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1.  Randomized controlled trial of a primary care–based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for skeletal health in Bristol and Avon (COSHIBA) 
Approximately 12% of postmenopausal women have osteoporotic vertebral fractures (VFs); these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures. Despite this, less than one-third come to clinical attention, partly due to lack of clear clinical triggers for referral for spinal radiographs. The aim of this study was to investigate whether a novel primary care–based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis. A randomized controlled trial was undertaken in 15 general practices within the Bristol area of the UK. A total of 3200 women aged 65 to 80 years were enrolled, with no exclusion criteria. A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs. All identified high-risk women were offered a diagnostic thoracolumbar radiograph. Radiographs were reported using standard National Health Service (NHS) reporting, with results sent back to each participant's general practitioner (GP). Participants in the control arm did not receive the screening tool or radiographs. The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a random 5% subsample verified against electronic GP records. Secondary outcome was self-reported incidence of new fractures. Results showed that allocation to screening increased prescription of osteoporosis medications by 124% (odds ratio [OR] for prescription 2.24 at 6 months; 95% confidence interval [CI], 1.16 to 4.33). Allocation to screening also reduced fracture incidence at 12-month follow-up (OR for new fracture 0.60; 95% CI, 0.35–1.03; p = 0.063), although this did not reach statistical significance. This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK. © 2012 American Society for Bone and Mineral Research
PMCID: PMC3378696  PMID: 22113935
2.  Epidemiology of falls and osteoporotic fractures: a systematic review 
Background and methods
Fractures in elderly populations result from the combination of falls and osteoporosis. We report a systematic review of studies indexed in PubMed reporting annual rates of low-trauma falls and associated osteoporotic fractures among older community-dwelling people (age ≥ 50 years). An osteoporotic fracture was defined as either a fracture resulting from a low-impact fall in subjects with clinical osteoporosis, a fall resulting in an investigator-defined osteoporotic fracture, or a fall resulting in a low-trauma fracture. Rates are presented using descriptive statistics. Meta-analysis was conducted for statistically homogeneous data sets.
The median (range) annual fall prevalence rates (median proportion of people who experienced one or more falls during the past year) for cohorts of women and men (10 determinations), women alone (seven determinations), and men alone (four determinations) were, respectively, 0.334 (0.217–0.625), 0.460 (0.372–0.517), and 0.349 (0.284–0.526). In studies that reported fall prevalence rates for Western men and women separately (four determinations), the pooled risk ratio (95% confidence interval [CI]) for men versus women was 0.805 (95% CI 0.721–0.900). The ranges of fall prevalence rates in East Asian women (two studies) and East Asian men (two studies) were, respectively, 0.163–0.258 and 0.087–0.184. The risk ratio (95% CI) for fall prevalence in East Asian men versus women was 0.634 (0.479–0.838) in studies (two determinations) reporting results for East Asian men and women separately. In cohorts of Western women and men (five determinations), the pooled rate (95% CI) of low-impact falls resulting in fractures was 0.041 (0.031–0.054). The proportion of low-trauma fractures attributable to falls among the Western community-dwelling elderly was within the range of 0.860–0.950 for fractures at all sites or the hip (five determinations). A range of 0.716–0.924 of all fractures were osteoporotic (eight determinations).
Fall rates are higher in women than in men in Western community-dwelling populations and lower in East Asian populations. Extrapolated to the US population, the statistics imply that low-impact falls cause approximately 0.53 million osteoporotic fractures annually among the US community-dwelling elderly.
PMCID: PMC3536355  PMID: 23300349
accidental falls; aged; bone density; fractures; osteoporosis
3.  Depression after low-energy fracture in older women predicts future falls: a prospective observational study 
BMC Geriatrics  2011;11:73.
Falls are one of the main causes of fractures in elderly people and after a recent fracture, the risk of another fall is increased, resulting in subsequent fracture. Therefore, risk factors for future falls should be determined. We prospectively investigated the relationship between depression and the incidence of falls in post-menopausal women after a low-energy fracture.
At baseline, 181 women aged 60 years and older who presented with a recent low-energy fracture were evaluated at the fracture and osteoporosis outpatient clinics of two hospitals. As well as clinical evaluation and bone mineral density tests, the presence of depression (measured using the Edinburgh Depression Scale, EDS, depression cut-off > 11) and risk factors for falling were assessed. During two years of follow-up, the incidence of falls was registered annually by means of detailed questionnaires and interviews.
Seventy-nine (44%) of the women sustained at least one fall during follow-up. Of these, 28% (n = 22) suffered from depression at baseline compared to 10% (n = 10) of the 102 women who did not sustain a fall during follow-up (Χ2 = 8.76, df = 1, p = .003). Multiple logistic regression showed that the presence of depression and co-morbidity at baseline were independently related to falls (OR = 4.13, 95% CI = 1.58-10.80; OR = 2.25, 95% CI = 1.11-4.56, respectively) during follow-up.
The presence of depression in women aged 60 years and older with recent low-energy fractures is an important risk factor for future falls. We propose that clinicians treating patients with recent low-energy fractures should anticipate not only on skeletal-related risk factors for fractures, but also on fall-related risk factors including depression.
PMCID: PMC3225332  PMID: 22060677
4.  Lifestyle predicts falls independent of physical risk factors 
Osteoporosis International  2009;20(12):2025-2034.
Many falls occur among older adults with no traditional risk factors. We examined potential independent effects of lifestyle on fall risk. Not smoking and going outdoors frequently or infrequently were independently associated with more falls, indicating lifestyle-related behavioral and environmental risk factors are important causes of falls in older women.
Physical and lifestyle risk factors for falls and population attributable risks (PAR) were examined.
We conducted a 4-year prospective study of 8,378 community-dwelling women (mean age = 71 years, SD = 3) enrolled in the Study of Osteoporotic Fractures. Data on number of falls were self-reported every 4 months. Fall rates were calculated (# falls/woman-years). Poisson regression was used to estimate relative risks (RR).
Physical risk factors (p ≤ 0.05 for all) included tall height (RR = 0.89 per 5 in.), dizziness (RR = 1.16), fear of falling (RR = 1.20), self-reported health decline (RR = 1.19), difficulty with Instrumental Activities of Daily Living (IADLs) (RR = 1.12, per item), fast usual-paced walking speed (RR = 1.18, per 2 SD), and use of antidepressants (RR = 1.20), benzodiazepines (RR = 1.11), or anticonvulsants (RR = 1.62). Protective physical factors (p ≤ 0.05 for all) included good visual acuity (RR = 0.87, per 2 SD) and good balance (RR = 0.85 vs. poor). Lifestyle predicted fewer falls including current smoking (RR = 0.76), going outdoors at least twice weekly but not more than once a day (RR = 0.89 and vs. twice daily). High physical activity was associated with more falls but only among IADL impaired women. Five potentially modifiable physical risk factors had PAR ≥ 5%.
Fall interventions addressing modifiable physical risk factors with PAR ≥ 5% while considering environmental/behavioral risk factors are indicated.
PMCID: PMC2777208  PMID: 19319617
Behavioral risk factors; Fall rates; Falls; Lifestyle; Physical risk factors; Risk factors
5.  Mikkeli Osteoporosis Index Identifies Fracture Risk Factors and Osteoporosis and Intervention Thresholds Parallel with FRAX 
Journal of Osteoporosis  2011;2011:732560.
Osteoporosis Index (MOI) was developed from Fracture Index (FI), a validated fracture risk score, to identify also osteoporosis. MOI risk factors are age, weight, previous fracture, family history of hip fracture or spinal osteoporosis, smoking, shortening of the stature, and use of arms to rise from a chair. The association of these risk factors with BMD was examined in development cohorts of 300 Finnish postmenopausal women with a fracture and in a population control of 434 women aged 65–72. Validation cohorts included 200 fracture patients and a population control of 943 women aged 58–69. MOI identified femoral neck osteoporosis in these cohorts as well as the Osteoporosis Self-Assessment Tool (OST). In the pooled fracture cohort, the association of BMI-based FRAX fracture risk with MOI was good. After BMD measurement, MOI identified well FRAX hip fracture risk-based Intervention Thresholds (ITs) (AUC 0.74–0.90).
PMCID: PMC3135263  PMID: 21772977
6.  Risk of falling in patients with a recent fracture 
Patients with a history of a fracture have an increased risk for future fractures, even in short term. The aim of this study was to assess the number of patients with falls and to identify fall risk factors that predict the risk of falling in the first three months after a clinical fracture.
Prospective observational study with 3 months of follow-up in a large European academic and regional hospital. In 277 consenting women and men aged ≥ 50 years and with no dementia and not receiving treatment for osteoporosis who presented to hospital with a clinical fracture, fall risk factors were assessed according to the guidelines on fall prevention in the Netherlands. Follow-up information on falls and fractures was collected by monthly telephone interview. Incidence of falls and odds ratio's (OR, with 95% confidence intervals) were calculated.
512 consecutive patients with a fracture were regarded for analysis, 87 were not eligible for inclusion and 137 patients were excluded. No follow-up data were available for 11 patients. Therefore full analysis was possible in 277 patients.
A new fall incident was reported by 42 patients (15%), of whom five had a fracture. Of the 42 fallers, 32 had one new fall and 10 had two or more.
Multivariate analysis in the total group with sex, age, ADL difficulties, urine incontinence and polypharmacy showed that sex and ADL were significant fall risk factors. Women had an OR of 3.02 (95% CI 1.13–8.06) and patients with ADL-difficulties had an OR of 2.50 (95% CI 1.27–4.93).
Multivariate analysis in the female group with age, ADL difficulties, polypharmacy and presence of orthostatic hypotension indicated that polypharmacy was the predominant risk factor (OR 2.51; 95% CI: 1.19 – 5.28). The incidence of falls was 35% in women with low ADL score and polypharmacy compared to 15% in women without these risk factors (OR 3.56: CI 1.47 – 8.67).
15% of patients reported a new fall and 5 patients suffered a new fracture within 3 months. Female sex and low ADL score were the major risk factors and, in addition, polypharmacy in women.
PMCID: PMC1933426  PMID: 17598891
7.  Fall frequency and incidence of distal forearm fracture in the UK. 
STUDY OBJECTIVE--This analysis aimed to determine the frequency of falls in men and women aged 50 years and over and to explore whether age variation in fall frequency may explain variation in the incidence of distal forearm fracture in women. DESIGN--This was a cross sectional survey. SETTING--Primary care based registers in four UK areas. PARTICIPANTS--Altogether 501 men and 702 women age 50-79 years participated. MAIN RESULTS--A total of 131 (26.1%) men and 181 (25.8%) women reported falling in the previous year. In women, the frequency of falls rose with age (chi 2 test for trend 4.33; p = 0.04), with no obvious early post-menopausal peak or subsequent decline. Men aged 50-54 years had a significantly increased risk of falls compared with women of this same age group, (odds ratio (OR) = 2.4; 95% confidence interval (CI) 1.3, 4.6), though above this age, the risk of falling was greater in women (OR = 1.2; 95% CI 0.9, 1.5). CONCLUSION--There are important differences in the frequency of falls in relation to age and sex. The data suggest that variation in fall frequency per se does not explain age variation in the incidence of distal forearm fracture in women.
PMCID: PMC1060175  PMID: 8596095
8.  What Accounts for Rib Fractures in Older Adults? 
Journal of Osteoporosis  2011;2011:457591.
To address the epidemiology of rib fractures, an age- and sex-stratified random sample of 699 Rochester, Minnesota, adults age 21–93 years was followed in a long-term prospective study. Bone mineral density (BMD) was assessed at baseline, and fractures were ascertained by periodic interview and medical record review. During 8560 person-years of followup (median, 13.9 years), 56 subjects experienced 67 rib fracture episodes. Risk factors for falling predicted rib fractures as well as BMD, but both were strongly age-related. After age-adjustment, BMD was associated with rib fractures in women but not men. Importantly, rib fractures attributed to severe trauma were associated with BMD in older individuals of both sexes. Self-reported heavy alcohol use doubled fracture risk but did not achieve significance due to limited statistical power. Bone density, along with heavy alcohol use and other risk factors for falling, contributes to the risk of rib fractures, but no one factor predominates. Older women with rib fractures, regardless of cause, should be considered for an osteoporosis evaluation, and strategies to prevent falling should be considered in both sexes.
PMCID: PMC3199083  PMID: 22028986
9.  Clinical risk factors for osteoporosis are common among elderly people in Nuuk, Greenland 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.19596.
Osteoporosis is a debilitating condition characterized by fractures, pain and premature death. Risk factors for osteoporosis predict the risk of fragility fractures.
To describe the occurrence of risk factors for osteoporosis among populations in Nuuk, the capital of Greenland.
A random sample of women born in 1934–42, 1945–47, 1956, and men born in 1956 were selected from the national civil registry. A questionnaire was sent out in Greenlandic and Danish on risk factors for osteoporosis: family history, smoking habits, alcohol intake, presence of disease, sun exposure, intake of dairy products, age at menopause (women) and number of falls. Additional questions included the frequency of back pain, previous fractures, intake of vitamin D and calcium supplements, use of anti-osteoporotic drugs, steroids and other drugs.
The questionnaire was sent to 317 subjects confirmed to be living at an address in Nuuk and 181 (57.1%) responded. More young women than older women were smokers (60.6% vs. 35.0%; p=0.022) while limited sun exposure was reported by more of the old women (37.2% vs. 5.6%; p=0.003). Family history of osteoporosis was reported by 15.0%, without difference between groups. Alcohol and milk intake did not differ between groups. Premature menopause was reported by 17.9% of the women. Falls within the last year were reported by 42.4% with fewer falls in the oldest age group (21.9% vs. 50.0%; p=0.005). Frequency of fragility fractures increased with age (5.7% vs. 24.3% vs. 30.4%; p=0.02) and the risk of a fragility fracture increased with age (p=0.004; OR, 95% CI: 4.5, 1.6–12.2, reference: below 70 years), when adjusted for smoking, gender and falls. The use of anti-osteoporotic drugs was low (3.4%) while 28.8% took calcium and vitamin D supplements.
Age is a dominating risk factor for fragility fractures in Greenland. The use of anti-osteoporotic drugs is low in Greenland, even if osteoporotic fractures are common in old age.
PMCID: PMC3546323  PMID: 23326764
risk factors; osteoporosis; fragility fractures; Greenland Inuit; old people
10.  Predictors of fracture from falls reported in hospital and residential care facilities: a cross-sectional study 
BMJ Open  2013;3(8):e002948.
Fall-related fractures are associated with substantial human and economic costs. An improved understanding of the predictors of fall-related fractures in healthcare settings would be useful in developing future interventions. The objective of this study was to identify such predictors by exploring associations between fall-related factors and fracture outcomes through logistic regression analysis of routinely collected fall incident data.
Retrospective cross-sectional study.
197 public healthcare facilities in Queensland, Australia.
We included data from incident reports completed after falls among admitted adult hospital patients (n=24 218 falls, 229 fractures) and aged-care residents (n=8980 falls, 74 fractures) between January 2007 and November 2009.
Primary and secondary outcomes
The outcomes of interest were fall-related predictors of fracture.
Hospital patients who reported to have been screened for their risk of falling at admission were less likely to fracture after a fall (OR: 0.60, 95% CI 0.41 to 0.89) than those who had not been screened. Further, falls from standing (OR: 2.08, 95% CI 1.22 to 3.55) and falls while walking (OR: 1.86, 95% CI 1.32 to 2.62) were associated with higher fracture odds than falls during other activities. In line with these results, falls while reaching in standing (OR: 3.51, 95% CI 1.44 to 8.56) and falls while walking (OR: 2.11, 95% CI 1.24 to 3.58) were also predictive of fracture in the adjusted residential care model.
Our findings indicate that screening of hospital patients for their risk of falling may contribute towards the prevention of fall-related injury. Falls from upright postures appear to be more likely to result in fractures than other falls in healthcare settings. Further prospective research is warranted.
PMCID: PMC3733318  PMID: 23906949
Geriatric Medicine
11.  Prevalence of Fracture and Osteoporosis Risk Factors in American Indian and Alaska Native People 
Journal of health care for the poor and underserved  2012;23(3):10.1353/hpu.2012.0110.
Little is known about prevalence of osteoporosis risk factors among American Indians and Alaska Natives (AIAN).
We included AIAN people (n = 8,039) enrolled in the Education and Research Towards Health (EARTH) Study. Prevalence ratios were used to determine cross-sectional associations of risk factors with self-reported bone fractures.
There is a high prevalence of multiple risk factors for osteoporosis in AIAN, although the factors that are associated with past fracture vary by gender and geographical area. In general, women who reported a fracture reported more risk behaviors, more than two medical conditions, and low physical activity. Men with higher BMI were less likely to report a fracture. Smoking history was associated with fracture for both genders, though not significantly in all sub-groups.
We prevent a high prevalence of risk factors for osteoporosis for AIAN. Future research for osteoporosis risk reduction and prevention in AIAN people is indicated.
PMCID: PMC3824157  PMID: 24212166
Osteoporosis; fracture; American Indian; Alaskan Native
12.  Assessment of Individual Fracture Risk: FRAX and Beyond 
Current Osteoporosis Reports  2010;8(3):131-137.
The World Health Organization fracture risk assessment tool (FRAX) and the Garvan fracture risk calculator are both widely available tools for individualized fracture risk prediction in daily practice. The FRAX model is implemented in several guidelines and most widely used at present. However, clinicians should take into account the differences between the models, especially with regard to the effect of the number of falls, number and clustering of previous fractures, and the number of clinical risk factors on the outcome of predicted fracture risk. Further development will be needed for optimal integration of bone- and fall-related risks, clustering of fractures, and dosing of risk factors to validate the models in different populations and to validate the ability to select patients who will achieve fracture risk reduction with anti-osteoporosis therapy. FRAX may be used as the primary model, and in patients with recurrent fractures and falls the use of the Garvan model may be of additional value.
PMCID: PMC2902745  PMID: 20563901
Osteoporosis; Fractures; FRAX; Garvan; Timing of fractures; Risk factors
13.  Evaluation and Management of Osteoporosis Following Hospitalization for Low-impact Fracture 
To evaluate the pattern of osteoporosis evaluation and management in postmenopausal women who present with low-impact (minimal trauma) fracture.
Retrospective chart review of patients admitted with a fracture in the absence of trauma or bone disease. Telephone follow-up survey was conducted at 12 months after discharge to collect information on physician visits, pharmacological therapies for osteoporosis, functional status, and subsequent fractures.
Postmenopausal women admitted to a hospital in St. Paul, Minnesota between June 1996 and December 1997 for low-impact fractures were identified. Low-impact fracture was defined as a fracture occurring spontaneously or from a fall no greater than standing height. Retrospective review of 301 patient medical records was conducted to obtain data on pre-admission risk factors for osteoporosis and/or fracture, and osteoporosis-related evaluation and management during the course of hospitalization. Follow-up 1 year after the incident fracture was obtained on 227 patients.
Two hundred twenty-seven women were included in the study. Osteoporosis was documented in the medical record in 26% (59/227) of the patients at hospital discharge. Within 12 months of hospital discharge, 9.6% (22/227) had a bone mineral density test, and 26.4% (60/227) were prescribed osteoporosis treatment. Of those who were prescribed osteoporosis treatment, 86.6% (52/60) remained on therapy for 1 year. Nineteen women suffered an additional fracture. Compared to women without a prior fracture, women with at least 1 fracture prior to admission were more likely to have osteoporosis diagnosed and to receive osteoporosis-related medications.
Despite guidelines that recommend osteoporosis evaluation in adults experiencing a low-trauma fracture, we report that postmenopausal women hospitalized for low-impact fracture were not sufficiently evaluated or treated for osteoporosis during or after their hospital stay. There are substantial opportunities for improvement of care in this high-risk population to prevent subsequent fractures.
PMCID: PMC1494813  PMID: 12534759
low-impact; fracture; osteoporosis; evaluation; osteoporosis treatment
14.  Is health-related quality of life associated with the risk of low-energy wrist fracture: a case-control study 
Some risk factors for low-energy wrist fracture have been identified. However, self-reported measures such as health-related quality of life (HRQOL) have not been examined as potential risk factors for wrist fracture. The aims of this study were to compare HRQOL prior to a low-energy wrist fracture in elderly patients (≥ 50 years) with HRQOL in age- and sex-matched controls, and to explore the association between HRQOL and wrist fracture after adjusting for known risk factors for fracture such as age, weight, osteoporosis and falls.
Patients with a low-energy wrist fracture (n = 181) and age- and sex-matched controls (n = 181) were studied. Shortly after fracture (median 10 days), patients assessed their HRQOL before fracture using the Short Form 36 (SF-36). Statistical tests included t tests and multivariate logistic regression analysis.
Several dimensions of HRQOL were significantly associated with wrist fracture. The direction of the associations with wrist fracture varied between the different sub-dimensions of the SF-36. After controlling for demographic and clinical variables, higher scores on general health (odds ratio (OR) = 1.31, 95% confidence interval (CI) = 1.10–1.56), bodily pain (OR = 1.18, 95% CI = 1.03–1.34) and mental health (OR = 1.39, 95% CI = 1.09–1.79) were related to an increased chance of being a wrist fracture patient rather than a control. In contrast, higher scores on physical role limitation (OR = 0.87, 95% CI = 0.79–0.95) and social function (OR = 0.65, 95% CI 0.53–0.80) decreased this chance. Significant associations with wrist fracture were also found for living alone (OR = 1.91, 95% CI 1.07–3.4), low body mass index (BMI) (OR = 0.92, 95% CI 0.86–0.98), osteoporosis (OR = 3.30, 95% CI 1.67–6.50) and previous falls (OR = 2.01, 95% CI 1.16–3.49).
Wrist fracture patients perceive themselves to be as healthy as the controls before fracture. Our data indicate that patients with favourable and unfavourable HRQOL measures may be at increased risk of wrist fracture.
PMCID: PMC2714004  PMID: 19573252
15.  Randomised controlled trial of calcium and supplementation with cholecalciferol (vitamin D3) for prevention of fractures in primary care 
BMJ : British Medical Journal  2005;330(7498):1003.
Objective To assess whether supplementation with calcium and cholecaliferol (vitamin D3) reduces the risk of fracture in women with one or more risk factors for fracture of the hip.
Design Pragmatic open randomised controlled trial.
Setting Practice nurse led clinics in primary care.
Participants 3314 women aged 70 and over with one or more risk factors for hip fracture: any previous fracture, low body weight (< 58 kg), smoker, family history of hip fracture, or fair or poor self reported health.
Intervention Daily oral supplementation using 1000 mg calcium with 800 IU cholecaliferol and information leaflet on dietary calcium intake and prevention of falls, or leaflet only (control group).
Main outcome measures Primary outcome measure was all clinical fractures and secondary outcome measures were adherence to treatment, falls, and quality of life (measured with the SF-12).
Results 69% of the women who completed the follow-up questionnaire at 24 months were still taking supplements (55% with inclusion of randomised participants known to be alive). After a median follow-up of 25 months (range 18 to 42 months), clinical fracture rates were lower than expected in both groups but did not significantly differ for all clinical fractures (odds ratio for fracture in supplemented group 1.01, 95% confidence interval 0.71 to 1.43). The odds ratio for hip fracture was 0.75 (0.31 to 1.78). The odds of a woman having a fall at six and 12 months was 0.99 and 0.98, respectively. Quality of life did not significantly differ between the groups.
Conclusion We found no evidence that calcium and vitamin D supplementation reduces the risk of clinical fractures in women with one or more risk factors for hip fracture.
Registration ISRCTN26118436, controlled trials registry.
PMCID: PMC557150  PMID: 15860827
16.  Positive predictive values for self-reported fractures in an adult Japanese population 
Self-reporting provides useful information for assessing the risk factors of osteoporotic fractures in large cohort studies. However, to data, no studies in Japan have confirmed the accuracy of this approach in this context. The aim of the study reported here was to determine the positive predictive value (PPV) for the self-reporting of fractures.
A total of 133 participants of the Oguni cohort in the Japan Public Health Center-based Prospective Study who reported a vertebral, upper limb, or hip fracture on the 15-year follow-up questionnaire survey were evaluated. The accuracy of fractures was confirmed by cross-referencing medical records.
The average age of the participants was 72.4 (standard deviation 7.9) years. The PPV for vertebral fracture in the last 15 years was 17/20 (85.0%) for women and 2/9 (22.2%) for men, for a total of 19/29 (65.5%). PPVs for upper limb and hip fractures were as low as 30/68 (44.1%) and 12/22 (54.5%), respectively.
Female self-reporting provided PPVs suitable for symptomatic vertebral fracture over 15 years and can be used as an outcome measure in large cohort studies in Japan.
PMCID: PMC3047665  PMID: 21432228
Cohort studies; Fractures; Osteoporosis; Predictive value of tests
17.  Low handgrip strength is a predictor of osteoporotic fractures: cross-sectional and prospective evidence from the Hong Kong Osteoporosis Study 
Age  2011;34(5):1239-1248.
Handgrip strength (HGS) is a potentially useful objective parameter to predict fracture since it is an indicator of general muscle strength and is associated with fragility and propensity to fall. Our objective was to examine the association of HGS with fracture, to evaluate the accuracy of HGS in predicting incident fracture, and to identify subjects at risk of fracture. We analyzed a cross-sectional cohort with 2,793 subjects (1,217 men and 1,576 women aged 50–101 years) and a subset of 1,702 subjects which were followed for a total of 4,855 person-years. The primary outcome measures were prevalent fractures and incident major fragility fractures. Each standard deviation (SD) reduction in HGS was associated with a 1.24-fold increased odds for major clinical fractures even after adjustment for other clinical factors. A similar result was obtained in the prospective cohort with each SD reduction in HGS being associated with a 1.57-fold increased hazard ratio of fracture even after adjustment for clinical factors. A combination of HGS and femoral neck bone mineral density (FN BMD) T-score values (combined T-score), together with other clinical factors, had a better predictive power of incident fractures than FN BMD or HGS T-score alone with clinical factors. In addition, combined T-score has better sensitivity and specificity in predicting incidence fractures than FN BMD alone. This study is the first study to compare the predictive ability of HGS and BMD. We showed that HGS is an independent risk factor for major clinical fractures. Compared with using FN BMD T-score of −2.5 alone, HGS alone has a comparable predictive power to BMD, and the combined T-score may be useful to identify extra subjects at risk of clinical fractures with improved specificity.
Electronic supplementary material
The online version of this article (doi:10.1007/s11357-011-9297-2) contains supplementary material, which is available to authorized users.
PMCID: PMC3448988  PMID: 21853264
Osteoporosis; Fracture; Handgrip strength; Falls
18.  Vigorous Physical Activity Increases Fracture Risk in Children Irrespective of Bone Mass: A Prospective Study of the Independent Risk Factors for Fractures in Healthy Children 
Low bone mass is a determinant of fractures in healthy children. Small studies provide limited evidence on the association between ethnicity, birth weight, family size, socioeconomic status, dietary calcium intake, or physical activity and fracture incidence. No studies have investigated whether these determinants of fracture risk act through affecting bone mass or through other mechanisms. The aim of this study was to use a population-based birth cohort to confirm which variables are determinants of fracture risk and to further study which of these risk factors act independently of bone mass. Children from the Avon Longitudinal Study of Parents and Children have been followed up from birth to 11 yr of age. Maternal self-reported data have been collected contemporaneously on early life factors, diet, puberty, and physical activity. These were linked to reported fractures between 9 and 11 yr of age. Multivariable logistic regression techniques were used to assess whether these potential determinants were independent of, or worked through, estimated volumetric BMD or estimated bone size relative to body size measured by total body DXA scan at 9.9 yr of age. A total of 2692 children had full data. One hundred ninety-three (7.2%) reported at least one fracture over the 2-yr follow-up period. Children who reported daily or more episodes of vigorous physical activity had double the fracture risk compared with those children who reported less than four episodes per week (OR, 2.06; 95% CI, 1.21–1.76). No other independent determinants of fracture risk in healthy children were found. In conclusion, reported vigorous physical activity is an independent risk factor for childhood fracture risk. However, the interrelationship between physical activity, bone mass, and childhood fracture risk suggests that the higher bone mass associated with increased physical activity does not compensate for the risk caused by increased exposure to injuries.
PMCID: PMC2742075  PMID: 18570539
fractures; children; physical activity; epidemiology; BMD; ALSPAC
19.  P22 - Cognitive Impairment in Hip Fracture Patients 
Proximal femur fractures are the most frequent traumatic skeletal lesions. Despite improved understanding of the risk factors for and means of preventing these fractures, their frequency continues to increase. In Italy there are estimated to be more than 80000 new proximal femur fracture cases every year. These fractures are closely correlated with osteoporosis and are therefore more frequent in the elderly population. Indeed, other fracture risk factors are age and falls. Cognitive decline is one of the intrinsic risk factors for falling as it influences postural control and lower limb muscle strength.
Hip fracture itself is an event capable of triggering a progressive cognitive decline; the incidence of this ranges from 16% to 62% and it is associated with increased morbidity and mortality. The aim of this study was to describe the association between cognitive decline and proximal femur fractures.
Materials and methods:
As part of Indaco 2, an epidemiological survey proposed by SIOT (the Italian Society of Orthopaedics and Traumatology), data were collected relating to 7355 patients attending over 100 orthopaedics and traumatology clinics throughout Italy, recruited over a 6-month period. A questionnaire was administered that, as well as covering various aspects of the patient’s history, also included the Short Portable Mental Status Questionnaire(SPMSQ). This instrument is made up of 10 items that assess the patient’s cognitive abilities.
From the 7355 questionnaires collected, we excluded those referring to patients under the age of 65 years, this parameter being a criterion for exclusion from the study; we also excluded those with an incomplete SPMSQ. We then excluded, from the remaining 6294 questionnaires, those that failed to provide anamnestic data on the femur fracture. Therefore, the final analysis was performed on 6285 patients, who had a mean age of 77 years (±7.55).
The patients with a femur fracture totalled 2877 and their mean age was 80.3 years (±7.55). The fracture-free patients numbered 3408, and had a mean age of 74.2 years (±6.32). For the final analysis, we dichotomised the SPMSQ variable, thus forming two groups: one comprising patients with normal to mildly impaired cognitive status, and the other patients with moderately to severely impaired cognitive status.
In the group of fracture patients, the SPMSQ showed normal to mildly impaired cognitive status in 67% of the patients, who had a mean age of 78.28 years (±7.2), and moderately to severely impaired cognitive status in 33%, who had a mean age of 84.41 years (±6.49). In the fracture-free population, on the other hand, 90.75% of the patients, with a mean age of 73.64 years (±6.03), showed normal to mildly impaired cognitive status, while only 9.25%, with a mean age of 79.64 years (±6.56), showed moderately to severely impaired cognition. The difference in cognitive status between the two groups (fracture and fracture-free) was statistically significant (p< 0.0001), even after adjusting for the age of the patients.
The results of our epidemiological study confirm that cognitive status is more impaired in patients with fractures compared with fracture-free subjects, even after adjusting for age. However, the question of whether cognitive decline was the cause of, or secondary to, the fracture it remains to be established.
PMCID: PMC3213850
Bone  2012;52(2):541-547.
The FRAXtr algorithm uses clinical risk factors (CRF) and bone mineral density (BMD) to predict fracture risk but does not include falls history in the calculation. Using results from the Hertfordshire Cohort Study, we examined the relative contributions of CRFs, BMD and falls history to fracture prediction. We studied 2299 participants at a baseline clinic that included completion of a health questionnaire and anthropometric data. A mean of 5.5 years later (range 2.9-8.8yrs) subjects completed a postal questionnaire detailing fall and fracture history. In a subset of 368 men and 407 women, bone densitometry was performed using a Hologic QDR 4500 instrument. There was a significantly increased risk of fracture in men and women with a previous fracture. A one standard deviation drop in femoral neck BMD was associated with a hazards ratio (HR) of incident fracture (adjusted for CRFs) of 1.92 (1.04-3.54) and 1.77 (1.16-2.71) in men and women respectively. A history of any fall since the age of 45 years resulted in an unadjusted HR of fracture of 7.31(3.78-14.14) and 8.56(4.85-15.13) in men and women respectively. In a ROC curve analysis, the predictive capacity progressively increased as BMD and previous falls were added into an initial model using CRFs alone. Falls history is a further independent risk factor for fracture. Falls risk should be taken into consideration when assessing whether or not to commence medication for osteoporosis and should also alert the physician to the opportunity to target falls risk directly.
PMCID: PMC3654628  PMID: 23159464
Epidemiology; osteoporosis; BMD; fracture; fall; FRAX
21.  Scores on the Safe Functional Motion Test Are Associated with Prevalent Fractures and Fall History 
Physiotherapy Canada  2013;65(1):75-83.
Purpose: The Safe Functional Motion test (SFM) was developed to measure observed body mechanics and functional motion associated with spine load, balance, strength, and flexibility during everyday tasks to profile modifiable risks for osteoporotic fracture. This cross-sectional study evaluated the associations between SFM score and history of vertebral compression fracture (VCF), hip fracture, and injurious falls, all established predictors of future risk. Method: An osteoporosis clinic database was queried for adults with an initial SFM score and corresponding data for prevalent VCF and/or hip fracture, femoral neck bone mineral density (fnBMD), and history of injurious fall (n=847). Multiple logistic regressions, adjusted for age, gender, and fnBMD (and injurious falls in the prevalent fracture analyses), were used to determine whether associations exist between SFM score and prevalent VCF, prevalent hip fracture, and history of injurious fall. Results: SFM score was associated with prevalent VCF (odds ratio [OR]=0.89; 95% CI, 0.79–0.99; p=0.036), prevalent hip fracture (OR=0.77; 95% CI, 0.65–0.92; p=0.004), and history of injurious fall (OR=0.80; 95% CI, 0.70–0.93; p=0.003) after adjusting for other important covariates. Conclusions: Adults with higher SFM scores (“safer motion” during performance of everyday tasks) were less likely to have a history of fracture or injurious fall. Further study is warranted to evaluate the predictive value of this tool.
PMCID: PMC3563381  PMID: 24381386
activities of daily living; compression fractures; hip fractures; musculoskeletal system; osteoporosis; risk assessment; évaluation des risques; fracture de compression; fracture de la hanche; ostéoporose; système musculosquelettique
22.  Independent external validation of nomograms for predicting risk of low-trauma fracture and hip fracture 
A set of nomograms based on the Dubbo Osteoporosis Epidemiology Study predicts the five- and ten-year absolute risk of fracture using age, bone mineral density and history of falls and low-trauma fracture. We assessed the discrimination and calibration of these nomograms among participants in the Canadian Multicentre Osteoporosis Study.
We included participants aged 55–95 years for whom bone mineral density measurement data and at least one year of follow-up data were available. Self-reported incident fractures were identified by yearly postal questionnaire or interview (years 3, 5 and 10). We included low-trauma fractures before year 10, except those of the skull, face, hands, ankles and feet. We used a Cox proportional hazards model.
Among 4152 women, there were 583 fractures, with a mean follow-up time of 8.6 years. Among 1606 men, there were 116 fractures, with a mean follow-up time of 8.3 years. Increasing age, lower bone mineral density, prior fracture and prior falls were associated with increased risk of fracture. For low-trauma fractures, the concordance between predicted risk and fracture events (Harrell C) was 0.69 among women and 0.70 among men. For hip fractures, the concordance was 0.80 among women and 0.85 among men. The observed fracture risk was similar to the predicted risk in all quintiles of risk except the highest quintile of women, where it was lower. The net reclassification index (19.2%, 95% confidence interval [CI] 6.3% to 32.2%), favours the Dubbo nomogram over the current Canadian guidelines for men.
The published nomograms provide good fracture-risk discrimination in a representative sample of the Canadian population.
PMCID: PMC3033952  PMID: 21173069
23.  A cross-sectional study of bone health in multiple sclerosis 
Neurology  2009;73(17):1394-1398.
Osteoporosis is an important risk factor for fragility fractures. Although osteoporosis is considered common in multiple sclerosis (MS), few previous studies focused on fractures in MS.
Using the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry, we investigated the frequency of osteoporosis, fractures, and clinical risk factors for fracture in MS.
In 2007, 9,346 NARCOMS participants reported fractures and clinical risk factors for fractures including history of osteoporosis or osteopenia (low bone mass), sedentary level of physical activity, falls in the last year, current smoking status, family history of osteoporosis, and impaired mobility.
Among responders, 2,501 (27.2%) reported low bone mass. More than 15% of responders reported a history of fracture after age 13 years (n = 1,482). Among those reporting fractures, 685 (46.2%) reported multiple fractures, while 522 (35.2%) reported a wrist fracture, 165 (11.1%) reported a vertebral fracture, and 100 (7.4%) reported a hip fracture. Excluding age, 1,413 (15.1%) participants had 1 clinical risk factor for fracture, 2,341 (25.0%) had 2, and 5,393 (57.7%) had 3 or more. Among participants with a history of fracture, 746 (55%) reported taking calcium supplements, 858 (68.8%) reported taking vitamin D supplements or a multivitamin with vitamin D, and 334 (22.5%) reported taking a bisphosphonate.
Patients with multiple sclerosis (MS) often have multiple risk factors for osteoporotic fractures. Many patients with MS with low bone mass or previous fractures are not taking supplemental calcium or vitamin D, suggesting a potential area of improvement in care.
= multiple sclerosis;
= North American Research Committee on Multiple Sclerosis;
= Patient Determined Disease Steps;
= socioeconomic status.
PMCID: PMC2769555  PMID: 19858462
24.  Risk factors of falls among elderly living in Urban Suez - Egypt 
Falling is one of the most common geriatric syndromes threatening the independence of older persons. Falls result from a complex and interactive mix of biological or medical, behavioral and environmental factors, many of which are preventable. Studying these diverse risk factors would aid early detection and management of them at the primary care level.
This is a cross sectional study about risk factors of falls was conducted to 340 elders in Urban Suez. Those are all patients over 60 who attended two family practice centers in Urban Suez.
When asked about falling during the past 12 months, 205 elders recalled at least one incident of falling. Of them, 36% had their falls outdoors and 24% mentioned that stairs was the most prevalent site for indoor falls. Falls were also reported more among dependant than independent elderly. Using univariate regression analysis, almost all tested risk factors were significantly associated with falls in the studied population. These risk factors include: living alone, having chronic diseases, using medications, having a physical deficit, being in active, and having a high nutritional risk. However, the multivariate regression analysis proved that the strongest risk factors are low level of physical activity with OR 0.6 and P value 0.03, using a cane or walker (OR 1.69 and P value 0.001) and Impairment of daily living activities (OR 1.7 and P value 0.001).
Although falls is a serious problem among elderly with many consequences, it has many preventable risk factors. Health care providers should advice people to remain active and more research is needed in such an important area of Family Practice.
PMCID: PMC3597910  PMID: 23504298
Falls; elderly; risk factors; primary care; assessment; causes
25.  Osteoporosis: Prevention and Management Strategies 
Canadian Family Physician  1987;33:151-155.
Osteoporosis is a major cause of morbidity in post-menopausal women. Strategies to prevent or delay bone loss in normal post-menopausal women and to reduce the risk of fractures in women with osteoporosis are within the scope of family practice. Certain factors, such as inadequate calcium intake, estrogen deficiency, cigarette smoking and lack of physical activity can be modified in peri- and post-menopausal women. For patients with osteoporosis, there is potential for lowering the risk of fractures by means of calcium supplements or other therapies, physical training and rehabilitation, and modification of factors associated with risk of falling.
PMCID: PMC2218284  PMID: 21267348
osteoporosis; post-menopausal women; prevention

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