TRAUMATOLOGIA Y ORTOPEDIA

#High-Intensity Weight Training Is Safe and Effective in Osteoporosis

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High-Intensity Weight Training Is Safe and Effective in Osteoporosis
Nancy A Melville  October 04, 2017

Resultado de imagem para osteoporosis and exercise

A novel, twice-weekly, high-intensity resistance training scheme shows significant gains in bone-mineral density (BMD) and strength in postmenopausal women with low bone mass, without the safety issues that are of particular concern in that population.”Importantly, no fractures or major adverse events were observed, suggesting high-intensity resistance and impact training (HIRIT) may be safe for postmenopausal women with low to very low bone mass, despite previous safety concerns,” report Steven L Watson, of Griffith University, in Queensland, Australia, and colleagues in the Journal of Bone and Mineral Research.”The evidence from (this) trial…justifies a quantum change in attitude in this regard,” they add.Concerns about fracture risk associated with weight training in people with low BMD have resulted in osteoporosis exercise guidelines typically recommending only routines of moderate intensity. Not surprisingly, improvements in BMD in such exercise programs are typically lackluster.With some shorter studies showing encouraging improvements and safety with higher-intensity interventions, however, the researchers developed a novel, bone-targeted, HIRIT program with the specific aim of improving femoral neck and lumbar spine BMD in postmenopausal women with low to very low bone mass.With the widely held assumption that high-intensity resistance training represents a risk to people with low BMD, research in the area is scant, underscoring the importance of the new findings, senior author Belinda R Beck, PhD, director of the Bone Clinic, in Queensland, Australia, told Medscape Medical News.”What we have done is essentially ‘bitten the bullet’ to find out if the conventional assumption was correct by taking the risk of testing it under tightly controlled randomized controlled trial conditions, and it turns out the assumption was not correct,” said Dr Beck, who is also a professor with the Menzies Health Institute, Griffith University.An important caveat, she noted, is that supervision and administration of the program by trained personnel is key: “This is not a program to simply be handed to a person with osteoporosis and told to go to a gym.”
“This is why we established the Bone Clinic, where we have translated the research findings into practice and continue to conduct research.”LIFTMOR: HIRIT Shows Improvement in Bone Mass and Muscle Strength
In the Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation (LIFTMOR) trial, 101 postmenopausal women with a mean age of 65 and low bone mass (T-score < -1.0) were enrolled.The women were randomized to either 8 months of the intervention (n = 49), consisting of twice-weekly, 30-minute supervised HIRIT or a control group receiving a home-based low-intensity program (n = 52).The HIRIT intervention was initiated gradually in small groups with a maximum of eight participants, with the first month consisting of body weight and low-load exercise variants and a focus on progressive learning.

For the remainder of the study, the exercise sessions involved five sets of five repetitions, including resistance exercises of dead lift, overhead press, and back squat, maintaining an intensity of greater than 80% to 85% of one repetition maximum. Impact-loading exercises included jumping chin-ups with drop landings.
After the 8-month program, women in the intervention groups showed significantly greater improvements in key bone measures than the control group, including changes in lumbar spine BMD (+2.9% vs –1.2%, P < .001), femoral neck BMD (+0.3% vs –1.9%, P = .004), and femoral neck cortical thickness (+13.6% vs +6.3%, P = .014).
The intervention group also showed greater improvements in height (+0.2 cm vs –0.2 cm, P = .004), and all functional performance measures (P < .001).
There was only one adverse event reported — a minor lower-back spasm in the HIRIT group. Compliance was meanwhile high in both groups, with dropout rates of 12% in the HIRIT group and 17% for the control group.
While the intervention arm was not sufficiently powered to examine the important issue of falls, improvements were nevertheless seen in measures associated in other studies with a reduction of the risk of falling, such as muscle strength and functional and neuromuscular performance, the authors note.

“Improvements in those functional performance scores therefore suggest HIRIT may not only reduce the risk of fracture by enhancing parameters of bone strength but by preventing falls in postmenopausal women with low bone mass,” they stress.
They add that the study’s design, as well as findings, are new.
“To our knowledge, there has been no trial of adequate size and/or duration to determine the efficacy of high-intensity loading to improve bone mass in postmenopausal women with low to very low bone mass; thus, our findings are novel.
“Our observed improvements in BMD surpass previous reports from reputable exercise interventions, an observation that could be considered intuitive in light of the well-known positive relationship between load magnitude and bone adaptation.”
Key to Safety Is Gradual Introduction of Exercises, Rest Days

Key to safety and efficacy of the program is the gradual introduction of the exercises, including the need for rest days between sessions, stressed Dr Beck.
“Heavy lifting requires significant recovery, so I would always recommend at least 1 day of rest between trainings,” she said, adding, “The people with poorest bones respond the most but will probably require the most rest days to begin with.”
Comparing the twice-weekly HIRIT program with most exercise advice for osteoporosis — which generally recommends activities on a 5-day-per-week basis — Dr Beck noted the latter “are more focused on falls prevention and employ a more conservative program, which will not notably improve bone mass.
Meanwhile, some of the HIRIT program improvements in bone mass in fact exceeded expectations.
“To be honest, I was surprised we would build so much bone at the spine — with some increases as much as 12%, because previous exercise interventions have not been very effective, but our high-intensity approach was key,” Dr Beck said.
In contrast, changes in hip BMD were unexpectedly not as impressive as the spine.
“Given the type of loading we were doing, we would have thought the hip would respond more markedly,” she said. “We are currently doing some biomechanical analyses to examine exactly the nature of the loads experienced at the femoral neck to try to understand the BMD response.”
Of note, 3D analyses of the proximal femur suggested the cortex of the femoral neck thickened in the absence of BMD gains, which is highly significant in terms of improving strength, Dr Beck observed.
“It is possible that bone geometry of the femoral neck changes in an advantageous way in response to our program, rather than BMD.”
The improvements seen in height were also unexpected.
“That was certainly a pleasant surprise, partly because many naysayers of heavy lifting for osteoporosis think it will cause compression fractures in the spine; however, there was absolutely no evidence of that in our trial,” she noted.
She acknowledged that the HIRIT program’s need for training and supervision is perhaps its most notable limitation, but the findings indicate that the effort is worthwhile.
“The reality is, if you want to grow bone, this is the form of exercise you need to do. Doing a more conservative form of exercise so you can roll it out for unsupervised exercise training might be great for the heart, but it will not improve bone.”

The authors have no relevant financial relationships.
J Bone Miner Res. Published October 4, 2017. Abstract

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#La #hipertensión de la madre durante la #gestación se asocia a un mayor #riesgo de obesidad infantil de su futuro hijo (J Clin Endocrinol Metab)

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Un nuevo estudio subraya la necesidad de que todas las embarazadas tengan controladas sus cifras tensionales.

Un nuevo estudio subraya la necesidad de que todas las embarazadas tengan controladas sus cifras tensionales.

La hipertensión arterial de la madre durante el embarazo se asocia a un mayor riesgo de obesidad infantil de su futuro hijo, según un estudio publicado en ‘Journal of Clinical Endocrinology & Metabolism’.
El estudio, según investigadores de la Universidad de Qingdao, en China, y de la Universidad de Cambridge, en Reino Unido, es el primero en demostrar que en mujeres embarazadas la hipertensión se relaciona con un mayor riesgo de sobrepeso y obesidad para sus hijos, según el primer firmante del estudio, Ju-Sheng Zheng.
El estudio prospectivo de cohortes examinó las cifras de presión arterial y el peso en 88.406 parejas madre-hijo que participaron en la Cohorte de Nacimiento Jiaxing en el sureste de China entre 1999 y 2013. Los investigadores midieron las cifras tensionales de las mujeres en los tres trimestres del embarazo y, durante las visitas de seguimiento, se pesó a los hijos entre 4 y 7 años de edad.
Para las mujeres que eran hipertensas durante el segundo trimestre, sus hijos presentan 49% más probabilidades de ser clasificados como sobrepeso u obesidad en comparación con los hijos de madres que tenían niveles más bajos de presión arterial. Los niños de mujeres con hipertensión arterial durante el tercer trimestre fueron tuvieron 14% más probabilidades de cumplir con los criterios de sobrepeso u obesidad. El tamaño corporal de la madre antes del embarazo no afectó a la relación.
“Los resultados indican que todas las mujeres embarazadas y sus médicos deben controlar y tratar de limitar un aumento sustancial de la presión arterial en el embarazo entre mediados y finales de la gestación -apunta Zheng-. Esto puede ayudar a reducir la probabilidad de que sus hijos resulten afectados por la obesidad”.

#FDA Expands Indication for Exoskeleton in Paraplegia

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FDA Expands Indication for Exoskeleton in Paraplegia
Megan Brooks September 27, 2017

The US Food and Drug Administration (FDA) has cleared an expanded indication for the Indego exoskeleton (Parker Hannifin), a device that allows individuals with paraplegia to stand and walk, the company has announced.The Indego exoskeleton was previously cleared by the FDA in February 2016 for use by individuals with spinal cord injury levels of T4 and lower in rehabilitation facilities, and with T7 and lower injury levels for use in home and community settings

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Indego exoskeleton

 
The new indication expands the population that can use the device to include patients with spinal cord injury at C7 and lower injury levels in rehabilitation facilities and T3 and lower injury levels for use in home and community settings.”The new clearance by the FDA provides the Indego exoskeleton with the broadest IFU [indication for use] of any commercial exoskeleton available in the United States,” Achilleas Dorotheou, head of the human motion and control business unit for Parker Hannifin, said in a news release.”Indego is now available to a significantly larger segment of the spinal cord injury population and is an option for personal use among more than 40% of spinal cord injured Americans. We credit several VA [Veterans Affairs] medical directors with urging us to pursue this expanded clearance and it is likely that some of the 40,000 spinal cord injured veterans served by the VA system will be among the immediate beneficiaries,” Dorotheou added.The company also said it’s working on new powered and programmable variants of Indego to be submitted for regulatory approval over the next several years that will address other partial or moderate impairments, such as multiple sclerosis, stroke, and musculoskeletal weakness.

Medscape Neurology news.

#Vertebral Fractures Frequently Underreported by #Radiologists

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Pam Harrison

Vertebral fragility fractures (VFFs) are largely underreported by radiologists, especially those who do not specialize in musculoskeletal imaging, thus missing an opportunity to offer treatment to patients with osteoporosis to prevent further fracture, a single center study in the United Kingdom suggests.

“Patients with osteoporosis vertebral fragility fractures are at increased risk of future fractures, including hip fractures,” lead author Ruth Mitchell, MD, Merton College, University of Oxford, and colleagues observe in their paper, published online recently in the Archives of Osteoporosis.

“Our data demonstrate that VFFs are significantly underreported by radiologists, particularly by nonmusculoskeletal radiologists, [and] vigilance for vertebral fractures should be increased in a population such as this [one], where the mean age [was] over 80 and therefore a high incidence of vertebral fractures should be anticipated,” they add.

Fewer Than Half of VFFs Were Logged at Time of Scan

Using data from the UK local Fracture Liaison Service, the researchers identified 157 evaluable patients who presented to the Oxford University Hospital NHS Trust in Oxford in 2013 with a hip fracture.

All had undergone some form of imaging of the spine in the preceding 5 years, including a CT scan, MRI, or plain film in which at least five thoracic or lumbar vertebrae were visible.

Almost two-thirds of the group were female, and the mean age at the time participants sustained their hip fracture was 82.5 years.

“Of the 157 individuals who had spinal imaging prior to their hip fracture…41% had detectable VFFs. Of these detectable VFFs, fewer than half, at 46%, were reported as ‘fractured’ by the radiologist at the time the image was taken,” the researchers note.

However, satisfactory reporting at the time the image was taken varied substantially, depending on the type of radiology practiced, with 89% of musculoskeletal radiologists reporting the presence of a VFF on first imaging, compared with only 14% of nonmusculoskeletal radiologists.

Similarly, only 7% of grade 1 fractures — the least severe type of fracture — were reported on imaging compared with 68% of grade 2 fractures and 75% of grade 3 fractures; the latter is the most severe grade of fractures.

And “of those patients with a previously detectable VFF, only…25% were documented taking bone-specific therapy at the time of hip fracture,” Dr Mitchell and colleagues note.

However, the database would not allow the researchers to determine whether treatment had been initiated because a vertebral fracture had been identified.

Lack of Awareness to Specifically Look for Fractures

Asked by Medscape Medical News to comment further, Dr Mitchell noted that most of the fractures that were successfully identified were reported by musculoskeletal radiologists reviewing imaging where the primary focus was the spine.

“Fewer fractures were picked up on imaging performed for other indications — for example, CT scans of the abdomen or pelvis,” she noted in an email, “so it is probably not the detection of fractures that presents a challenge to the radiologist, but lack of awareness of the need to specifically look for them,” she suggested.

This may be especially true when it comes to less severe fractures, which are often overlooked, she observed.

“We don’t know how the levels of vertebral fracture reporting in our trust compared with other areas; however, this is not the first study to highlight underreporting [of VFFs],” Dr Mitchell said.

“But by reporting vertebral fractures, radiologists can help identify patients with osteoporosis who are at increased risk of hip fracture, and then the patient’s general practitioner or local fracture prevention service can be alerted to this risk and offer follow-up investigations and osteoporosis treatment,” she observed.

The International Osteoporosis Foundation has already recognized that the prevalence of vertebral fractures is underreported and has initiated a Vertebral Fracture Initiative to raise awareness among radiologists about the risk of vertebral fractures in the elderly and how to more effectively prevent further fractures through more thorough reporting.

Undiagnosed Vertebral Fractures Equate With Back Pain

In an unrelated investigation, US researchers evaluated the impact that clinically undiagnosed, incident radiographic vertebral fracture (VF) had on quality of life, including symptoms of back pain and associated limitations in usual activities, in older men enrolled in the Osteoporotic Fractures in Men (MrOS) study.

The data were published online September 7, 2017 in the Journal of Bone and Mineral Research.

Some 4396 men underwent spinal X-ray and filled out a symptom questionnaire at baseline and again at a second follow-up visit, at approximately 4.6 years later.

During the study interval, 3.8% of the cohort experienced a radiographic-only vertebral fracture while 0.6% had a documented radiographic plus clinical vertebral fracture.

Perhaps not surprisingly, “men with incident radiographic plus clinical VF were most likely to have back-pain symptoms and associated activity limitation at follow-up,” lead author, Howard Fink, MD, MPH, Veterans Affairs Health Center, Minneapolis, Minnesota, and colleagues report.

Men with an incident radiographic plus clinical vertebral fracture were also significantly more likely to report any back pain or severe back pain, to be bothered most of the time by back pain, and to have limitations in their usual daily activities because of back pain, compared with men with no incident vertebral fracture.

MROS Quality-of-Life Indices at Follow-up

Index Incident radiographic plus clinical VF (%) No incident VF (%)
Any back pain 93 59
Severe back pain 18 4
Bothered most or all the time by back pain 50 13
Limited usual daily activities because of back pain 64 18

“In this cohort of community-dwelling older men, those with clinically undiagnosed incident radiographic VFs were significantly more likely to have back-pain symptoms and activity limitations due to back pain at follow-up than were men without incident VF,” Dr Fink and colleagues observe.

Dr Mitchell and coauthors had no relevant financial relationships. Dr Fink had no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

Arch Osteoporos. Published online August 7, 2017. Article

J Bone Miner Res. Published online September 7, 2017. Abstract

 

#Older people with #diabetes at higher #risk for fracture

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A new study suggests deficits in cortical bone density and microarchitecture may be responsible.
While older people with type 2 diabetes (T2D) tend to have normal or higher bone density than their peers, a new study has found that they are more likely to succumb to fractures than seniors without T2D.
In a study, published in the Journal of Bone and Mineral Research , scientists examined data on 1,069 community-based older adults from the Framingham study. Participants underwent high-resolution peripheral quantitative computed tomography (HR-pQCT) to evaluate volumetric bone density, microarchitecture, and geometry, separately for cortical and trabecular compartments.
The authors found seniors with T2D had lower cortical volumetric BMD (vBMD) at the tibia and cortical thickness at the radius, but only in those with prior fracture. Cortical porosity at the radius was higher in T2D than non-T2D, but only in those without prior fracture.
“Fracture in older adults with type 2 diabetes is a highly important public health problem and will only increase with the aging of the population and growing epidemic of diabetes. Our findings identify skeletal deficits that may contribute to excess fracture risk in older adults with diabetes and may ultimately lead to new approaches to improve prevention and treatment,” said Dr Elizabeth Samelson, lead author of the study.

#Médicos recomiendan introducir los #soportes electrónicos en la #escuela para reducir el #dolor de espalda en los #niños

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El 51% de los chicos y el 69% de las chicas padecen dolencias de la espalda antes de cumplir los 15 años.

La Organización Médica Colegial (OMC) y la Red Española de Investigaciones en Dolencias de la Espalda (REIDE) recomiendan introducir los soportes electrónicos en la escuela como medida para reducir el dolor de espalda entre escolares, un problema que afecta ya a casi el 60% de los menores de 15 años.
Lo cierto es que estos años se han tomado medidas para reducir el peso que el escolar transporta – y que no debe superar el 10% de su peso corporal- como instalar taquillas o editar los libros en fascículos trimestrales. Sin embargo, la realidad es que “en un simple teléfono ya podemos guardar casi todo”, ha señalado el presidente de la OMC, Serafín Romero, para quien “no tiene sentido que a nuestros pequeños se les siga cargando”.
Apoyando esta iniciativa el director de REIDE, el Dr. Francisco Kovacs, se ha preguntado “qué sentido tiene cargar con kilos de carga escolar a unos niños que a lo largo de su vida muy probablemente nunca van a trabajar en papel sino en soporte electrónico”, y como ejemplo destacaba a la Administración que, adaptándose a las nuevas tecnologías, en cuestión de años, ha pasado de presentar los Presupuestos Generales del Estado en furgonetas a usar USBs y códigos bidi.
En estos términos se referían en la rueda de prensa para presentar decimoquinta edición de la campaña de Prevención de las Dolencias de la Espalda, donde han presentado la aplicación ‘El Tebeo de la Espalda’, que acompaña al tebeo que editan todos los años, donde enseña a los niños cómo cuidar su espalda desde los primeros años de vida escolar, y les permite adquirir conocimientos y hábitos que han demostrado ser útiles toda la vida.
Este tebeo, que se puede descargar en la página ‘web’ de la organización colegial y de REIDE, también se ha adaptado a los nuevos tiempos. Este tebeo muestra este cambio, destaca Romero, quien señala que “hace 15 años no se hubiese apostado por la tecnología como medida para reducir las dolencias vertebrales”.
Esta nueva ‘App’ es multiplataforma (Android e iOS) e incluye escenas de realidad aumentada para acceder a contenidos adicionales a la edición impresa del ‘Tebeo de la Espalda’. También cuenta con varios juegos donde los niños podrán realizar un puzle, ejercicios de memorización, colorear y un videojuego que consiste en que el personaje realice una ‘carrera sana’ saltando obstáculos.
Entre las recomendaciones recogidas en el ‘Tebeo de la Espalda’ para mantener una musculatura fuerte y sana destaca no reposar en cama cuando se padece dolor de espalda, ya que se prolonga la dolencia y su posible reparación en el futuro.
También, se recomienda hacer deporte continuado desde edades tempranas porque se aumenta la resistencia de la columna vertebral ante las cargas excesivas. Además, “adquirir esos hábitos desde la niñez es la mejor manera de mantenerlos durante la vida adulta, y resulta beneficioso para la salud cardiovascular y general, además de para la espalda”, ha añadido Romero.
Los expertos aconsejan utilizar mochilas con ruedas pero, en el caso de que esto no sea posible, lo correcto sería en el eje de la columna, colgada de ambos hombros, a la altura de la “zona dorsolumbar, ya que su eje de equilibrio se encuentra ahí”, ha declarado Kovacs.
En esta misma línea, se debería reducir el peso del material escolar, de forma que este no supere el 10% del peso corporal del niño, en concreto “un niño que pese 40 kilos no debe cargar más de 4”, según el médico, que ha alertado de que aunque la realidad demuestra que en algunos ámbitos suele superar el 30% del peso.
Por último, el mobiliario escolar se debe adaptar a la edad y altura de los escolares, lo óptimo sería que contasen con sillas que permitieran adecuar su altura. Además, se recomienda evitar mantener la misma postura durante horas, cambiando la postura frecuentemente y levantándose cada 45-60 minutos.
Realizar ejercicio físico es clave para reducir el dolor de espalda “ya que se refuerza la musculatura”, según el presidente de REIDE. Se estima que el 12,1% de los adolescentes de 14 años no realiza ningún tipo de ejercicio, según datos del informe anual del Sistema Nacional de Salud de 2016
Este dolor afecta a los adolescentes entre 13 y 15 años, siendo más frecuente en las chicas (69%) que en los chicos (51%), repercutiendo posteriormente en la edad adulta.
Por ello, los expertos aconsejan realizar ejercicio hasta incluso cuando se esté padeciendo el dolor, ya que los diferentes deportes resultan beneficios para el desarrollo, “es un hábito que si se adquiere desde niños se puede reducir las consecuencias en edades adultas”, ha señalado Kovacs.
En el caso de deportistas de alto rendimiento, el cual se asocia con dolencias de espalda, se recomienda hacer “ejercicios adaptados que fortalezcan la musculatura” y seguir los consejos de los entrenadores, fisioterapeutas y médicos deportivos.

#Undiagnosed #vertebral fractures common cause of #pain in #older men

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Fewer than a quarter of new vertebral fractures are clinically diagnosed, yet they often cause symptoms.
There are calls for increased efforts to prevent vertebral fractures (VF) in older men, and in doing so attempt to reduce back pain and related disability in this population.
The call is made by the authors of a new study, published in the Journal of Bone and Mineral Research, which found incident, clinically undiagnosed radiographic VF were associated with a significantly increased likelihood of back pain symptoms and associated activity limitation in a large cohort of older men.
In the study of 4,396 men, approximately one in five patients with incident radiographic-only VF had new or worse back pain in excess of what was observed in men without incident VF. The authors said the findings suggest that incident radiographic-only VFs are clinically important patient outcomes.
Preventing these fractures may reduce back pain and related disability in older men. Randomised trials to prevent such fractures will provide the strongest evidence about the effect of interventions on back pain and related disability in older adults,” the authors write.
The results are consistent with results previously reported in older community-dwelling women.