One leg standing time predicts fracture risk in older women independent of clinical risk factors and BMD

Plantar cutaneous sensation is independently associated with postural balance and lower limb motor function in older adults: the Shizuoka study

PURPOSE

A relationship between decreased plantar cutaneous sensation and impaired balance function has been reported in patients with peripheral neuropathy and diabetes. This cross-sectional study aimed to investigate the relationship between plantar sensation and postural balance, as well as the association between plantar sensation and sarcopenia-related motor function in community-dwelling older adults.

METHODS

The participants included 1659 community-dwelling older adults with a mean age of 74 ± 5 years, of which 43% were male patients. Plantar cutaneous sensation thresholds were assessed using an automatic plantar sensation testing device. Postural balance was measured using one-leg standing (OLS) time. Grip strength, five-time sit-to-stand (STS) time, and normal gait speed were measured as components of muscle strength and physical function related to sarcopenia. The skeletal muscle mass index (SMI) and leg phase angle were obtained using bioelectrical impedance analysis.

RESULTS

Age, sex, body mass index, and leg phase angle, but not SMI and grip strength, were independently associated with the plantar sensation threshold. Plantar sensation threshold was independently associated with the OLS time (P = 0.001) and STS time (P = 0.001) after adjusting for potential confounders. No significant association was found between plantar sensation threshold and normal gait speed (P = 0.741).

CONCLUSION

Plantar sensation was independently associated with postural balance and lower limb function in community-dwelling older adults. The assessment of plantar sensation could be useful for identifying factors contributing to poor postural balance and lower limb motor function.

Are balance and lower extremity muscle strength correlated with fracture risk independent of bone mineral density in postmenopausal women?: A cross-sectional study

BACKGROUND

Postmenopausal women are at increased risk of fractures due to reduced bone mineral density (BMD) and impaired physical function. While fracture risk assessment tools like FRAX include clinical factors and BMD, they exclude functional measures such as balance and muscle strength, which are critical for fall prevention. This study aimed to evaluate the correlation between two functional tests- the 30-Second Sit to Stand Test (30STS) and the One Leg Stance Test (OLST)- and fracture risk, independent of BMD in postmenopausal women aged 50-70.

METHODS

This cross-sectional study included 156 postmenopausal women aged 50-70. Fracture risk was assessed using FRAX. Postural balance was evaluated using the OLST, while lower extremity muscle strength was measured with the 30STS. Both tests were analyzed for correlations with 10-year risks of major osteoporotic fractures (MOF), hip fractures, femoral neck BMD, and T-score at the lumbar spine and femoral neck. Participants were grouped based on OLST (<10 s) and 30STS (<15 repetitions) cut-offs, and fracture risks were compared.

RESULTS

OLST and 30STS scores were significantly negatively correlated with 10-year hip fracture risk (r = -0.347, p < 0.001 and r = -0.197, p = 0.014, respectively). A significant negative correlation was also observed between OLST scores and 10-year MOF risk (r = -0.245, p = 0.002). Participants with OLST <10 s had significantly higher 10-year hip and MOF risks, while those with 30STS <15 had significantly higher 10-year hip fracture risk only. No correlation was found with femoral neck BMD.

CONCLUSION

LST and 30STS are associated with fracture risk independent of BMD in postmenopausal women aged 50-70. These practical tests may help identify individuals at higher fracture risk and support early interventions.

One-Leg Standing Test with Eyes Open as a Screening Tool for Prefrailty in Community-Dwelling Older Japanese Women

Background/Objectives: One-leg standing test with eyes open (OLST), a well-known balance assessment, is simple to implement and requires no special measuring equipment or space. Prefrailty has greater reversibility than frailty, and early detection of prefrailty is essential for frailty prevention in older adults, especially women. However, the association between the OLST and prefrailty remains unclear. Therefore, this study aimed to verify the relationship between the OLST and prefrailty and to validate the effectiveness of the OLST as a screening tool for prefrailty in older Japanese women. Methods: This study included 208 community-dwelling older women (mean age: 74.4 ± 5.1 years; range: 65-89) who underwent frailty assessments and OLST. Prefrailty was assessed using the Japanese version of the Cardiovascular Health Study (J-CHS) criteria. The association between prefrailty and OLST was assessed by binary logistic regression analysis, and receiver operating characteristic analyses were performed to examine the effectiveness of OLST as a screening tool for prefrailty. Results: OLST time was significantly associated with prefrailty, and those with higher OLST times were less likely to have prefrailty (ORs: 0.98; 95% CI: 0.97-0.99; p < 0.001). The area under the curve of the OLST for prefrailty was 0.713 (p < 0.001), and the optimal OLST cut-off time for discriminating prefrailty was 24 s (sensitivity: 0.56, specificity: 0.77). Conclusions: OLST could be used as a screening tool for prefrailty in older Japanese women. These findings may contribute to the early detection and prevention of frailty.

High physical activity is associated with greater cortical bone size, better physical function, and with lower risk of incident fractures independently of clinical risk factors in older women from the SUPERB study

The Physical Activity Scale for the Elderly (PASE) is a validated test to assess physical activity in older people. It has not been investigated if physical activity, according to PASE, is associated with fracture risk independently from the clinical risk factors (CRFs) in FRAX, bone mineral density (BMD), comorbidity, and if such an association is due to differences in physical performance or bone parameters. The purpose of this study was to evaluate if PASE score is associated with bone characteristics, physical function, and independently predicts incident fracture in 3014 75-80-yr-old women from the population-based cross-sectional SUPERB study. At baseline, participants answered questionnaires and underwent physical function tests, detailed bone phenotyping with DXA, and high-resolution peripheral quantitative CT. Incident fractures were X-ray verified. Cox regression models were used to assess the association between PASE score and incident fractures, with adjustments for CRFs, femoral neck (FN) BMD, and Charlson comorbidity index. Women were divided into quartiles according to PASE score. Quartile differences in bone parameters (1.56% for cortical volumetric BMD and 4.08% for cortical area, Q4 vs Q1, p = .007 and p = .022, respectively) were smaller than quartile differences in physical performance (27% shorter timed up and go test, 52% longer one leg standing time, Q4 vs Q1). During 8 yr (median, range 0.20-9.9) of follow-up, 1077 women had any fracture, 806 a major osteoporotic fracture (MOF; spine, hip, forearm, humerus), and 236 a hip fracture. Women in Q4 vs. Q1 had 30% lower risk of any fracture, 32% lower risk of MOF, and 54% lower risk of hip fracture. These associations remained in fully adjusted models. In conclusion, high physical activity was associated with substantially better physical function and a lower risk of any fracture, MOF and hip fracture, independently of risk factors used in FRAX, FN BMD, and comorbidity.

The role of different physical function tests for the prediction of fracture risk in older women

BACKGROUND

Physical function is an important risk factor for fracture. Previous studies found that different physical tests (e.g., one-leg standing [OLS] and timed up and go [TUG]) predict fracture risk. This study aimed to determine which physical function test is the most optimal independent predictor of fracture risk, together with clinical risk factors (CRFs) used in fracture risk assessment (FRAX) and bone mineral density (BMD).

METHODS

In total, 2321 women out of the included 3028 older women, aged 77.7 ± 1.6 (mean ± SD), in the Sahlgrenska University Hospital Prospective Evaluation of Risk of Bone Fractures study had complete data on all physical function tests and were included in the analysis. At baseline, hand grip strength, OLS, TUG, walking speed and chair stand tests were performed. All incident fractures were confirmed by X-ray or review of medical records and subsequently categorized as major osteoporotic fractures (MOFs), hip fractures and any fracture. Multivariate Cox regression (hazard ratios [HRs] and 95% confidence intervals [CIs]) analyses were performed with adjustments for age, body mass index (BMI), FRAX CRFs, femoral neck BMD and all physical function tests as predictors both individually and simultaneously. Receiver operating characteristic (ROC) analyses and Fine and Gray analyses were also performed to investigate associations between physical function and incident fractures.

RESULTS

OLS was the only physical function test to be significantly and independently associated with increased risk of any fracture (HR 1.13 [1.04-1.23]), MOF (HR 1.15 [1.04-1.26]) and hip fracture (HR 1.34 [1.11-1.62]). Adjusting for age, BMI, CRFs and femoral neck BMD did not materially alter these associations. ROC analysis for OLS, together with age, BMI, femoral neck BMD and CRFs, yielded area under the curve values of 0.642, 0.647 and 0.732 for any fracture, MOF and hip fracture, respectively. In analyses considering the competing risk of death, OLS was the only physical function test consistently associated with fracture outcomes (subhazard ratio [SHR] 1.10 [1.01-1.19] for any fracture, SHR 1.11 [1.00-1.22] for MOF and SHR 1.25 [1.03-1.50] for hip fracture). Walking speed was only independently associated with the risk of hip fracture in all Cox regression models and in the Fine and Gray analyses.

CONCLUSIONS

Among the five physical function tests, OLS was independently associated with all fracture outcomes, even after considering the competing risk of death, indicating that OLS is the most reliable physical function test for predicting fracture risk in older women.

Type 2 Diabetes and Fracture Risk in Older Women

Importance

The reasons for the increased fracture risk in type 2 diabetes (T2D) are not fully understood.

Objective

To determine if poorer skeletal characteristics or worse physical function explain the increased fracture risk in T2D.

Design, Setting, and Participants

This prospective observational study is based on the population-based Sahlgrenska University Hospital Prospective Evaluation of Risk of Bone Fractures study cohort of older women, performed in the Gothenburg area between March 2013 and May 2016. Follow-up of incident fracture data was completed in March 2023. Data analysis was performed between June and December 2023.

Exposures

Data were collected from questionnaires and through examination of anthropometrics, physical function, and bone measurements using bone densitometry (dual-energy x-ray absorptiometry), and high-resolution peripheral computed tomography. A subsample underwent bone microindentation to assess bone material strength index (BMSi).

Main Outcomes and Measures

Baseline assessment of bone characteristics and physical function and radiograph verified incident fractures.

Results

Of 3008 women aged 75 to 80 years, 294 women with T2D (mean [SD] age, 77.8 [1.7] years) were compared with 2714 women without diabetes (mean [SD] age, 77.8 [1.6] years). Women with T2D had higher bone mineral density (BMD) at all sites (total hip, 4.4% higher; femoral neck (FN), 4.9% higher; and lumbar spine, 5.2% higher) than women without. At the tibia, women with T2D had 7.4% greater cortical area and 1.3% greater density, as well as 8.7% higher trabecular bone volume fraction. There was no difference in BMSi (T2D mean [SD], 78.0 [8.3] vs controls, 78.1 [7.3]). Women with T2D had lower performance on all physical function tests. The study found 9.7% lower grip strength, 9.9% slower gait speed, and 13.9% slower timed up-and-go time than women without diabetes. During a median (IQR) follow-up of 7.3 (4.4-8.4) years, 1071 incident fractures, 853 major osteoporotic fractures (MOF), and 232 hip fractures occurred. In adjusted (for age, body mass index, clinical risk factors, and FN BMD) Cox regression models, T2D was associated with an increased risk of any fracture (HR, 1.26; 95% CI, 1.04-1.54) and MOF (HR, 1.25; 95% CI, 1.00-1.56).

Conclusions and Relevance

In this cohort study of older women, T2D was associated with higher BMD, better bone microarchitecture, and no different BMSi but poorer physical function, suggesting that poor physical function is the main reason for the increased fracture risk in T2D women.

Radiographic knee osteoarthritis severity has no impact on fall risk: the locomotive syndrome and health outcomes in the aizu cohort study (LOHAS): a cross-sectional study

BACKGROUND

To investigate factors that have an impact on the risk of falls and determine whether radiographic knee osteoarthritis (KOA) is a factor involved in falls independent of knee pain, psychological factors, and physical function.

METHODS

A cross-sectional analysis was conducted on 1083 subjects for the 2009 Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS). A logistic regression analysis was performed to examine the relationship between radiographic KOA and fall history.

RESULTS

Fall history was significantly associated with the severity of knee pain. Compared to subjects with no knee pain, the odds ratio (OR) was 1.53 times higher in the subjects with mild knee pain (95% confidence interval [CI]: 1.04-2.25), 1.69 times higher in those with moderate knee pain (95%CI: 1.03-2.79), and 2.98 times higher in those with severe knee pain (95%CI: 1.67-5.30). In subjects with depression, the OR was 1.91 (95%CI: 1.25-2.92), and in those with decreased mobility, the OR was 1.70 (95%CI: 1.08-2.69). Age, gender, knee crepitus, BMI, OLST, and sleeping pill use were not significantly associated with fall risk. In a multivariate analysis, radiographic KOA severity was not significantly associated with fall risk (OR 0.81, 95%CI 0.44-1.50 in mild OA; OR 1.10, 95%CI 0.57-2.14 in severe OA).

CONCLUSION

Knee pain, decreased mobility, and depression, but not the radiographic KOA severity, were significantly associated with a fall risk. Regardless of the individual's radiographic KOA severity, the risk of falls may be reduced by treating his/her knee pain, mobility problems, and/or psychological factors.

Geographic variation in bone mineral density and prevalent fractures in the Canadian longitudinal study on aging

Awareness of the prevalence of osteoporosis and fractures across jurisdictions can guide the development of local preventive programs and healthcare policies. We observed geographical variations in total hip bone mineral density and in the prevalence of major osteoporotic fractures across Canadian provinces, which persisted after adjusting for important covariates.

PURPOSE

We aimed to describe sex-specific total hip bone mineral density (aBMD) and prevalent major osteoporotic fractures (MOF) variation between Canadian provinces.

METHODS

We used baseline data from 21,227 Canadians (10,716 women, 10,511 men) aged 50-85 years in the Canadian Longitudinal Study on Aging (CLSA; baseline: 2012-2015). Linear and logistic regression models were used to examine associations between province of residence and total hip aBMD and self-reported MOF, stratified by sex. CLSA sampling weights were used to generate the prevalence and regression estimates.

RESULTS

The mean (SD) age of participants was 63.9 (9.1) years. The mean body mass index (kg/m2) was lowest in British Columbia (27.4 [5.0]) and highest in Newfoundland and Labrador (28.8 [5.3]). Women and men from British Columbia had the lowest mean total hip aBMD and the lowest prevalence of MOF. Alberta had the highest proportion of participants reporting recent falls (12.0%), and Manitoba (8.4%) the fewest (p-value=0.002). Linear regression analyses demonstrated significant differences in total hip aBMD: women and men from British Columbia and Alberta, and women from Manitoba and Nova Scotia had lower adjusted total hip aBMD than Ontario (p-values<0.02). Adjusted odds ratios (95% confidence intervals, CI) for prevalent MOF were significantly lower in women from British Columbia (0.47 [95% CI: 0.32; 0.69]) and Quebec (0.68 [95% CI: 0.48; 0.97]) and in men from British Columbia (0.40 [95% CI:0.22; 0.71]) compared to Ontario (p-values<0.03). Results were similar when adjusting for physical performance measures and when restricting the analyses to participants who reported White race/ethnicity.

CONCLUSION

Geographical variations in total hip aBMD and in the prevalence of MOF between provinces persisted after adjusting for important covariates which suggests an association with unmeasured individual and environmental factors.

Exercise therapy as a digital therapeutic for chronic disease management: consideration for clinical product development

Digital exercise therapies (DET) have the potential to bridge existing care gaps for people living with chronic conditions. Acting as either a standalone, embedded within multi-modal lifestyle therapy, or adjunct to pharmacotherapy or surgery, evidence-based DETs can favorably impact the health of a rapidly growing population. Given the nascent nature of digital therapeutics, the regulatory landscape has yet to mature. As such, in the absence of clear guidelines clinical digital product developers are responsible for ensuring the DET adheres to fundamental principles such as patient risk management and clinical effectiveness. The purpose of this narrative review paper is to discuss key considerations for clinical digital product developers who are striving to build novel digital therapeutic (DTx) solutions and thus contribute towards standardization of product development. We herein draw upon DET as an example, highlighting the need for adherence to existing clinical guidelines, human-centered design and an intervention approach that leverages the Chronic Care Model. Specific topics and recommendations related to the development of innovative and scalable products are discussed which ultimately allow for differentiation from a basic wellness tool and integration to clinical workflows. By embodying a code of ethics, clinical digital product developers can adequately address patients' needs and optimize their own future digital health technology assessments including appropriate evidence of safety and efficacy.

Hemoglobin Levels Improve Fracture Risk Prediction in Addition to FRAX Clinical Risk Factors and Bone Mineral Density

CONTEXT

Anemia and decreasing levels of hemoglobin (Hb) have previously been linked to increased fracture risk, but the added value to FRAX, the most utilized fracture prediction tool worldwide, is unknown.

OBJECTIVE

To investigate the association between anemia, Hb levels, bone microstructure, and risk of incident fracture and to evaluate whether Hb levels improve fracture risk prediction in addition to FRAX clinical risk factors (CRFs).

METHODS

A total of 2778 community-dwelling women, aged 75-80 years, and part of a prospective population-based cohort study in Sweden were included. At baseline, information on anthropometrics, CRFs, and falls was gathered, blood samples were collected, and skeletal characteristics were investigated using dual-energy x-ray absorptiometry and high-resolution peripheral quantitative computed tomography. At the end of follow-up, incident fractures were retrieved from a regional x-ray archive.

RESULTS

The median follow-up time was 6.4 years. Low Hb was associated with worse total hip and femoral neck bone mineral density (BMD), and lower tibia cortical and total volumetric BMD, and anemia was associated with increased risk of major osteoporotic fracture (MOF; hazard ratio 2.04; 95% CI 1.58-2.64). Similar results were obtained for hip fracture and any fracture, also when adjusting for CRFs. The ratio between 10-year fracture probabilities of MOF assessed in models with Hb levels included and not included ranged from 1.2 to 0.7 at the 10th and 90th percentile of Hb, respectively.

CONCLUSION

Anemia and decreasing levels of Hb are associated with lower cortical BMD and incident fracture in older women. Considering Hb levels may improve the clinical evaluation of patients with osteoporosis and the assessment of fracture risk.

Diurnal pattern of breaks in sedentary time and the physical function of older adults

BACKGROUND

The association of breaks in sedentary time with outcomes of physical function can vary according to the time of day. We examined the association of the diurnal pattern of breaks in sedentary time with physical function outcomes in older adults.

METHODS

A cross-sectional analysis was conducted among 115 older adults (≥60 years). The overall and time-specific breaks (morning: 06:00-12:00; afternoon: 12:00-18:00; evening: 18:00-24:00) in sedentary time were assessed using a triaxial accelerometer (Actigraph GT3X+). A break in sedentary time was defined as at least 1 min where the accelerometer registered ≥100 cpm following a sedentary period. Five physical function outcomes were assessed: handgrip strength (dynamometer), balance ability (single leg stance), gait speed (11-m walking), basic functional mobility (time up and go), and lower-limb strength (five times sit-to-stand). Generalized linear models were used to examine the associations of the overall and time-specific breaks in sedentary time with the physical function outcomes.

RESULTS

Participants showed an average of 69.4 breaks in sedentary time during the day. Less frequent breaks in the evening (19.3) were found than that in the morning (24.3) and the afternoon (25.3) (p < 0.05). Breaks in sedentary time during the day were associated with less time on gait speed in older adults (exp (β) = 0.92, 95% confidence interval [CI] 0.86-0.98; p < 0.01). Time-specific analysis showed that breaks in sedentary time were associated with less time on gait speed (exp (β) = 0.94, 95% CI 0.91-0.97; p < 0.01), basic functional mobility (exp (β) = 0.93, 95% CI 0.89-0.97; p < 0.01), and lower-limb strength (exp (β) = 0.92, 95% CI 0.87-0.97; p < 0.01) in the evening only.

CONCLUSION

A break in sedentary time, particularly during the evening, was associated with better lower extremity strength in older adults. Further strategies to interrupt sedentary time with frequent breaks, with an emphasis on evening hours, can be helpful to maintain and improve physical function in older adults.

The Effects of Er Xian Decoction Combined with Baduanjin Exercise on Bone Mineral Density, Lower Limb Balance Function, and Mental Health in Women with Postmenopausal Osteoporosis: A Randomized Controlled Trial

Background

Postmenopausal osteoporosis (PMOP) is a common disease in older women that can severely jeopardize their health. Previous studies have demonstrated the effect of Er xian decoction (EXD) or Baduanjin exercise (BE) on PMOP. However, reports on the effect of EXD combined with BE on PMOP are limited. This study aimed to investigate the impact of EXD combined with BE on bone mineral density (BMD), lower limb balance, and mental health in women with PMOP.

Methods

A 1 : 1 : 1 simple randomization technique was employed. Fifty participants with postmenopausal osteoporosis were allocated to three groups: the EXD group (EXD = 15); the BE group (BE = 18); and the combined group (EXD + BE = 17). After both 8 weeks and 16 weeks of intervention treatment, participants improved significantly with respect to BMD and the one-leg standing test (OLST), Berg balance scale (BBS), timed up and go (TUG) test, self-anxiety scale (SAS), and self-rating depression scale (SDS). The results were used to compare the effect of the intervention on BMD, lower limb balance function, and mental health in patients with PMOP.

Results

Compared to the EXD and BE groups, the EXD + BE group showed the strongest effects on BMD, lower limb balance function, and mental health (p < 0.01). A correlation between BMD and lower limb balance and mental health was noted in the EXD + BE group. The change in mental health (SAS score) was correlated with BMD (femoral neck) improvement.

Conclusions

The present study demonstrates that EXD combined with BE (EXD + BE) may have a therapeutic advantage over both monotherapies for treating BMD, lower limb balance function, and mental health in patients with PMOP. The feasibility of the approach for a large-scale RCT was also confirmed. Er xian decoction combined with Baduanjin exercise (EXD + BE) might offer a viable treatment alternative for participants with postmenopausal osteoporosis given its promising effects in disease control and treatment, with good efficacy and safety profiles.

The relationship between cervical proprioception and balance in patients with fibromyalgia syndrome

Proprioceptive abnormalities, balance, and postural disorders have been previously reported in fibromyalgia syndrome (FMS). Unlike previous research, the aim of this study was to compare the proprioception of the cervical region of patients with FMS with a healthy control group. The relationship between cervical proprioception impairment and loss of balance was also examined. A total of 96 female FMS patients and 96 female healthy control subjects were enrolled in this case-control study. The cervical joint position error test (CJPET) was administered to the patient and control groups for cervical proprioception evaluation. FMS patients were assessed with a visual analogue scale (VAS), fibromyalgia impact questionnaire (FIQ), and fatigue severity scale (FSS). Balance tests were applied to both groups. FMS patients had significantly impaired CJPET results in all directions (p < 0.001). There were significant positive correlations between FIQ scores and CJPET results (r = 0.542 and p < 0.001 for right rotation; r = 0.604 and p < 0.001 for left rotation; r = 0.550 and p < 0.001 for flexion; r = 0.612 and p < 0.001 for extension). Significant correlations were found between CJPET measurements and balance tests (for sit-to-stand test; r = 0.510 and p < 0.001 for right rotation; r = 0.431 and p < 0.001 for left rotation; r = 0.490 and p < 0.001 for flexion; r = 0.545 and p < 0.001 for extension), (for timed up and go test; r = 0.469 and p < 0.001 for right rotation; r = 0.378 and p < 0.001 for left rotation; r = 0.410 and p < 0.001 for flexion; r = 0.496 and p < 0.001 for extension) and (for one-legged balance test; r = -0.479 and p < 0.001 for right rotation; r = -0.365 and p < 0.001 for left rotation; r = -0.392 and p < 0.001 for flexion; r = -0.469 and p < 0.001 for extension). Cervical proprioception and balance were impaired in FMS patients. As the disease activity and fatigue level increased, so the deterioration in cervical proprioception became more evident. There were correlations that demonstrated an association between impaired cervical proprioception and poor balance tests. Therefore, proprioception and balance assessments should be integrated into the physical examination processes of FMS patients.