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In recent years, numerous studies have examined the relative bone density values of residual limbs following amputation, comparing these against the values of the sound-side limbs or those observed in matched controls. With only rare, individual exceptions, the density values of the amputated limbs are consistently below those of controls.

Does Amputation Level Matter?

The answer to this question depends on who you ask. The observations of Smith et al. suggest that amputation level has no effect on BMD values at either the femoral neck or the total proximal femur.The observations from other samples suggest that amputation level does matter and that the residual limb of individuals with transfemoral amputations have markedly lower BMD (bone mineral density) than the residual limbs of individuals with transtibial amputations. Leclerq et al., in their analysis of 99 lower-limb amputees, found that hip BMD was lower in the affected side than it was in the intact limbs and the percentage difference in BMD between limbs was significantly greater for subjects with transfemoral amputations than it was for transtibial subjects.In the most carefully controlled trial, Sherk et al. compared the BMD values of 14 amputee subjects. DXA bonedensity values at the femoral neck and found fairly substantial BMD compromise within the transfemoral group.

Male vs. Female?

It is commonly recognized that women are at greater risk for osteoporosis than men. There has been only one published report with data by gender and the findings are quite pronounced.  Smith et al. found that male DXA examination of the lumbar spine were within normal limits for bone mineral density, but the females were soundly in the osteopenic category irrespective of the BMD of their affected femurs. Similarly, the observed BMD values of the sound-side femur in the two groups were markedly different.  The male subgroup reported normal BMD values and that of the female subgroup was identified as having osteopenia in the soundside femur. Thus, the elevated risk of osteoporosis among able-bodied women appears to carry over into those with amputations, with women demonstrating significantly lower BMD values than their male counterparts at all tested bony locations, with particularly concerning values at the affected femur.

Does Activity Level Impact BMD?

The research by Leclercq et al. suggests that those subjects who wear a prosthesis at least six hours a day have significantly greater BMD than those who wore their prosthesis less than that.  The data of Yazicioglu et al. seem to support this premise.

In Summary

The greatest concern with decreased BMD values is elevated fracture risk. The likelihood of a fracture at a location of declining SD roughly doubles. So for the amputee in the research of Smith et al., 48 percent carry a two-fold risk of hip fracture, and 33 percent face at least a four-fold risk of hip fracture. For the older amputee like that examined in Kulkarni et al.,  the patients carried a fourfold risk of femoral neck fracture.

Younger, more active amputees seemed to have the largest fracture risk, suggesting one of the possible reasons for the high number of fractures among transtibial amputees. Second, the possible influence of the prosthetic socket as either a causative or protective agent can be reasonably questioned.  The current role of the prosthesis in promoting or guarding against femur fracture is uncertain.

Compromise to bone density appears to be considerably greater among females and those with transfemoral amputation levels and is aggravated with increasing time since amputation, reduced activity levels, and general aging. While the published observations regarding BMD levels would suggest sizeable elevations in ultimate fracture risks, the older literature fails to support large fracture rates in this population, and there is no recent literature to confirm or refute actual fracture rates in the past few decades. In the absence of such literature, it becomes the responsibility of treating clinicians to be mindful of the relative BMD compromises their patients face and plan their treatment strategies accordingly.

Adapted from an article by Phil Stevens, MEd, CPO with Hanger Prosthetics & Orthotics, Salt Lake City, Utah.

A Virginia man has filed a $1 million lawsuit against a local PetSmart, claiming he slipped and fell on a pile of feces in the store. Robert Holloway accuses the manager and store employees of failing to create a safe environment for customers in the store. He claims in his lawsuit that the fall injured his back and head and knocked out four of his teeth.  Staff Report, The Washington Post 04/01/2010 Read Article: The Washington Post

I am not sure how one falls onto their back and knocks out four teeth at the same time, but it makes for an interesting headline!

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Traditionally vitamin D has been recommended with respect to preventing osteoporosis, reasoning that improving the absorption of calcium improves bone strength making them less likely to fracture, should there be a fall.  Thereafter it was discovered that vitamin D has direct effects on muscle strength.  Severe vitamin D deficiency (as one might see in those nursing home residents who do not eat well and are virtually never in the sun) can present as muscle weakness and pain which resolves with vitamin D supplementation.  

Several early trials examining the extent to which vitamin D could prevent falls were unsuccessful.  These studies may have failed to produce the hypothesized result due to methodological issues:  low doses of vitamin D were used; vitamin D is available over-the-counter and may have been in use by those in the control group creating bias toward the null; and finally an issue we can all identify with — the difficulties associated with ascertaining the prevalence of falls due to using an unstandardized definition or incomplete ascertainment.  

A meta-analysis (“study of studies”) conducted by an international team of researchers, was recently published in the British Medical Journal1 to further address this issue.  The meta-analysis included 8 double blind randomized controlled trials of individuals 65 years or older receiving a defined oral dose of supplemental vitamin D3,  vitamin D2  or an active form of vitamin D and with sufficiently robust fall ascertainment.  The aim was to assess the efficacy of vitamin D supplementation for the prevention of falls among older persons by dose and serum concentration of vitamin D [25(OH)D].  The primary outcome measure was the relative risk of having at least one fall among persons receiving vitamin D (with or without calcium) compared to those receiving placebo or calcium supplementation alone.  Note that the current recommended adult daily dose of vitamin D is 400 international units. 

Results:

No fall reduction was observed for a daily dose of less than 700 IU vitamin D or achieved serum 25(OH)D concentrations below 60 nmol/l. 

Daily vitamin D doses in the range of 700 IU to 1000 IU or achieved serum concentrations between 60 nmol/l and 95 nmol/l reduced the risk of falling by 19%.   It is possible that higher doses of vitamin D or higher 25(OH)D concentrations would further reduce falls.  Results were attained with treatment for less than a year (2-5 months) and the benefit was sustained for 12-36 months.

 Preventing falls using this higher dose of vitamin D may not depend on taking additional calcium.

The authors note: “Binding of vitamin D to its nuclear receptor in muscle tissue may lead to de novo protein synthesis, a benefit that appears to precede the effect of vitamin D on bone.”  

*Since vitamin D is fat soluble and stored in the body it can accumulate to toxic levels over time and therefore periodic blood levels should be assessed.

1.  Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP and Henschkowski J.  Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials.  BMJ 2009; 339:b3692.

Source: CT Collaboration for Fall Prevention

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I had a workers compensation case not long ago in which an older lady (Ms. “S”) fell at her job as a waitress and suffered a tibial plateau fracture.  The fracture healed, but she required a very lengthy healing period primarily because she was fearful of falling again.  Ms. “S” continued to use a walker long after she was told to discontinue this.  She even took it upon herself to move to a cane before discontinuing the walker as directed.  Returning her to the work environment was nearly impossible due to self restrictions due to this fear of falling.  Case management, the physician, and the therapist all worked diligently to improve her functioning while eliminating her fear.  This proved difficult at best.

Falling and fear of falling have been identified as common problems among older adults.  This fear of falling may reduce physical activity and decrease ability to perform activities of daily living thereby increasing the likelihood of future falls.  It is a vicious cycle.

A recent study estimated the frequency of falls and the prevalence of the fear of falling among a sample of community-living older adults aged 65 and older.  The CDC conducted a telephone survey and asked respondents if they had fallen recently (within three months).  If so they were then asked to rate their fear of falling.  Several questions were posed about beliefs and behaviors for preventing calls such as, “In the past twelve months, has your doctor or pharmacist reviewed with you each bottle of medication you are taking?” and “How important do you believe it is to be physically active in order to keep from falling?”.

The study found that 10% of the US adults questioned had fallen in the past three months.  About 1.7 million of those were injury and 875,000 sought medical treatment.  More than one-third of US older adults were moderately or very afraid of falling.  Those who were moderately or very afraid of falling were more likely to be women, single, have lower incomes and aged 75 or older.  My patient mentioned above met all of these criteria with the exception of age.  Ms. “S” was in her late 60′s.

The study also revealed that while many older adults believed that physical activity and medication review could prevent falls, the majority of the people who had falling did not change their behavior in order to prevent future falls.  65% reported no change in the physical activity and almost 22% had actually decreased their physical activity.
Healthcare providers should ask senior adults about falls, address risk factors for falling and implement interventions to reduce those risks.  Home exercise plans, multi-factorial fall-related programming and community-based Tai Chi provided in a group format have been proven to be effective in reducing fear of falling and therefore should be encouraged.  What do you do to encourage your patients after a fall?  Do you find fear of falling a significant problem in your practice?

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UAMS Seeks Stroke Patients for Study on Preventing Falls

Good posture means keeping the three natural curves of the spine in balanced alignment. When viewed from the side, a normal spine curves slightly forward in the neck or cervical area, slightly backwards in the upper back or thoracic segment of the spine, and slightly forward in the lower back or lumbar region. The back’s natural curves depend on strong and flexible muscles along with healthy hip, knee and ankle joints to make it possible to maintain good posture in any position and during movement.  Kyphosis in the thoracic spine means an exaggerated deviation from the thoracic spine’s normal backward curve. In addition, the normal curvature in the cervical and lumbar regions may be reduced contributing to an over-all “pitched forward posture”. Hyperkyphosis, or forward leaning posture, is commonly observed among older adults. Initially thought to be primarily a consequence of osteoporotic fractures, recent studies have demonstrated that many older adults who are most affected by hyperkyphosis do not have vertebral fractures. Other conditions associated with excessive curvature include degenerative joint disease, decreased physical functioning, sedentary lifestyle, and impaired pulmonary function.

While prior research has demonstrated that abnormal postural changes alter the fundamental characteristics of balance and gait, the association between hyperkyphosis and increased risk of falling had not been studied.

A study of 1,900 older adults revealed that 31.6% exhibited hyperkyphosis and twice as many men were hyperkyphotic.  Their hyperkyphosis was also was more severe than that of the women.  The participants reported falls in which 33% reported a serious injury such as fracture.  Women were more likely to fall, but when adjusting for hyperkyphotic posture the men with moderate hyperkyphosis were at greatest risk for injury in a fall.

The study did not address how hyperkyphotic posture might influence the biomechanics of falling.  The study does provide support for including postural exercises in balance training programs to prevent or delay the progression of hyperkyphosis.

*Taken from CT Collaboration for Fall Prevention; by Mary E. Tinetti, MD

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My friend, Pat Iyer, hosts regular teleseminars on a variety of medicolegal topics.  Recently, Barbara Levin was her guest and discussed the clinical. legal and financial implications of falls.  She covered a long list of points which are posted below.

If you are working on a case that involves falls, I suggest you contact MedLeague.com or PatientSafetyNow.com for a copy of this seminar.  It is available in CD, MP3, or transcript.

photo credit: purplemattfish

1. How do you define a fall?

2. Is an assisted fall really a fall?

3. How many falls occur each year?

4. How much money does the Centers for Medicare and Medicaid pay out each year because of falls?

5. What are some of the ways that a nurse could identify somebody who is at risk for falls?

6. Is there one standard falls risk assessment that facilities should be working towards implementing?

7. When you have got a high risk population on anursing unit, what are some of the strategies useful for reducing the risk of falls?

8. What are the benefits of hourly rounds?

9. Why do older people tend to have poor outcomes after a fall has occurred?

10. What are the financial consequences for falls that occur in hospital settings?

11. How does documentation affect the analysis of liability after a fall occurs?

12. What are facilities doing to modify the environment to make it safer?

13. What is the role of a sitter?

14. What are the common types of fractures?

15. How does the type of fall affect the fracture that results?

16. Is there any outside window that the surgeon can wait before it becomes too late to attempt a surgical closure of a fractured hip?

17. How are closed reductions performed?

18. What are some of the postoperative risks following surgery for fractures? Aren’t these “never events”?

19. Could you comment about some of the controversies regarding surgical site infections?

20. Could you comment about pressure sores developing in people who’ve had surgery to repair a fracture?

21. Are you seeing less use of Foley catheters in patients after they have had hip fractures repaired?

22. Why are a third of patients who suffer a serious fracture dead within a year?

As  a nurse caring for the geriatric communication, fall prevention can mean the difference in a long life or a complicated hospital stay.  Whether you, yourself are a senior, or if you have senior loved ones, take a look at this post from the Mayo Clinic staff which addresses six ways in which to reduce your risk of falling.

photo credit: fish2000

You may feel you already know how to prevent falls, but take a look and you may be surprised at just how many things you have never considered before.  Isn’t it better to be safe than sorry?