Osteoporosis International

, Volume 16, Issue 8, pp 861–870

Impact of incident vertebral fractures on health related quality of life (HRQOL) in postmenopausal women with prevalent vertebral fractures

  • Anna M. Oleksik
  • Susan Ewing
  • Wei Shen
  • Natasja M. van Schoor
  • Paul Lips
Original Article


Vertebral fractures are a common complication of osteoporosis and may cause a decrease of health-related quality of life (HRQOL). This study was designed to determine the impact of incident vertebral fractures on HRQOL. The Multiple Outcomes of Raloxifene Evaluation (MORE), a multicenter, randomized, double blind trial, in which women were taking raloxifene or placebo. This study was done in European centers only in a subset of 361 women from seven European countries, all with prevalent vertebral fractures. A specific questionnaire for osteoporosis developed by the International Osteoporosis Foundation was used for assessment at baseline, 1, 2 and 3 years. This questionnaire, Qualeffo, contains 41 questions in the domains pain, physical function, social function, general health perception and mental function. Domain and total scores are expressed on a 100-point scale with 0 corresponding to the best HRQOL. Standardized lateral spinal radiographs were made at baseline, 2 and 3 years and evaluated in a central facility. Sixty-seven patients sustained a fracture in a vertebra that was not fractured at baseline (incident vertebral fractures). Twenty of these were accompanied by signs and symptoms necessitating immediate doctor’s attention (clinical vertebral fractures) and 47 vertebral fractures were only diagnosed on radiographs (subclinical vertebral fractures). Incident vertebral fractures (clinical and subclinical) were associated with an increase of back pain (mean score change 6.4; 95% CI 2.1–10.7), deterioration of physical function (mean score change 2.4; 95% CI 0.1–4.8), and worse general health perception (mean score change 3.8; 95% CI 0.1–7.5). Score changes for patients with subclinical vertebral fractures were intermediate between those for patients with clinical vertebral fractures and patients without incident vertebral fracture. Clinical and subclinical incident vertebral fractures both have an adverse impact on HRQOL.


Incident vertebral fractures Health-related quality of life Osteoporosis Quality of life change 


  1. 1.
    Wasnich RD (1999) Epidemiology of osteoporosis. In: Favus MJ (ed) Primer on the metabolic bone diseases and disorders of mineral metabolism, 4th edn. Lippincott Williams & Wilkins, Philadelphia, pp 257–259Google Scholar
  2. 2.
    Lips P (1997) Epidemiology and predictors of fractures associated with osteoporosis. Am J Med 103:3S–8SCrossRefGoogle Scholar
  3. 3.
    Melton LJ III (1997) Epidemiology of spinal osteoporosis. Spine 22:2S–11SCrossRefPubMedGoogle Scholar
  4. 4.
    Fitzpatrick RA, Shorenstein R (1990) Stopping the “silent thief”. J Am Med Women Assoc 45:68Google Scholar
  5. 5.
    Dequeker J (1992) Preventie en behandeling van osteoporose. Ned Tijdschr Geneeskd 136:1188–1192PubMedGoogle Scholar
  6. 6.
    Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ III (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 7:221–227PubMedGoogle Scholar
  7. 7.
    Spector TD, McCloskey EV, Doyle DV, Kanis JA (1993) Prevalence of vertebral fracture in women and the relationship with bone density and symptoms: the Chingford study. J Bone Miner Res 8:817–822PubMedGoogle Scholar
  8. 8.
    Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Cummings SR, Genant HK and The Study of Osteoporotic Fractures Research Group (1992) Contribution of vertebral deformities to chronic back pain and disability. J Bone Miner Res 7:449–456PubMedGoogle Scholar
  9. 9.
    Ross PD, Davis JW, Epstein RS, Wasnich RD (1994) Pain and disability associated with new vertebral fractures and other spinal conditions. J Clin Epidemiol 47:231–239CrossRefPubMedGoogle Scholar
  10. 10.
    Ross PD (1997) Clinical consequences of vertebral fractures. Am J Med 103:30S–43SPubMedGoogle Scholar
  11. 11.
    Huang C, Ross PD, Wasnich RD (1996) Vertebral fractures and other predictors of back pain among older women. J Bone Miner Res 11:1026–1032PubMedGoogle Scholar
  12. 12.
    Ettinger B, Black DM, Palermo L, Mevitt MC, Melnikoff S, Cummings SR (1994) Kyphosis in older women and its relation to back pain, disability and osteopenia: the Study of Osteoporotic Fractures. Osteoporos Int 4:55–60PubMedGoogle Scholar
  13. 13.
    Cortet B, Houvenagel E, Puisieuz F, Roches E, Garnier P, Delcambre B (1999) Spinal curvatures and quality of life in women with vertebral fractures secondary to osteoporosis. Spine 15:1921–1925CrossRefGoogle Scholar
  14. 14.
    Ismail AA, Cooper C, Felsenberg D, Varlow J, Kanis JA, Silman AJ, O’Neill TW (1999) Number and type of vertebral deformities: epidemiological characteristics and relation to back pain and height loss. European Vertebral Osteoporosis Study Group. Osteoporos Int 9:206–213CrossRefPubMedGoogle Scholar
  15. 15.
    Burger H, van Daele PLA, Grashuis K, Hofman A, Grobbee DE, Schütte HE, Birkenhäger JC, Pols HA (1997) Vertebral deformities and functional impairment in men and women. J Bone Miner Res 12:152–157PubMedGoogle Scholar
  16. 16.
    Huang C, Ross PD, Wasnich RD (1996) Vertebral fracture and other predictors of physical impairment and health care utilization. Arch Intern Med 156:2469–2475CrossRefPubMedGoogle Scholar
  17. 17.
    Leidig G, Minne HW, Sauer P, Wüster C, Wüster J, Lojen M, Raue F, Ziegler R (1990) A study of complaints and their relation to vertebral destruction in patients with osteoporosis. Bone Miner 8:217–229CrossRefPubMedGoogle Scholar
  18. 18.
    Leidig-Bruckner G, Minne HW, Schlaich C, Wagner G, Scheidt-Nave C, Bruckner T, Gebest HJ, Ziegler R (1997) Clinical grading of spinal osteoporosis: quality of life components and spinal deformity in women with chronic low back pain and women with vertebral osteoporosis. J Bone Miner Res 12:663–675PubMedGoogle Scholar
  19. 19.
    Lyles KW, Gold DT, Shipp KM, Pieper CF, Martinez S, Mulhausen PL (1993) Association of osteoporotic vertebral compression fractures with impaired functional status. Am J Med 94:595–601CrossRefPubMedGoogle Scholar
  20. 20.
    Schleich C, Minne HW, Bruckner T, Wagner G, Gebest HJ, Gruntze M, Ziegler R, Leidig-Bruckner G (1998) Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int 8:261–267CrossRefPubMedGoogle Scholar
  21. 21.
    Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR (1999) Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 159:1215–1220CrossRefPubMedGoogle Scholar
  22. 22.
    Ross PD (1997) Clinical consequences of vertebral fractures. Am J Med 103:30S–42SPubMedGoogle Scholar
  23. 23.
    Gold DT (1996) The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone 18:185–189CrossRefPubMedGoogle Scholar
  24. 24.
    Cook DJ, Guyatt GH, Adachi JD, Clifton J, Griffith LE, Epstein RS, Juniper EF (1993) Quality of life in women with vertebral fractures due to osteoporosis. Arthr Rheum 36:750–756Google Scholar
  25. 25.
    Chrischilles EA, Shireman T, Wallace R (1994) Costs and health effects of ostoporotic fractures. Bone 15:377–386CrossRefPubMedGoogle Scholar
  26. 26.
    Kanis JA, Geusens P, Christiansen C on behalf of the Working Party of the Foundation (1991) Guidelines for clinical trials in osteoporosis. A position paper of the European Foundation for Osteoporosis and Bone Disease. Osteoporos Int 1:182–188PubMedGoogle Scholar
  27. 27.
    Reginster JY, Compston JE, Jones EA, Kaufman JM, Audran M, Bouvenot G, Frati L, Mazzuoli G, Gennari C, Lemmel EM, Ringe JD, Sebert JL, Vanhaelst L, Avouac B on behalf of the Group for the Respect of Ethics and Excellence in Science (1995) Recommendations for the registration of new chemical entities used in the prevention and treatment of osteoporosis. Calcif Tissue Int 57:247–250CrossRefPubMedGoogle Scholar
  28. 28.
    Patrick D, Erickson P (1988) Assessing health-related quality of life for clinical decision-making. In: Walker, Rosser (eds) Quality of life assessment and application. R M CMR Workshop Series, MTP Press, England, pp 11–63Google Scholar
  29. 29.
    Oleksik A, Lips P, Dawson A, Minshall ME, Shen W, Cooper C, Kanis J (2000) Health-related quality-of-life (HRQOL) in postmenopausal women with low BMD with or without prevalent vertebral fractures. J Bone Miner Res 15:1384–1392PubMedGoogle Scholar
  30. 30.
    Silverman SL, Minshall ME, Shen W, Harper KD, Xie S (1998) The impact of vertebral fracture(s) on health related quality of life (HRQOL) in established postmenopausal osteoporosis depends on the number and location of the fracture(s). J Bone Miner Res 23:S305 (abstract)Google Scholar
  31. 31.
    Matthis C, Raspe H (1998) Krankheitslast bei vertebralen Deformitaten. EVOS-Gruppe in Deutschland. Med Klin 93:41–46PubMedGoogle Scholar
  32. 32.
    Nevitt MC, Ettinger B, Black DM, Stone K, Jamal SA, Ensrud K, Segal M, Genant HK, Cummings SR (1998) The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 128:793–800PubMedGoogle Scholar
  33. 33.
    Silverman SL, Minshall ME, Shen W, Harper KD, Xie S, on behalf of the Health-related quality of life subgroup of the Multiple Outcomes of Raloxifene Evaluation Study (2001) The relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis: results from the Multiple Outcomes of Raloxifene Evaluation Study. Arthr Rheum 44:2611–2619CrossRefGoogle Scholar
  34. 34.
    Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, Kanis JA, Liberman U, Minne H, Reeve J, Reginster JY, de Vernejoul MC, Wiklund I (1997) Quality of life as outcome in the treatment of osteoporosis; the development of a questionnaire for quality of life by the European Foundation for Osteoporosis. Osteoporos Int 7:36–38PubMedGoogle Scholar
  35. 35.
    Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, Kanis JA, Kellingray S, Leplage A, Liberman U, Reeve J, Reginster JY, Scholz M, Vernejoul MC, Wiklund I on behalf of the Working Party of the European Foundation for Osteoporosis (1999) Quality of life in patients with vertebral fractures: Validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Osteoporos Int 10:150–160CrossRefPubMedGoogle Scholar
  36. 36.
    Ettinger B, Black DM, Mitlak BH, Knickerbocker RK, Nickelsen T, Genant HK, Christiansen C, Delmas PD, Zanchetta JR, Stakkestad J, Glüer CC, Krueger K, Cohen FJ, Eckert S, Ensrud KE, Avioli LV, Lips P, Cummings SR (1999) Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene. JAMA 282:637–645CrossRefPubMedGoogle Scholar
  37. 37.
    Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148PubMedGoogle Scholar
  38. 38.
    Genant HK, Jergas M, Palermo L, Nevitt M, Valentin RS, Black D, Cummings SR for the Study of Osteoporotic fractures Research Group (1996) Comparison of semiquantitative visual and quantitative morphometric assessment of prevalent and incident vertebral fractures in osteoporosis. J Bone Miner Res 11:984–996Google Scholar
  39. 39.
    Paier GS (1996) Specter of the crone: the experience of vertebral fracture. ANS Adv Nurs Sci 18:27–36PubMedGoogle Scholar
  40. 40.
    Lydick E, Epstain RS (1993) Interpretation of quality of life changes. Qual Life Res 2:221–226CrossRefPubMedGoogle Scholar
  41. 41.
    Fletcher A, Gore S, Jones D, Fitzpatrick R, Spiegelhalter D, Cox D (1992) Quality of life measures in health care. II: Design, analysis, and interpretation. BMJ 305:1145–1148PubMedGoogle Scholar
  42. 42.
    Guyatt GH, Juniper EF, Walter SD, Griffith LE, Goldstein RS (1998) Interpreting treatment effects in randomised trials. BMJ 16:690–693Google Scholar
  43. 43.
    Guyatt GH, Naylor CD, Juniper E, Heyland DK, Jaeschke R, Cook DJ for the Evidence-Based Medicine Working Group (1997) Users’ guide to the medical literature. XII. How to use articles about health-related quality of life. JAMA 277:1232–1237CrossRefPubMedGoogle Scholar
  44. 44.
    Guyatt GH, Walter S, Norman G (1987) Measuring change over time: assessing the usefulness of evaluative instruments. J Chron Dis 40:171–178CrossRefPubMedGoogle Scholar
  45. 45.
    Hall SE, Criddle RA, Comito TL, Prince RL (1999) A case-control study of quality of life and functional impairment in women with long-standing vertebral fracture. Osteoporos Int 9:508–515CrossRefPubMedGoogle Scholar
  46. 46.
    Coehle R, Silva C, Maia A, Prata, J Barros H (1999) Bone mineral density and depression: a community study in women. J Psychosom Res 46:29–35CrossRefPubMedGoogle Scholar
  47. 47.
    Lydick E (1996) Martin A, Yawn B. Impact of fears on quality of life in patients with silent disease: osteoporosis. Clin Ther 18:1307–1315CrossRefPubMedGoogle Scholar
  48. 48.
    Ensrud KE, Thompson DE, Cauley JA, Nevitt MC, Hochberg M, Santora AC IInd, Black DM for the Fracture Intervention Trial (FIT) Research Group (2000) Prevalent vertebral fractures predict mortality and hospitalization in older women with low bone mass: Fracture Intervention Trial (FIT). J Am Geriatr Soc 48:241–249PubMedGoogle Scholar
  49. 49.
    Ismail AA, O’Neill TW, Cooper, C, Finn JD, Bhalla AK, Cannata JB, Delmas P, Falch JA, Felsch B, Hoszowski K, Johnell O, Diaz-Lopes JB, Lopes Vaz A, Marchand F, Raspe H, Reid DM, Todd D, Weber K, Woolf A, Reeve J, Silman AJ on behalf of the EPOS Study Group (1998) Mortality Associated with vertebral deformity in men and women: results from the European prospective osteoporosis study (EPOS). Osteoporos Int 8:291–297CrossRefPubMedGoogle Scholar
  50. 50.
    Begerow B, Pfeifer M, Pospeschill M, Scholz M, Schlotthauer T, Lazarescu A, Pollaehne W, Minne HW (1999) Time since vertebral fracture: an important variable concerning quality of life in patients with postmenopausal osteoporosis. Osteoporos Int 10:26–33CrossRefPubMedGoogle Scholar
  51. 51.
    Cummings SR, Eckert S, Krueger KA, Grady D, Powles TJ, Cauley JA, Norton L, Nickelsen T, Bjarnason NH, Morrow M, Lippman ME, Black D, Glusman JE, Costa A, Jordan VC (1999) The effects of raloxifene on risk of breast cancer in postmenopausal women. JAMA 28:2189–2197CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Authors and Affiliations

  • Anna M. Oleksik
    • 1
  • Susan Ewing
    • 2
  • Wei Shen
    • 3
  • Natasja M. van Schoor
    • 4
  • Paul Lips
    • 1
    • 4
  1. 1.Department of EndocrinologyVU University Medical CenterAmsterdamThe Netherlands
  2. 2.Prevention Sciences GroupUCSFSan FranciscoUSA
  3. 3.Eli Lilly & Co.IndianapolisUSA
  4. 4.EMGO InstituteVU University Medical CenterAmsterdamThe Netherlands

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