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Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures

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Abstract

Summary

An international consensus process resulted in exercise and physical activity recommendations for individuals with osteoporosis. Emphasis was placed on strength, balance, and postural alignment. Rather than providing generic restrictions, activity should be encouraged while considering impairments, fracture risk, activity history, and preference, and guidance on spine sparing techniques should be provided.

Introduction

The objectives of this study were to establish expert consensus on key questions posed by patients or health care providers regarding recommended assessment domains to inform exercise prescription, therapeutic goals of exercise, and physical activity and exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture.

Methods

The Too Fit To Fracture expert panel identified researchers and clinicians with expertise in exercise and osteoporosis and stakeholder groups. We delivered a modified online Delphi survey (two rounds) to establish consensus on assessment, exercise, and physical activities for three cases with varying risk (osteoporosis based on bone mineral density; 1 spine fracture and osteoporosis; multiple spine fractures, osteoporosis, hyperkyphosis, and pain). Duplicate content analyses of free text responses were performed.

Results

Response rates were 52 % (39/75) and 69 % (48/70) for each round. Key consensus points are the following: (a) Current physical activity guidelines are appropriate for individuals with osteoporosis without spine fracture, but not for those with spine fracture; (b) after spine fracture, physical activity of moderate intensity is preferred to vigorous; (c) daily balance training and endurance training for spinal extensor muscles are recommended for all; (d) providing guidance on spine-sparing techniques (e.g., hip hinge) during activities of daily living or leisure, considering impairments, fracture risk, activity history, and preference, is recommended rather than providing generic restrictions (e.g., lifting <10 lbs, no twisting), but for those with vertebral fracture, especially in the presence of pain, multiple fractures, or hyperkyphosis, the risks of many activities may outweigh the benefits—physical therapist consultation is recommended. Examples of spine-sparing techniques and exercise prescription elements are provided.

Conclusions

Our recommendations guide health care providers on assessment, exercise prescription, and safe movement for individuals with osteoporosis.

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Notes

  1. According to FRAX and Canadian Association of Radiologists and Osteoporosis Canada criteria.

  2. Reader should consult clinical practice guidelines adopted by their country for recommended risk calculator. Example risk calculators available online include the FRAX risk calculator (http://www.shef.ac.uk/FRAX/), CAROC risk calculator (http://www.osteoporosis.ca/health-care-professionals/clinical-tools-and-resources/fracture-risk-tool/), Garvan Risk Calculator (http://garvan.org.au/promotions/bone-fracture-risk/calculator/)

  3. A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level (http://www.who.int/mediacentre/factsheets/fs344/en/).

  4. The consensus process did not extend to a consensus on the type of assessments to be used for falls or physical function, only the domains to be assessed. The AGS/BGS Guidelines include more detailed suggestions regarding assessment of fall risk and physical function for fall prevention. However, some domains that may inform exercise prescription (e.g., aerobic capacity, strength) may not be adequately represented in the AGS/BGS guidelines—http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations. The cut points that have been used to define slow gait speed as it pertains to predicting adverse health outcomes or mortality vary from <0.8 to <1.0 m/s [15, 16].

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Acknowledgments

This work was completed in partnership with Osteoporosis Canada: Contributions include participation from members of the Scientific Advisory Council and the Bone Fit Development Committee, input from the Canadian Osteoporosis Patient Network, and financial support. We would like to acknowledge financial support from the University of Waterloo. The International Osteoporosis Foundation was a participating stakeholder and provided feedback on the report. The recommendations were reviewed and endorsed by the National Osteoporosis Foundation. Dr. Harri Sievanen and Dr. Maarit Piirtola reviewed the report on behalf of the Finnish Osteoporosis Association, and also contributed at all stages of the consensus process. Osteoporosis Australia’s Medical and Scientific Advisory Committee reviewed the report at several stages and contributed to the final recommendations. We thank Dr. Andrew Briggs from Arthritis and Osteoporosis Victoria, Dr. Cathie Sherrington and Dr. Raymond Lee for their review of and feedback on the manuscript. We would like to thank Cheryl Kieswetter, Eric Bowman, and Michael McLeod for their assistance with the consensus process. Dr. Giangregorio is a recipient of a Canadian Institutes of Health Research (CIHR) New Investigator Award and an Early Researcher Award from the Ontario Ministry of Research and Innovation. Dr. Ashe has received career awards from CIHR and the Michael Smith Foundation for Health Research. Dr. Papaioannou is the Scientific Director for the Geriatric Education and Research in Aging Sciences (GERAS) Centre at St. Peter's Hospital. She is the CIHR and Eli Lilly Research Chair in Osteoporosis. Dr. Cheung is supported by a CIHR Senior Investigator Award. Dr. Papaioannou is a CIHR- Eli Lilly Canada Research Chair. We would like to acknowledge funding from the Hallman Undergraduate Research Fellowship.

Conflicts of interest

A. Papaioannou is or has been a consultant, or on a speaker’s bureau for, or received unrestricted grants from the following: Amgen, Eli Lilly, Merck Canada Inc., Novartis, Pfizer, Warner Chilcott. L. Giangregorio has received one grant from Merck Canada Inc. that is unrelated to the current work and has consulted for Eli Lilly. McGill S, Wark JD, Laprade J, Heinonen A, Ashe MC, MacIntyre NJ, Cheung AM, Shipp K, Keller H, and Jain R state that they have no conflicts of interest.

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Authors and Affiliations

  1. Department of Kinesiology, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada

    L. M. Giangregorio, S. McGill & H. Keller

  2. Toronto Rehabilitation Institute–University Health Network, Toronto, Canada

    L. M. Giangregorio

  3. Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Canada

    L. M. Giangregorio & H. Keller

  4. Royal Melbourne Hospital Department of Medicine, University of Melbourne, Parkville, Australia

    J. D. Wark

  5. Division of Anatomy, University of Toronto, Toronto, Canada

    J. Laprade

  6. Ontario Osteoporosis Strategy and Osteoporosis Canada, Ontario, Canada

    J. Laprade & R. Jain

  7. Department of Physiotherapy, Health Sciences, University of Jyvaskyla, Jyvaskyla, Finland

    A. Heinonen

  8. Department of Family Practice and Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada

    M. C. Ashe

  9. School of Rehabilitation Science, McMaster University, Hamilton, Canada

    N. J. MacIntyre

  10. Department of Medicine, University of Toronto, Toronto, Canada

    A. M. Cheung

  11. Department of Community and Family Medicine, Duke University, Durham, USA

    K. Shipp

  12. Department of Medicine, McMaster University and The Geriatric Education and Research in Aging Sciences (GERAS), Centre at St. Peter’s Hospital, Hamilton, Canada

    A. Papaioannou

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  1. L. M. Giangregorio
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  2. S. McGill
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  3. J. D. Wark
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  4. J. Laprade
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  5. A. Heinonen
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  6. M. C. Ashe
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  7. N. J. MacIntyre
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  8. A. M. Cheung
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  9. K. Shipp
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  10. H. Keller
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  11. R. Jain
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  12. A. Papaioannou
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Correspondence to L. M. Giangregorio.

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Giangregorio, L.M., McGill, S., Wark, J.D. et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int 26, 891–910 (2015). https://doi.org/10.1007/s00198-014-2881-4

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