Summary
ONERO is an exercise program shown to improve bone mass and functional risk factors for falling and fracture for people living with osteroporosis. It was developed from a series of groundbreaking randomised controlled trials (the LIFTMOR and MEDEX-OP trials) conducted through Griffith University, Gold Coast, Australia. The caveat was the program required heavy lifting, once thought to be too risky for osteoporosis. We found it could be achieved with proper supervision so we opened a translational research clinic, The Bone Clinic (Brisbane, QLD Australia), and implemented Onero for people living with poor bone health, using only trained exercise practitioners. We monitor effectiveness and safety of Onero in this high risk population through ongoing rigorous standardised data collection in this real life clinic setting in order to measure meaningful improvements in the lives of older people. Results from The Bone Clinic have been as impressive as the clinical trial findings, helping hundreds of ageing adults to prevent debilitating osteoporotic fracture. To increase the availability of Onero beyond The Bone Clinic but maintain safety and fidelity of the program, we licensed Onero so it can be delivered by physiotherapists and exercise physiologists anywhere. Over the last 5 years we have grown the number of Onero providers around Australia to over 90 (in 39 clinics) and have recently begun distributing the program internationally. As the global population ages, so does chronic disease increase. Onero not only prevents osteoporotic fracture but reduces other chronic diseases that respond to exercise intervention, thereby improving longevity and quality of life.
Planning and Implementation
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What was the challenge you were trying to address?
Osteoporosis is a condition of very low bone mass that greatly increases the risk of low trauma fracture. Primarily a condition of later life, the trend of aging populations will increase the already substantial global personal and financial burden of osteoporosis. In 2010, there were an estimated 137 million women and 21 million men over the age of 50 at high risk of osteoporotic fracture, and this number is expected to double by 2040. Exercise has been proposed as a potential strategy to manage osteoporosis for many years, but in reality, the magnitude of benefit from exercise intervention was modest at best. Bone responds preferentially to weight bearing loading that induces high magnitude strains at high rates. High intensity, progressive resistance and impact weight bearing training (HiRIT) can generate such loads but was assumed to be too dangerous for individuals with fragile skeletons. As a result, osteoporosis exercise guidelines typically recommended only moderate intensity exercises that would be ineffective for building bone, but would reduce falls, and thereby fracture. In the absence of any safety data for HiRIT exercise with osteoporosis, we felt we could do better than this. The LIFTMOR trial was the first to examine the efficacy of supervised bone-targeted HiRIT for improving bone mass in postmenopausal women at risk of osteoporotic fracture, followed by the LIFTMOR-M trial (older men), then the MEDEX-OP trial (HiRIT +/- bone medications). All studies reported greater efficacy than moderate-intensity exercise programs, and excellent safety. The next challenge was to implement the program broadly while retaining fidelity and safety.
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Who were you trying to impact?
Older people in general, Older people with chronic health conditions or disability, Older people with vulnerabilities
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What sectors were you targeting?
Education, Health, Information and Communication
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Who else was involved?
Academia, Health Care, Private Sector
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How did older people participate?
Older people were part of the process at multiple or all stages
Lessons learned
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Please describe how collaboration worked in your initiative.
Many years of academic research collaboration, involvement in and contribution to scientific and professional bodies (American College of Sports Medicine, Australian and New Zealand Bone Mineral Society, American Society for Bone and Mineral Research, Exercise and Sport Sciences Australia, Sports Medicine Australia, Fragility Fracture Network, etc) as well as not-for-profit osteoporosis consumer-advocacy organisations (Healthy Bones Australia), underwrote the creation of The Bone Clinic and the Onero program. At the grass roots level ongoing collaboration with primary care providers and patients ensures optimal patient-centred application of our non-pharmacological program for osteoporosis.
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What was the impact of your initiative on older people, their families, and/or their communities?
It is difficult to describe the magnitude of the impact of improving strength, function, mobility and confidence to the feelings of well-being and quality of life experienced by clients of The Bone Clinic and Licensees delivering the Onero program. The most deconditioned clients normally experience the greatest gains from Onero – benefits that are magnified by simultaneous improvements in other body systems and chronic conditions. We have a number of video testimonials which would articulate these benefits in very personal ways, which I may be able to provide if permission is obtained. I will also upload a plot of physical outcomes measured from over 400 clients who have completed a minimum of 12 months of Onero training in the relevant section below.
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What issues did you face, and how did you address them?
Running a busy translational research clinic as a health service certainly has its challenges. As access and evidence is our primary goal, profit is secondary. This means clients are charged the minimum amount for classes and services that will allow us to remain viable. This approach maximises equity for consumers by minimising financial barriers to participate, but limits funding available to support a dedicated research assistant to undertake regular data analysis. COVID also created a hurdle – forcing The Bone Clinic and most of our Onero Licensees to close doors for an extended period (4 months for The Bone Clinic). This not only placed extreme pressure on business viability, but interrupted Onero training for clients who required face-to-face classes for reasons of safety. It was the clients who championed our return to full function post-COVID shutdown and who continue to motivate me to continue to persevere with our lofty goals in this challenging endeavour.
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What lessons did you learn from implementing this initiative?
1) The abilities of older adults should not be underestimated. 2) There is huge demand for evidence-based non-pharmacological interventions for chronic disease for ageing adults. 3) The benefits of targeted exercise greatly transcend the physical for older adults.
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Do you have any other reflections you would like to share?
We understand a high intensity exercise program is not for everyone, and many people do not live near us or an Onero provider. In the interests of equity and reach, we created Onero Online to fill the void for these people. Onero Online is not the same as Onero. It is a very low cost strength, mobility and falls prevention program based on exercises used in evidence-based fall prevention programs with the addition of exercises to help maintain bone mass - all designed to be safe when undertaken unsupervised. Onero Online is intentionally a lower intensity program than Onero and therefore does not target bone as heavily as Onero but is likely to prevent osteoporotic fracture by preventing falls.