Exercise for people with osteoporosis: translating the science into clinical practice.

The "holy grail" of inquiry regarding exercise and osteoporosis has been identifying a type of exercise that builds bone. Investigation using animal models has provided many insights into how bone responds to mechanical loading, but translating these findings into an exercise prescription for patients with osteoporosis is difficult. Patients expect bone to respond to exercise in a linear fashion, such as they are accustomed to experiencing with muscles in response to progressive strength training or with the cardiopulmonary system in response to endurance training. If the skeleton accrued greater mass in response to increasing intensity and duration of mechanical strain, our bones would weigh so much that we could not move. A unique requirement of bone is that adaptations to loading produce the strongest and the lightest structure. More exercise is not always better, but we are not yet sure exactly what and how much is enough and what and how much is too much. This complexity stymies clear communication, both in the clinic and in public health initiatives.

A clinical trial of a rehabilitation expert clinician versus usual care for providing manual wheelchairs.

OBJECTIVES: To determine the effect of differing methods of dispensing wheelchairs. DESIGN: Quasi-experimental by day of week. SETTING: Department of Veterans Affairs Medical Center. PARTICIPANTS: Eighty-four community-dwelling, cognitively intact patients prescribed a standard manual wheelchair. INTERVENTION: A multifactorial intervention consisting of an expert physical/occupational therapist who used a scripted evaluation that included an evaluation based on medical record review and self-reported and physical performance measures; individualization of the wheelchair and initiation of orders for additional occupational/physical therapy, equipment, or home modifications as needed; multimodal patient education; and telephone follow-up at 3 and 6 weeks. MEASUREMENTS: The primary outcome was amount of wheelchair use. Secondary outcomes were shoulder pain, wheelchair comfort and confidence, and home modifications. RESULTS: The intervention group had significantly greater wheelchair use than usual care at 2 weeks, 3 months, and 6 months (P=.01). Wheelchair use declined monotonically over time for the entire study sample (P<.001). There were no significant differences between the two groups in shoulder pain, wheelchair comfort or confidence, or home modifications. CONCLUSION: New wheelchair owners used the wheelchair more often if they received it from an expert therapist using a multifactorial intervention.

Group treatment improves trunk strength and psychological status in older women with vertebral fractures: results of a randomized, clinical trial.

OBJECTIVES: To assess whether group exercise and coping classes reduce physical and psychological impairments and functional disability in older women with prevalent vertebral fractures (VFs). DESIGN: Randomized, controlled trial (modified cross-over) with site as unit of assignment; testing at baseline and 3, 6, 9, and 12 months. SETTING: Nine North Carolina retirement communities. PARTICIPANTS: One hundred eighty-five postmenopausal Caucasian women (mean age 81), each with at least one VFs. INTERVENTION: The intervention group had 6 months of exercise (3 meetings weekly, 45 minutes each) and coping classes (2 meetings weekly, 45 minutes each) in Phase 1, followed by 6 months of self-maintenance. The control group had 6 months of health education control intervention (1 meeting weekly, 45 minutes) in Phase 1, followed by the intervention described above. MEASUREMENTS: Change in trunk extension strength, change in pain with activities, and change in psychological symptoms. RESULTS: Between-group differences in the change in trunk extension strength (10.68 foot pounds, P<.001) and psychological symptoms (-0.08, P=.011) were significant for Phase 1. Changes in pain with activities did not differ between groups (-0.03, P=.64); there was no change in the pain endpoint. In Phase 2, controls showed significant changes in trunk strength (15.02 foot pounds, P<.001) and psychological symptoms (-0.11, P=.006) from baseline. Change in pain with activities was not significant (-0.03, P=.70). During self-maintenance, the intervention group did not worsen in psychological symptoms, but improved trunk extension strength was not maintained. CONCLUSION: Weak trunk extension strength and psychological symptoms associated with VFs can be improved in older women using group treatment, and psychological improvements are retained for at least 6 months.

Activity restriction among wheelchair users.

OBJECTIVES: To identify factors associated with activity restriction. DESIGN: Cohort study. SETTING: Patients prescribed a new wheelchair at one of two teaching hospitals (one Veterans Affairs and one private hospital). PARTICIPANTS: One hundred fifty-three consecutive, community-dwelling wheelchair users, who had a Short Portable Mental Status Score greater than 6 out of 10 and could be interviewed within 7 to 21 days of receiving the wheelchair. MEASUREMENTS: Dependent variables were self-reported nonmedical visits and medical visits in the preceding week (any vs no visits and the number of visits). Independent variables were self-reported sociodemographic and health characteristics, mobility limitations, and environmental barriers. RESULTS: Study subjects reported, on average, 1.79 mobility limitations, 11.17 hours out of bed, and 5.56 hours of personal assistance per day. Multivariate analyses show that higher income was the only significant sociodemographic factor; it was associated with more medical visits (beta=0.44, P<.01). Of health status characteristics, more comorbid conditions predicted fewer nonmedical visits (beta=-0.14, P<.10) and amputation was associated with fewer medical visits (beta-0.82, P<.05). Regarding mobility limitations, more mobility limitations was associated with lower odds of any nonmedical visit (odds ratio (OR)=0.71, P<.5) and fewer nonmedical visits (beta=-0.28, P<.05); more hours out of bed predicted more nonmedical visits (beta=0.05, P<.5) and lower odds any medical visit (OR=0.92, P<.05). More environmental barriers predicted fewer nonmedical (beta=-0.32, P<.01) or medical visits (beta=-0.21, P<.05). CONCLUSION: Mobility limitations and environmental barriers were associated with restricted participation in diverse activities outside the home.