Muscle strength and physical performance contribute to and improve fracture risk prediction in older people: A narrative review.

Osteoporotic fractures present a major health problem with an increasing prevalence in older people. Fractures are associated with premature mortality, reduced quality of life, subsequent fracture, and increased costs. Hence, it is crucial to identify those at higher risk of fracture. Fracture risk assessment tools incorporated clinical risk factors to improve fracture predictive power over BMD alone. However, fracture risk prediction using these algorithms remains suboptimal, warranting further improvement. Muscle strength and physical performance measurements have been associated with fracture risk. In contrast, the contribution of sarcopenia, the composite condition of low muscle mass, muscle strength and/or physical performance, to fracture risk is unclear. It is uncertain whether this is due to the problematic definition of sarcopenia per se or limitations of the diagnostic tools and cut-off points of the muscle mass component. The recent position statement from the Sarcopenia Definition and Outcomes Consortium confirmed the inclusion of muscle strength and performance in the definition of sarcopenia but not DXA-assessed lean mass. Therefore, clinicians should focus on functional assessment (muscle strength and performance) rather than muscle mass, at least as assessed by DXA, as predictors of fractures. Muscle strength and performance are modifiable risk factors. Resistance exercise improves muscle parameters in the elderly, potentially leading to reduced risk of falls and fractures in the general population and in those who sustained a fracture. Therapists may consider exercise intervention to improve muscle parameters and potentially reduce the risk of fractures. The aim of this review was to explore 1) the contribution of muscle parameters (i.e., muscle mass, strength, and physical performance) to fracture risk in older adults, and 2) the added predictive accuracy of these parameters beyond the existing fracture assessment tools. These topics provide the rationale for investigating strength and physical performance interventions to reduce fracture risk. Most of the included publications showed that muscle mass is not a good predictor of fracture risk, while poor muscle strength and performance are associated with an increased risk of fracture, particularly in men, independent of age, BMD, and other risk factors for fractures. Muscle strength and performance can potentially improve the predictive accuracy in men beyond that obtained by the fracture risk assessment tools, Garvan FRC and FRAX.
Competing Interests: Declaration of competing interest Alajlouni, Bliuc, and Tran declare that they have no conflict of interest or personal relationships in relation to this work. Blank declares having received personal fees from Bristol-Myers Squibb Company, stock ownership in Abbott Laboratories, AbbVie, Amgen Inc., GSK PLC, Johnson & Johnson, and Procter & Gamble Company, served on the advisory board of Amgen Inc., and ownership interest in JangoBio outside the submitted work; received an editorial stipend from Elsevier; received royalties from Wolters Kluwer NV; and served on the board of the Asia-Pacific Fragility Fracture Alliance; served as treasurer of the International Federation of Musculoskeletal Research Societies and the International Society for Clinical Densitometry. Center declares having received personal fees for educational talks from Amgen Inc. and Actavis Generics and served on the advisory boards of Amgen Inc. and Bayer AG outside the submitted work.
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