Correlation between postural balance and quality of life in older women with low bone density: a cross-sectional studyABSTRACT
This study aimed to correlate postural balance with quality of life in older women with low bone mineral density. Overall, 46 participants aged 60 years or older who practiced no regular resistance exercises and who had hypovitaminosis D, osteopenia, osteoporosis, and low bone mineral density were evaluated in this prospective cross-sectional study. A characterization questionnaire of participants’ sociodemographic and anthropometric data was constructed. Participants were classified according to their level of physical activity by the International Physical Activity Questionnaire. Quality of life assessment questionnaires (WHOQOL-BREF and WHOQOL-OLD) were also used. Static postural balance assessments were carried out via posturography on a AccuSwayPlus AMTI® portable force platform. In total, three assessments were carried out with eyes open and three with eyes closed. This study found that low bone mineral density and hypovitaminosis D showed no relationship between postural balance and quality of life in older women, only obtaining some specific correlations.
Keywords:
Quality of Life; Postural Balance; Bone Mineral Density; Vitamin D; Osteoporosis; Aging
RESUMO
O objetivo do estudo foi correlacionar equilíbrio postural com a qualidade de vida em idosas com baixa densidade óssea. Trata-se de um estudo transversal. Foram avaliados 46 participantes com 60 anos ou mais, não praticantes de exercícios resistidos regularmente e que tivessem hipovitaminose D, osteopenia, osteoporose e baixa densidade mineral óssea. Utilizou-se um questionário de caracterização construído pelos pesquisadores, com dados sociodemográficos e antropométricos. As participantes do estudo foram classificadas quanto ao nível de atividade física pelo questionário internacional de atividade física (IPAQ). Em seguida foram aplicados os questionários de avaliação de qualidade de vida, os instrumentos WHOQOL-BREF e WHOQOL-OLD. Além disso, foram realizadas as avaliações de equilíbrio postural estática, por meio da posturografia, utilizando uma plataforma de força portátil do modelo AccuSwayPlus, AMTI®. Realizaram-se três avaliações com os olhos abertos (OA), e três com os olhos fechados (OF). Foi observado como principal achado do nosso estudo e como conclusão que mulheres com baixa densidade mineral óssea (DMO) e hipovitaminose D não apresentam relação do equilíbrio postural com a qualidade de vida, apenas algumas correlações pontuais.
Descritores:
Qualidade de vida; Equilíbrio postural; Densidade Mineral Óssea; Vitamina D; Osteoporose; Envelhecimento
RESUMEN
El objetivo de este estudio fue correlacionar el equilibrio postural con la calidad de vida en mujeres mayores con baja densidad ósea. Este es un estudio transversal. Se evaluaron 46 participantes, de 60 años o más de edad, que no practicaban ejercicio de resistencia regularmente y que tenían hipovitaminosis D, osteopenia, osteoporosis y baja densidad mineral ósea. Se utilizó un cuestionario de caracterización elaborado por los investigadores, con datos sociodemográficos y antropométricos. Las participantes del estudio se clasificaron de acuerdo con el nivel de actividad física mediante el Cuestionario Internacional de Actividad Física (IPAQ). Después, se aplicaron los cuestionarios de evaluación de la calidad de vida, los instrumentos WHOQOL-BREF y WHOQOL-OLD. Además, se realizaron evaluaciones de equilibrio postural estático mediante posturografía, utilizando una plataforma de fuerza portátil del modelo AccuSwayPlus, AMTI®. Se realizaron tres evaluaciones con los ojos abiertos (OA) y tres con los ojos cerrados (OC). El principal hallazgo de este estudio y conclusión reveló que las mujeres con baja densidad mineral ósea (DMO) e hipovitaminosis D no tuvieron relación entre el equilibrio postural y la calidad de vida, solo algunas correlaciones específicas.
Palabras clave:
Calidad de Vida; Equilibrio Postural; Densidad Mineral del Hueso; Vitamina D; Osteoporosis; Envejecimiento
INTRODUCTION
Aging, a natural phase of life, influences physiological and metabolic processes, including the loss of bone mineral density (BMD). Such musculoskeletal decline can lead to postural instability, gait speed disturbances and reduction, and limited range and movement since they depend on the visual, vestibular, and somatosensory system1. Moreover, aging is linked to the chronological time of life or to the physical and psychological changes throughout it, rendering it a complex social construction such as other experiences in life2.
After peak bone mass, the human skeleton tends to progressively lose bone tissue3. During the resorption, osteoclasts and osteoblasts determine the mineralization of tissues, which must replace the lost bone mass in a balanced way. Bone weakening occurs4 under excessive resorption, favoring a higher risk of fractures and loss of postural control, such as the falls fragile women with osteoporosis endure, one of the biggest problems for the Brazilian public health system5.
BMD loss, a multifactorial metabolic disorder, occurs in bone structure, decreasing its density. It has two classifications: primary and secondary. Primary BMD loss is subdivided into type I and type II-type I accelerates bone loss (especially in postmenopausal women), decreases estrogen, and decreases vitamin D synthesis in the body; BMD loss type II causes the chronic loss of calcium and decreased bone formation due to aging. Secondary BMD loss stems from metabolic inflammatory processes6.
Several studies abroad have investigated the relationship between postural balance, quality of life, low BMD, and hypovitaminosis D in older women. Studies have indicated that decreased balance and muscle strength in older women with osteoporosis is associated with an increased risk of falls, negatively affecting their quality of life7-9. Physical exercises play an important role in these cases10. Despite advances, the scientific literature still contains gaps. The specific interaction between hypovitaminosis D, postural balance, and quality of life in older women with low BMD is yet to be fully explained. Future research could explore combined interventions, such as physical exercise programs combined with vitamin D supplementation, to assess their effects on improving postural balance and quality of life in this population. Finally, longitudinal studies are necessary to better understand the causal relationships between these factors and to develop more effective preventive strategies.
Thus, despite significant research on only postural balance, BMD, and hypovitaminosis D in older women, the integrated understanding of these factors and their implications for quality of life remains limited. Further investigations are essential to fill such gaps and provide evidence-based guidelines for healthcare providers and public policy makers.
Estimates suggest that about 30% of older adults experience at least one fall episode per year11. Faced with loss of balance, older adults face the challenge of adapting to their environment. The concept of quality of life adopted by the World Health Organization states that individuals’ environment, values, objectives, and expectations influence their perception; a subjective, multidimensional, and positively and negatively varying definition5.
Thus, this study aimed to evaluate the correlation between postural balance and quality of life in older women with low BMD and hypovitaminosis D.
METHODOLOGY
Study type and location
This cross-sectional study was carried out by the Movement Study Laboratory of the Institute of Orthopedics and Traumatology at the Faculdade de Medicina de São Paulo in collaboration with Universidade São Judas Tadeu and the Anima Brasil system. All evaluations were carried out at the Laboratory. Its data belong to a database from a randomized clinical trial that was developed from December 2017 to February 2019. The main results of that study were published in 202112.
Participants
After approval by the Research Ethics Committee, 422 participants were invited to this research via social media and dissemination by the Hospital das Clínicas. The following were chosen: 46 participants aged 60 years or older who had been diagnosed with osteopenia or osteoporosis (BMD below −1.5 T-score standard deviations) who had hypovitaminosis D (above 30 nmol/L); practiced no resistance exercises regularly; had suffered no injuries or traumas to their lower limbs in the previous three months that would prevent or impair the practice of physical activity; who could walk independently and without lameness for at least 100 meters; who could perform daily activities independently and had no restrictions for the practice of resistance exercises, including a recent stress test (the occurrence had to have taken place at least six months prior). They could neither use medications such as estrogens and diuretics to gain bone mass or food supplements with vitamin D nor suffer from hyperparathyroidism, diabetes, uncontrolled hypertension, hyperprolactinemia, hypercalciuria, urolithiasis, or high serum calcium (evaluated by tests requested by a physician). All agreed to participate in this study. Those who were unable to perform the proposed tests, had some type of complication performing these tests, or refused to answer any question in the applied questionnaires were excluded. After agreeing to participate in this study, all participants underwent evaluations on the same day and signed an informed consent form. If they were illiterate, the researcher read the form for the candidate, who could then choose to participate in this project.
Instruments and procedures
A sociodemographic, health, and anthropometric questionnaire developed by the researchers was used to characterize the sample, including questions on participants’ age, race, education, marital status, family income, housing, medical follow-ups, number of falls, habits, and medications. Data requested in screening (as an inclusion criterion) on body composition and height and body mass were analyzed. Their body mass index was calculated, which was later added to bone densitometry results to confirm osteopenia or osteoporosis. During data collection, the volunteers were asked to wear light and comfortable clothing without shoes.
Regarding physical activity classification, the International Physical Activity Questionnaire (IPAQ) was used in the interviews, an instrument that evaluates the practice of physical activities according to the number of days of the week, time per day and week, and intensity (light, moderate, or vigorous) in various situations of daily life, including work, daily activities, leisure, transportation, and passive activities sitting13. This variable was used to classify participants’ physical activity levels.
Next, the questionnaires to assess quality of life were applied to evaluate quality of life and well-being. The WHOQOL-BREF is an abridged version of the WHOQOL-100 method. It has 26 questions to be answered individually14: two questions refer to quality of life in general and contentment with one’s own health, the other 24 questions are divided into four domains: physical, psychological, social relationships, and environment. This instrument can be used in healthy individuals or in those with some impairment interfering with their health15. The answers are calculated according to a 1-to-5 scale for each question in which the higher the score, the better the individual’s satisfaction with their quality of life. This variable was used to classify participants’ quality of life.
The WHOQOL-OLD, a version targeting older adults (who currently make up a large part of the global population), was also used. Due to the few evaluation methods for this population, the assessment of quality of life aimed to compare the aging of sick individuals with that of healthy ones. It has 24 questions in six domains: physical, psychological, level of independence, social relationships, environment and spirituality, and religiosity and personal beliefs (selected as relevant). The WHOQOL-OLD questionnaire is a complement and should be applied together with the WHOQOL-BREF16. This variable was used to classify participants’ quality of life.
Static postural balance assessments aim to analyze and score body oscillation according to fixed anatomical points of the feet. The first evaluation was performed via posturography with a portable AMTI® AccuSwayPlus force platform that was connected to an amplifier and computer to collect data and store it on Balance Clinic®. Participants were to climb the force platform barefoot and remain standing for 60 seconds with their feet parallel to their arms comfortably. The average was calculated from three evaluations with their eyes open (EO) and three times with their eyes closed (EC). An evaluation using another balance device, Balance Master® System (Neurocom International, Inc. Clackamas, Oregon, USA), was performed with individuals on the force plate for oscillation analysis, three times for 10 seconds each with their eyes open and closed, resulting in the moving average of the three measurements17. The following stabilometric parameters were analyzed for eyes open and closed: Total displacement of the center of pressure in the medial-lateral and anteroposterior planes: the total number of displacements of the center of pressure in this direction (c); mean amplitude of the displacement of the center of pressure in the medial-lateral (XSD) and anteroposterior planes (YSD), i.e., the root mean square of the displacements of the center of pressure in this direction (cm); and the average resultant velocity (VAvg), i.e., the average velocity according to the total displacement of the center of pressure in all directions over the period (cm/s).
Statistical analysis
Analysis data were treated on STATA. They are shown as means, medians, standard deviations, minimums, and maximums. The Shapiro-Wilk test was performed to assess the normal distribution of the continuous variables. Categorical variables are shown as frequencies and proportions. The correlation between quality of life (WHOQOL-BREF and WHOQOL-OLD) and the applicability of static (static posturography) and functional balance assessments were evaluated by the Spearman’s test. A p<0.05 significance level was adopted in all statistical analysis.
RESULTS
The study population consisted of postmenopausal women with low BMD and hypovitaminosis D living in the state of São Paulo. Table 1 shows the sample characterization data.
Table 2 shows the descriptive results of participants’ posturography, referring to static equilibrium variables with their eyes open and closed.
Table 3 shows the analysis of the correlation of the quality-of-life questionnaires WHOQOL-OLD and WHOQOL-BREF according to the domain with the variables of static balance (posturography) with eyes open and closed.
DISCUSSION
Aging brings physiological changes that affect cognitive, motor, and other functions. Vitor et al.18 found that older women with osteopenia and especially osteoporosis lack postural balance, which can result in falls, causing permanent or temporary physical dependence and restricting functional activities, further worsening functional decline and negatively influencing their quality of life.
This study aimed to evaluate the correlation between postural balance and quality of life in older women with low BMD. It found that low BMD and hypovitaminosis D have no relationship with postural balance and quality of life, only obtaining a few punctual correlations. However, previous studies19,20 have shown associations between postural imbalance, decreased body composition, loss of functional capacity, and aging, resulting in falls and compromising quality of life.
Regarding the sociodemographic characteristics of the sample, the participants were women. According to studies, this population has the highest prevalence of postural and hormonal imbalances, resulting in a greater number of falls21,22. Participants in this sample mentioned using two or more medications. Silva et al.20 found that continuous medication interferes with the perception of the body in space, justifying postural imbalance.
BMD loss falls into two classifications (modifiable and non-modifiable) according to factors resulting from advanced age, white and Yellow skin-color, sedentary lifestyle, body composition, diet, and low exposure to the sun22. These factors are in line with the characterization of the sample in this study, in which most volunteers were white and sedentary and had hypovitaminosis D.
The age ground included individuals aged 60 years or older in our study, a larger audience than that in Cordeiro et al.23, which ranged from 70 to 74 years. Women in this age group could have the protective effects of a sedentary lifestyle as they had raised their children and often found themselves retired. Older women aged 60 years or older practiced no type of physical activity, but most remained active according to the IPAQ, which evinced an irregularly active A frequency, that is, they practiced physical activities with insufficient frequency and duration to be classified as active. Thus, regardless of age, women prioritize their social role, leaving physical activity and leisure in the background.
This study applied questionnaires to evaluate correlations between postural balance and quality of life, finding no significant improvement in postural balance variables in most WHOQOL-OLD (sensory functioning, autonomy, past, present and future activities, social participation, death or dying, and intimacy) and WHOQOL-BREF quality-of-life domains (physical, psychological, social relationships, and environment).
Paz et al.24, also using the WHOQOL-OLD, found a low score for autonomy and social participation, as in this study, which observed a weak negative correlation with the latero-lateral displacement of pressure under eyes open and closed (EO XSD=−0.29; EO XSD=−0.32). This means that the greater the displacement of the center of pressure to the sides, the lower the autonomy of the study participants. Such loss of autonomy influences interpersonal and functional relationships as older adults stop performing daily and leisure activities, which negatively impacts their health in general and quality of life25.
Emotional changes have great relevance for individuals in aging since they can take the initiative to perform tasks via emotions. Silva et al.20 showed that older women had less participation restrictions and better WHOQOL-BREF psychological domain scores. However, the mean age in their sample differed from the one in this study. This research found a weak negative correlation with the displacement of the anteroposterior pressure center with eyes open and the WHOQOL-BREF psychological domain (EO Ampl Y=−0.30; EO YSD=−0.30). This means that the greater the displacement of the anteroposterior pressure center, the lower participants’ psychological scores. Ribeiro et al.26 observed that functioning and improved postural balance bettered the quality of life of older adults with depression and emotional issues.
Chodzko-Zajko27 and Fleck14 showed that older women who practice physical activities significantly improve their health as exercising regularly leads to healthy aging, providing autonomy and self-care. Bulat et al.28, Cabral et al.29, Macêdo et al.30, and Karlsson et al.31 also stated that the practice of physical activity improves gait and postural balance, reducing the risk of falls and improving postural balance and quality of life.
Although this study found no direct evidence correlating quality of life with postural balance in older women with low BMD, it raises relevant questions about health. Its results, when associated with the literature, contribute to furthering the scientific knowledge in the area, helping to formulate new, more effective, and targeted studies. Its findings can support and improve healthcare providers’ clinical practices, promoting more assertive strategies to prevent and rehabilitate postural disorders in older adults.
Declining postural balance, especially in older women with low BMD, can negatively impact their quality of life. The fear of falling generates insecurity and limits participation in activities of daily living, increasing the risk of social isolation and impairment of autonomy. Thus, although this study found no direct relationship between quality of life and postural balance, its relevance stems from its furthering of the technical and scientific knowledge that is available to healthcare providers and its reinforcement of the importance of preventive and interventional strategies to care for this population. Thus, the results in this study can contribute to the implementation of more effective health policies, directly benefiting affected individuals, health systems, and society.
This study has some limitations, such as its short evaluation of older women, small sample size (i.e., number of volunteers at baseline), lack of data such as on the frequency and time of irregular and daily activities that could improve postural balance, and no comparison groups with older women without osteoporosis or osteopenia in its statistical analyses.
FINAL CONSIDERATIONS
Despite no significant correlation between quality of life and postural balance, this study found a punctual association in four of these variables, evincing less autonomy in the displacement of the lateral center of pressure and an influence on the psychological aspect in the displacement of the anteroposterior center of pressure.
Regarding physical activity, this research found a direct relationship with healthy aging in individuals who actively practice physical activities (unlike the profile of the analyzed sample, most of whom lived a sedentary or irregularly active lifestyle.
DATA AVAILABILITY STATEMENT
The entire dataset supporting the results of this study is available within the article.
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