Osteoarthritis and Falls
Having OA may make you more likely to suffer falls and fractures. Here’s what the research shows and what you should do to reduce your risk.
For an older person who falls, the pain can go far beyond the impact of the fall or the immediate injuries resulting from it. A broken hip, for example, may necessitate the surgery with all its inherent risks in addition to the risks related to immobility including blood clots and muscle atrophy. A fractured wrist may permanently interfere with the ability to perform daily tasks such as carrying heavy items, turning door knobs or keys, cutting food or pouring a drink.
While fractures have long been attributed to the brittle bone disease, osteoporosis, increasingly scientists are considering the role that osteoarthritis may play in the risk of falling and/or the type and severity of resulting injuries.
For example, an analysis of the 51,386 women in the Global Longitudinal Study of Osteoporosis in Women (GLOW), a large international study designed to improve care of patients who are at risk of osteoporosis-related fractures, revealed those who had osteoarthritis (about 40 percent of the study population) experienced 30 percent more falls and had a 20 percent greater risk of facture than those without OA.
While it is not completely understood why people with OA would be more likely to fall or experience more fractures, new research is providing some clues. Here’s what doctors are learning about how and why OA may affect falls and fracture risk—and what you can do to reduce that risk.
The Problem with Pain
Several studies have shown an association between pain and fall risk. One 2009 study of 749 adults aged 70 years and older, for example, found that those who reported two or more locations of musculoskeletal pain, severe pain or pain that interfered with their ability to perform daily activities were significantly more likely to fall than those with no pain or low levels of pain. The study was published in the Journal of the American Medical Association.
A separate study of 6,641 men and women 75 or older who participated in a three-year trial of intramuscular vitamin D therapy found that those who reported prevalent knee pain had a 25 percent increased risk of falls and almost twice the risk of hip fractures compared to those without prevalent pain. Increasing severity of knee pain was associated with a greater risk of falls and hip fracture. Authors of the study, which was published in Arthritis & Rheumatism, say the increased risk of fractures could not be explained by the increased risk of falls, but was likely due to the severity of the falls suffered by those with knee OA.
Another explanation for the OA-fall connection is that people with OA have risk factors such as decreased function, muscle weakness and impaired balance that make them more likely to fall, says Catherine Arnold, professor of physical therapy at the University of Saskatchewan, Canada. “Those are all very common in individuals that have arthritis in their lower extremities like their hips and knees.”
Adding to the problem is that OA makes exercise difficult, she says, so that many people with OA tend to be less active. “They are not as engaged in physical activity and therefore that is a bit of a spiral in terms of their confidence in their ability to balance, says Arnold, whose research expertise is focused on educational and exercise programs to decrease fall risk in the older and other vulnerable populations. “Their balance deteriorates more and puts them at higher risk. ”
In a cross-sectional, population-based study published in Osteoarthritis and Cartilage, researchers used several tools including the Western Ontario McMasters Osteoarthritis Index (WOMAC) to measure pain, stiffness and functional ability of 850 randomly selected men and women aged 50 to 80. WOMAC is a score derived from patients’ answers to a questionnaire concerning arthritis symptoms, including pain and stiffness, and how those symptoms affect their ability to function. While the group as a whole had a low risk of falls, those who had higher WOMAC scores – which significantly associated with factors such as reaction time, balance, proprioception (the ability to sense the position and location and orientation and movement of the body and its parts) – had a greater risk of falling compared to those with lower scores.
Some researchers believe the risk of falls and fractures in patients with OA may have less to do with the arthritis itself than the medications used for pain relief, citing an increase in falls and fractures among OA patients since the COX-2 inhibitor rofecoxib (Vioxx) was taken off the market in 2004 and the discovery of cardiovascular risks associated with NSAID use prompted the prescription of narcotic analgesics instead.
In a study presented at the 2011 scientific meeting of the American College of Rheumatology, researchers at New York University (NYU) reviewed the medical records of 10,000 patients diagnosed with osteoarthritis between 2001 and 2009, and found that the percentage of study patients who received prescriptions for narcotic analgesics increased from 8 percent in 2002 to 40 percent in 2009. During the same time frame, the incidence of falls and fractures more than quadrupled.
Specifically the researchers found the prescription narcotic analgesics was associated with a 3.7-times greater risk for falls and fractures than he prescription off COX-2 inhibitors and a 4.4-times greater risk than non-COX-2 inhibitor NSAIDs from 2005 to 2009.
“We couldn’t prove cause and effect,” says Lydia Rolita, MD a geriatric researcher at NYU and the study’s lead author. “We couldn’t prove that people were actually taking what was prescribed to them, but it’s reasonable to guess that’s what was going on.”
In a separate large study of Medicare beneficiaries in Pennsylvania and New Jersey, investigators at Brigham and Women’s Hospital in Boston identified those with rheumatoid arthritis or osteoarthritis who were started on a nonselective NSAID, a COX-2-selective NSAID, or a narcotic analgesic during 1999-2005 and then calculated the fracture risk. The composite incidence of nonvertebral fracture – those of the hip, pelvis, humerus (upper arm bone) or wrist -- 26 per 1,000 person-years among patients on nonselective NSAIDs, 19 with COX-2-selective NSAIDs, and 101 with narcotic analgesics.
While Brigham and Women’s study, like the NYU study, clearly showed a connection between the prescription of narcotic analgesics and fall risk, the study was not designed to explain the connection.
Regardless of the cause of falls and fractures, research points to the need to more efforts to prevent them. A study by Arnold published in the Journal of Aging and Physical Activity suggests an aquatic exercise and education program can help. In the study, 79 adults age 65 and older with hip OA and at least one other fall risk factor were randomly assigned into one of three groups: aquatic exercise twice a week plus a once weekly education; aquatic exercise twice weekly or a usual activity control group. Factors like balance, falls efficacy (the feeling of confidence that you are able to move better), walking performance and functional performance were measured before and after the study. The combination of aquatic exercise and education was more effective in improving fall risk factors than exercise alone, says Arnold.
To reduce your risk of falling, Arnold recommends taking an exercise class such as those offered by the Arthritis Foundation with an educational aspect to it. “Look for a program that teaches how to use good biomechanics when doing activities at home and talks a bit about falls education,” she says. “Certainly individual attention and getting that advice from a physical therapist would be helpful as well.”
Taking another look at medications, too, could help reduce fall risk, says Dr. Rolita. “I think we need to think more carefully about pain medication regiments and take into consideration people’s risk factors,” she says.
For example, if someone doesn’t have significant cardiovascular risk factors that might make an NSAID inadvisable, their doctors might do well to pay a little more attention to fall risk, she says. “I think it’s important to just kind of weigh the risks and benefits on a more individual level.”