Elisabeth Preisinger

Ultrasound Therapy for Calcific Tendinitis of the Shoulder

BACKGROUND AND METHODS Although ultrasound therapy is used to treat calcific tendinitis of the shoulder, its efficacy has not been rigorously evaluated. We conducted a randomized, double-blind comparison of ultrasonography and sham insonation in patients with symptomatic calcific tendinitis verified by radiography. Patients were assigned to receive 24 15-minute sessions of either pulsed ultrasound (frequency, 0.89 MHz; intensity, 2.5 W per square centimeter; pulsed mode, 1:4) or an indistinguishable sham treatment to the area over the calcification. The first 15 treatments were given daily (five times per week), and the remainder were given three times a week for three weeks. Randomization was conducted according to shoulders rather than patients, so a patient with bilateral tendinitis might receive either or both therapies. RESULTS We enrolled 63 consecutive patients (70 shoulders). Fifty-four patients (61 shoulders) completed the study. There were 32 shoulders in the ultrasound-treatment group and 29 in the sham-treatment group. After six weeks of treatment, calcium deposits had resolved in six shoulders (19 percent) in the ultrasound-treatment group and decreased by at least 50 percent in nine shoulders (28 percent), as compared with respective values of zero and three (10 percent) in the sham-treatment group (P=0.003). At the nine-month follow-up visit, calcium deposits had resolved in 13 shoulders (42 percent) in the ultrasound-treatment group and improved in 7 shoulders (23 percent), as compared with respective values of 2 (8 percent) and 3 (12 percent) in the sham-treatment group (P=0.002). At the end of treatment, patients who had received ultrasound treatment had greater decreases in pain and greater improvements in the quality of life than those who had received sham treatment; at nine months, the differences between the groups were no longer significant. CONCLUSIONS In patients with symptomatic calcific tendinitis of the shoulder, ultrasound treatment helps resolve calcifications and is associated with short-term clinical improvement.

Systematic strength training as a model of therapeutic intervention. A controlled trial in postmenopausal women with osteopenia.

Physical exercise is often recommended as a therapeutic tool to combat pre- and postmenopausal loss of bone density. However, the relationship between training dosage (intensity, duration, frequency) and the effect on bone density still is undergoing discussion. Furthermore, the exercise quantification programs are often described so inadequately that they are neither quantitatively nor qualitatively reproducible. The aim of this investigation was to determine whether a clearly defined training of muscle strength, under defined safety aspects, performed only twice weekly, can counteract bone density loss in women with postmenopausal osteopenia. Data from 16 women in the training group (age, 63.6 +/- 6.2 yr) and 15 women in the control group (age, 67.4 +/-9.7 yr), of comparable height and weight, were evaluated. Strength training was performed for 6 mo as continually adapted strength training, providing an intensity of about 70% of each test persons one repetition maximum. Bone mineral density of lumbar vertebrae 2 to 4 and the femoral neck was measured by dual-energy x-ray absorptiometry. Maximum performance in watts and parameters of hemodynamics were controlled with a bicycle ergometer test to maximal effort. In addition, metabolic data were assessed. In the lumbar spine and femoral neck, the training group showed no significant changes, whereas the control group demonstrated a significant loss of bone mineral density, especially in the femoral neck (P<0.05). The strength increase was highly significant in all exercised muscle groups, rising to about 70% above the pretraining status (P<0.001). Heart rate and blood pressure data indicated a slight economization, metabolism was not significantly influenced. Based on these findings, we conclude that continually adapted strength training is an effective, safe, reproducible, and adaptable method of therapeutic strength training, following only two exercise sessions per week.

Therapeutic exercise in the prevention of bone loss. A controlled trial with women after menopause.

To evaluate the efficacy of therapeutic exercises in the prevention of bone loss, 146 untrained healthy postmenopausal women were prospectively controlled for (mean +/- SD) 3.0 +/- 1.3 yr. Eighty-two subjects aged (mean +/- SD) 61.5 +/- 6.1 yr participated in an exercise program (group 1) and sixty-four aged (mean +/- SD) 59.1 +/- 7.4 yr served as controls (group 2). Periodically during the study period, we measured womens bone density at two forearm sites and recorded their physical activities. Because bone loss differed insignificantly between the groups, group 1 was retrospectively subdivided into group 1a (regular exercise) and group 1b (nonregular exercise). The results showed that only 39 women (48 percent) of group 1 (group 1a) performed the exercise program regularly for the prescribed time. Regression slopes of forearm bone density (distal and proximal scans) v time were significantly less negative (P < 0.05) in group 1a (distal, -0.3 percent and proximal, -0.7 percent per year) than in group 1b (distal, -1.8 percent and proximal -1.6 percent per year) or group 2 (distal, -1.7 percent and proximal, -1.9 percent per year). We conclude that in untrained elderly women, poor compliance with regular physical activities is a main factor, explaining the lack of response to exercise treatment in prevention of osteoporosis.

Functional impact of unvarying exercise program in women after menopause.

Low bone mass, functional impairment, low muscle strength, and postural instability are predictors of the risk of fracture in an elderly person. The purpose of this study was to investigate the functional impact of an unvarying long-term exercise program to be carried out at home. The exercises had been shown to delay bone loss in an elderly population. At the Department of Physical Medicine and Rehabilitation, University of Vienna, postmenopausal women who had been stratified into exercise or control groups 5 to 10 yr ago were called in for a follow-up examination. Frequency of training, habits, and pain causing disability in activities of daily living were recorded. Walking velocity, muscle strength, and postural stability were measured. Functional assessment, blood analysis, and x-rays of the spine were performed additionally. One hundred twenty-four women aged 68.3 +/- 6.8 yr (mean +/- SD) underwent a follow-up investigation at the outpatient clinic. After 7.7 +/- 1.1 yr the compliance of the training group was still 36%. Self-chosen gait velocity was slightly higher in the regular exercisers than in the controls. No intergroup differences were found for pain induced disability, muscle strength, body sway, and fracture rate. The pain disability index was significantly associated with corrected self-chosen gait velocity. The results suggest that an unvarying home-based exercise program may support general agility but does not yield enough force to improve muscle strength and postural stability in healthy, nondisabled, postmenopausal women who start exercising at the age of 60 yr. Further studies are needed to define more appropriate exercise programs for a comprehensive improvement of functional outcome in a population at high risk for osteoporosis.

Exercise therapy for osteoporosis: results of a randomised controlled trial.

OBJECTIVE: To define the effects of therapeutic exercise on bone density and back complaints. METHODS: A randomised controlled trial with parallel groups was conducted in an outpatient clinic, Medical School, University of Vienna. Ninety two sedentary post-menopausal women with back problems were randomly allocated to either exercise (groups 1 and 2) or control (group 3, no exercise, n = 31); the exercise group was retrospectively subdivided into compliant (group 1, n = 27) and not fully compliant patients (group 2, n = 34). Regular, initially supervised therapeutic exercise aimed at restoring biomechanical function was performed for four years. Bone density in the forearm was measured by single photon absorptiometry at entry and after four years; subjective back complaints were documented. RESULTS: A significant decrease in bone density was observed in groups 2 and 3; no change was noted in group 1; back complaints decreased in group 1 only. CONCLUSIONS: Sedentary postmenopausal women may benefit from regular long term therapeutic exercise in terms of subjective back complaints and slowed loss of bone mass.

Immune phenotype and intracellular cytokine production of peripheral blood mononuclear cells from postmenopausal patients with osteoporotic fractures

A number of factors with known effects on bone turnover are also immune regulatory factors. Disturbances of bone remodeling thus may be a consequence of altered local immune reactivity. We therefore determined surface markers and intracellular cytokine production of peripheral blood mononuclear cells by four-color flow cytometry in 19 postmenopausal patients with established osteoporosis and a control group of 11 postmenopausal women without fragility fractures. No significant differences in bone mineral density as assessed by dual energy X-ray absorptiometry were observed between the two groups. The following surface markers and cytokines were studied: CD3, CD4, CD8, CD16, CD19, CD29, CD45RA, CD56, CD57, HLA-DR, interleukin (IL)-1beta, IL-2, IL-4, IL-6, IL-13, tumor necrosis factor (TNF)-alpha, interferon (IFN)-gamma and granulocyte macrophage colony stimulating factor. In the fracture patients, the percentage of CD8+ cells co-expressing CD57 was increased (14+/-2 vs. 8+/-1%; p=0.03). Moreover, the proportion of CD8+ cells co-expressing TNF-alpha (47+/-5 vs. 33+/-4; p=0.05) and both TNF-alpha and IFN-gamma was significantly higher in the patients than the controls (41+/-6 vs. 22+/-3%; p=0.04). IL-1beta expression tended to be increased in monocytes from patients with established osteoporosis. Distinct subsets of CD8+ cells thus appear to contribute to the development of osteoporotic fractures.

Forearm bone density and grip strength in women after menopause, with and without estrogen replacement therapy.

Peaking in young adulthood, both bone mass and muscle strength decrease with ageing, but bone loss may accelerate after the menopause and can be delayed by estrogen replacement therapy (ERT). This study was designed to evaluate whether, like bone density, the muscle strength was affected by the onset of menopause and/or ERT. First grip strength (GS) of young female adults (group III; n = 18; age (+/- S.E.M.) 21.8 +/- 0.4 years) was compared to that of postmenopausal women, who were divided into two groups. Group I (n = 22; age 59.6 +/- 1.6 years) was 12.5 +/- 1.7 years after the menopause and received no ERT, and group II (n = 21; age 59.5 +/- 1.1 years) was 8.3 +/- 1.2 years after the menopause and had received ERT for 3.9 +/- 2.3 years at the time of the study. GS of the postmenopausal women was significantly (P < 0.005) lower than that of the young female adults. GS did not differ significantly between both postmenopausal groups. Further analysis revealed a weak negative correlation of years since menopause with forearm bone density (r = -0.37, P < or = 0.023 for group II and III together), but not with GS. It is concluded that the later onset of menopause and estrogen replacement therapy do not seem to have a noticeable influence on muscle strength.

Long-term home exercise program: Effect in women at high risk of fracture

OBJECTIVE To determine whether a better outcome in terms of physical frailty could be achieved with a regular home exercise program in women at high risk of fracture. DESIGN Prospective long-term observational study. SETTING Outpatient clinic of physical medicine and rehabilitation. PARTICIPANTS Women with a history of postmenopausal fractures and an age-adjusted low bone mass, as determined 7 to 12 years earlier. INTERVENTION Home exercise program. OUTCOME MEASURES Thirty-three women were followed. The exercise group and control group were compared with regard to fracture rates, episodes of falling, neuromuscular performance (one-leg stance, chair rise, body sway, tandem walk, tapping test), and bone mineral density (BMD). RESULTS Twenty-five women with a mean age of 73.8+/-5.7 yrs appeared for the investigation. An exercise program had been prescribed in 19 women, and six served as controls. Seven women of the exercise group (36.8%) regularly performed the exercises. No differences between participants of the groups in terms of fracture rates, falling episodes, neuromuscular performance, and BMD were observed. CONCLUSION It appears that a home exercise program does not affect the outcome of postmenopausal women at high risk of fracture.

The effect of calisthenic home exercises on postmenopausal fractures—a long-term observational study

OBJECTIVES To evaluate the long-term effects of calisthenic home exercises on the incidence of fractures in postmenopausal women. DESIGN Controlled long-term observational study. METHODS Postmenopausal women between 45 and 75 years of age who had been randomly assigned to an exercise or control group in the course of a previous study conducted 5-10 years ago, were invited for follow-up. The number of fractures before and during the observation time were recorded by means of a questionnaire. Vertebral deformities due to fractures were diagnosed by X-rays at entry and at follow-up. Walking speed, muscle strength, static posturography, and maximum oxygen uptake were measured in addition. RESULTS After an average follow-up time of 7.6+/-1.1 years, 73 women of the exercise group and 64 subjects of the control group were investigated. Thirty-three per cent (n=24) of the exercise group reported to have exercised continuously at least three times a week for 20 min. No intergroup differences between the compliant and non-compliant exercisers and the control group were seen in the number of fractures. However, the incidence of fracture was lowest in women with a baseline bone mass less than one standard deviation (SD) below the mean for young adults (high BMC) and highest in those with more than 2.5 SD below the mean for young adults (low BMC) (P<0.001, odds ratio 2.9 [95% CI, 1.59-5.39]). CONCLUSION This long-term follow-up did not produce any evidence that prescription of a calisthenic home exercise program may prevent fractures in postmenopausal women aged between 61+/-6.4 and 68+/-6.5 years.

Österreichischer Leitfaden zur medikamentösen Therapie der postmenopausalen Osteoporose: Addendum 2010

Osteoporosis is a systemic skeletal disease characterized by diminished bone mass and deterioration of bone microarchitecture, leading to increased fragility and subsequent increased fracture risk. Therapeutic measures therefore aim at reducing individual fracture risk. In Austria, the following drugs, all of which have been proven to reduce fracture risk, are currently registered for the treatment of postmenopausal osteoporosis: alendronate, risedronate, etidronate, ibandronate, raloxifene, teriparatide (1-34 PTH), 1-84 PTH, strontium ranelate and salmon calcitonin. Fluorides are still available, but their role in daily practice has become negligible. Currently, there is no evidence that a combination of two or more of these drugs could improve anti-fracture potency. However, treatment with PTH should be followed by the treatment with an anticatabolic drug such as bisphosphonates. Calcium and vitamin D constitute an important adjunct to any osteoporosis treatment.SummaryOsteoporosis is a systemic skeletal disease characterized by diminished bone mass and deterioration of bone microarchitecture, leading to increased fragility and subsequent increased fracture risk. Therapeutic measures therefore aim at reducing individual fracture risk. In Austria, the following drugs, all of which have been proven to reduce fracture risk, are currently registered for the treatment of postmenopausal osteoporosis: alendronate, risedronate, etidronate, ibandronate, raloxifene, teriparatide (1-34 PTH), 1-84 PTH, strontium ranelate and salmon calcitonin. Fluorides are still available, but their role in daily practice has become negligible. Currently, there is no evidence that a combination of two or more of these drugs could improve anti-fracture potency. However, treatment with PTH should be followed by the treatment with an anticatabolic drug such as bisphosphonates. Calcium and vitamin D constitute an important adjunct to any osteoporosis treatment.ZusammenfassungDie Osteoporose ist eine systemische Skeletterkrankung, die durch eine verminderte Knochenmasse sowie eine gestörte Mikroarchitektur des Knochens charakterisiert ist. Die Folge dieser Veränderungen ist eine eingeschränkte Knochenqualität mit einem entsprechend erhöhten Risiko für Frakturen. Oberstes Ziel jeder therapeutischen Intervention ist daher die Reduktion dieses erhöhten Frakturrisikos. Die Palette der in Österreich zur Therapie der postmenopausalen Osteoporose zugelassenen Pharmaka mit nachgewiesenem Potenzial zur Senkung des Frakturrisikos umfasst derzeit fünf Bisphosphonate (Alendronat, Risedronat, Etidronat, Ibandronat und Zoledronat), einen selektiven Östrogen-Rezeptormodulator (Raloxifen), zwei Parathormon-Analoga (1-34 PTH bzw. Teriparatid sowie 1-84 PTH), Strontiumranelat sowie Lachskalzitonin. Fluoride stehen theoretisch zur Verfügung, gelangen in der Praxis jedoch nicht mehr zur Anwendung. Es gibt keine Evidenz dafür, dass Kombinationstherapien Einzeltherapien überlegen sind. Im Anschluss an eine Therapie mit Parathormon-Analoga sollte jedoch eine antikatabole Therapie erfolgen. Eine adäquate Zufuhr von Kalzium und Vitamin D stellt ein wichtiges Adjunkt jeder Osteoporosetherapie dar.