Volume 87, Issue 7, Pages 914-917 (July 2006)

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The Relation Between Previous Fractures and Physical Performance in Elderly Women

Abstract

Gerdhem P, Ringsberg KA, Åkesson K. The relation between previous fractures and physical performance in elderly women.

Objective

To examine the association between previous fracture and different aspects of physical performance.

Design

Population-based retrospective study.

Setting

Orthopaedic research department.

Participants

Randomly selected women (N=1044), all 75 years old and participants of the Malmö Osteoporosis Prospective Risk Assessment study.

Interventions

Not applicable.

Main Outcome Measures

Type of and time since any previous fracture event were compared with results of tests on physical performance function (Romberg test, computerized sway test, gait speed, questionnaire) at the age of 75.

Results

Women with no previous fractures (n=505) had a better median Romberg balance of 94 seconds (interquartile range [IQR], 75–118s) than women with 1, 2, or 3 or more fractures, who had a median balance of 88 seconds (IQR, 71–111s), 85 seconds (IQR, 68–107s), and 81 seconds (IQR, 65–109s), respectively (Kruskal-Wallis analysis of variance, P=.002). Balance was inferior in women who had sustained a previous fracture between the ages of 65 and 75 years compared with women with no previous fractures or fractures before the age of 65 years. Gait speed and questions on tendency to fall followed the same pattern. The computerized sway test could not differ between women with and without previous fractures.

Conclusions

Poor physical performance is associated with previous fractures. Inferior physical performance may exist up to 10 years after a fracture.

Key Words: Balance , Elderly , Fractures , Rehabilitation , Women

Article Outline

• Abstract

• Methods

• Participants

• Fractures

• Balance

• Gait

• Questionnaire

• Statistics

• Results

• Romberg Test

• Sway Test

• Gait

• Questionnaire

• Discussion

• Conclusions

• References

• Copyright

SEVERAL FACTORS MAKE UP the risk for fracture at old age.1 The most widely studied is low bone mass. In addition, decreased balance is an important risk factor for fracture,2, 3 and impaired balance may also be more important than osteoporosis at old age.4 Balance is a complex function and is composed by visual and sensory inputs and vestibular and neuromuscular function.5 Also among reported risk factors for fracture are slow gait and decreased vision,2, 6, 7 both measures that are related to balance. There are several reports8, 9, 10, 11, 12, 13 concerning decreased balance and function a few years after a fracture. There is only 1 study covering a longer time span (17y)14 and none with an even longer perspective. Also, balance and function seem to be less affected after a wrist fracture than after a hip, arm, or vertebral fracture.13, 14

Our aim with this study was to investigate balance and other physical performance variables (gait performance, falling tendency) after a previous fracture in elderly women. Do women with earlier fractures have inferior physical performance at the age of 75 years compared with women with no previous fracture? If so, is the inferior physical performance a condition affected by type of and time from fracture occurrence?

Methods

Participants

From December 1995 to May 1999, 75-year-old women were randomly recruited from the city files of Malmö, Sweden, to participate in the Malmö Osteoporosis Prospective Risk Assessment (OPRA) study.15 Of the initially invited 1604 women, 1044 (65%) women participated in the baseline investigation. As stated elsewhere,15 560 women did not participate (13 died, 139 were ill, 376 were not interested or could not attend for reasons other than illness, 32 could not be reached). Of the participants, 40 had a modified examination at home.

The Ethics Committee of Lund University approved the study, and informed consent was obtained from all subjects.

Fractures

All radiographs and radiography files have been saved since the beginning of the 1900s at the Malmö University Hospital, which makes it possible to trace all women with fractures that have been x-rayed at our hospital. In addition, each woman was asked to record age and type of any previous fracture and where fracture treatment had taken place. If a self-assessed fracture could not be verified in the radiography archives, an additional search was performed in the files of the orthopedics department unless fracture treatment had taken place elsewhere. In these cases no further verification was made. For this specific study, a fracture was considered to have occurred if the participant had a self-assessed fracture or a fracture registered in the radiography archive.

Of the women who had at least 1 self-assessed fracture in the questionnaire, 21% had no fracture registered in the hospital files and had not registered the fracture as treated elsewhere. Sixteen percent of the women with no self-assessed fracture in the questionnaire had in fact had at least 1 fracture according to the radiography archive.

Balance

The 2 different balance tests used here have been described.15 The Romberg test for standing balance consists of 5 parts: (1) standing on both legs with feet together and eyes closed; the time until balance was lost or a maximum of 60 seconds was recorded and (2–5) standing on 1 leg at a time with eyes open or closed; the maximum time in these tests were 30 seconds. A result of less than 5 seconds in one of the standing balance tests was registered as 0. The best of 3 trials per test was registered. The results were added, and the maximum was 180 seconds (eg, in the case of a failure of one 1-legged stance test but success in the other 4 parts, the maximum would be 150 points instead of 180). The Romberg test was performed and a score was obtained for 1018 women. Intraclass correlation coefficients (ICCs) for Romberg interrater reliability have been reported to be between .73 and .93; intrarater reliability has been reported between .95 and .99.16

A Chattecx computerized balance system,a consisting of independent force-measuring transducers (footplates) for the toe and heel of each foot, was used to test static and dynamic balance. Subjects were assessed using four 25-second standing balance tests: (1) stable platform with eyes open, (2) stable platform with eyes closed, (3) platform gliding horizontally, backward, and forward with eyes closed, and (4) platform moving up and down with eyes open. At least 1 of these 4 parts was performed by 979 women. A sway index was calculated by this equipment by using the standard deviation of the time and the distance a subject spent away from her center of balance for each test. ICCs for retest reliability of the Chattecx computerized balance system have been reported to be greater than .65 for static tests and greater than .35 for dynamic tests.17, 18

Gait

The women were instructed to walk as fast as they could in their ordinary shoes back and forth along a 15-m distance (total distance, 30m). The turn was included in the time recorded. The women were closely monitored during the test. Gait speed was obtained for 983 women.

Questionnaire

A perceived tendency to fall or not was registered. This question was added during the course of the study, and answers were available in 903 women.

Statistics

Groups were compared with nonparametric tests (Mann-Whitney U test, Kruskal-Wallis), parametric tests (t test, analysis of variance [ANOVA]), or—in the case of dichotomous variables—a chi-square test. P less than .05 was considered significant. For comparisons the women were divided into those with or without any fracture, those with 1, 2, or 3 or more previous fractures, and according to some fracture types (hip, vertebral, wrist or proximal humerus fractures). The women were also divided into groups according to the age when the last fracture occurred (<55, 55–59, 60–64, 65–69, 70–75y).

Results

All women were 75 years old at the examination date (range, 75.0–75.9y). We found that 535 of 1044 women had had a previous fracture. In 82% of the women with at least 1 fracture, the last fracture was sustained after the age of 55 years. A tendency to fall was perceived by 372 of 903 (41%) women. The results from the sway test and gait were normally distributed, but the Romberg balance test had a skewed distribution and therefore nonparametric tests were used for the statistical calculations of this variable.

Romberg Test

The group of women with a previous fracture had an inferior result on the Romberg test when compared with the group of women without previous fractures (table 1). Women with a previous hip fracture had an inferior result compared with women with no fracture or no previous hip fracture (see table 1). When the women were subdivided into groups according to number of previous fractures, we found that each additional fracture was associated with a further decrease in the Romberg test result (table 2).

Table 1.

Inferior Balance Was Seen in Women With a Fracture History Compared With Women Without Any Fractures


Fracture History	Romberg		P⁎	Gait		P†
Fracture History	n	Median (Range; IQR) (s)	P⁎	n	Mean ± SD (Range) (s)	P†
All women	1018	90(0–159;71–114)		983	25±8(14–105)
No fracture	505	94(0–159;75–118)		487	24±9(14–105)
Any fracture	513	87(0–141;68–110)	<.001	496	25±9(14–93)	.090
Hip fracture	50	77(0–137;65–99)	.003	48	28±9(18–64)	.002
Wrist fracture	204	87(0–140;67–109)	.005	199	24±8(14–64)	.330
Vertebral fracture	56	81(0–135;62–110)	.012	49	29±14(15–93)	<.001
Proximal humerus fracture	44	84(0–140;60–108)	.012	43	30±12(17–66)	<.001

NOTE. Slower 30-m gait was seen in women with previous hip, vertebral, or proximal humerus fractures compared with women without fractures. The women are divided into subgroups according to previous fracture history and compared with women with no previous fractures.

Abbreviations: IQR, interquartile range; SD, standard deviation.

⁎

Mann-Whitney U test.

†

t test.

Table 2.

With Each Additionally Sustained Fracture, the Romberg Test Result Decreased (Kruskal-Wallis, P=.002)


Fracture History	Romberg		Gait
Fracture History	n	Median (Range by 1st and 4th quartiles) (s)	n	Mean ± SD (Range) (s)
No fractures	505	94(0–159;75–118)	487	24±8(14–105)
One fracture	305	88(0–141;71–111)	293	24±7(15–58)
Two fractures	121	85(0–140;68–107)	118	26±10(16–66)
Three or more fractures	87	81(0–137;65–109)	85	27±12(14–93)

NOTE. The same pattern was seen with gait speed at the 30-m walk (ANOVA, P=.002).

To elucidate the possible long-term effect of a fracture on balance ability, we looked at the time between the examination and the most recent fracture. Women with fractures after the age of 65 years had an inferior Romberg balance result compared with women with no fracture history. Women with the most recent fracture before the age of 65 years did not have an inferior balance result compared with women without previous fractures (fig 1). Excluding women whose most recent fracture was a lower-extremity fracture did not change the result, and the same pattern was evident (data not shown). Women with fractures earlier in life had had fewer fractures than women with their most recent fractures at an older age (data not shown).

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Fig 1. Women with no previous fractures had better balance, measured with the Romberg test (range, 0−180s), than women whose most recent fracture had occurred at 65 to 75 years of age. There was no difference in balance between women with a fracture before the age of 65 years and women with no previous fractures. P values denote significance for comparisons with women without previous fractures (Mann-Whitney U test).

Sway Test

The computerized sway test was unable to distinguish between participants with and without a fracture history (P range, .08–.94).

Gait

The group of women with any previous fracture or wrist fracture did not have slower gait than women with no previous fracture. Women with hip, vertebral, and proximal humerus fractures had a slower gait speed than women without a previous fracture (see table 1). Each additional fracture was associated with slower gait (see table 2).

Questionnaire

A perceived tendency to fall was more common in women with any fracture (48%) and previous hip (57%), wrist (48%), or vertebral fracture (72%) compared with women with no previous fractures (34%) (P<.001, P=.002, P<.001, P<.001, respectively). A perceived tendency to fall in women with proximal humerus fractures (49%) was not significantly lower (P=.051) when compared with women with no previous fractures. Each additional fracture was associated with a higher percentage of women with a self-perceived tendency to fall (44%, 45%, 64%, respectively) compared with women without a previous fracture (34%) (χ2 test, P<.001). Women with a perceived tendency to fall had a lower median Romberg test result than women without any perceived tendency to fall (81s; range, 0–143s vs 97s; range, 0–159s; P<.001).

Discussion

In this population-based study we have found that 75-year-old women with earlier fractures have inferior balance compared with women with no previous fractures. Women with several previous fractures have a poorer balance performance than women with few or no previous fractures at the age of 75 years. Women who had their most recent fracture before the age of 65 years have a balance similar to women without a previous fracture. To our knowledge, this is the only study to cover the association between balance and previous fractures with a time-span of up to 75 years.

The simple Romberg test was able to discriminate between women with and without previous fractures, which is in concordance with others9, 11, 13, 14 who have compared differences in balance, gait, or other measures of physical performance up to 17 years after a fracture history. In this study, the Romberg test results of women with specific types of fractures versus women without fractures differed by up to 17 seconds, with corresponding gait speed results that were up to 12% lower (see table 1). These differences may be clinically significant. The Romberg test has been frequently used because it is a simple measure of balance function. It has been shown to predict falls in the OPRA cohort19 and to predict injurious falls in another cohort.20 Various other balance tests have been shown to predict falls or fractures in other cohorts.6, 21, 22

The seemingly more sophisticated method, the computerized balance platform, measuring postural sway, could not discriminate between women with and without previous fractures in this study. A recent publication19 from the OPRA cohort could not find any predictive value for falls or fractures during a 1-year prospective follow-up for this specific computerized balance plate. However, other sway tests have been able to discriminate between subjects with and without a recent fracture10, 11 and also have a prospective fall-23 and fracture-predicting ability.3 How sway is measured, therefore, seems important.

We found normalized Romberg balance when the most recent fracture event occurred before the age of 65 years (see fig 1). There are several possible explanations for this finding. Fractures sustained at earlier ages may occur in women with a more physically active lifestyle (therefore having better balance) who at the same time expose themselves to a greater risk of injury—for example, in sports. A lower-limb disability, for example, due to a lower-limb fracture may affect the Romberg balance result. A recent hip fracture could affect balance11, 13 and functioning12, 14, 24 more than, for example, a recent wrist fracture.9, 13 However, when all lower-extremity fractures were excluded the result was the same, which indicates that fracture location may be of less importance for the results achieved in this study. Because each additional fracture was associated with a decreased Romberg test result (see table 2), we cannot exclude the possibility that a higher number of previous fractures in women after the age of 65 years also could affect these results. Another possible explanation could be that a fracture after the age of 65 years gives a higher level of dysfunction and therefore a more impaired balance.

Gait speed correlated fairly well to balance (r=−.50) in a subset of women taking part in the OPRA study.25 That gait shows the same pattern of change in reference to previous fractures is therefore not surprising. This is also consistent with the only prospective studies (0.5-y and 8-y follow-up) on the effect of fracture on physical performance.12, 13 A smaller effect of wrist fractures on physical performance (including gait and balance) is also consistent with other reports.9, 13, 14

In a retrospective study there is always the question of what comes first, impaired balance leading to a fracture or fracture leading to impaired balance. Nevertheless, our study clearly shows that impaired balance is associated with previous fracture. Impaired balance is a risk factor for future fractures.1, 19, 26 An improvement of balance may therefore be of the utmost importance in patients with several previous fractures. Self-efficacy, in this study represented by the question on perceived tendency to fall, may also be important to address.

This study has some limitations. The attendance rate was high (65%), but the nonattendees may represent a frailer subgroup of the population, and as many as 27% claimed illness as a reason not to participate.15 The data may not be valid for this frailer subgroup. One also has to be aware of the drawbacks of retrospective fracture registration. However, considering the retrospective nature of this study, we believe that it is very difficult or impossible to achieve 100% verification of fractures covering a time-span of up to 75 years. In this study, we accepted that 21% of the women had fractures that were not objectively verified. Even if not recorded by the women, fractures may have been treated elsewhere, considering the long time period this study covers.

Valid information on the circumstances that led to the fracture was not available. Some fractures may have been due to traffic collisions, but even if so, such a fracture would presumably give an effect on balance because of disability or fear of falling. Inferior balance is associated with falling tendency,21 which is one of the more important risk factors for fractures,2, 27 and interventions for fall prevention include balance training, which may also be successful at higher ages.26

Conclusions

In elderly women, previous fractures are associated with inferior physical performance and a perceived tendency to fall. Physical performance is mostly impaired in those with hip and multiple fractures. An association between a fracture and decreased physical performance may last for several years. In the elderly, fracture treatment (medical, surgical, physiotherapeutic) should aim at minimizing the effects on physical function, which also may be beneficial in decreasing future fracture risk.

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References

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Department of Orthopaedics, Malmö University Hospital, Lund University, Malmö, Sweden.

Correspondence to Paul Gerdhem, MD, PhD, Dept of Orthopaedics, Malmö University Hospital, Lund University, SE 205 02 Malmö, Sweden

Supported by the Swedish Medical Research Council and Trygg-Hansa Research Fund.

No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

Reprints are not available from the author.

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PII: S0003-9993(06)00328-5

doi:10.1016/j.apmr.2006.03.019

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