Abstract
Objective
Osteoporosis, characterized by low bone mass and microarchitectural deterioration, leads to increased fracture risk. Beyond skeletal fragility, it is associated with postural deformities, balance impairments, and potentially diminished postural awareness, which are critical factors for fall prevention. This study aims to investigate the relationship between postural balance, posture, and postural awareness in postmenopausal women diagnosed with osteoporosis compared to those with osteopenia.
Materials and Methods
A cross-sectional study was conducted with 32 postmenopausal women (osteoporosis, n=16; osteopenia, n=16). Participants were assessed using the timed up and go (TUG) test for functional mobility, the Berg balance scale (BBS) for balance, the New York posture scale (NYPS) for postural alignment, and the postural awareness scale (PAS) for body awareness. Bone mineral density was determined by lumbar spine T-scores. Statistical analyses included the Mann-Whitney U test for group comparisons and Spearman’s correlation to examine relationships between variables.
Results
The osteoporosis group demonstrated significantly lower postural awareness (PAS), poorer balance (BBS), longer TUG times, and more postural deviations (NYPS) compared to the osteopenia group (p<0.05), despite similar age and body mass index. Lumbar T-scores were significantly correlated with better PAS, BBS, and NYPS scores (p<0.01), and negatively correlated with TUG times (p<0.01), with stronger correlations observed in the osteoporosis group. A significant proportion of the osteoporosis group was classified as having low awareness, high fall risk, and poor posture.
Conclusion
Osteoporosis is associated with significantly impaired postural awareness, poorer postural alignment, and reduced balance compared to osteopenia. The strong correlations between bone mineral density and functional parameters underscore the interconnection between skeletal and neuromuscular health. These findings highlight the necessity of integrating functional assessments and targeted interventions, such as balance training and postural awareness education, into standard osteoporosis management to reduce fall risk and improve quality of life.
Introduction
Osteoporosis is a chronic and progressive disease characterised by low bone mass and deterioration of the bone’s microarchitecture, resulting in brittle bones (1). Osteoporosis is considered a silent disease because it usually does not cause symptoms until the first fracture occurs (2). Bone density decreases with age, and the incidence of fractures increases (3). Osteoporosis is one of the musculoskeletal problems commonly seen in women during menopause (4). One of the most significant changes observed in the musculoskeletal system due to ageing and osteoporosis is postural deformities. Postural changes in osteoporotic cases can lead to complications such as falls, balance problems, and vertebral fractures (5).
Decreased bone mass, vertebral fractures, and spinal deformities can lead to loss of vertebral height. Granito et al. (6) noted an increase in thoracic kyphosis associated with low bone mineral density (BMD). The sagittal vertical axis, pelvic tilt, lumbar lordosis, and thoracic kyphosis were all found significantly different between osteoporotic patients and the control group (7). In addition to postural abnormalities, spinal deformities like thoracic and/or lumbar kyphosis can result in decreased spinal mobility and range of motion. Osteoporotic patients with spinal kyphosis use their hip or ankle joints more (8). However, a shift in the center of gravity and impaired balance control due to postural changes can make it more difficult for the person to stand and walk. Furthermore, because kyphosis changes the center of mass of the body, it results in a relatively unstable posture. These factors may affect control over the centre of mass position and the ability to compensate for balance changes (9). In osteoporosis patients, reduced muscle mass and deformities in the spinal structure can disrupt postural balance and increase posture disorders. In such cases, postural awareness is important for the individual to develop and maintain correct posture habits in their daily life (10).
Postural awareness is the ability to recognise changes in posture and body position that an individual makes in daily life. This awareness is crucial for maintaining healthy postural habits and preventing poor posture. Good posture ensures minimal stress on the joints (11), while poor posture leads to increased stress on the joints due to misalignment of body parts (12).
In the prevention and management of osteoporosis, it is important to determine the level of knowledge, particularly among postmenopausal women who are at risk for this disease (13). Identifying individuals’ knowledge and attitudes regarding osteoporosis may contribute to the development of public health programs aimed at effective prevention of osteoporosis (14). While the relationship between osteoporosis, progressive postural deformities such as kyphosis, and subsequent impairments in balance and fall risk is well-established in the literature, the impact of these physical changes on an individual’s postural awareness remains a significant and under-investigated gap. Postural awareness is a critical component for maintaining healthy posture and executing compensatory strategies to prevent falls. This study, therefore, moves beyond the well-documented pathophysiology to investigate the specific relationship between objective postural balance, spinal alignment, and the level of postural awareness in individuals with osteoporosis. By quantitatively assessing this triad, our research aims to provide original insights that could inform the development of targeted rehabilitation programs, shifting the focus from strength and bone health alone to include the enhancement of body perception and proprioceptive feedback for better postural control and fracture prevention. Investigating the effects of osteoporosis on postural awareness and balance may contribute to the development of education and exercise programs aimed at increasing postural awareness. Therefore, the aim of this study is to investigate the relationship between postural balance, posture, and postural awareness in individuals with osteoporosis.
Materials and Methods
The study included postmenopausal women diagnosed with osteoporosis and osteopenia who were under follow-up at Elazığ Medical Hospital. The required sample size and power calculation for the study were calculated using the G*Power Ver.3.1.9.4 program. The sample volume representing the population was determined based on the conditions of a= 0.05 risk and 1-a =0.80 accuracy rate, using the results of the comparison of the mean Berg balance scale (BBS) scores in the study by Alshahrani and Reddy (15). Based on the results of the power analysis, the effect size was 1.09 and the actual power was 0.82, indicating that the sample size for the study required a minimum of 15 participants in each group.
This study had ethical approval from the Fırat University Ethics Committee (approval number: 2024/15-32, date: 19.12.2024). The study was completed with 32 participants. At the beginning of the study, the participants’ medical histories were obtained through face-to-face interviews. Fracture history was obtained through a structured interview and, when available, verified by reviewing medical records and/or imaging reports. Informed consent forms were obtained from the participants who volunteered to participate in the study. Information on the duration of osteoporosis diagnosis, age, occupation, body mass index, duration of menopause, history of vertebral or non-vertebral fractures, and comorbidities was obtained and recorded. Dynamic and functional balance was measured using the timed up and go (TUG) test and the BBS. Postural awareness was measured using the postural awareness scale (PAS). Posture was assessed using the New York posture scale.
Women in the postmenopausal period, patients diagnosed with osteoporosis or osteopenia according to World Health Organization criteria, and patients who could stand independently were included in the study. Patients with any ongoing orthopaedic or neurological disease, lower extremity pain that prevented standing and bearing weight, any other systemic chronic disease that could affect posture or balance, cognitive dysfunction, and a history of vertebral surgery were excluded from the study. In addition, participants using medications known to impair balance (e.g., sedatives/hypnotics or other centrally acting agents) were excluded.
Balance Assessment
Dynamic balance and functional mobility were evaluated using the TUG. The person was instructed to get up from a seated position, walk three meters at a normal and safe pace, turn around, walk back, and then sit down once more. The time was noted in seconds (s). The patient started the test with their arms resting on the chair’s armrests and their feet flat on the ground. To finish the task, patients were instructed to walk at a pace that felt safe to them. For people with mobility impairments or the elderly, 10-20 seconds is acceptable, while less than 10 seconds is regarded as normal mobility (16).
The patient’s performance was observed and scored on a scale of 0-4 for each of the 14 instructions in the BBS, a measure of balance. If the patient cannot complete the task at all, they receive a score of 0, and if they can finish it on their own, they receive a score of 4. A score of 0-20 indicates impaired balance, 21-40 indicates acceptable balance, and 41-56 indicates good balance. The maximum score is 56. The scale takes ten to twenty minutes to complete (17).
Postural Awareness Evaluation
Postural awareness, a German measure created by Cramer et al. in 2018, was assessed using the PAS. Twelve items make up the PAS, and each one is scored on a Likert-style scale that goes from 1 (not applicable to me at all) to 7 (completely applicable to me). The structure of the PAS scale is two-factor. Need for attention regulation with postural awareness is the second factor, and ease/familiarity with postural awareness is the first. Each of the twelve items on the scale has a score ranging from 1 (not applicable to me at all) to 7 (completely applicable to me). The PAS scale has reverse scoring for items 1, 2, 3, 4, 5, and 12. Item 12 has been omitted from the Turkish adaptation of the PAS. The Turkish adaptation of the PAS consists of 11 items. A minimum of 11 and a maximum of 77 points can be obtained on the scale (18).
Posture Assessment
Thirteen distinct sections of the body were assessed for potential posture changes using the New York Posture Scale. Five points are awarded for proper posture, three points for moderately impaired posture, and one point for severely impaired posture. The final test score falls between 13 and 65. Good posture is indicated by a high score. The New York posture assessment scale is used to measure changes in posture from the lateral (neck, chest, shoulders, upper back, torso, abdomen, waist) and posterior (head, shoulders, back, hips, feet, and heels) perspectives (19).
Statistical Analysis
The data obtained in the study were analysed using the SPSS for Windows 22.0 (Statistical Package for the Social Sciences) program. The data was analyzed using descriptive statistical techniques, including number, percentage, median, minimum, and maximum values. The data did not exhibit a normal distribution, according to the Shapiro-Wilk normality test, which was used to assess whether continuous variables did. As a result, the chi-square test was employed for categorical data analysis and the Mann-Whitney U test for intergroup comparisons. Whereas categorical data are displayed as numbers and percentages [n (%)], continuous variables are displayed as medians (25th-75th percentile); minimum-maximum. The relationship between the variables was assessed using Spearman’s rank correlation coefficient. All tests were conducted bilaterally (two-tailed), with a significance level of p<0.05.
Results
The comparative results of the demographic, clinical, and functional characteristics of the osteoporosis and osteopenia groups are summarized in Table 1. None of the participants had a history of vertebral or non-vertebral fracture. While no significant difference was found between the groups in age, body mass index, and duration of menopause, lumbar spine T-scores were found to be significantly lower in the osteoporosis group. Furthermore, postural awareness levels, balance, and mobility performance were found to be significantly weaker in individuals in this group compared to the osteopenia group.
The categorical distributions of participants were compared according to postural awareness levels, fall risk, postural alignment, and balance levels (Table 2). A significant proportion of individuals in the osteoporosis group had low awareness levels, high fall risk, and poor posture, while most of these parameters were better in the osteopenia group. Significant differences were also observed between the groups in terms of balance level.
The relationships between functional and clinical parameters were analysed separately for each group (Table 3). In both groups, positive and significant correlations were found between the T-score and awareness, posture, and balance scores. The TUG, however, demonstrated a negative and significant relationship with these parameters. These relationships were particularly stronger in the osteoporosis group.
Discussion
This study examined the relationship between posture, balance, and postural awareness levels in postmenopausal women diagnosed with osteoporosis. The findings indicate that osteoporosis is not limited to a decrease in BMD; it also affects important functional areas such as balance, posture, and body awareness.
This study concluded that individuals in the osteoporosis group had significantly lower levels of postural awareness. It implies that these women are navigating their world with an inaccurate “internal postural map”. As thoracic kyphosis increases and the body’s center of gravity shifts, proprioceptive feedback from the spine and trunk muscles may become unreliable. The individual may thus lose the ability to sense their own slump, allowing minor, uncorrected postural errors to accumulate into fixed deformities. This places them in a precarious position as they are less likely to consciously engage protective strategies to maintain stability. This result suggests that changes in the spinal structure may negatively affect the body’s ability to perceive its position. In particular, the shift of the body’s centre of gravity forward, accompanied by an increase in thoracic kyphosis, may prevent individuals from receiving adequate proprioceptive feedback. As a result, individuals may not notice the deterioration in their posture, which may lead to more serious postural problems over time. Osteoporosis is associated with more pronounced postural changes, such as increased thoracic kyphosis and reduced spinal length, which are less severe or absent in osteopenia. These structural changes further impair postural awareness and stability (9). In addition, the worsening of postural awareness in osteoporosis is linked to lower BMD, vertebral deformities, and muscle weakness, which are less pronounced in osteopenia (20, 21). Women with osteoporosis exhibit significantly greater postural sway (both anteroposterior and mediolateral) than those with osteopenia or normal bone density, indicating worse postural control. The osteoporosis group consistently demonstrated the highest instability across all tested positions, while the osteopenia group had intermediate values between osteoporosis and healthy controls (22).
This study was concluded that individuals in the osteoporosis group had lower balance levels and higher risk of falling according to the results of BBS and TUG. These findings reveal that osteoporosis may negatively affect individuals’ ability to safely perform daily living activities. This study corroborate that osteoporosis does not merely weaken the skeleton; it undermines the very system designed to protect it, creating a perfect storm for fracture. In particular, the negative effects of spinal deformities on static and dynamic balance are consistent with previous literature. People with osteoporosis consistently demonstrate poorer balance compared to those without osteoporosis. This includes greater postural sway, altered balance control strategies, and reduced ability to maintain stability, especially in challenging positions (8, 23). Muscle weakness, increased spinal kyphosis, and vertebral fractures further compromise balance in osteoporosis, making postural control more difficult (5, 23, 24). In some studies, balance impairment is a stronger predictor of future fractures than BMD itself, highlighting its clinical importance (25). Studies found that individuals with osteoporosis have significantly worse balance than those with osteopenia, which is parallel to this study. Osteoporotic patients demonstrate greater postural sway (both anteroposterior and mediolateral) and more pronounced instability in all tested positions compared to osteopenic and healthy individuals (22, 26). Objective and behavioral balance tests reveal a higher proportion of abnormal results in osteoporosis, and vestibular dysfunction is more prevalent in this group (27).
The study indicates that individuals in the osteoporosis group have significant posture abnormalities. Osteoporosis leads to vertebral fractures and spinal deformities, which shift the body’s center of gravity forward, increasing instability and the risk of falls. Muscle weakness, proprioceptive deficits, and pain further contribute to postural problems (28). The weakening of the vertebral structure not only affects bone health but also disrupts the functional integrity of posture, thereby reducing the individual’s mobility and quality of life. Recent genetic and clinical studies confirm a causal association between low bone BMD in osteoporosis and increased postural instability. Lower BMD, especially at the femoral neck and lumbar spine, is significantly associated with greater postural instability and impaired balance (29). Postural deficits in osteoporosis are a major contributor to increased fall and fracture risk, making their assessment and management crucial in clinical practice (30). Postural deformities and reduced spinal mobility in osteoporosis are strongly linked to lower quality of life, greater fear of falling, and reduced functional independence (9).
The positive relationships observed between T-score, postural awareness, posture and balance have revealed that decreases in BMD have a significant effect on these three parameters in this study. Lower BMD is associated with postural changes such as increased thoracic kyphosis, spinal deformities, and altered body alignment. These changes further compromise postural control and awareness (31). Poor balance and postural deficits in those with low BMD are strong predictors of falls and fractures. Balance and functional mobility tests independently predict BMD status and fracture risk (32). Large-scale genetic and clinical studies confirm a significant negative correlation between BMD (especially at the femoral neck and lumbar spine) and postural instability. Lower BMD increases the risk of postural instability and impaired balance, making individuals with osteoporosis more susceptible to falls (30). In contrast, a negative relationship was found between TUG duration and these parameters. This indicates that movement safety decreases alongside a reduction in functional capacity. Studies concluded that women with lower BMD have greater postural sway, reduced limits of stability, and poorer performance on balance tests. These deficits are more pronounced in osteoporosis than in osteopenia or normal BMD (33).
The current findings have important clinical implications. The identification of high fall risk in osteoporosis patients highlights the urgent need for targeted fall-prevention strategies. Interventions should not only aim to improve bone density through pharmacological treatment but also incorporate physiotherapy programs that enhance balance, postural control, and functional awareness. Previous studies have shown that exercise interventions focusing on strength, balance, and proprioception significantly reduce fall incidence and improve functional performance in osteoporotic populations (34). Finally, the findings support the concept of tailored rehabilitation approaches. Given the inter-individual variability observed in postural and functional parameters, exercise interventions should be personalised according to baseline performance and awareness levels. This aligns with current perspectives in precision rehabilitation, advocating for interventions that address both skeletal and neuromuscular dimensions of osteoporosis.
Study Limitations
This study has several limitations. The sample size was relatively small, which may limit the generalisability of findings. Furthermore, the cross-sectional design precludes causal inference regarding the relationship between bone density and functional performance. Longitudinal studies are needed to clarify the directionality of these associations and to examine whether improvements in postural awareness and balance can mitigate bone loss or reduce fracture risk. Future research should also explore the role of psychosocial factors, such as fear of falling, which may further influence the interaction between osteoporosis and functional decline.
Conclusion
In conclusion, this study shows that, in contrast to osteopenia, osteoporosis is linked to significantly worse postural awareness, poorer postural alignment, and decreased balance. The interdependence of skeletal and neuromuscular health is highlighted by the strong relationships found between BMD and functional parameters. To maintain independence and lower fall-related morbidity in this population, these findings emphasize the necessity of comprehensive rehabilitation strategies that combine functional training with traditional osteoporosis management.
