Home Pelvic joint stiffness and fear of falling in patients over 75 years of age: a prospective cohort study of 100 patients
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Pelvic joint stiffness and fear of falling in patients over 75 years of age: a prospective cohort study of 100 patients

  • Chloe Laizeau EMAIL logo , Sebastien Jochmans and Sylvie Aufaure
Published/Copyright: May 8, 2024
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 124 Issue 11

Abstract

Context

A third of the population aged 65 and over experiences a fall during a given year, often with severe traumatic consequences, dependence, and consequently, a decline in quality of life. The fear of falling itself leads to avoidance behavior from daily activities leading to a downward spiral of dependence, loss of confidence, and therefore an increased risk of falling. Joint stiffness is often observed during clinical examination of elderly people. However, the association between lumbopelvic stiffness and fear of falling has not been studied.

Objectives

Osteopathic manipulative treatment/medicine (OMT/OMM), targeted to improve the stiffness of the pelvic girdle, may improve the prognosis of patients afraid of falling and slow down their loss of autonomy.

Methods

We performed a prospective cohort study enrolling hospitalized patients and nursing home residents over 75 years of age. Patients able to walk and without significant cognitive impairment completed the International Fall Efficacy Scale (FES-I) questionnaire to assess their intensity of fear of falling. The modified Schober test and hip goniometry (flexion and extension) were measured and compared to the FES-I score.

Results

A total of 100 patients were included. A high fear of falling (FES-I≥28) was associated with female sex (31 [79.5 %] vs. 29 [47.5 %]; p=0.002) and with a reduction in the amplitudes tested by the Schober test (2 [1.5–3] vs. 3 [2–4]; p=0.002), the hip extension goniometry (7 [4–10] vs. 10 [7–15]; p<0.001) and the hip flexion goniometry (70 [60–77] vs. 82 [71–90]; p<0.001). The association between FES-I score and each anthropometric variable was strongly linear (p<0.001 for all), especially with hip flexion goniometry (R2=30 %).

Conclusions

Lumbopelvic stiffness, especially in hip flexion, is strongly associated with a high fear of falling in patients over 75 years of age. When combined with other movement-based therapies, OMM targeted to improve the stiffness of the pelvic girdle may improve the prognosis of patients afraid of falling and slow down their loss of autonomy.

Keywords: elderly; Fall Efficacy Scale; fear of falling; hip goniometry; joint stiffness

The aging of the population will change the health needs and care offered in the future. Falls in particular are a frequent event that weakens the elderly. A third of the population aged 65 and over experiences a fall within any given year, often with severe traumatic consequences, dependence, and consequently, a decline in quality of life [1]. Falls are a frequent reason for medical consultation or hospitalization. A fall is only explained in less than a third of cases [2]. Six predictors of falls have been identified: history of falls, social isolation, use of walking aids, depression, cognitive impairment, and the consumption of more than six medications [3].

The fear of falling is defined as the enduring preoccupation with falling, leading the patient to avoid activities that they are able to perform. It affects 92 % of patients who have fallen but also 65 % of the elderly who have not fallen. The fear of falling, and being female, are independent risk factors for falls in older people [4]. The fear of falling leads to avoidance behavior from daily activities, leading to a downward spiral of dependence, loss of confidence, and therefore an increased risk of falling. Restriction of activities also affects participation in social activities and consequently impairs the quality of life.

Joint stiffness is often observed during the clinical examination of elderly people. It is often due to a degenerative origin (osteoarthritis in 9.6 % of men and 18 % of women over 60 years) [5], an inflammatory arthritis (rheumatoid arthritis in 0.3–1.0 % of the population, crystalline arthritis), a traumatic origin (after osteosynthesis or arthroplasty for hip fracture), a musculoskeletal origin (lower back pains in 4–33 % of the population) [5], a neurological origin (Parkinson’s disease with a 60 % risk of a fall per year and 70 % of recurrence [6], secondary extrapyramidal syndrome, after-effects of stroke), or an infectious origin. It is also promoted and increased by immobilization.

The main objective of our study was to assess whether there was an association between joint stiffness and fear of falling in patients over 75 years of age.

Methods

We performed a prospective cohort study in the Geriatric Department of the Melun-Sénart second-level Hospital in the French region of Greater-Paris. The study was conducted from March 2021 to January 2022 and included 100 patients.

Population

Patients (76 %) were screened in the geriatric acute care department and in the geriatric long-stay department; the other participants (24 %) were the residents of the Melun nursing home, which is partnered with the geriatric service of the hospital. Patients who were over 75 years old, able to walk, and willing to participate in the study were eligible. Patients with major cognitive disorders or non-French speakers (i.e., not able to respond to a questionnaire), with a history of lumbar surgery, not affiliated with the French social health system or under tutorship or curatorship, were not included (Figure 1).

Figure 1: Flowchart.
Figure 1:

Flowchart.

Measurements

After assessing patient eligibility, we collected: age, sex, history of falls within the last 6 months, number of different daily prescription drugs and their therapeutic chemical classification, the autonomie gérontologie groupes iso-ressources (AGGIR) scale score (Dependency scale utilized by the French Ministry of Health, varying from 1 to 6 with a score inversely proportional to dependency) [7, 8], and the Charlson Comorbidity Index.

The fear of falling was quantified by the International Fall Efficacy Scale (FES-I) [9, 10]. This questionnaire is validated for the assessment of the worry about the risk of falling. It is usually utilized in clinical practice. The FES-I is a 16-item questionnaire resulting in a global score ranging from 16 to 64. Three categories have been described: from 16 to 19 (not very concerned), from 20 to 27 (moderately concerned), and from 28 to 64 (highly concerned) [11].

Lumbar joint stiffness was assessed by the modified lumbar Schober test (in centimeters). Because of the elderly population of our study and the possible ankylosis of the sacroiliac joints, we chose to evaluate our patients with the modified Schober version, initially developed to detect patients with ankylosing spondylitis [12, 13]. This test has a low sensitivity (0.25–0.30), which does not allow detection of all patients with lumbar pathology but does allow good reproducibility (0.87) and good specificity (0.86–0.95).

Hip joint stiffness was assessed by hip flexion and extension goniometry (in degrees). The measure was performed for active movements. Hip functions are integrated into the lumbo-pelvi-femoral complex. Only sagittal plane movements were observed in this study because flexion and extension are the only ones essential for walking, climbing stairs, and sitting. Flexion also represents the bulk of hip mobility. The flexion is approximately 100°–110°; beyond that, it involves lumbopelvic engagement [14]. This amplitude slightly decreases with age. The extension is from 0° to 20° and highly variable with age, decreasing to less than 5°–10° in the elderly [15].

Statistical analysis

We pooled together the slightly and moderately concerned categories (FES-I ranging from 16 to 27) in a FES-I Group A, that we compared to the highly concerned category (FES-I ranging from 28 to 64) called FES-I Group B. We compared all collected data between Group A and B with the Mann-Whitney test for quantitative variables and the Fischer exact test for qualitative values. Then we performed a linear regression test between all FES-I values and the three anthropomorphic measures (modified Schober test, hip flexion and extension goniometries) with estimates of β linear regression slope, β linear correlation coefficient, and R2 determination coefficient. All tests were two-tailed with a significant p value<0.05. Statistical analyses were performed with SPSS Statistics V20 software (IBM®, New York, NY) and the graphic with Prism 5 software (GraphPad Software Inc®, San Diego, CA).

Ethical statement and study registration

All patients gave their informed consent to participate. No follow-up has been planned. The study protocol was approved by the French Ethics Committee (“Comité de Protection des Personnes Sud-Est IV”) (registration A01885-36, authorization A21242) on November 3, 2021. It was in agreement with the European General Data Protection Regulation (GDPR). The study was registered in ClinicalTrials.gov on November 24, 2021, before the first inclusion (NCT05134038).

Results

A total of 101 patients met the eligibility criteria between November 29, 2021 and December 23, 2021 but one patient withdrew his consent to participate during the consultation. Therefore, 100 patients were included. Cohort characteristics are presented in Table 1. There was 60 (60 %) female patients with a median age of 85 years (range, 81–90 years), mostly hospitalized in acute geriatric care (76 [76 %]). A total of 53 people (53 %) experienced at least one fall in the last 6 months. The median FES-I score was 27 (21–30).

Table 1:

Baseline characteristics of the cohort.

Parameters Values
Number of subjects 100
Age, years (range) 85 (81–90)
Female sex, n (%) 60 (60 %)
Acute geriatric care, n (%) 76 (76 %)
Charlson comorbidity index score 6 [4–7]
AGGIR score 4 [3–4]
History of fall in the 6 last months, n (%) 53 (53 %)
FES-I score 27 [21–30]
Schober test, cm 2.8 [2–4]
Hip flexion goniometry, degree 76 [65–88]
Hip extension goniometry, degree 10 [5–13]
Number of drugs 10 [8–12]
 Psychotropic, n (%) 48 (48 %)
 Antihypertensive and diuretic, n (%) 79 (79 %)
 Anticoagulant and antiaggregant, n (%) 64 (64 %)
 Antidiabetic, n (%) 15 (15 %)
 Antiarrhythmic, n (%) 54 (54 %)
 Antiparkinsonian, n (%) 7 (7 %)
 Antiepileptic, n (%) 6 (6 %)
 Statin, n (%) 26 (26 %)

  1. Quantitative values are presented by median [25th–75th quartile]. AGGIR, “autonomie gérontologie groupes iso-ressources” scale; FES-I, International Fall Efficacy Scale.

After having split the cohort into Group A (FES-I<28) and Group B (FES-I≥28), the only parameters associated, in univariate analysis, with a high fear of falling were to be a female (31 [79.5 %] vs. 29 [47.5 %]; p=0.002) and to have a reduction in the amplitudes tested by the Schober test (2 [1.5–3] vs. 3 [2–4]; p=0.002), the hip extension goniometry (7 [4–10] vs. 10 [7–15]; p<0.001), and the hip flexion goniometry (70 [60–77] vs. 82 [71–90]; p<0.001) (Table 2). There was no association of elevated FES-I with age, recent history of fall, or number of medications taken chronically.

Table 2:

Patients of FES-I Group A (FES-I below 28: low to moderate fear of falling) compared to FES-I Group B (FES-I above or equal to 28: high fear of falling).

Parameters FES-I Group A (FES-I<28) FES-I Group B (FES-I≥28) p-Value
Number of subjects 61 49 –
FES-I score 22 [18–24] 33 [29–43] <0.001
Age, years 85 [81–90] 85 [78–90] 0.890
Female sex, n (%) 29 (47.5 %) 31 (79.5 %) 0.002
Charlson comorbidity index score 6 [5–7] 5 [4–6] 0.054
AGGIR score 4 [3–4] 4 [3–4] 0.417
History of fall in the 6 last months, n, % 32 (52.5 %) 21 (53.8 %) 1
Schober test, cm 3 [2–4] 2 [1.5–3] 0.002
Hip flexion goniometry, degree 82 [71–90] 70 [60–77] <0.001
Hip extension goniometry, degree 10 [7–15] 7 [4–10] <0.001
Number of drugs 10 [8–12] 10 [7–13] 0.739
 Psychotropic, n (%) 29 (48.3 %) 19 (48.7 %) 1
 Antihypertensive and diuretic, n (%) 48 (80 %) 31 (79.5 %) 1
 Anticoagulant and antiaggregant, n (%) 39 (65 %) 25 (64.1 %) 1
 Antidiabetic, n (%) 12 (20 %) 3 (7.7 %) 0.150
 Antiarrhythmic, n (%) 34 (56.7 %) 20 (51.3 %) 0.681
 Antiparkinsonian, n (%) 2 (3.3 %) 5 (12.8 %) 0.109
 Antiepileptic, n (%) 5 (8.3 %) 1 (2.6 %) 0.398
 Statin, n (%) 18 (30 %) 8 (20.5 %) 0.355

  1. Quantitative values are presented by median [25th–75th quartile]. AGGIR, “autonomie gérontologie groupes iso-ressources” scale; FES-I, International Fall Efficacy Scale.

Moreover, there was a linear correlation between FES-I values and each anthropometric variable (p<0.001 for all) (Figure 2 and Table 3). Hip flexion goniometry had the higher determination coefficient R2 (30 %).

Figure 2: Linear regression models between FES-I and the anthropometric measurements. p<0.001 for all variables.
Figure 2:

Linear regression models between FES-I and the anthropometric measurements. p<0.001 for all variables.

Table 3:

Tabular results of the linear regression models between FES-I and the anthropometric measurements.

Parameters βa P a R 2
Hip flexion goniometry −0.58 ± 0.13 −0.46 [−0.6; −0.28] 30 %
Hip extension goniometry −0.2 ± 0.04 −0.43 [−0.58; −0.25] 18.2 %
Schober test −0.06 ± 0.01 −0.42 [−0.57; −0.24] 17.5 %

  1. β, slope of the linear regression ± standard deviation; P, linear correlation coefficient (95 % confidence interval [CI]); R2, linear determination coefficient. ap<0.001.

Discussion

Our study shows that there is a strong negative linear association between the fear of falling, assessed by the FES-I scale, and joint stiffness, measured by hip goniometry and the Schober test. Without prejudging causality, the lower the lumbopelvic joint amplitude, the greater the fear of falling. Table 2 shows that there is a statistically significant difference between the two groups, FES A et FES B, in terms of FES-I score and gender (females being more affected by fear of falling), thus confirming the data in the literature and anthropometric measurements.

Our group was homogeneous in terms of age, and contrary to what we have seen in the literature, we found no statistically significant difference between the two groups in terms of history of falls or polypharmacy.

Figure 2 illustrates that as joint amplitude decreases, the FES-I test score increases. This is confirmed by the linear regression tests, whose slopes are negative for all three anthropometric values. Spearman’s correlation test indicates a p value<0.001, so we can conclude that there is an association between the fear of falling and coxofemoral and lumbar joint stiffness.

In our study, hip flexion was the parameter most significantly associated with the fear of falling. This can be explained by the fact that flexion accounts for most of the mobility of the hip. Its decrease in amplitude hinders a number of everyday movements such as sitting and walking. The useful sector of the extension is small, between 5° and 10°, and can be compensated very quickly by the anteversion of the pelvis [16]. Lumbar stiffness is well supported if the stability function is well safeguarded [17]. If the stiffness is global, mobility is transferred to the hips (lumbopelvi-femoral complex).

To our knowledge, the impact of hip flexion on fear of falling has not been shown to date. Some authors find that joint stiffness increases walking disorders and is the cause of loss of autonomy [18]. Others find that the fear of falling and reduced range of motion persists even after hip prosthesis placement in the context of a fractured femur and conclude that the fear of falling is a prognostic factor [19], [20], [21], [22]. Most authors find that joint mobilization (by tai chi stretching) has a beneficial effect on the fear of falling, thereby improving muscle strength, balance, walking, and mood [23, 24]. Also, some authors have demonstrated the benefit of yoga (because of prolonged stretching and physical postures) for the prevention of falls by improving balance and walking disorders in Parkinson’s patients [25].

It can be noticed that in our cohort, age, dependence, polypharmacy, Charlson Comorbidity Index score, and even a history of fall within 6 months were not associated with a higher fear of falling. On the other hand, women were more concerned by this fear, confirming previous publications [26]. We must remember that the FES-I scale assesses the fear of falling and not the risk of falling.

The first limitation of this study concerns the FES-I questionnaire. Indeed, a large part of our population had entered hospitalization following a fall or decompensation from a chronic disease. The FES-I questionnaire was not always suitable because it asks the subject about activities of daily living. If the patient is unable to handle the different situations as they are, they are advised to answer the question by imagining the level of concern they would feel if they actually performed this activity. This exercise in imagination was not easy for everyone and could have led to judgment errors. Some questions concerning the exits were also difficult to answer because many subjects in our cohort no longer leave their home at all. The COVID-19 health crisis has also significantly reduced social interactions, thus excluding many items of the score such as “visiting a friend,” “walking in a place with a lot of people,” and “going out for associative or religious meetings.”

In addition, subjects were often hospitalized for a fall. However, they did not necessarily seem worried about a recurrence. It is indeed surprising that a recent history of falling is not associated with a high fear of falling. The ergonomics of the home also play a significant role in worrying about the possibility of falling. The installation of handrails in the house and in the bathroom, a stairlift, and walkers are major aids that radically change the feelings of the patients about the fear of falling.

Another limitation is that anthropometric measurements were not always easy to perform. Whereas it was easy to measure correct hip flexion without interference from other joints, extension measurements were less reliable because the lumbar tilt quickly activated to compensate.

Finally, it would have been useful to measure the pain experienced, because it is often associated with joint stiffness and contributes to the fear of falling [27].

Conclusions

Our study shows that lumbopelvic stiffness, especially in hip flexion, is strongly associated with a high fear of falling in patients over 75 years of age. These simple anthropometric measurements could be part of the systematic assessment tools in elderly patients.

Osteopathic medicine is a movement-based discipline. It has the advantage of being noninvasive and nonmedicinal for a population that we wish to encourage to be active and to avoid polymedication. Osteopathic manipulations, adapted to age-related musculoskeletal specificities, are beneficial for increasing overall mobility, relieving pain, and treating muscles and joints. It therefore has its place alongside other movement therapies such as yoga and tai chi.

Physical therapy and osteopathic manipulative treatment/medicine (OMT/OMM) sessions, targeted to improve the stiffness of the pelvic girdle, may improve the prognosis of patients who are afraid of falling and slow down their loss of autonomy.

To pursue this line of questioning, it would be interesting to conduct a randomized controlled trial to evaluate the effect of manual therapy, such as osteopathy, on the fear of falling.

Corresponding author: Chloe Laizeau, DO, MSc, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun-Sénart, 270 avenue Marc Jacquet, 77000 Melun, France, E-mail:

Acknowledgments

We would like to thank Charles Timoney and Beatrice Flipse for their corrections of the English text. We would also like to thank Adeline Truan, MKDE, for her expert advice.

  1. Research ethics: The study protocol was approved by French Ethics Comity “Comité de Protection des Personnes Sud-Est IV” (registration A01885-36, authorization A21242) on November 3, 2021. It was in agreement with the European General Data Protection Regulation (GDPR). The study was registered in ClinicalTrial.gov on November 24, 2021, before the first inclusion (NCT05134038).

  2. Informed consent: All patients gave their informed consent to participate. Informed consent was obtained from all individuals included in this study, or their legal guardians or wards.

  3. Author contributions: All authors agree to be accountable for all aspects of the work in ensuring that question related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  4. Competing interests: None declared.

  5. Research funding: None declared.

  6. Data availability: The raw data can be obtained on request from the corresponding author.

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Received: 2024-01-05
Accepted: 2024-04-08
Published Online: 2024-05-08

© 2024 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

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  2. Medical Education
  3. Original Article
  4. Concerns of osteopathic medical students during the COVID-19 pandemic
  5. Musculoskeletal Medicine and Pain
  6. Original Article
  7. Pelvic joint stiffness and fear of falling in patients over 75 years of age: a prospective cohort study of 100 patients
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https://doi.org/10.1515/jom-2024-0004
Keywords for this article
elderly; Fall Efficacy Scale; fear of falling; hip goniometry; joint stiffness
Creative Commons
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Articles in the same Issue

  1. Frontmatter
  2. Medical Education
  3. Original Article
  4. Concerns of osteopathic medical students during the COVID-19 pandemic
  5. Musculoskeletal Medicine and Pain
  6. Original Article
  7. Pelvic joint stiffness and fear of falling in patients over 75 years of age: a prospective cohort study of 100 patients
  8. Neuromusculoskeletal Medicine (OMT)
  9. Review Article
  10. A systematic review of manual therapy modalities and anxiety
  11. Pediatrics
  12. Original Article
  13. Association of prenatal substance exposure and the development of the amygdala, hippocampus, and parahippocampus
  14. Public Health and Primary Care
  15. Original Article
  16. Feasibility of a cinematic-virtual reality training program about opioid use disorder for osteopathic medical students: a single-arm pre–post study
  17. Letters to the Editor
  18. Regarding “Issues of informed consent for non-specialists conducting colorectal cancer screenings”
  19. Response to: Regarding “Issues of informed consent for non-specialists conducting colorectal cancer screenings”
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