The health consequences of vertebral deformity in elderly Chinese men and women

Validation of the ECOS-16 Questionnaire in Koreans with Osteoporosis

Study Design

Prospective study.

Purpose

To evaluate the reliability and validity of the adapted Korean version of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (ECOS-16).

Overview of Literature

The validity of the Korean version of ECOS-16 has not been completely demonstrated.

Methods

Translation/retranslation of the English version of ECOS-16, and full cross-cultural adaptation were performed. The Korean version of a visual analog scale measure of pain, and the Korean versions of ECOS-16 and of the previously validated short form-36 (SF-36) were mailed to 158 consecutive patients with osteoporosis. Factor analysis and reliability assessment using kappa statistics of agreement for each item, intraclass correlation coefficient, and Cronbach's α were done. Construct validity was evaluated by comparing responses to ECOS-16 with responses to SF-36 using Pearson's correlation coefficient.

Results

Factor analysis extracted three factors. All items had a kappa statistics of agreement >0.6. The ECOS-16 showed good test/re-test reliability (0.8469) and internal consistency of Cronbach's α (0.897). The Korean version of ECOS-16 showed significant correlation with SF-36 total scores and with single SF-36 domains scores.

Conclusions

The adapted Korean version of the ECOS-16 was successfully translated and showed acceptable measurement properties. It is considered suitable for outcome assessments in Korean patients with osteoporosis.

High risk of fall, poor physical function, and low grip strength in men with fracture-the STRAMBO study

BACKGROUND

Several studies assessed the association of prevalent fractures with muscle mass, strength, and physical capacity in men. Clinical impact of these associations is not clear, and they could be influenced by confounders. Our aim was to assess the association of the prevalent fractures with muscle strength, physical function, and the risk of subsequent falls in older men after adjustment for muscle mass and potential confounders.

METHODS

In a cohort of 890 men aged 50 and older, we assessed appendicular skeletal muscle mass (ASM) by DXA, grip strength, physical function (chair stands, static, and dynamic balance). Relative ASM (RASM) was calculated as ASM / (height)(2). Then, 813 men aged 60 and over were followed up prospectively for 5 years and 144 sustained >1 incident falls. All the analyses were adjusted for lifestyle factors, co-morbidities, and hormones known to influence muscle and physical function.

RESULTS

Low leisure physical activity, very high occupational physical activity, Parkinson's disease, diabetes mellitus, low apparent free testosterone concentration (AFTC), as well as Grade 2 and 3 vertebral fractures and multiple fractures were associated with lower grip strength when adjusted for confounders including upper limb RASM. Low leisure physical activity, very high occupational physical activity, diabetes mellitus, prior stroke, low AFTC and 25-hydroxycholecalciferol, high C-reactive protein, vertebral fractures, and non-vertebral fractures were associated with poor physical function (lowest quintile of the score of tests) when adjusted for confounders including lower limb RASM. Grade 2 and 3 and multiple vertebral fractures were associated with twofold higher risk of multiple falls after adjustment for confounders. Men having multiple fractures had a twofold higher risk of multiple falls after adjusting for confounders. In multivariable models, risk of falls increased proportionally to the increasing severity and number of vertebral fractures as well as to the increasing number of all fractures.

CONCLUSIONS

In older men, Grade 2 and 3 vertebral fractures and multiple vertebral and non-vertebral fractures are associated with lower grip strength, poor physical function, and higher risk of multiple falls after adjustment for multiple confounders. This suggests a real direct association. One fracture can initiate a vicious circle leading to another fracture; thus, patients with fractures need physical therapy regardless of their general health status.

Validation of the Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-26) in Korean population

We aimed to evaluate the reliability and validity of the adapted Korean version of the Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-26). Translation/retranslation of the English version of QUALEFFO was conducted, and all steps of the cross-cultural adaptation process were performed. The Korean version of the visual analog scale measure of pain, QUALEFFO-26 and the previously validated Short Form-36 (SF-36) were mailed to 162 consecutive patients with osteoporosis. Factor analysis and reliability assessment by kappa statistics of agreement for each item, the intraclass correlation coefficient and Cronbach's α were conducted. Construct validity was also evaluated by comparing the responses of QUALEFFO-26 with the responses of SF-36 using Pearson's correlation coefficient. Factor analysis extracted 3 factors. All items had a kappa statistics of agreement greater than 0.6. The QUALEFFO-26 showed good test/retest reliability (QUALEFFO-26: 0.8271). Internal consistency of Cronbach's α was found to be very good (QUALEFFO-26: 0.873). The Korean version of QUALEFFO-26 showed good significant correlation with SF-36 total score and with single SF-36 domains scores. The adapted Korean version of the QUALEFFO-26 was successfully translated and showed acceptable measurement properties and, as such, is considered suitable for outcome assessments in the Korean-speaking patients with osteoporosis.

Morphological changes of lumbar vertebral bodies and intervertebral discs associated with decrease in bone mineral density of the spine: a cross-sectional study in elderly subjects

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To investigate changes in the morphology of the lumbar vertebrae and intervertebral discs associated with osteoporosis of the spine in elderly subjects.

SUMMARY OF BACKGROUND DATA

Osteoporosis is a common condition that primarily affects the elderly with significant impact on quality of life. How exactly osteopenia and osteoporosis influence vertebral and intervertebral disc morphology remains unknown and needs exploration.

METHODS

A total of 395 community-dwelling ambulatory adults from 67 to 89 years of age were studied. The lumbar bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry. T2-weighted sagittal images of the lumbar spine were obtained using a 1.5-T magnet. For each subject, the anterior height (Ha), middle height (Hm), posterior height (Hp), and anterior-posterior (AP) dimension of the 5 lumbar vertebrae (L1-L5) and 6 intervertebral discs (T12-L1 to L5-S1) were measured. To minimize the age effect, volume of these vertebrae and discs was measured in subgroups of 47 men (mean age = 74 yr, range: 73-75 yr) and 67 women (mean age = 72 yr, range: 71-73 yr). Continuous variables were examined by analysis of covariance after adjustment of height and age.

RESULTS

There was no significant age difference between the groups of normal BMD, osteopenia, and osteoporosis. For the vertebral bodies, lower BMD was associated with a decrease of Ha, Hm, and Hp but not AP in both sexes, leading to an increased biconcavity index. For the discs, lower BMD was associated with a decrease of Ha and Hp, as well as AP, and an increase in Hm in both men and women. The disc biconvexity index was increased. Lower BMD is associated with an overall decrease in both vertebral volume and disc volume.

CONCLUSION

Lower BMD is associated with a decreasing trend in both lumbar vertebral and disc volumes in elderly subjects but an increase in the Hm of the intervertebral discs.

Epidemiology and structural basis of racial differences in fragility fractures in Chinese and Caucasians

Chinese have similar vertebral fracture prevalence but lower incidence of hip and distal forearm fractures than in Caucasians. The underlying structural and biomechanical basis of racial differences in bone fragility is still largely undefined but Chinese assemble their smaller appendicular skeleton with thicker cortices and trabeculae compared with Caucasians. Vertebral fracture prevalence is similar by race, but the incidence of hip and distal forearm fractures is lower in Chinese than in Caucasians. This racial dimorphism cannot be explained by differences in areal bone mineral density (aBMD) as aBMD is lower in Chinese mainly due to their smaller size. The underlying structural and biomechanical basis of racial differences in bone fragility is still largely undefined but Chinese assemble their smaller appendicular skeleton with more mineralised bone matrix within it; the cortices are thicker and perhaps less porous while trabeculae are fewer but thicker and more connected. This configuration produces a bone with a lower surface/volume ratio, which in turn reduces the surface available for remodelling to occur upon so that the lower surface/volume ratio may make the bone less exposed to remodelling and the thicker cortices and trabeculae less vulnerable to remodelling when it does occur during advancing age. However, prospective studies are needed to define racial differences at the age of onset, rate of bone loss from the intracortical, endocortical and trabecular components of the endosteal envelope and bone formation upon the periosteal envelope; notions of bone 'loss' are derived mainly from cross-sectional studies. Studies of the site- and surface-specific changes in bone modelling and remodelling are needed to better define racial differences in bone fragility in old age.

Validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-31) in Chinese

QUALEFFO-31 is a recently developed disease-specific instrument derived from QUALEFFO-41 and intended to have improved efficacy and response rates. We aimed to validate QUALEFFO-31 in Chinese and examine the use of QUALEFFO-31 in clinical practice. This questionnaire was translated into Chinese and applied to 118 case-control pairs aged between 50 and 85 years with prevalent osteoporotic vertebral fractures to evaluate its validity, repeatability, and discriminatory ability. It was also used to evaluate the quality of life (QOL) of 69 case-control trios with prevalent clinical and morphometric fractures. The QOL of all subjects was concurrently assessed using SF-36 for comparison. QUALEFFO-31 had good internal consistency with adequate convergent and discriminatory validity. The median test-retest repeatability ranged from 0.65-0.85. In general, there were good correlations between QUALEFFO-31 and SF-36. ROC curve analysis revealed that QUALEFFO-31 had significant ability to discriminate between clinical fracture subjects versus morphometric fracture subjects and controls. QUALEFFO-31 also demonstrated higher discriminatory capacity for pain. Subjects with clinical vertebral fractures (CVFs) had a significant reduction in QOL compared with other subjects. The QUALEFFO-31 is a useful tool for assessing QOL in Chinese. It was well accepted and significantly predictive of subjects with CVFs.

Cross-geographic region differences in quality of life in women with and without vertebral fracture

SUMMARY

Not much is known about cross-geographic region differences in quality of life (QoL) in women with and without prevalent vertebral fractures (VFX). QoL differed between continents, countries, and ethnicities. The observed differences in QoL mostly appeared larger than the difference in QoL between women with or without mild to moderate VFX.

INTRODUCTION

Quality of life (QoL) is an increasingly important outcome measure in randomized controlled trials and cost-utility studies. However, not much is known about cross-geographic region differences in QoL. The objective of this study was to describe the cross-geographic region differences in QoL in women with and without mild to moderate prevalent vertebral fractures (VFX).

METHODS

The study was performed using baseline data of the bazedoxifene study. The study was carried out in 25 countries in six continents (n = 7117). QoL was assessed using the index and Visual Analogue Scale (VAS) scores of the EQ-5D, Qualeffo-41, and Women's Health Questionnaire (WHQ). VFX were assessed using semi-quantitative and quantitative morphometric methods.

RESULTS

In general, all four instruments followed more or less the same pattern. In most analyses, the reported QoL was lowest in Asia and Europe and highest in North America and Oceania. To examine the influence of ethnicity, North and South America were stratified on race. In both continents, a lower QoL was observed in Hispanic people.

CONCLUSIONS

QoL differed between continents, countries, and ethnicities. The observed differences in QoL appeared larger between most continents and countries than the difference in QoL between women with or without mild to moderate VFX.

Effect of osteoporosis on morphology and mobility of the lumbar spine

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The purpose of this study was to examine disc morphology and spinal mobility in subjects with varying degrees of osteoporosis.

SUMMARY OF BACKGROUND DATA

There was limited information on the effect of osteoporosis on lumbar morphology and spinal mobility. It was also unclear how osteoporosis affects the nonosseous tissues such as the intervertebral disc.

METHODS

Ninety elderly subjects with varying bone mineral densities (22 normal, 28 osteopenia, 40 osteoporosis) were recruited from an osteoporosis clinic. Lateral radiographs and magnetic resonance images of their lumbar spines were obtained. An electromagnetic tracking device was employed to measure the ranges of motion of the whole lumbar spine.

RESULTS

Although the thoracic spine had been shown to have decreased anterior vertebral body height in subjects with osteoporosis, this study revealed that the anterior height was increased in the lumbar region. Osteoporosis was associated with expansion of the middle of the disc with corresponding collapse of vertebral bodies, but osteoporosis was found not to be related to either disc preservation or degeneration. No significant change in spinal mobility was observed in patients with osteoporosis.

CONCLUSION

Osteoporosis does not only affect the bone but also the nonosseous tissues. It was found to be associated with expansion of the intervertebral disc, which was likely to be secondary to changes in the vertebral endplate.

Impact of prevalent and incident vertebral fractures on utility: results from a patient-based and a population-based sample

Data are scarce on the impact of vertebral fractures (VFX) on utility. The objective of this study was to assess the impact of prevalent and incident VFX on utility in both a patient-based and population-based sample. Data from the Multiple Outcomes of Raloxifene Evaluation (MORE) study (n = 550 for prevalent VFX and n = 174 for incident VFX) and the European Prospective Osteoporosis Study (EPOS) (n = 236) were used. Utility was assessed by the index score of the EQ-5D. In the MORE study, highly statistically significant associations were found between utility and the presence of prevalent VFX (p < 0.001), number of prevalent VFX (p < 0.001), severity of prevalent VFX (p < 0.001), the combination of number and severity of prevalent VFX (p = 0.001) and location of prevalent VFX (p = 0.019). The mean utility was significantly lower among women who suffered an incident VFX (utility = 0.67) than among women who did not (utility = 0.77) (p = 0.005), although utility loss was not significantly different between the two groups (p = 0.142). In EPOS, the combination of number and severity of incident VFX was significantly related to utility (p = 0.030). In conclusion, utility is lower among persons with prevalent and incident VFX, especially in a patient-based sample. Utility loss was not significantly different between women without and with incident VFX.

Development of the Qualeffo-31, an osteoporosis-specific quality-of-life questionnaire

INTRODUCTION

Vertebral deformities are a common consequence of osteoporosis and are known to decrease quality of life. The Qualeffo-41 is a quality-of-life questionnaire especially developed for measuring quality of life in patients with vertebral deformities. It consists of 41 questions arranged in five domains: pain, physical function, social function, general health perception, and mental function. The objectives of this study were: (1) to develop a shorter version of the Qualeffo-41 by removing redundant questions; and (2) to investigate the scale characteristics, reliability, and validity of this shorter version.

METHODS

The study was performed using data from the Qualeffo validation study and the Multiple Outcomes of Raloxifene Evaluation (MORE) study. The analyses were performed in patients with vertebral deformities (n=579). Factor analysis on polychoric correlations and an item response theory (IRT) model, i.e., the generalized partial credit model (GPCM), were used to create a shorter version of Qualeffo-41. Using GPCM, scoring weights were computed for all items.

RESULTS

Three items were removed from the data set because of too many missing values. Factor analysis identified three instead of five domains: (1) pain, (2) physical function, and (3) mental function. Five items had factor loadings <0.4 and were not included in the GPCM. After excluding several items, the domains pain (four items), physical function (18 items), and mental function (nine items) showed a good, reasonable, and excellent fit, respectively. This indicates that the mental function domain and the pain domain are more unidimensional than the physical function domain. All three domains showed a very high correlation (r > or =0.95) with the corresponding domains of the Qualeffo-41.

CONCLUSIONS

Qualeffo-31 was developed, consisting of three domains with a reasonable to excellent fit to the GPCM. Although the fit to the GPCM supports the construct validity of the Qualeffo-31, validation in a new study should be performed before using it in practice.

Impact of vertebral deformities, osteoarthritis, and other chronic diseases on quality of life: a population-based study

Vertebral deformities and spinal osteoarthritis are common disorders in elderly persons and are associated with back pain, impaired physical functioning, and loss of quality of life. The objectives of this study were to assess the impact of vertebral deformities and osteoarthritis on quality of life in a population-based sample, and to compare this with the impact of six other important chronic diseases on quality of life. The study was performed as a substudy of the Longitudinal Aging Study Amsterdam. Vertebral deformities and osteoarthritis were assessed by spinal radiographs; chronic diseases were assessed by self-report; quality of life was estimated by the SF-12, EQ-5D (EuroQol) and Qualeffo-41 (n = 336). In univariate analyses, severe osteoporosis of the vertebrae significantly worsened the physical component summary scale of the SF-12 and the total score of Qualeffo-41, while osteoarthritis of the spine did not significantly reduce quality of life. The other chronic diseases reduced quality of life, although not all changes reached statistical significance. In multivariate analyses, severe osteoporosis of the vertebrae, cardiac disease, peripheral arterial disease, and diabetes mellitus significantly reduced quality of life. In conclusion, most persons in an elderly population suffer from one or more chronic diseases, and therefore experience loss of quality of life. After adjustment for age, sex, and other chronic diseases, severe osteoporosis of the vertebrae, cardiac disease, peripheral arterial disease, and diabetes mellitus significantly reduced quality of life in the general population.

Trunk deformity is associated with a reduction in outdoor activities of daily living and life satisfaction in community-dwelling older people

We have evaluated the association between trunk deformities of the sagittal plane and functional impairment of daily living in community-dwelling elderly subjects. The analysis involved a detailed assessment of indoor and outdoor activities of daily living, satisfaction with life, and mental status. The participants in this study were 236 community-dwelling older adults, aged 65 years and older, living in Kahoku district of Kochi in Japan. The participants were classified based on their posture, which was assessed using photographs of the subjects, and interviewed to assess their basic activities of daily living (BADL), instrumental ADL (IADL), and cognitive well-being in the cross-sectional study. The statistical analysis was performed using the Mann-Whitney U-test. The lumbar kyphosis group received significantly lower BADL and IADL scores than the normal group. The trunk deformity group which were defined as kyphosis, flat back, and lumbar lordosis groups exhibited decreases in activities that included going out, shopping, depositing and withdrawing money, and visiting friends in the hospital. These activities require going outdoors; thus, this study showed that the trunk deformity group had limitations in outdoor activities. There was no significant difference between the geriatric depression score (GDS) and the pattern of posture. The abnormal trunk deformity groups tended to score lower than the normal group with regard to subjective healthiness and life satisfaction measures, including subjective health condition, everyday feeling, satisfaction with human relationships, satisfaction with economic condition, and satisfaction with present life.

Epidemiology of osteoporosis

The epidemiology of osteoporosis is reviewed in this article. Attempts were made to answer the following questions: How should osteoporosis be defined? How can risk factors and bone mineral density (BMD) measurements be applied to diagnose osteoporosis? How do the rates for osteoporotic fractures vary by country, sex, age and time? What are the costs for osteoporosis in terms of direct and indirect cost, morbidity and mortality? According to the WHO criteria, osteoporosis can be defined as a BMD of 2.5 standard deviations or more below the young normal mean. BMD measurements are predictive of fracture risks. Hip fracture is by far the most costly of osteoporotic fractures, and the rates are highest in Caucasians, intermediate in Asians and lowest in Blacks. Risk factors could be used to assist in the decision to measure BMD.

Unresolved issues in osteoporosis in men

Fragility fractures in men are a public health problem. The increasing longevity in men is likely to increase the public health burden of fractures in men. This problem remains unrecognized by doctors, the public and governments. About one third of all hip fractures occur in men but the incidence and gender ratio varies from country to country for reasons that are not understood. The prevalence of spine fractures is about half that of women in most studies, but similar to that of women in several other studies. The incidence of spine fractures is uncertain but is likely to be about half that of women except in 80+ year olds, when it appears to be similar. The causes of the higher mortality in men than in women following hip or spine fracture are not well defined. Areal bone mineral density (aBMD) predicts fracture risk in men; the relative risk for spine and hip fracture conferred by a 1 SD lower aBMD, or by a prevalent fracture, is similar in men and women. The age-specific absolute risk (number of cases per 1,000 per year) conferred by a given hip aBMD is similar in men and women. The age-specific absolute risk conferred by aBMD at the calcaneus or radius for spine fracture is similar for men and women. If the absolute and relative risks are similar then the lower incidence of fractures in men than women may reflect the lower proportion of the male population distribution below a given structural determinant of bone fragility. That is, at any age, there may be fewer men than women with smaller bones, lower volumetric bone mineral density (vBMD), thinner trabeculae or cortices, architectural disruption, or higher remodeling rates. Higher mortality and fewer falls may also contribute to the lower incidence of fractures in men. This tail end of the male population distribution (for traits like bone size, vBMD, architecture, and remodeling rates) is the likely source of fracture cases in males. Hypogonadism is a risk factor for osteoporosis. However, the definition, prevalence, causes and structural consequence of hypogonadism are inadequately defined. At what level of testosterone is bone balance negative? What structural determinants of axial and appendicular strength are regulated by testosterone, estrogen, growth hormone (GH), insulin like growth factor 1 (IGF-1) (or their interactions)? Is reduced bone size in men with spine or hip fractures due to failed growth-related or age-related periosteal expansion? If reduced vBMD is due to reduced accrual, is this due to reduced cortical thickness? What factors regulate and coregulate the periosteal and endocortical modeling and remodeling? Are reduced trabecular numbers due to failed formation at the growth plate, excess resorption of primary trabeculae or reduced formation of secondary trabeculae? Is reduced trabecular thickness due to failed prepubertal or pubertal bone formation? Is reduced cortical and trabecular thickness during aging due to excessive endosteal resorption or reduced bone formation? If the former, is this due to increased remodeling sites or increased resorption depth? Most evidence favors reduced bone formation as the cause of bone loss with trabecular bone loss occurring by reduced formation and thinning more than by increased resorption and loss of connectivity. Cortical bone loss is less than in women because endocortical resorption is less and periosteal apposition is greater. If the reduced bone formation is most important, is this due to reduced osteoprogenitors, reduced osteoblast matrix synthesis or early osteoblast apoptosis? Anti-spine-fracture efficacy has been demonstrated in only one randomized heated with alendronate drug in men. The gaps in our knowledge remain large.