk of distal upper limb fractures with increasing WC (1.49 [1.04, 2.15]). No significant relationship was observed regarding WC and fracture risk at any site or major osteoporotic fractures. An effect modification of BMI on the relationships between WC and distal lower limb fractures was observed. CONCLUSION: WC provides both independent and additive information to BMI for the identification of individuals at risk of obesity-related fractures.

Transition from Pediatric to Adult Health Care in Osteogenesis Imperfecta.

PURPOSE: Here, we review issues regarding the transition from pediatric to adult-focused health care for individuals with osteogenesis imperfecta (OI). RECENT FINDINGS: The clinical consequences of OI change during the lifespan. Fracture rates are lower in adults than in children with OI, whereas other manifestations are typically becoming more prominent in adults. The evidence base for the transition to adult health care in OI is thin, as the literature on the topic is limited to qualitative investigations on a small number of participants. A few tools to help with transition, such as a program to improve self-management skills, have been developed. The transition process varies markedly between health care systems, which makes generalizations difficult. However, a better definition of follow-up requirements and care of adults with OI might be helpful for the transition from pediatric to adult health care.

Relationships between Obesity and Incidence of Fractures in a Middle-Aged Population: A Study from the CARTaGENE Cohort.

The association between obesity and fracture risk is complex and may vary by definition of obesity, skeletal site, and sex. We aimed to evaluate the relationships between obesity, defined using body mass index (BMI) or waist circumference (WC), and fracture incidence at any site and by skeletal site (i.e., major osteoporotic fractures [MOFs], distal lower limb fractures [tibia, ankle, feet], and distal upper limb fractures [forearm/elbow, wrist]). The secondary aim was to assess the aforementioned relationships by sex. We used CARTaGENE, a large population-based cohort of individuals aged 40-70 years from Quebec, Canada, who were assessed in 2009-2010. Incident fractures were identified via linkage with healthcare administrative databases over a 7-year period. Cox proportional hazard models adjusted for several potential confounders were used to estimate the relationships, with exposures treated as continuous variables. Results are reported as adjusted hazard ratios (aHRs) and 95% confidence intervals. We identified 19 357 individuals (mean ± standard deviation: age 54 ± 8 years, BMI 27 ± 5 kg/m2, WC 94 ± 14 cm; 51.6% women). During follow-up, 497 women and 323 men sustained a fracture. There was a linear relationship between fracture incidence and WC, while cubic splines best fitted the relationship for BMI. Greater WC was associated with an increased risk of fracture at the distal lower limbs in the whole cohort and in the subgroup of women: aHR for each 10 cm increased in WC of 1.12 (1.03, 1.21) and 1.12 (1.01, 1.24), respectively. In men, WC was not significantly associated with any fracture outcome. Higher BMI was also significantly associated with distal lower limb fracture risk in the whole cohort (p = 0.018). No significant relationships were found between either WC or BMI and the risk of any fracture, MOFs, and distal upper limb fractures. In middle-aged individuals, obesity, and mainly abdominal obesity, was associated with distal lower limb fracture risk. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Personalized Telehealth: Redesigning Complex Care Delivery for the 65+ During the COVID Pandemic: a Survey of Patients, Caregivers, and Health-care Providers.

Background: In the context of the ongoing COVID-19 pandemic, rapid transitions have been made towards telehealth. Optimal use of telehealth in elderly patients remains poorly understood and adaptation challenges persist. Our study aimed at identifying perceptions, barriers, and possible facilitators to telehealth use amongst elderly patients with comorbidities, their caregivers, and health-care providers (HCPs). Methods: Health-care providers, patients 65 years and older with multiple comorbidities, and caregivers were recruited from outpatient clinics and invited to complete an electronic self-administered or telephone-administered survey on their perceptions of telehealth and of barriers to its implementation. Results: A total of 39 health-care providers, 40 patients, and 22 caregivers responded to the survey. Most patients (90%), caregivers (82%), and HCPs (97%) had experienced telephone visits, but few were conducted via videoconference platforms. Patients and caregivers showed interest in pursuing some future telehealth visits (68%, 86%, respectively), but felt they lacked access to technology and skills (n=8, 20%), and some felt that telehealth visits may be inferior to in-person visits (n=9, 23%). HCPs showed interest in incorporating telehealth visits into practice (n=32, 82%), but identified challenges in lack of administrative support (n=37), lack of HCP (n=28) and patient (n=37) technological skills, and limited infrastructure (n=37)/internet access (n=33). Conclusions: Older patients, caregivers, and HCPs show interest in pursuing future telehealth visits but elucidate similar barriers. Facilitating access to technology, as well as to administrative and technology support guides, could promote high quality and equal access to virtual care for the older adult.

Performance of FRAX in Men With Prostate Cancer: A Registry-Based Cohort Study.

The Fracture Risk Assessment Tool (FRAX®) was created to predict major osteoporotic fractures (MOF) and hip fractures in the general population. Whether FRAX accurately predicts fractures in men with prostate cancer is unknown. Our objective was to assess the performance of FRAX for predicting incident fractures in men with prostate cancer. Men from the Manitoba Bone Mineral Density (BMD) Registry (1996-2018) with prostate cancer diagnoses in the 3 years prior to dual-energy X-ray absorptiometry (DXA) were identified. FRAX scores with and without BMD were calculated. From population-based healthcare data we identified incident MOF, hip fracture, any osteoporotic fracture and death from the date of BMD testing to March 31, 2018. Cox regression was performed to estimate hazard ratios (HRs) with 95% confidence intervals (95% CIs) per standard deviation increase in FRAX score. Observed 10-year probability (estimated with competing risk of mortality) was compared with 10-year FRAX-predicted fracture probability to assess calibration. The study population included 684 men with prostate cancer (mean age 74.6 years) and 8608 men without prostate cancer (mean age 65.5 years). FRAX stratified risk for MOF (HR 1.91, 95% CI 1.48-2.45 with BMD; HR 1.96, 95% CI 1.43-2.69 without BMD) and hip fracture (HR 3.37, 95% CI 1.90-6.01 with BMD; HR 4.58, 95% CI 2.17-9.67 without BMD) in men with prostate cancer. There was no effect modification observed with prostate cancer status or current androgen deprivation therapy. Observed 10-year fracture probability in men with prostate cancer showed good agreement with FRAX with and without BMD included in the calculation (observed/predicted calibration ratios MOF 0.97, hip 1.00 with BMD; MOF 0.92, hip 0.93 with BMD). In conclusion, FRAX reliably predicts incident fractures in men with prostate cancer. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).