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Can you increase the quality of life for women with Osteoporosis?

' The use of strength and balance training to reduce the risk of falls

The following Wiki Fact Sheet summary is on the article: Carter, N. D., Khan, K. M., Petit, M. A., Heinonen, A., Waterman, C., Donaldson, M. G., ... & McKay, H. A. (2001), ‘Results of a 10 week community based strength and balance training programme to reduce fall risk factors: a randomised controlled trial in 65–75 year old women with Osteoporosis’. British journal of sports medicine, 35(5), 348-351.

CONTENT
1. What is the background of this research?

1.1 Definition

1.2 Who osteoporosis affects

1.3 The risks for people with Osteoporosis

2. Where is the research from?
3. What kind of research was this?
4. What did the research involve?

4.1 Diagnosis

4.2 Randomisation into separate groups

4.3 Physical tests for baseline capabilities are taken

4.4 Ten week exercise intervention applied

4.5 Physical tests for comparison - post intervention

4.6 Data analysis

4.7 Results and interpretations

5. What were the basic results?
6. How did the researchers interpret the results?
7. What conclusions should be taken away from this research?

7.1 Limitations of this test

8. What are the implications of this research?
9. References

What is the Background of this research?

Definition
Osteoporosis is defined by the World Health Organisation as ‘a disease characterised by low bone mass and micro-architectural deterioration [bone growth being out-weighted by bone deterioration] of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk.’

Aims of the study
This study is looking at factors like; static and dynamic balance along with quadriceps strength as the testing variables ‘to test the efficacy of a community based 10 week exercise intervention to reduce fall risk factors in women with Osteoporosis’.

Who Osteoporosis affects
Unfortunately, women are more prone to this disease than men as bone deterioration tends to outweigh bone growth in women, especially after menopause. It is a worldwide problem that currently affects over 75 million people in Europe, Japan and the US alone.<ref?Carter, N. D., et al (2002) p.1.</ref> It is also affecting 1% of Australian women aged 40-44 and 87% of women aged 79 and over.

The risks for people with Osteoporosis: • Increased risk of fractures (particularly in their hip and femur) • Reduced daily functional abilities • Increased risk of falls (due to lack of balance)

Osteoporosis has been widely researched with evidence showing that factors like bone mineral density, muscle strength, and postural stability are risk factors for osteoporotic fractures. It has also been well supported that both balance and strength training can reduce the risk of fractures.

Where is this Research From?
This research was conducted in the British Colombian Women’s Hospital and Health Centre (BC Health Centre) and was conducted for the Osteoporosis Program and Faculty of Medicine of the same hospital. The research is in association with the University of British Colombia (UBC), Vancouver, Canada. The journal article was published in the British Journal of Sports Medicine and was conducted by N. D. Carter et al (of UBC).

What kind of research is this?
This study was a 10 week community based randomised controlled trial in the population: women with Osteoporosis aged 65-75. This kind of study is very commonly used in scientific research. However, there are staggering amounts of evidence indicating that it is not optimal unless there is total transparent reporting of the findings. Without transparent reporting it is difficult to interpret the reliability and validity of the study and it lends itself to bias or easily manipulable conclusions from the results.

Carter’s study has transparent reporting, noting that the retest reliability (the degree of certainty of obtaining the same results when repeating the test) on most of the tests they ran except the timed, Figure of Eight running test. This test was supposed to be testing for dynamic balance but as there is no stated retest reliability to question whether it is or not.

It is also due to the fact that the cones are two metres apart during this test and it is a repeated timed effort therefore, it is also testing aerobic capacity and not only dynamic balance. In this population group is detrimental because it will bring them to a fatigued state and risk potential injury.

What did the research involve?
The research involved a seven step process: 1. Diagnosis o Using dual energy x-ray absorptiometry (DEXA) to measure bone mineral density (BMD) at the hip and lumbar spine o A positive result from DEXA scoring at least 2.5 standard deviations (SD) below a young normal sex matched BMD of the lunar reference index (database for bone mineral density)

2. Randomisation into separate groups

• N = number of subjects

o Exercise group (n=45) o Control group (n=48) o Total= 93 subjects

3. Physical tests for baseline capabilities are taken

o Questionnaires are taken to assess general health

o Physical activity in last 7 days recall questionnaire

o Quadriceps Strength

• Dominant leg knee extension on Lords Strap assembly using a strain gauge to assess • 92% retest reliability

o Static balance

• Equitest computerised posturography testing the response to sensory disturbance • Composite balance indicator used as representation of static balance (compilation of different sways of the body on different axeses) • 98% retest reliability

o Dynamic balance

• Timed figure 8 test around 2 cones 10m apart • Best out of 2 trials are recorded
4. Ten week exercise intervention applied

o Twice a week

o Exercises to improve

• Balance and coordination • Functional status

o Exercises include

• Chair squats • Getting up and down from the floor

5. Physical tests for comparison - post intervention o Only 79 of the 93 subjects were available for final testing after the 10 week intervention o Control = 39 subjects o Exercise= 40 subjects

6. Data analysis o 95% confidence intervals (CI) o Unpaired t-tests used to compare baseline characteristics o Covariant analysis was used to analyse the percentage difference after intervention

7. Results and interpretations

What where the basic results?

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  Caption2

Control group reported fewer years of Oestrogen medication use (medication used to manage BMD) o Also reported higher levels of activity pre study Dynamic Balance o Exercise group: increased by 6.9% o Control group: increased by 5.0% Static balance o Exercise group: increased by 3.6% o Control group: increased by 1.3% Quadriceps strength o Exercise group: increased by 13.9% o Control group: decreased by 0.2%

There were no significant statistical differences found for any of the variables or between groups.

How did the researchers interpret the results?
According to the researchers the 10 week program was safe for women with Osteoporosis but did not show any improvements in static, or dynamic balance or quadriceps strength. However, it is worth noting that there was a 14% increase in quadriceps strength, which is of biological significance but not statistical. The researchers think that such short term interventions may be too insufficient of a duration to show any meaningful results. This does not reduce the efficacy of longer duration interventions. The researchers also recognise that the subjects of this study were particularly healthy for their age and made the effort to partake in this study and therefore may not be a clear representation of general populous with Osteoporosis.

'What conclusions should be taken away from this research?'
The conclusions that should be drawn from this study is the fact that the 10 week program developed by the BC Health Centre’s Osteoporosis program does not reduce the risk of falls and therefore the fracture risk associated. The aim of this program was to increase subject’s balance and strength, which in turn would result in increasing their quality in life as they age. The results of this study show no correlation to that affect.

What are the limitations/implications of this research?
There were some limitations of the study that may need to be taken into consideration, such as:
• Subjects recorded their involvement in the exercise program and reported that:

o It allows for reporter bias

o Given the age group there is the possibility/risk that they forgot to participate or forgot to record it

• Dynamic balance test

o Also there was no test for participants aerobic capacity, which in such an elderly population is bound to have an effect on the results

o Only test that there is, not a retest, reliability stated for it. So how reliable is the retesting of it?

• Their diagnosis criteria for Osteoporosis

o Only needs to be greater than 1 SD of sex matched BMD

They are choosing women with severe Osteoporosis and how much difference does that make to the results? There are not many implications that can be taken from this study, which is its biggest weakness. I do note however the following implications:

• The need for more research into this form of exercise intervention to confirm or rebut this study
• Potential for longer duration exercise interventions, to reduce risk factors associated with Osteoporosis

Citations

REFERENCES
Carter, N. D., Khan, K. M., Petit, M. A., Heinonen, A., Waterman, C., Donaldson, M. G., ... & McKay, H. A. (2001). Results of a 10 week community based strength and balance training programme to reduce fall risk factors: a randomised controlled trial in 65–75 year old women with Osteoporosis. British journal of sports medicine, 35(5), 348-351.

Heinonen, A., Kannus, P., Sievänen, H., Oja, P., Pasanen, M., Rinne, M., & Vuori, I. (1996). Randomised controlled trial of effect of high-impact exercise on selected risk factors for osteoporotic fractures. The Lancet, 348 (9038), 1343-1347.

Henderson, N. K., White, C. P., & Eisman, J. A. (1998). The roles of exercise and fall risk reduction in the prevention of Osteoporosis. Endocrinology and metabolism clinics of North America, 27(2), 369-387.

Henry, M. J., Pasco, J. A., Nicholson, G. C., Seeman, E., & Kotowicz, M. A. (2000). Prevalence of Osteoporosis in Australian Women: Geelong Osteoporosis study. Journal of clinical densitometry, 3(3), 261-268.

Kai, M. C., Anderson, M., & Lau, E. (2003). Exercise interventions: defusing the world's osteoporosis time bomb. Bulletin of the World Health Organization, 81(11), 827-830.

Kanis, J. A., McCloskey, E. V., Johansson, H., Oden, A., Melton, L. J., & Khaltaev, N. (2008). A reference standard for the description of Osteoporosis. Bone, 42(3), 467-475.

Madureira, M. M., Takayama, L., Gallinaro, A. L., Caparbo, V. F., Costa, R. A., & Pereira, R. M. (2007). Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with Osteoporosis: a randomised controlled trial. Osteoporosis International, 18(4), 419-425.

Moher, D., Hopewell, S., Schulz, K. F., Montori, V., Gøtzsche, P. C., Devereaux, P. J., ... & Altman, D. G. (2010). CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Journal of clinical epidemiology, 63(8), e1-e37.

Seeman, E., Cooper, M. E., Hopper, J. L., Parkinson, E., McKay, J., & Jerums, G. (1988). Effect of early menopause on bone mass in normal women and patients with Osteoporosis. The American journal of medicine, 85(2), 213-216.

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Heinonen, A., Kannus, P., Sievänen, H., Oja, P., Pasanen, M., Rinne, M., ... & Vuori, I. (1996). Randomised controlled trial of effect of high-impact exercise on selected risk factors for osteoporotic fractures. The Lancet, 348(9038), 1343-1347

Henderson, N. K., White, C. P., & Eisman, J. A. (1998). The roles of exercise and fall risk reduction in the prevention of Osteoporosis. Endocrinology and metabolism clinics of North America, 27

Madureira, M. M., Takayama, L., Gallinaro, A. L., Caparbo, V. F., Costa, R. A., & Pereira, R. M. (2007). Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with Osteoporosis: a randomised controlled trial. Osteoporosis International, 18(4), 419-425.