A combination of clinical balance measures and FRAX® to improve identification of high-risk fallers

BMC Geriatrics, May 2016

Background The FRAX® algorithm quantifies a patient’s 10-year probability of a hip or major osteoporotic fracture without taking an individual’s balance into account. Balance measures assess the functional ability of an individual and the FRAX® algorithm is a model that integrates the individual patients clinical risk factors [not balance] and bone mineral density. Thus, clinical balance measures capture aspects that the FRAX® algorithm does not, and vice versa. It is therefore possible that combining FRAX® and clinical balance measures can improve the identification of patients at high fall risk and thereby high fracture risk. Our study aim was to explore whether there is an association between clinical balance measures and fracture prediction obtained from FRAX®. Method A cross-sectional study design was used where post hoc was performed on a dataset of 82 participants (54 to 89 years of age, mean age 71.4, 77 female), with a fall-related wrist-fracture between 2008 and 2012. Balance was measured by tandem stance, standing one leg, walking in the figure of eight, walking heel to toe on a line, walking as fast as possible for 30 m and five times sit to stand balance measures [tandem stance and standing one leg measured first with open and then with closed eyes] and each one analyzed for bivariate relations with the 10-year probability values for hip and major osteoporotic fractures as calculated by FRAX® using Spearman’s rank correlation test. Results Individuals with high FRAX® values had poor outcome in balance measures; however the significance level of the correlation differed between tests. Standing one leg eyes closed had strongest correlation to FRAX® (0.610 p = < 0.01) and Five times sit to stand was the only test that did not correlate with FRAX® (0.013). Conclusion This study showed that there is an association between clinical balance measures and FRAX®. Hence, the use of clinical balance measures and FRAX® in combination, might improve the identification of individuals with high risk of falls and thereby following fractures. Results enable healthcare providers to optimize treatment and prevention of fall-related fractures. Trial registration The study has been registered in Clinical Trials.gov, registration number NCT00988572.

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A combination of clinical balance measures and FRAX® to improve identification of high-risk fallers

Najafi et al. BMC Geriatrics A combination of clinical balance measures and FRAX® to improve identification of high-risk fallers David A. Najafi 0 2 Leif E. Dahlberg 1 Eva Ekvall Hansson 0 2 0 Department of Health Sciences, Health Sciences Centre, Lund University , Baravägen 3, 22240 Lund , Sweden 1 Department of Clinical Sciences, Lund University , Lund , Sweden 2 Department of Health Sciences, Health Sciences Centre, Lund University , Baravägen 3, 22240 Lund , Sweden Background: The FRAX® algorithm quantifies a patient's 10-year probability of a hip or major osteoporotic fracture without taking an individual's balance into account. Balance measures assess the functional ability of an individual and the FRAX® algorithm is a model that integrates the individual patients clinical risk factors [not balance] and bone mineral density. Thus, clinical balance measures capture aspects that the FRAX® algorithm does not, and vice versa. It is therefore possible that combining FRAX® and clinical balance measures can improve the identification of patients at high fall risk and thereby high fracture risk. Our study aim was to explore whether there is an association between clinical balance measures and fracture prediction obtained from FRAX®. Method: A cross-sectional study design was used where post hoc was performed on a dataset of 82 participants (54 to 89 years of age, mean age 71.4, 77 female), with a fall-related wrist-fracture between 2008 and 2012. Balance was measured by tandem stance, standing one leg, walking in the figure of eight, walking heel to toe on a line, walking as fast as possible for 30 m and five times sit to stand balance measures [tandem stance and standing one leg measured first with open and then with closed eyes] and each one analyzed for bivariate relations with the 10-year probability values for hip and major osteoporotic fractures as calculated by FRAX® using Spearman's rank correlation test. Results: Individuals with high FRAX® values had poor outcome in balance measures; however the significance level of the correlation differed between tests. Standing one leg eyes closed had strongest correlation to FRAX® (0.610 p = < 0.01) and Five times sit to stand was the only test that did not correlate with FRAX® (0.013). Conclusion: This study showed that there is an association between clinical balance measures and FRAX®. Hence, the use of clinical balance measures and FRAX® in combination, might improve the identification of individuals with high risk of falls and thereby following fractures. Results enable healthcare providers to optimize treatment and prevention of fallrelated fractures. Trial registration: The study has been registered in Clinical Trials.gov, registration number NCT00988572. FRAX®; Falls; Fracture; Balance Background Fall-related fractures are a problem for society, and account for significant morbidity and healthcare expenses in elderly patients [ 1–3 ]. Approximately one third of persons over 65 years of age fall each year [ 4, 5 ]. In 5–15 % of cases, a fall in an elderly person results in a fracture [ 6, 7 ]. Fractures are the most costly fall-related injuries. In the United States, fractures account for 35 % of injuries from falls but 61 % of the healthcare costs [ 3 ]. In Sweden the annual number of hip fractures is expected to double between 2002 and 2050, predicting 30,000 hip fractures in 2050 [ 8 ]. Risk factors for falling Several risk factors for fall-related hip fracture have been identified, such as increasing age and previous fracture [ 9 ], and older adults with multiple risk factors and low bone mineral density are at the highest risk of hip fracture [ 10 ]. Balance is also a risk factor for falls but the variety of methods of assessing balance makes it difficult to appreciate the impact of balance on fall risk [ 11 ]. However, balance deficits can predict falls [ 12 ]. Asymmetric vestibular function affects balance [ 13 ] and is overrepresented among elderly persons with hip fractures [ 14 ] and wrist fractures [ 15 ]. It is also a strong predictor of falls among the elderly [ 13 ]. The age-related changes seen in the incidence of wrist fractures differs significantly from the increase seen in hip fracture incidence [ 16 ]. A deterioration of multiple sensory receptor systems and neuro-muscular function occurs in ageing, which probably result in a decrease in ability to extend the arm to alleviate the consequences of a fall [ 17 ], a pattern that explains the age differences between wrist and hip fracture incidence. Fracture risk prediction tools Since fall-related fractures are a huge problem for the society, and not seldom lethal for the affected person [ 18 ], the use of tools for the prediction of fracture seems essential. As many as 13 different tools have been identified, including between 4 and 31 clinical risk factors [ 19 ]. The most frequent used tool in research is the FRAX® algorithm which was devel (...truncated)


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David Najafi, Leif Dahlberg, Eva Hansson. A combination of clinical balance measures and FRAX® to improve identification of high-risk fallers, BMC Geriatrics, 2016, pp. 94, 16, DOI: 10.1186/s12877-016-0266-6