# data[].attributes.attachment_link.title
Parkinson’s Podcast | 2 Parkies In A Pod

# data[].attributes.attachment_link.description
If you want to know more about Parkinson’s, or how to cope with chronic illness, then 2 Parkies in a Pod is for you. Between them Clarky & Kuhan have been living with Parkinson’s for more than 20 years. They chat openly about the challenges and even the benefits of living with the condition

# data[].attributes.attachment_link.title
Cure Parkinson’s | UK charity working to end Parkinson’s

# data[].attributes.attachment_link.description
Our mission is to find a cure for Parkinson’s. Learn how we fund, facilitate and encourage research to find a cure for the condition.

# data[].attributes.attachment_link.description
This website brings together resources from around the world to help understand and apply how to build better bones if you are someone living with osteoporosis or a care partner. The website is a project of the International Osteoporosis Foundation.

# data[].attributes.attachment_link.title
eLibrary, Knowledge and Archive Services

# data[].attributes.attachment_link.description
Access physiotherapy and related research, evidence and publications via our wide range of online tools, digital resources and archive services.

# data[].attributes.attachment_link.readable_text
What is osteoporosis?

Bone loss slowly increases as part of the natural ageing process. It is more rapid in women for several years after the menopause. Bone loss can lead to osteoporosis and an increased risk of broken bones (fractures).

The main reasons why people develop osteoporosis are genes, age and gender. Other risk factors include smoking, drinking more than three units of alcohol a day and not being active.

How can physiotherapy help with osteoporosis?

Physiotherapy can help you strengthen your bones, as well as your muscles. It can prevent bone thinning, reduce falls and help you manage any pain.

Bone is a living tissue that can be improved through some types of exercise. A physiotherapist can work with you to find activities that suit your needs and that will strengthen your bones.

Sometimes a compression fracture, when bones in the spine collapse, can produce pain. Physiotherapy can help to manage this pain.

Osteoporosis is more common in older people and often the reason why they fall. Falling is a common problem for people aged 65 and over. If you are at risk of falling, a physio can help you improve your balance.

Physios are the third largest health profession after doctors and nurses. They work in the NHS, in private practice, for charities and in the work-place, through occupational health schemes.

What will happen when I see a physiotherapist?

When you see a physio, they will assess your problem and give you advice. They may give you a physical treatment. Everything you tell the physio will be completely confidential.

So that your physio can have a good look at how you move, they may need you to remove some clothes. It's a good idea to dress comfortably and wear suitable underwear.

How can I help myself?

If you are worried about osteoporosis or having a fall, ask your GP or a physio for advice.

Weight bearing exercise, such as walking or dancing, can help to strengthen your bones. Weight bearing exercise is any exercise in which you are supporting your own body weight through your feet and legs (or arms and hands).

If you have osteoporosis check with your GP or a physio about what types of exercise would be suitable for you. They may recommend water based exercise classes (at your local swimming pool perhaps) as the water takes some of your weight.

Eat a healthy diet with plenty of calcium and get outside in the sunlight to boost your vitamin D. Calcium and vitamin D are both important for strong bones.

Our skeletons are growing from childhood into early adulthood. During this time, it is very important to make our bones as strong as possible. You can do this by taking plenty of weight bearing exercise and eating a balanced, calcium-rich diet.

Top tips for osteoporosis

Weight bearing exercise, such as walking, can help to strengthen bones

Exercises to improve your balance and strength will help to prevent falls

Follow a healthy diet that includes enough calcium and Vitamin D

Wear sensible, well-fitting shoes to avoid falls

Avoid rugs and sloppy slippers - both can cause trips

Have good lighting on your stairs

Get your eyesight checked regularly (free for people over 60)

Try to avoid heavy lifting - consider home delivery grocery shopping

Guidance and evidence for physiotherapy

Links and further information

Disclaimer
The content on this page is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation. The CSP is not responsible for the content of any external sites, nor should selection be seen as an endorsement of them.

# data[].attributes.attachment_link.description
What is osteoporosis? Bone loss slowly increases as part of the natural ageing process. It is more rapid in women for several years after the menopause. Bone loss can lead to osteoporosis and an increased risk of broken bones (fractures). The main reasons why people develop osteoporosis are genes, age and gender.

# data[].attributes.attachment_link.description
What is Parkinson’s? Do you or someone you care for need treatment? Find a Physio Parkinson’s is a neurological condition in which the brain function becomes gradually more impaired. The main cause is thought to be a loss of the chemical called dopamine that helps to regulate the body’s movements.

# data[].attributes.attachment_link.description
Our longest running course and founding Academy, we specialise in Parkinson’s and other movement disorders.

# data[].attributes.headline
Parkinson's UK - Better bone health resources

# data[].attributes.subject
Parkinson's UK - Better bone health resources

# data[].attributes.attachment_link.description
Learn about bone health in Parkinson’s, the Bone health service improvement project, and access information and resources for professionals.

# data[].attributes.headline
Parkinson's UK - Bone Health Assessment Form

# data[].attributes.subject
Parkinson's UK - Bone Health Assessment Form

# data[].attributes.attachment_link.description
Staying active helps to maintain your balance, strength and coordination. Match your ability to lessons and groups in your area.

# data[].attributes.attachment_link.title
Parkinson’s UK information, leaflets and resources

# data[].attributes.attachment_link.description
Our information booklets cover all aspects of Parkinson’s.

# data[].attributes.attachment_link.description
Information about how bone density scans or DEXA scans are used to diagnose osteoporosis.

# data[].attributes.attachment_link.title
Osteoporosis: Exercises to improve balance and muscle strength

# data[].attributes.attachment_link.description
Information about exercises to improve balance and muscle strength for people with osteoporosis.

# data[].attributes.attachment_link.description
We’re here to help health and social care professionals provide better support for people with Parkinson’s.

# data[].attributes.attachment_link.description
The FRAX® models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia.

# data[].attributes.attachment_link.title
International Osteoporosis Foundation | IOF

# data[].attributes.attachment_link.description
Osteoporosis is a disease which makes bones weak and fragile. This greatly increases the risk of breaking a bone even after a minor fall or bump.

# data[].attributes.attachment_link.description
NICE helps practitioners and commissioners get the best care to patients, fast, while ensuring value for the taxpayer.

# data[].attributes.attachment_link.title
National Osteoporosis Guidelines Group UK

# data[].attributes.attachment_link.description
The National Osteoporosis Guideline Group (NOGG), established in 2007, is a multidisciplinary group that includes patient representation and professionals involved in the care of people with osteoporosis. NOGG provides a clinical guideline that reviews the assessment and diagnosis of osteoporosis, the therapeutic interventions available and the approaches for the prevention of fragility fractures, in postmenopausal women, and in men aged 50 years or older.

# data[].attributes.attachment_link.readable_text
Besides unlimited projects, you'll get pings for private conversations, reports to summarize the essentials, notification protections so you aren't constantly distracted, a timeline showing you everything that's happening, exceptional customer service, and plenty more to round it out.

Basecamp also helps you consolidate billing, cut costs, and simplify onboarding. When you use Basecamp you don't need separate apps for chat, file sharing, tasks, or basic scheduling. No more bouncing around, losing stuff, wondering where someone put something, paying multiple bills or onboarding people in multiple places. Less isn't more, it's better.

Running a sane, sustainable business is part of our commitment to you. We've written bestselling books about our straightforward approach, and our employee handbook is public for everyone to see.

Email our CEO anytime, as well. He wants to hear from you.

Used by top notch marketers, ad agencies, designers, client services firms, consultants, software developers, freelancers, PR agencies, contractors, schools, non-profits, first responders, and many others. Over 75,000 organizations, across every industry imaginable, in 166 countries.

"I've used Basecamp for a million projects over the last decade and a half. It's beautiful software that has resisted every wrong trend and stayed true to the things that mattered most. Highly recommended."-Tobi Lütke, CEO, Shopify

# data[].attributes.attachment_link.description
Trusted by millions, Basecamp puts everything you need to get work done in one place. It's the calm, organized way to manage projects, work with clients, and communicate company-wide.

# data[].attributes.attachment_link.description
The leading voice for Parkinson’s in Europe. Find trusted information (including Parkinson’s symptoms and treatment), and join our campaigns.

# data[].attributes.attachment_link.description
Exercise and physical activity can improve many motor and non-motor Parkinson’s symptoms.

# data[].attributes.attachment_link.readable_text
Division of Geriatrics, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil

Department of Health Sciences, Medical School of Universidade de Fortaleza, Fortaleza, Ceará, Brazil

Clinical Research Unit, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará/EBSERH, Fortaleza, Ceará, Brazil

Diagnostic Imaging Department, Division of Radioloy and Sports Medicine of Hospital Geral do Fortaleza, Fortaleza, Ceará, Brazil

Diagnostic Imaging Department, TS Health Center, Fortaleza, Ceará, Brazil

Division of Endocrinology and Metabolism, Department of Clinical Medicine, Fortaleza, Ceará, Brazil

Medical School of Faculty of Universidade Federal do Ceará, Department of Clinical Medicine, Universidade Federal do Ceará (UFC), Fortaleza, Ceará, Brazil

Division of Neurology, Clinical Medicine Department, Universidade Federal do Ceará (UFC), Fortaleza, Ceará, Brazil

Health Sciences Center, Universidade Federal do Ceará (UFC), Fortaleza, Ceará, Brazil

Background: Parkinson's disease (PD) is the second most common neurodegenerative illness and has the highest increase rate in recent years. There is growing evidence to suggest that PD is linked to higher osteoporosis rates and risk of fractures.

Objective: This study aims to estimate the prevalence and factors associated with osteoporosis as defined by the National Osteoporosis Foundation (NOF) and World Health Organization in patients with mild to moderate PD.

Methods: We performed a cross-sectional study at a tertiary public hospital in Fortaleza, Brazil, dating from May 2021 until April 2022. The study sample was comprised of patients with mild to moderate PD who were at least 40 years old and who had the ability to walk and stand unassisted. Bone Mineral Density (BMD) of both the hip (neck of the femur) and the lumbar spine were obtained via properly calibrated Dual Energy X-ray Absorptiometry (DXA) scanning. The FRAX (Fracture Risk Assessment Tool) score was used to determine a person's 10-year risk of major osteoporotic fracture. The Revised European Working Group on Sarcopenia in Older People (EWGSOP 2) was used as a basis to confirm a sarcopenia diagnosis with the following parameters: low muscle strength gauged by handgrip strength and low muscle quantity by DXA. Physical performance was carefully evaluated by using the Short Physical Performance Battery test. Osteoporosis and osteopenia were diagnosed following the NOF guidelines and WHO recommendations.

Results: We evaluated 107 patients in total, of whom 45 (42%) were women. The group's mean age was 68 ± 9 years, and the mean disease time span was 9.9 ± 6.0 years and mean motor UPDRS was 43 ± 15. We found that 42.1% and 34.6% of the sample had osteopenia and osteoporosis following NOF criteria, respectively, and 43% and 33.6% following the WHO recommendations. Lower lean appendicular mass was associated to osteopenia and osteoporosis in multinomial logistic regression analysis in both diagnostic criteria.

Conclusion: Our findings provide additional evidence for the protective role of lean mass against osteoporosis in patients with PD.

Introduction

Parkinson's disease (PD) is the second most common neurodegenerative illness and has the highest increase rate in recent years ( 1). It affects 1% of adults over 60 years of age with a rate of 5 and 35 new cases per 100,000 people per year in the world population ( 2).

PD is clinically characterized by bradykinesia, tremor at rest, rigidity, and progresses to postural instability which predisposes the individual to falls and fractures, resulting in increased hospitalization and institutionalization risk, as well as a lower quality of life ( 3). Falls are the leading cause of emergency hospital admissions in PD patients and are also a recognized risk factor for fractures ( 4). In fact, over 90% of all fractures occur following a fall. There is growing evidence to suggest that PD is associated with a higher rate of osteoporosis and fracture risk ( 5).

Osteoporosis is a metabolic bone disease characterized by decreased bone mass, deterioration of bone microarchitecture, with consequent impairment of bone strength and increased fracture risk ( 6). According to the World Health Organization (WHO) diagnostic classification, osteoporosis is defined by the history of fractures and/or bone mineral density (BMD) at the femoral neck, total hip or lumbar spine less than or equal to 2.5 standard deviations below the mean BMD of a reference population of young adults measured by dual energy bone densitometry (DXA) ( 5). However, since the initial publication by the WHO, it has become increasingly evident that many patients are not being diagnosed and do not receive appropriate treatment. Therefore, in order to promote diagnosis and treatment of osteoporosis in postmenopausal women and men aged 50 years or older, the National Osteoporosis Foundation (NOF) proposed the use of the FRAX algorithm (Fracture Risk Assessment Tool) to assess the risk of osteoporosis and fracture aiming to determine the need for BMD testing, spinal imaging and treatment ( 6) ( 7).

The prevalence of osteoporosis is 18.3% worldwide. It is silent until the appearance of a fracture, a complication which together with population aging is increasing in prevalence, being expected to reach 160,000 hip fractures per year in Brazil by 2050 ( 8). Hip fractures are associated with 8 to 36% increase in mortality within 1 year. After a hip fracture episode, 20% of patients require long-term home care and only 40% fully recover their pre-fracture level of independence ( 8). A large multinational cohort study called "the Global Longitudinal Study of Osteoporosis in Women" (GLOW) was performed to investigate influence of co-morbidities on the risks of fracturing bones, and the strongest association was seen with PD ( 9).

Given these findings, it appears that osteoporosis is a major public health issue, since it has a very detrimental impact on quality of life and costs. Information regarding the prevalence of osteoporosis in PD patients in Brazil is deficient ( 10). Furthermore, PD is often neglected by specialists in assessing fracture risk, as they are unaware of the relevance of fractures and osteoporosis in this movement disorder ( 11). Therefore, the present study aims to assess and discuss the prevalence and risk factors associated with osteoporosis as defined by NOF and WHO in patients with mild to moderate PD in a tertiary center of Northeast Brazil.

Materials and methods

Study participants

A cross-sectional study was conducted at a tertiary public hospital in Fortaleza, Brazil, lasting from May 2021 until April 2022. The sample was comprised of patients with PD who had visited the Movement Disorders outpatient clinic of the hospital with varying levels of regularity.

The PD diagnosis was reached by following the Movement Disorders Society (MDS) criteria ( 12) by a pair of neurologists and one geriatrician specialized in dealing with PD. Participants were required to have a clinical diagnosis of PD and their disease severity score ranging from stage 1 to stage 3 when measured in the modified Hoehn and Yahr (HY) scale ( 13) to be deemed eligible for the study. Additionally, they were required to be at least 40 years old and have the ability to walk and stand without assistance. Patients with severe disease (HY 4 and 5) were not included due to their limitations, since they would be unfit to complete the Five Times Sit-to-Stand (FTSTS), gait speed or balance tests. Patients with HY 5 are no longer attended to in the outpatient clinic when it comes to face-to-face consultations, since home care is the better option for their situation. Patients who had uncontrolled chronic diseases or severe health conditions that could affect the data interpretation were excluded according to the following criteria: "Heart failure", specifically the New York Heart Association (NYHA) Functional Classification class III (fatigue caused by less than ordinary activity, dyspnea or palpitation) and IV (symptoms of heart failure even when at rest); Dialysis-dependent renal disease in its end-stage; Neurological diseases (non-PD) that cause motor impairment; Chronic obstructive pulmonary disease at severe (dyspnea at slight exertion) or very severe (dyspnea when at rest and/or during oxygen therapy) levels; Severe wrist, hand, knee or spine osteoarthritis; Cancer diagnosis, except when referring to localized prostate and skin cancer; or Dementia at moderate to severe stages (CDR 2 and 3).

Conditions that would hinder the interpretation of the Dual Energy X-ray Absorptiometry (DXA) were also excluded: Gastrointestinal contrast or radionuclides administered in the last 72 hours; Pregnancy; Heart pacemaker; or Deep Brain Stimulation.

All participants complied in participating by providing written informed consent for the study, which was then sanctioned by the hospital's Ethics Committee (register number 91075318.1.0000.5045). The researchers conducting the study explained the situation properly to every participant.

Clinical assessment

An interview was conducted to gather sociodemographic and medical data. The clinical data acquired from the patients were compared with information from their relatives, caregivers, and healthcare records to ensure precision. Data on the antiparkinsonian medications provided by the Brazilian public health system used such as L-dopa, COMT inhibitors (entacapone), MAO-B inhibitors (rasagiline), amantadine, and dopamine agonists (pramipexole), as well as L-dopa formulations such as L-dopa/carbidopa, L-dopa/benserazide, and controlled-release L-dopa formulations were collected. The Schwab and England Activities of Daily Living (SE ADL) Scale was employed to evaluate ADL, the modified Hoehn and Yahr (HY) staging was utilized to assess PD severity, and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS III) was employed to assess the severity of motor parkinsonian symptoms. Depressive symptoms were evaluated using the 15-item Geriatric Depression Scale (GDS-15), and cognition was assessed through the Mini-Mental Status Examination (MMSE). A fall was defined as "a situation in which the patient inadvertently dropped to the ground or to another lower level, which is not attributable to a seizure, a vehicle or bike accident, or a syncope". Prior to their medical visit, patients were asked about any similar incidents that occurred in the preceding one and six months earlier. Data on falls gathered from patients were compared with information from relatives, caregivers, and clinical records for accuracy purposes. All participants were weighed while not wearing shoes or holding any heavy accessories such as wallets and mobile phones. The body mass index was calculated by dividing the total body weight (in kilograms) by the square of the height (meters).

Sarcopenia assessment

The calf is the optimal location for measuring anthropometric parameters to evaluate loss of skeletal muscle mass (SMM) and has been chosen in various studies to estimate SMM ( 14) ( 15). Adult lower limbs consist of approximately 30% skeletal muscle. The extremities possess less fat mass than other body regions, thus minimizing their impact on these parameters. The calf perimeter (CP) measurement offers the additional advantage of being feasible, easy to perform, and does not require undressing. The right CP was assessed at the maximum girth of the right calf using a firm but malleable plastic tape while the individual is seated with their knee and ankle at a right angle and feet planted on the floor. The patient disrobed from the lower body to measure the CP on bare skin. There was no compression in the subcutaneous tissues. The right side was selected because Jeong et al. (2020) recently demonstrated that CP measured on the right side exceeded that on the left side, irrespective of hand dominance, in a sample of older adult ambulatory-patients ( 14). The SARC-F was administered to all patients. The SARC-F is a simple and cost-effective questionnaire employed as an initial screening tool for sarcopenia that is easily implemented in community healthcare settings and other clinical environments. It comprises 5 items to assess the patient's perception of their physical limitations, including their capacity to walk, lift a 10-pound object, rise from a chair, walk up the stairs and avoid falls ( 16). The suggestions of the Revised European Working Group on Sarcopenia in Older People (EWGSOP 2) concerning the handgrip strength measure and cut-offs (< 27 kg for men and < 16 kg for women) were adhered to ( 14). A SAEHAN ® dynamometer was employed following the Southhampton protocol, where patients were seated with their forearms resting on the arms of the chair, wrist just over the end of the chair arm, in a neutral position, thumb facing upwards, and their feet flat on the floor. Three attempts on each side were executed, alternating sides, and the maximum grip score from all six attempts was utilized ( 15). When evaluating physical performance, the Short Physical Performance Battery (SPPB) test was utilized ( 16). This test consists of evaluations of standing balance, 4-m gait speed, and the time taken to perform five chair stands. During the test, individuals were instructed to maintain their balance by standing with their feet together and spending 10 seconds in each of the semi-tandem and tandem positions. The patient's gait was measured by having them walk 4 meters at a regular, fast rate. However, the patient had to walk 8 meters, with 2 meters of acceleration and 2 meters of deceleration in addition to the 4 meters. The middle 4 meters were counted, while the first and last 2 meters were ignored ( 17). In the Five-Times-Sit-to-Stand-Test, patients stood up and sat down as soon as they could while crossing their arms over their chests. The time it took to complete five chair stands was recorded ( 18). Muscle mass was assessed using DXA to estimate appendicular skeletal muscle mass (ASMM) adjusted for height in meters squared, resulting in the measurement of the lean mass index (LMI = ASMM/Ht2). The lean mass in the arms and legs was used as a basis to gauge appendicular lean mass. For individuals with unilateral harm to body parts, the appendicular lean mass values were acquired by doubling the values for the unaffected side. Low muscle mass was defined as an ASMM index < 7 kg/m ² for men and < 5.5 kg/m ² for women according to EWGSOP 2 ( 14).

Osteoporosis diagnosis

The lumbar spine, femoral neck and total hip bone mineral density (BMD) were measured by a trained radiology technician using a properly calibrated DXA scanner (LUNAR PRODIGY ADVANCE software version 17, model PA+510328, GE Medical Systems). All metallic objects were removed from the participants before starting the scan. The participants were positioned in dorsal decubitus with their body centralized in the scanning area, their palms facing their body and upper and lower limbs extended, and with their arms slightly away from their trunk. A half-body scan called Mirror Image was used for participants who were wider than the scanning table.

The participants remained in dorsal decubitus and centralized in the scanning area, when performing the BMD measurement; however, for the femoral neck measurement, the participants' legs were turned slightly inwards, and their feet were fixed with Velcro tapes. Then, their legs were elevated with the aid of a foam block for performing the lumbar spine measurement, making a 90° angle. A radiologist of our research group analyzed all the densitometries.

Fragility fractures are defined as those resulting from low energy trauma, i.e. a fall from a high standing position or less, with the skull or face, hands or fingers, feet and toes or patella fractures being excluded ( 19). The FRAX was created to assess the 10-year absolute probability of hip fracture or major osteoporotic fractures combined (hip, spine, shoulder, or wrist) for an untreated woman or man utilizing widely accessible clinical risk variables for fracture with or without BMD values. FRAX has been tested in the largest number of cohorts ( 5, 20, 21). The FRAX tool incorporates eight clinical risk factors: previous fragility fracture, parental hip fracture, smoking, systemic glucocorticoid use, excess alcohol consumption, body mass index, rheumatoid arthritis, and other causes of secondary osteoporosis; these, along with age, gender, and BMD of the femoral neck (this input is optional), are used on the 10-year fracture risk estimate ( 6). The FRAX is a free online tool, and it is the first national fracture-prediction model made for Brazil. It was incorporated into country-wide recommendations for diagnosing and treating postmenopausal osteoporosis in 2017 ( 7). PD is not included in the FRAX list for calculating the 10-year probability of osteoporotic fractures, and the accuracy of FRAX for these individuals requires additional testing ( 22). The history of clinical fragility fractures in our study was investigated using a questionnaire that asked about the number and location of prior fractures, as well as their causes and outcomes.

The diagnosis of osteoporosis was performed according to the NOF as follows ( 6): a hip or vertebral low-trauma fracture (clinically apparent or found on vertebral imaging); and/or T-score ≤−2.5 at the femoral neck, total hip or lumbar spine by DXA; and/or low bone mass (when the T-score is between −1.0 and −2.5 at the total hip, lumbar spine and femoral neck) by DXA with a high probability of a hip fracture or a major fracture related to osteoporosis in the next 10 years (based on the Brazilian model of FRAX; i.e. above the fracture probability of a Brazilian woman with a prior fragility fracture ( 7). Therefore, according to FRAX Brazil, women with a fracture probability equal to or exceeding that of a woman with previous fragility fracture would be eligible for treatment. Low-trauma or low-energy fractures were considered as diagnostic for osteoporosis ( 6). Our definition excludes fractures resulting from significant trauma, such as those caused by vehicle accidents or falls from elevated surfaces ( 23). We also established an osteoporosis diagnosis using the WHO's criteria: T-score ≤−2.5 at the femoral neck or lumbar spine, and a clinical diagnosis of osteoporosis can be made in the presence of a fragility fracture, notably at the spine, hip, wrist, humerus, rib, and pelvis, without measuring BMD ( 5).

Statistical analysis

The study data were collected and managed using the electronic data collection and management tool REDCap hosted at the Clinical Research Unit of the University Hospitals Complex of UFC.

The variables were presented as mean, standard deviation and median, and frequency and prevalence rate. The Mann-Whitney U test and Student's t tests were used to analyze the participants' characteristics, verifying non-adherence of the data to the Gaussian distribution. The Pearson's chi-squared and Fisher's exact tests were used to investigate the association between categorical variables.

Variables with p < 0.05 entered multinomial analysis in order to find those that were associated independently with osteoporosis, osteopenia and normal bone. We performed Fleiss' Kappa coefficient to examines the agreement between the NOF and WHO diagnosis. A significance level of 5% was adopted. Statistical analyses were performed using the R statistical program and Microsoft Excel 2016.

Results

The sample amounted to a total of 107 patients, of which 45 (42%) were women. Their mean age was 68 ± 9 years, mean disease duration was 9.9 ± 6.0 years and mean motor UPDRS was 43 ± 15. For the modified HY, 26 (24.2%) had HY 1 to 2 and 81 (75.7%) had HY 3. According to NOF guidelines, a total of 37 (34.6%) patients had osteoporosis and 45 (42.1%) had osteopenia, while following the WHO recommendations, 36 (33.6%) patients had osteoporosis and 46 (43%) patients had osteopenia.

The mean handgrip strength was 19 ± 6 kg in women and 34 ± 9 kg in men. In addition, 51 (48%) patients had positive screening for sarcopenia according to the SARC-F and the prevalence of confirmed sarcopenia was 11 (N=10.3%). The most prevalent comorbidities were hypertension (N=51, 47.6%) and type 2 diabetes mellitus (n=14, 13.1%). When we inquired about falls during the last 6 months of the consultation, 47 (39.8%) patients reported having fallen at least once, while 31 (26.3%) had experienced two or more falls. Moreover, 14 (13.0%) patients with PD had 22 prior fragility fractures and, fractures were multiple in five (4.67%) of them. Fracture bone sites were wrist (n=8; 36.36%), costs (n=5; 22.72%), clavicle (n=4; 18.18%), shoulder (n=3; 13.63%), pelvis (n=1; 4.54%) and elbow (n=1; 4.54%).

Table 1 indicates the clinical features and the main demographic of those who participated in the study, and also the univariate analysis for osteoporosis and osteopenia according to the NOF guidelines. The following variables were associated with osteoporosis based on the NOF guidelines: female gender, lower handgrip strength, lower body mass index, lower appendicular skeletal muscle mass index, lower calf circumference, and lower gait speed. These variables entered the multinomial logistic regression model ( Table 2) and only lower appendicular skeletal muscle mass index was independently associated with osteoporosis with statistical significance. The multinomial logistic regression model did not include calf circumference since it has a high correlation with another variable in the analysis, appendicular lean mass.

Table 3 shows the univariate analysis for osteoporosis and osteopenia according to the WHO recommendations. The following variables were associated with osteoporosis based on WHO recommendations: female gender, lower handgrip strength, lower body mass index, lower appendicular skeletal muscle mass index, lower calf circumference and lower gait speed. These variables entered the multinomial logistic regression model ( Table 4) and only lower appendicular skeletal muscle mass index was independently associated with osteoporosis with statistical significance. The multinomial logistic regression model did not include calf circumference since it has a high correlation with another variable in the analysis, appendicular lean mass.

Table 5 presents overall agreement results between the NOF and WHO diagnosis by Fleiss' kappa coefficient. There was substantial overall agreement between both diagnostic criteria for normal, osteopenia and osteoporosis in this sample. Table 6 shows patients who received different diagnoses based on the NOF and WHO diagnostic criteria.

Figure 1 illustrates the association of osteoporosis, osteopenia and normal bone mass according to the NOF guidelines with appendicular lean mass adjusted for height in meters squared. Table 7 displays the fracture locations for each patient who positively answered to a prior fracture in the FRAX questionnaire.

According to Tables 1 and 3, patients with PD and osteoporosis exhibit lower BMI, reduced handgrip strength, decreased appendicular muscle mass (resulting in smaller calf circumference), and slower gait speed. These factors together point to indicators of frailty which is very prevalent in PD patients ( 24).

Discussion

The goal of the present study was to assess the pervasiveness of osteopenia and osteoporosis in PD patients who are dealing with HY stages 1 to 3, which were found to be 42.1% and 34.6% following NOF criteria, respectively, and were found to be 43% and 33.6% following the WHO recommendations.

The prevalence of osteoporosis and osteopenia was quite similar between the NOF and WHO criteria in our study. While the NOF considers a more comprehensive evaluation of fracture risk using the FRAX instrument ( 6), the WHO is primarily concerned with BMD and the presence of osteoporotic fractures ( 5). The choice between the two sets of criteria is based on the doctor's preferences and the clinical information provided by the patient. Six individuals in our sample had FRAX values indicating a high 10-year risk of fracture but no history of fractures, as well as osteopenia by DXA. Thus, the WHO labeled these patients as having osteopenia, but the NOF diagnosed them with osteoporosis. Meanwhile, four individuals with densitometric osteopenia suffered minor low-impact fractures, but had a low 10-year fracture risk based on FRAX score, with no need for treatment.

Overall, many factors may play a role in the development of bone loss associated PD, such as reduced mobility, malnutrition, low BMI, decreased muscular strength, drug usage, as well as insufficiency of vitamin D ( 25). Torsney et al. ( 26) demonstrated a higher association between PD with osteoporosis and osteopenia compared to healthy adults. The OR combination for osteoporosis in PD was 2.61 (1.69-4.03).

Ozturk et al. ( 25) managed to show that the lumbar and femoral BMD levels were inferior in the advanced stages and also in the early stages of PD, including HY 1-1.5. It is logical to deduce that bone mass might be impacted prior to the manifestation of motor symptoms, specifically during the prodromal period of PD. Furthermore, it can be proposed that PD is not only a chronic neurodegenerative disorder, but also a systemic catabolic process that impacts the musculoskeletal system ( 25). It is also suggested that trunk muscular strength is intimately linked to lumbar spine BMD, and there is an independent association between leg muscle strength and hip BMD in female patients ( 26). Additionally, alongside reduced axial mobility, postural changes such as anteflexion caused by increased abdominal rigidity with disease progression not only provoke festination, but also diminish axial loading on the lumbar spine due to forward displacement of the center of gravity. By reducing mechanical pressure on vertebrae, the decline in axial loading on lumbar vertebrae in an erect posture may potentially contribute to a low lumbar spine BMD ( 27).

Considering the patients with osteoporosis and osteopenia from our sample, 60% and 43% were woman, respectively. Most patients in our sample were male, aligning with studies that indicate a higher prevalence of the disease in males ( 27). The main reasons are that men tend to exhibit greater bone density. Females also experience bone loss at a younger age and a more accelerated pace than males, resulting in higher levels of bone resorption markers. These factors collectively lead to women who are 50 or older showing a fourfold higher osteoporosis rate and a twofold higher osteopenia rate compared to men ( 28).

Gao et al. ( 29) discovered that BMD in PD patients was significantly lower when compared to healthy controls during a cross-sectional study of 54 patients dealing PD and 59 age-matched controls. According to this study, the BMD scores of the total hip, lumbar and the femoral neck were reduced in females compared to males in the healthy group. Females in the PD group exhibited notably decreased BMD in the hip compared to males. They also identified a significant negative correlation between BMD in the femoral neck, lumbar spine and total hip and the overall severity of PD. In our study, 78% of osteoporosis patients had moderate-stage disease (HY 2.5-3), while 22% had mild-stage disease (HY 1-2).

Lorefalt et al. ( 30) discovered that BMD in the entire body, femoral neck and total hip was lower and declined throughout the examined year in 26 PD patients compared to 26 age and sex-matched healthy controls. Reduced body weight and decreased physical activity were identified as risk factors for low BMD in PD, while stiffness appeared to be rather protective. Schneider et al. ( 31) researched a cohort study that examined 8,105 older women with known PD status (n = 73 with PD) for six years. In comparison to women without PD, age-adjusted mean total hip BMD scored 7.3% lower in women with PD. Evatt et al. ( 32) determined that vitamin D deficiency was significantly more prevalent in PD patients (55%) than in age-matched healthy controls (36%) and those with Alzheimer's disease (41%). It is important to note that PD patients have inadequate calcium intake and minimal sun exposure ( 32).

A cross-sectional observational study conducted on subjects ≥20 years based on the Korea National Health and Nutrition Examination Survey (KNHANES) ( 33) demonstrated that physical and anthropometric composition parameters showed remarkable correlation with BMD in all age groups for both men and women. Data from the KNHANES (2005-2008), answered by adults in their 50s and older (n = 3.296), indicated that each increment in BMI was linked to a rise of 0.0082 g/cm ² in BMD, and a 10-unit increment in BMI can aid in restoring BMD levels back to normal.

Saarelainen et al. ( 34) discovered that women with a BMI of 20 kg/m ² had diminished bone mass at the femoral neck and the spine at 2 and 4 years after their menopause, respectively, while women with a BMI of 30 kg/m ² showed diminished bone mass at the femoral neck and the spine at 5 and 9 years after their menopause, respectively.

Our study also found a statically significant association between lower lean appendicular mass and osteoporosis in multinomial logistic regression analysis. This finding is an important contribution to the growing body of research as it suggests the critical role of muscle quality in bone health ( 35).

The mechanism underlying this association could be related to the mechanical loading exerted by muscles on bones, thereby stimulating bone formation and decreasing the risk of osteoporosis ( 28). Furthermore, muscles and bones share common anabolic pathways, and muscle-derived factors, such as irisin, may directly influence bone metabolism. The protective role of lean mass could therefore be attributed to these mechanical and biochemical interactions between muscles and bones ( 36).

This study also sheds light on the specific population of PD patients who are known to be at higher risk for osteoporosis due to factors like physical inactivity, vitamin D deficiency, and direct neurodegenerative effects on bone metabolism ( 37). While these findings are promising, it is important to consider that the handgrip strength test is a surrogate measure of overall muscle mass and not a direct measure. Although it has been widely used and validated in the research setting, it may not fully represent the complex interplay of factors that contribute to bone health, such as regional differences in muscle and bone mass ( 38- 41).

The association we found among osteoporosis and calf circumference, gait speed and handgrip strength are well-established parameters for assessing muscle and bone health ( 42). As muscle wasting is a well-recognized problem in PD ( 43), interventions that can help maintain or increase muscle mass may not only improve physical functioning, but also protect against osteoporosis. This underscores the undeniable need of comprehensive care for patients who struggle with PD, which should not only include pharmacological therapy but also physical and nutritional interventions ( 44).

It is worth noting that some studies have focused on identifying predictive factors for imminent fractures, meaning fractures expected to occur within the next 2 years, and found that poorer health status, slower walking speed, the presence of comorbidities, and a higher risk of falls are all predictors of an imminent fracture risk ( 45- 47). An imminent fracture risk corresponds to a very high risk of fracture, warranting consideration of anabolic therapy. We argue whether advanced PD, being a condition associated with frailty and high risk of falls, should not be considered as a predictor of imminent risk for fracture ( 48- 50). In essence, the association of these findings (such as appendicular lean mass and gait speed) with osteoporosis within PD patients suggests a potential need for more effective osteoporosis treatments, specifically anabolic therapies ( 20).

Furthermore, according to numerous authors and the consensus of the American College of Clinical Endocrinologists (AACE), the risk of falls is another critical aspect that categorizes patients as having a very high risk ( 51, 52). The incidence of falls experienced by these patients in the past year was nearly 40%, underscoring the critical need for fracture prevention in this population.

In summary, we found that approximately 33.6-34.6% of these patients have osteoporosis, with 14 patients (13%) having a history of fractures alongside sarcopenia, reduced gait speed, and an increased propensity to falls.

Nevertheless, our study does have some limitations. Firstly, the cross-sectional nature of the present study reduces its ability to establish causal relationships. Longitudinal studies are necessary to confirm the protective effect of lean mass on bone health in patients with PD. Secondly, as mentioned earlier, handgrip strength is a surrogate measure of overall muscle strength. Future studies should consider using more direct measures of muscle quality. Thirdly, severe disease cases (HY 4-5) were not included in the study, therefore our findings refer to mild to moderate disease (HY 1-3). Fourthly, we did not perform a vertebral fracture assessment (VFA) or conventional lateral thoracic and lumbar spine X-ray to investigate subclinical morphometric vertebral fractures.

Despite these limitations, our findings contribute to a growing body of evidence suggesting that lean mass may play a critical role in bone health, particularly in populations which are at risk for osteoporosis, like those with PD. They highlight the need for further research in this area, both to confirm these findings and to identify effective interventions for improving muscle mass and bone health in these patients.

In conclusion, our findings provide additional evidence that lean mass may have a protective role against osteoporosis in patients with PD. Future research should continue to explore the implications of these findings on preventing and managing osteoporosis in this population, with a focus on interventions that can enhance muscle mass and strength.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Hospital Universitário Walter Cantidio. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

DL: Writing - original draft, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. FC-N: Writing - original draft, Investigation. JG: Writing - original draft, Investigation. YM: Writing - original draft, Investigation. SA: Writing - original draft, Conceptualization. CF: Writing - original draft, Investigation. LG: Writing - original draft, Investigation. IR: Writing - original draft, Investigation. FL: Writing - original draft, Investigation. LA: Writing - original draft, Investigation. AV-J: Writing - original draft, Formal Analysis. KA: Writing - original draft, Conceptualization. JR-F: Writing - original draft, Supervision. CD'A: Writing - original draft, Supervision. RM-J: Writing - original draft, Supervision, Funding acquisition. PB-N: Writing - original draft, Supervision, Funding acquisition.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

# data[].attributes.attachment_link.title
Frontiers | Osteoporosis in Parkinson's disease and the role of lean body mass: a cross-sectional study in a Brazilian tertiary center

# data[].attributes.attachment_link.description
Background: Parkinson's disease (PD) is the second most common neurodegenerative illness and has the highest increase rate in recent years. There is growing ...

# data[].attributes.attachment_link.title
Ambulatory activity in incident Parkinson’s: more than meets the eye? - PubMed

# data[].attributes.attachment_link.description
Physical activity is important for people with Parkinson’s disease (PD) to improve disease-specific impairment and ameliorate secondary consequences related to deconditioning. Activity may also have a neuroprotective role if instigated early. Ambulatory activity has not been examined in incident PD. …

# data[].attributes.attachment_link.title
Bone Mineral Density and Serum Vitamin D Status in... : Neurology India

# data[].attributes.attachment_link.description
valuate the relationship between BMD and serum vitamin D level and stage or clinical features of the PD. Materials and Methods: One hundred twenty-four patients with PD recruited from Movement Disorders Outpatient Clinic and age- and sex-matched 116 healthy controls were included in the study. BMD and serum vitamin D level of all participants were measured. After patients had been divided into four groups according to Hoehn and Yahr (H and Y) staging, a total of 5 groups with controls, BMD (lumbar and femoral) and serum vitamin D level were compared between groups. The relationship between the clinical features of the PD [disease duration, medication history, Unified Parkinson’s Disease Rating Scale (UPDRS) part II and III, and subscores of UPDRS part III] and BMD or vitamin D was investigated. Results: Lumbar and femoral BMD values and serum vitamin D level were significantly lower in patients with PD compared to controls. Low BMD and low serum vitamin D level were identified in the early stages of the disease (H and Y stage 1 and 1.5) and were marked by the progress of the stage of the disease. There was a negative relationship between the clinical features of the PD and both BMD and serum vitamin D level. Conclusion: All patients with PD should be screened for developing osteoporosis and for sufficient vitamin D level in the early stages of the disease. Preventive methods for bone quality should be taken into consideration at the onset of PD.…

# data[].attributes.attachment_link.title
Causal effects of Parkinson’s disease on the risk of... : Medicine

# data[].attributes.attachment_link.description
Genomics Consortium and the Genetic Factors for Osteoporosis Consortium. We meticulously selected instrumental variables based on strict criteria, including significance thresholds, linkage disequilibrium, and the exclusion of confounding single-nucleotide polymorphisms. Our investigation utilized diverse MR methods, including inverse variance weighted, MR Egger regression, weighted median, and MR-PRESSO, to robustly evaluate the causal relationship. Our comprehensive analysis revealed noteworthy associations between PD and distinct measures of bone mineral density (BMD) (forearm BMD, femoral neck BMD, lumbar spine BMD). Specifically, the inverse variance weighted method underscored potential significant relationships between PD and forearm BMD (P = .037; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.00–1.09), femoral neck BMD (P = .034; OR, 1.02; 95% CI, 1.00–1.05), and lumbar spine BMD (P = .043; OR, 1.03; 95% CI, 1.00–1.06). The consistency of results across various methods and sensitivity analyses indicated both robustness and minimal pleiotropy concerns. Through a two-sample MR approach, this study establishes a plausible causal relationship between PD and decreased BMD. The outcomes underscore the urgency of targeted interventions to mitigate bone loss and manage osteoporosis in individuals with PD.…

# data[].attributes.attachment_link.readable_text
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Affiliations

¹ Department of Family Medicine, Hanyang University College of Medicine, Seoul, South Korea.

² Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, South Korea.

³ Department of Statistics and Actuarial Science, Soongsil University, Seoul, South Korea.

⁴ Department of Family Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea.

Affiliations

¹ Department of Family Medicine, Hanyang University College of Medicine, Seoul, South Korea.

² Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, South Korea.

³ Department of Statistics and Actuarial Science, Soongsil University, Seoul, South Korea.

⁴ Department of Family Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea.

Abstract

Background: Whether bone mineral density (BMD) is related to the risk of Parkinson's disease (PD) is unclear.

Objectives: The objective of this study was to examine the association between BMD status and incident PD in postmenopausal women.

Methods: We retrospectively examined a nationwide cohort of 272,604 women aged 66 years who participated in the 2009-2012 Korean national health screening for transitional ages. BMD was evaluated using dual-energy X-ray absorptiometry of the central bones. The use of antiosteoporosis medications (AOMs) was assessed. We performed multivariable Cox proportional hazards regression to evaluate the association between BMD and PD risk by calculating hazard ratios (HRs) and 95% confidence intervals (CIs).

Results: During the median follow-up of 7.7 years, 2,884 (1.1%) incident PD cases developed. After adjusting for confounding factors, lower BMD was associated with an increased risk of PD (P for trend <0.001). Individuals with osteoporosis had a 1.40-fold higher HR (1.40, 95% CI: 1.25-1.56) than those with a normal BMD. Sensitivity analyses suggested the associations robust to longer lag periods and further adjustment. These associations were prominent in individuals without AOM use before or after enrollment (P for interaction = 0.031 and 0.014). Increased risks of PD in individuals with osteopenia and osteoporosis who did not use AOMs were attenuated by the medication use during the follow-up period, regardless of previous AOM use.

Conclusions: Lower postmenopausal BMD and osteoporosis were associated with an increased risk of PD. In addition, this association could be mitigated using AOMs. Proper management of BMD in postmenopausal women may help prevent PD. © 2023 International Parkinson and Movement Disorder Society.

Keywords: Parkinson's disease; bone mineral density; cohort study; epidemiology; osteoporosis.

PubMed Disclaimer

References

Armstrong MJ, Okun MS. Diagnosis and treatment of Parkinson disease: a review. J Am Med Assoc 2020;323:548-560.

Schapira AHV, Chaudhuri K, Jenner P. Non-motor features of Parkinson disease. Nat Rev Neurosci 2017;18:435-450.

Chaudhuri KR, Healy DG, Schapira AHV, National Institute for clinical excellence. Non-motor symptoms of Parkinson's disease: diagnosis and management. Lancet Neurol 2006;5:235-245.

Wood B, Walker R. Osteoporosis in Parkinson's disease. Mov Disord 2005;20:1636-1640.

Zhao Y, Shen L, Ji H-F. Osteoporosis risk and bone mineral density levels in patients with Parkinson's disease: a meta-analysis. Bone 2013;52:498-505.

# data[].attributes.attachment_link.keywords[]
national center for biotechnology information

# data[].attributes.attachment_link.title
Bone Mineral Density and the Risk of Parkinson's Disease in Postmenopausal Women - PubMed

# data[].attributes.attachment_link.description
Lower postmenopausal BMD and osteoporosis were associated with an increased risk of PD. In addition, this association could be mitigated using AOMs. Proper management of BMD in postmenopausal women may help prevent PD. © 2023 International Parkinson and Movement Disorder Society.

# data[].attributes.attachment_link.title
Recurrent falls in Parkinson’s disease: a systematic review - PubMed

# data[].attributes.attachment_link.description
Most people with Parkinson’s disease (PD) fall and many experience recurrent falls. The aim of this review was to examine the scope of recurrent falls and to identify factors associated with recurrent fallers. A database search for journal articles which reported prospectively collected information …

# data[].attributes.body
Parkinson's Foundation

# data[].attributes.attachment_link.readable_text
This Parkinson's Foundation initiative offers genetic testing and counseling at no cost for people with Parkinson's disease (PD). When you participate, you can help scientists in their journey to better understand how Parkinson's works, leading to new, more effective therapies.

# data[].attributes.attachment_link.description
The Parkinson's Foundation makes life better for people with Parkinson's disease (PD) by improving care and advancing research toward a cure.

# data[].attributes.headline
NICE - Guideline Osteoporosis: assessing the risk of fragility fracture

# data[].attributes.subject
NICE - Guideline Osteoporosis: assessing the risk of fragility fracture

# data[].attributes.attachment_link.title
Overview | Osteoporosis: assessing the risk of fragility fracture | Guidance | NICE

# data[].attributes.attachment_link.description
This guideline covers assessing the risk of fragility fracture in people aged 18 and over with osteoporosis. It aims to provide guidance on the selection and use of risk assessment tools in the care of adults at risk of fragility fractures in all NHS settings

# data[].attributes.headline
GOV.UK - Vitamin D - advice on supplements for at risk groups

# data[].attributes.subject
GOV.UK - Vitamin D - advice on supplements for at risk groups

# data[].attributes.attachment_link.title
Vitamin D - advice on supplements for at risk groups

# data[].attributes.attachment_link.description
Vitamin D - advice on supplements for at risk groups

# data[].attributes.headline
NICE - Guidance Falls: assessment and prevention in older people and in people 50 and over at higher risk

# data[].attributes.subject
NICE - Guidance Falls: assessment and prevention in older people and in people 50 and over at higher risk

# data[].attributes.attachment_link.title
Falls: assessment and prevention in older people and in people 50 and over at higher risk

# data[].attributes.attachment_link.description
This guideline covers assessing risk of falling and interventions to prevent falls in all people aged 65 and over, and people aged 50 to 64 who are at higher risk of falls.

# data[].attributes.headline
NICE - Guideline on Parkinson's disease in adults

# data[].attributes.subject
NICE - Guideline on Parkinson's disease in adults

# data[].attributes.attachment_link.title
Parkinson's disease in adults | Guidance and guidelines | NICE

# data[].attributes.attachment_link.description
Evidence-based recommendations on diagnosing and managing Parkinson's disease in people aged 18 and over

# data[].attributes.headline
NICE - Guidance Vitamin D: supplement use in specific population groups

# data[].attributes.subject
NICE - Guidance Vitamin D: supplement use in specific population groups

# data[].attributes.attachment_link.title
Vitamin D: supplement use in specific population groups | Guidance and guidelines | NICE

# data[].attributes.attachment_link.description
Evidence-based recommendations on increasing vitamin D supplement use in at-risk groups

# data[].attributes.headline
Parkinson's UK - Foundation Learning Programme

# data[].attributes.subject
Parkinson's UK - Foundation Learning Programme

# data[].attributes.attachment_link.description
This suite of 8 free, online courses will develop your knowledge, understanding, and confidence to improve services and support for people living with Parkinson’s.

# data[].attributes.headline
Parkinson's UK - Exercise: Parkinson's Essentials

# data[].attributes.subject
Parkinson's UK - Exercise: Parkinson's Essentials

# data[].attributes.attachment_link.description
A free 15-minute online, interactive course for exercise professionals exploring what Parkinson’s is and how you can support your patients.

# data[].attributes.headline
Parkinson's UK - Foundation Learning Programme

# data[].attributes.subject
Parkinson's UK - Foundation Learning Programme

# data[].attributes.attachment_link.description
This suite of 8 free, online courses will develop your knowledge, understanding, and confidence to improve services and support for people living with Parkinson’s.

# data[].attributes.headline
Parkinson's UK - Managing bone health and fracture risk

# data[].attributes.subject
Parkinson's UK - Managing bone health and fracture risk

# data[].attributes.attachment_link.title
Parkinson’s: managing bone health and fracture risk

# data[].attributes.attachment_link.description
This free online course from Parkinson’s UK Excellence Network and the Open University is for Parkinson’s specialist nurses and other clinicians, to enhance understanding and recognition of bone health issues in Parkinson’s.

# data[].attributes.headline
Parkinson's UK - Physiotherapy: Parkinson's Essentials

# data[].attributes.subject
Parkinson's UK - Physiotherapy: Parkinson's Essentials

# data[].attributes.attachment_link.description
A free 15-minute online, interactive course for physiotherapy professionals exploring what Parkinson’s is and how you can support your patients.

# data[].attributes.attachment_link.provider_name
The Michael J. Fox Foundation for Parkinson's Research | Parkinson's Disease

# data[].attributes.attachment_link.readable_text
Parkinson's Disease Biomarker Found

Our landmark PPMI study helped discover a biological test that can detect Parkinson's. This discovery was made possible by thousands of study participants. Now, more volunteers are needed. Join the study that's changing everything.

Over $ 1 billion funded in research programs to date

You too can make a difference.

"Parkinson's patients are the experts on what we have. We have a responsibility as patients to share our experience - what works for us, what we respond to, what we can contribute to research."

- Michael J. Fox

"Participating in research changes how you view your diagnosis... and the world around you. It makes you feel like you are playing an important role in solving a problem that affects millions of people."

- Dan Kinel, Rochester, NY

# data[].attributes.attachment_link.title
The Michael J. Fox Foundation for Parkinson's Research

# data[].attributes.attachment_link.description
The Michael J. Fox Foundation is dedicated to finding a cure for Parkinson's disease through an aggressively funded research agenda and to ensuring the development of improved therapies for those living with Parkinson's today.

# data[].attributes.attachment_link.description
We're the Parkinson's charity that drives better care, treatments and quality of life. Because we're here, no one has to face Parkinson's alone.

# data[].attributes.body
Parkinson's Foundation

# data[].attributes.attachment_link.readable_text
This Parkinson's Foundation initiative offers genetic testing and counseling at no cost for people with Parkinson's disease (PD). When you participate, you can help scientists in their journey to better understand how Parkinson's works, leading to new, more effective therapies.

# data[].attributes.attachment_link.description
The Parkinson's Foundation makes life better for people with Parkinson's disease (PD) by improving care and advancing research toward a cure.

# data[].attributes.attachment_link.title
Spotlight YOPD – Shining a light on Young Onset Parkinson’s Disease

# data[].attributes.attachment_link.description
Young Onset Parksinson’s affects those diagnosed with Parkinson’s around age 50 or under. Join us in raising awareness and supporting those affected.​

# data[].attributes.attachment_link.title
Benefits and safety of dietary protein for bone health—an expert consensus paper endorsed by the European Society for Clinical and Economical Aspects of Osteopororosis, Osteoarthritis, and Musculoskeletal Diseases and by the International Osteoporosis Foundation - Osteoporosis International

# data[].attributes.attachment_link.description
A summary of systematic reviews and meta-analyses addressing the benefits and risks of dietary protein intakes for bone health in adults suggests that dietary protein levels even above the current RDA may be beneficial in reducing bone loss and hip fracture risk, provided calcium intakes are adequate. Several systematic reviews and meta-analyses have addressed the benefits and risks of dietary protein intakes for bone health in adults. This narrative review of the literature summarizes and synthesizes recent systematic reviews and meta-analyses and highlights key messages. Adequate supplies of dietary protein are required for optimal bone growth and maintenance of healthy bone. Variation in protein intakes within the “normal” range accounts for 2–4% of BMD variance in adults. In older people with osteoporosis, higher protein intake (≥ 0.8-g/kg body weight/day, i.e., above the current RDA) is associated with higher BMD, a slower rate of bone loss, and reduced risk of hip fracture, provided that dietary calcium intakes are adequate. Intervention with dietary protein supplements attenuate age-related BMD decrease and reduce bone turnover marker levels, together with an increase in IGF-I and a decrease in PTH. There is no evidence that diet-derived acid load is deleterious for bone health. Thus, insufficient dietary protein intakes may be a more severe problem than protein excess in the elderly. Long-term, well-controlled randomized trials are required to further assess the influence of dietary protein intakes on fracture risk.

# data[].attributes.headline
Parkinson's UK - YouTube  Channel (Exercises)

# data[].attributes.subject
Parkinson's UK - YouTube  Channel (Exercises)

# data[].attributes.attachment_link.description
Share your videos with friends, family, and the world

# data[].attributes.attachment_link.title
Movers and Shakers | A podcast about life with Parkinson's | Sign the Parky Charter

# data[].attributes.attachment_link.description
Movers and Shakers finds six friends - Rory Cellan-Jones, Gillian Lacey-Solymar, Mark Mardell, Paul Mayhew-Archer, Sir Nicholas Mostyn and Jeremy Paxman - gathered in a Notting Hill pub to discuss the realities of life with Parkinson's. And maybe find a few silver linings!

# data[].attributes.headline
North of Scotland Parkinson's Research Pod

# data[].attributes.subject
North of Scotland Parkinson's Research Pod

# data[].attributes.attachment_link.title
The North of Scotland Parkinson’s Research Podcast Series | The North of Scotland Parkinson’s Research Interest Group

# data[].attributes.attachment_link.description
The North of Scotland Parkinson’s Research Interest Group (NoSPRIG) is part of a nationwide network of research groups supporting Parkinson’s UK by increasing awareness and involvement in research at a regional level. We comprise of people with Parkinson’s…

# data[].attributes.attachment_link.title
Saturday S158 Managing multi-morbidity in rehabilitation R Davies