Correction: Management of vertebral compression fracture in general practice: BEACH program.

[This corrects the article DOI: 10.1371/journal.pone.0176351.].

Association between pain and the frailty phenotype in older men: longitudinal results from the Concord Health and Ageing in Men Project (CHAMP).

Objectives: to determine whether pain increases the risk of developing the frailty phenotype and whether frailty increases the risk of developing chronic or intrusive pain, using longitudinal data. Design/Setting: longitudinal data from the Concord Health and Ageing in Men Project (CHAMP), a prospective population based cohort study. Participants: a total of 1,705 men aged 70 years or older, living in an urban area of New South Wales, Australia. Measurements: data on the presence of chronic pain (daily pain for at least 3 months), intrusive pain (pain causing moderate to severe interference with activities) and the criteria for the Cardiovascular Health Study (CHS) frailty phenotype were collected in three waves, from January 2005 to October 2013. Data on age, living arrangements, education, smoking status, alcohol consumption, body mass index, comorbidities, cognitive function, depressive symptoms and history of vertebral or hip fracture were also collected and included as covariates in the analyses. Results: a total of 1,705 participants were included at baseline, of whom 1,332 provided data at the 2-year follow-up and 940 at the 5-year follow-up. Non-frail (robust and pre-frail) men who reported chronic pain were 1.60 (95% confidence interval (CI): 1.02-2.51, P = 0.039) times more likely to develop frailty at follow-up, compared to those with no pain. Intrusive pain did not significantly increase the risk of future frailty. Likewise, the frailty status was not associated with future chronic or intrusive pain in the adjusted analysis. Conclusions: the presence of chronic pain increases the risk of developing the frailty phenotype in community-dwelling older men.

Efficacy and Safety of Oral and Transdermal Opioid Analgesics for Musculoskeletal Pain in Older Adults: A Systematic Review of Randomized, Placebo-Controlled Trials.

This systematic review with meta-analysis was performed to evaluate the efficacy and safety of using opioid analgesics in older adults with musculoskeletal pain. We searched Cochrane Library, MEDLINE, EMBASE, Web of Science, AMED, CINAHL, and LILACS for randomized controlled trials with mean population age of 60 years or older, comparing the efficacy and safety of opioid analgesics with placebo for musculoskeletal pain conditions. Reviewers extracted data, assessed risk of bias, and evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. Random effects models were used to calculate standardized mean differences (when different scales were used across trials), mean differences and odds ratios with respective 95% confidence intervals (CIs). Meta-regressions were carried out to assess the influence of opioid analgesic daily dose and treatment duration on our main outcomes. We included 23 randomized placebo-controlled trials in the meta-analysis. Opioid analgesics had a small effect on decreasing pain intensity (standardized mean difference = -.27; 95% CI = -.33 to -.20) and improving function (standardized mean difference = -.27, 95% CI = -.36 to -.18), which was not associated with daily dose or treatment duration. The odds of adverse events were 3 times higher (odds ratio = 2.94; 95% CI = 2.33-3.72) and the odds of treatment discontinuation due to adverse events 4 times higher (odds ratio = 4.04; 95% CI = 3.10-5.25) in patients treated with opioid analgesics. The results show that in older adults suffering from musculoskeletal pain, using opioid analgesics had only a small effect on pain and function at the cost of a higher odds of adverse events and treatment discontinuation. For this specific population, the opioid-related risks may outweigh the benefits. PERSPECTIVE: The systematic review shows that, in older adults suffering from musculoskeletal conditions, opioid analgesics have only a small effect on pain and disability. Conversely, this population is at higher risk of adverse events. The results may reflect age-related physiological changes in pain processing, pharmacokinetics, and pharmacodynamics.

An overview of clinical guidelines for the management of vertebral compression fracture: a systematic review.

BACKGROUND CONTEXT: Vertebral compression fractures (VCFs) are the most common type of osteoporotic fracture comprising approximately 1.4 million cases worldwide. Clinical practice guidelines can be powerful tools for promoting evidence-based practice as they integrate research findings to support decision making. However, currently available clinical guidelines and recommendations, established by different medical societies, are sometimes contradictory. PURPOSE: The aim of this study was to appraise the recommendations and the methodological quality of international clinical guidelines for the management of VCFs. STUDY DESIGN: This is a systematic review of clinical guidelines for the management of VCF. METHODS: Guidelines were selected by searching MEDLINE and PubMed, PEDro, CINAHL, and EMBASE electronic databases between 2010 and 2016. We also searched clinical practice guideline databases, including the National Guideline Clearinghouse and the Canadian Medical Association InfoBase. The methodological quality of the guidelines was assessed by two authors independently using the Appraisal of Guidelines, Research and Evaluation (AGREE) II Instrument. We also classified the strength of each recommendation as either strong (ie, based on high-quality studies with consistent findings for recommending for or against the intervention), weak (ie, based on a lack of compelling evidence resulting in uncertainty for benefit or potential harm), or expert consensus (ie, based on expert opinion of the working group rather than on scientific evidence). Guideline recommendations were grouped into diagnostic, conservative care, interventional care, and osteoporosis treatment and prevention of future fractures. Our study was prospectively registered on PROSPERO. RESULTS: Four guidelines from three countries, published in the period 2010-2013, were included. In general, the quality was not satisfactory (50% or less of the maximum possible score). The domains scoring 50% or less of the maximum possible score were rigor of development, clarity of presentation, and applicability. The use of plain radiography or dual-energy X-ray absorptiometry for diagnosis was recommended in two of the four guidelines. Vertebroplasty or kyphoplasty was recommended in three of the four guidelines. The recommendation for bed rest, trunk orthoses, electrical stimulation, and supervised or unsupervised exercise was inconsistent across the included guidelines. CONCLUSIONS: The comparison of clinical guidelines for the management of VCF showed that diagnostic and therapeutic recommendations were generally inconsistent. The evidence available to guideline developers was limited in quantity and quality. Greater efforts are needed to improve the quality of the majority of guidelines.

Management of vertebral compression fracture in general practice: BEACH program.

IMPORTANCE: The pain associated with vertebral compression fractures can cause significant loss of function and quality of life for older adults. Despite this, there is little consensus on how best to manage this condition. OBJECTIVE: To describe usual care provided by general practitioners (GPs) in Australia for the management of vertebral compression fractures. DESIGN, SETTING AND PARTICIPANTS: Data from the Bettering the Evaluation And Care of Health (BEACH) program collected between April 2005 and March 2015 was used for this study. Each year, a random sample of approximately 1,000 GPs each recorded information on 100 consecutive encounters. We selected those encounters at which vertebral compression fracture was managed. Analyses of management options were limited to encounters with patients aged 50 years or over. MAIN OUTCOME(S) AND MEASURE(S): i) patient demographics; ii) diagnoses/problems managed; iii) the management provided for vertebral compression fracture during the encounter. Robust 95% confidence intervals, adjusted for the cluster survey design, were used to assess significant differences between group means. RESULTS: Vertebral compression fractures were managed in 211 (0.022%; 95% CI: 0.018-0.025) of the 977,300 BEACH encounters recorded April 2005- March 2015. That provides a national annual estimate of 26,000 (95% CI: 22,000-29,000) encounters at which vertebral fractures were managed. At encounters with patients aged 50 years or over (those at higher risk of primary osteoporosis), prescription of analgesics was the most common management action, particularly opioids analgesics (47.1 per 100 vertebral fractures; 95% CI: 38.4-55.7). Prescriptions of paracetamol (8.2; 95% CI: 4-12.4) or non-steroidal anti-inflammatory drugs (4.1; 95% CI: 1.1-7.1) were less frequent. Non-pharmacological treatment was provided at a rate of 22.4 per 100 vertebral fractures (95% CI: 14.6-30.1). At least one referral (to hospital, specialist, allied health care or other) was given for 12.3 per 100 vertebral fractures (95% CI: 7.8-16.8). CONCLUSIONS AND RELEVANCE: The prescription of oral opioid analgesics remains the common general practice approach for vertebral compression fractures management, despite the lack of evidence to support this. Clinical trials addressing management of these fractures are urgently needed to improve the quality of care patients receive.