The widespread implementation of lockdown, travel bans, quarantine, isolation, and
social distancing due to the Coronavirus Disease 2019 (COVID-19) pandemic forces individuals
to stay at home for extended periods. These restrictions have led people to adopt
sedentary behavior, which is characterized by physical inactivity, poor dietary habits,
and irregular sleep patterns that promote deterioration of muscle mass and function,
loss of bone mineral density (BMD), and increase in body fat or adiposity. Moreover,
lengthy hospitalization due to COVID-19 infection can result in a prolonged period
of bed rest.
1
Such undesirable body composition is associated with various chronic, lifestyle-related,
non-communicable diseases such as sarcopenia, osteoporosis, frailty, obesity, dyslipidemia,
diabetes mellitus, hypertension, cardiovascular and cerebrovascular diseases, cognitive
impairment, and depression.
2,3
These comorbidities put individuals at greater risk of contracting COVID-19 infection
and developing a more severe course of disease with life-threatening complications.
4
-10
Sarcopenia and osteoporosis often termed as osteosarcopenia, are both age-related,
progressive decline of the bone-muscle unit which causes are multifactorial, with
the lack of physical activity and inappropriate nutrition playing pivotal roles. These
conditions often coexist, primarily affecting the older population and are responsible
for serious clinical, societal, social, and financial burdens. Genetic, developmental,
paracrine, endocrine, and lifestyle factors have dual effects on bone-muscle mass
and function. Sarcopenia is characterized by gradual and generalized wasting of muscle
mass, strength, and quality or a loss of physical performance, whereas osteoporosis
is described by low bone mass and microarchitectural damage to bone tissue resulting
in increased bone fragility and vulnerability to fracture. While osteopenia and osteoporosis
can be distinctly classified based on the BMD T-score, the staging for sarcopenia
widely depends on the cut-off values on whole-body dual-energy X-ray absorptiometry
(DEXA) scan of relative appendicular lean mass (RaLM).
11,12
The alteration in lifestyle behavior due to COVID-19 containment measures result in
the imbalance in muscle-bone unit synthesis and breakdown, leading to acute changes
in body composition described as osteosarcopenic obesity. This unfavorable state promotes
more oxidative stress and proinflammatory cytokines, exacerbating muscle dysfunction,
impaired locomotion, bone deterioration, and increased long-term health risks as well
as COVID-19 risk.
1
Bone loss was faster in osteosarcopenic compared to individuals with osteopenia or
sarcopenia only.
13
The odds ratio of fracture was over 2 to 3 times higher in osteosarcopenic compared
to those with normal BMD or normal muscle mass.
14,15
Also, the relative risk of fracture is higher among individuals with sarcopenia.
12
In the age of COVID-19, musculoskeletal injury is on the lower list of clinical priorities,
with many healthcare providers deferring or minimizing elective orthopedic services
to make room for COVID-19 patients. Unfortunately, delays in managing emergency trauma
or fracture cases, including seeking alternative or traditional treatments, can lead
to catastrophic events such as osteomyelitis, soft tissue infection, compartment syndrome,
delayed union, malunion, and nonunion.
16
This has broad implications for the care of patients with bone fragility, with more
efforts should be deployed to prevent fragility fractures. Otherwise, a surge in fracture
incidence and associated morbidity and mortality is expected in the near future.
17
During the COVID-19 period, the proportion of low-energy fall increased over 2 times
compared to the pre-pandemic. This injury mostly found in the elderly, resulting in
fragility fractures. Home-confinement contributed to a rise in the proportion of injuries
that occur at home, which was almost 4 times higher during the current outbreak.
18
Although the incidence of major traumas has decreased markedly since the start of
COVID-19 outbreak, the rate of fragility hip fracture remains unaffected.
19
Osteoporosis, which is a highly preventable and treatable condition, is on the rise
globally and it has a profound impact on the physical, psychological, as well as the
financial status of individuals and their caregivers.
17
Osteoporotic hip fracture remains a leading cause of morbidity and mortality in the
older population where this condition often causes functional disability with a 1-year
mortality of 20%.
20
Concomitant COVID-19 infection substantially increased the risk of mortality in patients
with hip fracture to around 36%.
21
This raises great concerns among the geriatric population, since they were among individuals
at high-risk of contracting COVID-19 or experiencing osteoporotic fractures. Besides,
it has been found that the 30-day mortality of fracture patients during the pandemic
was up to 2 times higher than that observed in the pre-pandemic situation.
18
The prevalence of sarcopenia was 37% among previously ambulatory, community-based
hip fracture patients. Other than the DEXA scan, the use of anthropometry, grip strength,
and self-reported mobility could be an alternative option for determining sarcopenia
in postoperative hip fracture patients.
22
However, these assessments did not predict the change in mobility in the year after
hip fracture.
23
Even though sarcopenia did not affect the 1-year mortality rate of patients with osteoporotic
hip fracture, it significantly increased the risk of 5-year mortality. Both perioperative
sarcopenia and osteoporosis affected the 5-year mortality rate.
24
An osteoporotic fracture occurs in 1 in 3 men and 1 in 5 women throughout their lifetime
with an estimated 5.8 million disability-adjusted life years (DALYs) are lost every
year.
25
The risk of recurrent fracture and fracture-associated complications is greatest in
the next 12 months after the initial osteoporotic fracture. Therefore, timely assessment
and management to prevent further fracture are imperative. A multidisciplinary approach
is recommended to guarantee not only adequate surgical treatment but also appropriate
care after discharge through a Fracture Liaison Service (FLS). Under normal circumstances,
clinical management of patients with suspected osteoporosis or fragility fractures
is already complex and neglected. Since the beginning of the outbreak, routine bone
density assessments, such as DEXA scan, are no longer feasible given the extensive
restrictions related to COVID-19 and limitations on in-person medical appointment.
This eventually increases reliance on the use of fracture risk calculators alone,
such as Fracture Risk Assessment Tool (FRAX).
17,20
Older people tend to have at least 1 comorbidity, which results in chronic, low-grade,
systemic inflammation and increases the likelihood of experiencing cytokine storm
when contracting COVID-19.
10,26,27
Sedentariness and/or immobilization accelerates the loss of muscle mass and strength
as well as depletion of bone density, which contribute to an increased risk of falls
as well as COVID-19-related complications.
2,21
Frailty worsens the physical and mental health status which hinders the recovery and
return to the independence of performing activities of daily living (ADLs) if it is
ever achieved.
4
Furthermore, long-term glucocorticoid treatment increases the risk of fragility fracture
and leads to steroid dependency.
28
The continuity of care is not only a prerequisite for successful treatment but also
crucial for maintaining patient safety for a particular treatment, such as bisphosphonates
and denosumab. Joint guidance on osteoporosis management in the COVID-19 era have
been introduced by a multi-stakeholder and international coalition convened by the
American Society for Bone and Mineral Research (ASBMR).
29
The use of telehealth appointment instead of traditional visit is strongly advised
to preserve the continuity of care, including access to rehabilitation while minimizing
the risk of nosocomial transmission. This online-based, audiovisual guided session
proved to be a cost-effective option and was not inferior to the conventional face-to-face
appointment.
30,31
However, weighing the risks and benefits of escalating or alternating treatment will
be challenging in the current climate.
20
Patients with sarcopenia and bone fragility are encouraged to practice a physically
active lifestyle, complemented with proper diet and nutrition as well as good sleep
quality and stress management.
1
A multicomponent exercise, including aerobic, resistance, balance, and coordination
training is advised to enhance their strength, balance, posture, gait, and ultimately
reduce the risk of falls. These home-based exercise programs, under the supervision
of medical expertise, are proven to be feasible and effective in improving the quality
of life of the elderly.
32
Regular exercise, when practiced in moderation, is associated with better physical
and psychological well-being, a boost in the immune system, and a lower risk of opportunistic
infections.
33
A balanced diet consisting of sufficient amounts of proteins, calcium, and various
micronutrients should not be underestimated.
11
Also, vitamin D supplementation should be recommended given the beneficial effects
not only on the skeleton but also on muscle function, gait, and immunity in patients
with COVID-19.
17,34
During and after the COVID-19 crisis, more attention should be directed to the care
of people with osteoporosis and sarcopenia, especially the susceptible elderly, to
avoid a spike in fracture cases and a wave of non-communicable diseases in the coming
years.
3
Healthcare workers are already overwhelmed by the increasing number of new COVID-19
cases, which pose a serious economic burden to the community. While mitigation approaches
must be increasingly enforced to limit the spread of infection, prevention strategies
through the practice of a physically active lifestyle and healthy, quality diet and
appropriate management with continuity of care are considered to be substantial correctable
factors in lowering morbidity and mortality associated with fragility fractures and
chronic conditions.1