Risk Assessment and Interventions for Individuals At Risk of Osteoporotic Fractures

Older adults, especially with low bone mass, hyperkyphosis or vertebral fractures (OVF), and individual with spinal cord injury (SCI) are at increased risk of fragility fractures. Individuals with SCI and OVFs are subgroups of people with osteoporosis that are at high risk of fractures and present unique impairments, limitations, and restrictions that require population-specific and individually tailored and interventions.

The objectives of this thesis were: 1) to explore potential sources of error during LS bone densitometry and trabecular bone score (TBS) values in individuals with SCI, and the applicability of TBS in fracture risk assessment; 2) to assess the effects of PRT on health-related outcomes in people with low bone mass or hyperkyphosis; 3) to establish recommendations for the non-pharmacological management of osteoporotic vertebral fractures; 4) to co-develop a virtually delivered education and training program on safe movement, pain management, nutrition, and exercise among people with osteoporotic vertebral fractures, and to test its acceptability and usability.

Chapter one consists of a review of the literature on the epidemiology of fragility fractures, their consequences in the populations at greater risk, and the knowledge gaps in terms of risk assessment and non-pharmacological management. Chapter two presents the findings from two observational studies. Study 1 explored potential sources of error during LS densitometry in people with chronic SCI. Facet sclerosis and osteophytes and challenges in detecting bone edges are the most common sources of error, and most of the scans presented vertebrae with outlier BMD values. Study 2 described lumbar spine TBS values in a cohort of people with chronic SCI, whether they change over a two-year period, and how TBS affects fracture risk assessment in people with SCI. Individuals with chronic SCI on this cohort presented with normal bone microarchitecture based on TBS. TBS was not different between sexes, people with motor complete and motor incomplete injury or with and without previous fragility fracture. Clinical decisions regarding fracture prevention should not be based on TBS or FRAX® in people with chronic SCI at this time. The third chapter reports the protocols of two systematic reviews. One systematic review investigated the effects of PRT interventions on health-related outcomes in people with low bone mass, while the second investigated the effects of exercise interventions on improving postural and health-related outcomes in people with hyperkyphosis. The fourth chapter reports the outcomes of an International Modified Delphi Consensus process, which established recommendations on the non-pharmacological management of osteoporotic vertebral fractures. We generated recommendations on pain management (e.g., educate on pain expectation; assess pain-related psychological factors; limit prolonged sitting; lying supine with feet flat on surface and knees bent), nutrition (e.g., educating on recommended daily intake of protein, calcium, and vitamin D; refer to dietitian in presence of poor appetite or weight loss), safe movement (e.g., avoid heavy physical exertion, lifting, or activities that exacerbate pain for the first 12 weeks; bend at hip and knees; step to turn; hold objects close to body), and exercise (e.g., timing, intensity, example exercises, goals including improving back extensor endurance, spinal mobility, physical functioning, and balance). There was consensus on limiting bed rest, and on prescribing orthoses only to select patients. The fifth chapter presents the co-development of a virtual intervention for the non-pharmacological management of OVF (VIVA) and its acceptability and usability testing among people with OVF. VIVA has been co-developed to provide education and training on safe movement and pain management techniques, nutrition, and exercise, and involves seven 1-on-1 virtual sessions delivered by a physiotherapist over five weeks. We delivered VIVA to 8 individuals with vertebral fractures, to evaluate acceptability and usability. Participants perceived improvements in pain and felt more confident during the activities of daily living and in selfmanaging their OVF. All the participants believed that VIVA was very useful and were very satisfied with the 1-on-1 sessions. Three participants found the information received very easy to practice, four participants believed they were easy to practice, and one participant found them somewhat difficult. Four participants were very satisfied and four were satisfied with the supporting resources delivered throughout the program. Participants found accessing the resources easy, but think that logging in and out to access videos and resources, or to track adherence, was cumbersome. Chapter six provides a general discussion of how the present dissertation improved the knowledge in fracture risk assessment and non-pharmacological interventions in people at risk of fractures, and what the next steps to address the knowledge-to-action gaps in populations at high risk of fracture should be.

Year	Entry
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Year

Entry

2007

Center JR, Bliuc D, Nguyen TV, Eisman JA. Risk of subsequent fracture after low-trauma fracture in men and women. JAMA. January 24, 2007;297(4):387-394.

1992

Riggs BL, Melton LJ III. The prevention and treatment of osteoporosis. NEJM. August 27, 1992;327(9):620-627.

1999

Kreiger N, Tenenhouse A, Joseph L, Mackenzie T, Poliquin S, Brown JP, Prior JC, Rittmaster RS. The Canadian Multicentre Osteoporosis study (CaMos): background, rationale, methods. Can J Aging. 1999;18(3):376-387.

2006

Bousson V, Bras AL, Roqueplan F, Kang Y, Mitton D, Kolta S, Bergot C, Skalli W, Vicaut E, Kalender W, Engelke K, Laredo J-D. Volumetric quantitative computed tomography of the proximal femur: relationships linking geometric and densitometric variables to bone strength. role for compact bone. Osteoporos Int. June 2006;17(6):855-864.

2020

Morin SN, Djekic-Ivankovic M, Funnell L, Giangregorio L, Rodrigues IB, Ridout R, Feldman S, Kim S, McDonald-Blumer H, Kline G, Ward WE, Santesso N, Leslie WD. Patient engagement in clinical guidelines development: input from > 1000 members of the Canadian Osteoporosis Patient Network. Osteoporos Int. May 2020;31(5):867-874.