ABSTRACT

Objective:

This study examines the awareness and knowledge levels of osteoporosis in patients with multiple sclerosis (MS).

Materials and Methods:

A total of 88 adult patients with MS (22 male, 66 female) were included in the study. The demographic and socioeconomic status of all patients were recorded. First, a question was asked the participants: “Have you ever heard of osteoporosis before?”. After that, a survey was conducted on the participants. The survey consisted of a questionnaire assessing their knowledge using a 30-item instrument reflecting 9 knowledge domains (eg, risk factors, diagnosis, prognosis).

Results:

The mean age of the patients was 39.85±9.67 years. The duration of the disease was median [interquartile range (IQR) (Q1-Q3) 4 (1-10)] years. Expanded disability status scale score of the patients was median [IQR (Q1-Q3) 2 (1-4.5)]. Most of the participants (81.8%) were aware of osteoporosis. Awareness of osteoporosis was higher in those who received corticosteroid treatment and had comorbid diseases (respectively p=0.011 and p=0.009). On average, the knowledge questions score was 13 (0-23). Mean knowledge scores were not associated with education status or gender. The knowledge score levels were higher in those who had heard of osteoporosis than in those who had not heard, respectively 14 (10-18) to 4 (0-13,75) (p<0.001).

Conclusion:

Although awareness of osteoporosis was high in MS patients, the level of knowledge on osteoporosis was insufficient. Awareness and knowledge levels of osteoporosis were higher in those who received corticosteroid treatment. Additionally, osteoporosis awareness was higher in those who had comorbid diseases. Increasing knowledge about osteoporosis may be important for preventing osteoporosis and reducing its complications in MS patients.

Introduction

Multiple sclerosis (MS) is a chronic demyelinating disease affecting the brain and spinal cord, which usually has a relapsing-remitting course (1,2). It is one of the most common causes of neurological disability in young adults and affects approximately 1.3 million people worldwide (3). Osteoporosis is a disease characterized by low bone mineral density (BMD) and deterioration of bone tissue predisposing to fragility fractures (4-6). Several current studies have suggested that patients with MS have lower BMD and higher rates of osteoporosis than healthy adults (7-9). Causes of osteoporosis in MS include immobility, vitamin D deficiency, chronic inflammatory process, use of glucocorticoids (10-12). Patients with MS have an increased risk of falling due to impaired gait, balance, coordination, cognition, and cerebellar, sensory, and pyramidal functions (3). Therefore, there is an increased risk of osteoporotic fractures in patients with MS compared to the general population (3,9). Furthermore, since MS patients have a higher risk of fracture, the awareness of osteoporosis is crucial among them. If the awareness of osteoporosis is determined and information about the disease can be increased in MS patients, the negative consequences such as fractures and physical disabilities will also be reduced to that extent (11,13). There was not any study found during our literature search on the awareness of osteoporosis in patients with MS and the factors affecting it. The study examined the awareness and knowledge levels of osteoporosis and the factors affecting them in adult patients with MS.

Materials and Methods

Study Design and Population

We conducted a cross-sectional survey study. The approval of the local Ethics Committee at Dokuz Eylül University was obtained prior to the start of the study (decision no: 2016/26-31, date: 06.10.2016). Since MS is a rare disease, all MS patients who applied to the outpatient clinic during the study period (between May 2016 and May 2018) and met the inclusion criteria were included in the study, without a specific sample size. One hundred thirteen patients were interviewed. Nineteen patients did not want to participate in the study. One patient had been illiterated and one patient had severe cognitive dysfunction and four patients had a diagnosis of osteoporosis, they were not included. A total of 88 patients were included. All subjects gave written informed consent before participating in the study. The inclusion criteria of the study; being an adult patient with MS and volunteer to participate in the study. The exclusion criteria were not agreeing to voluntarily participate in the study, the presence of severe cognitive dysfunction, and the presence of a diagnosis of osteoporosis.

Data Collection

The demographic characteristics of the patients were recorded. The presence of additional disease, previous osteoporosis diagnosis, glucocorticoid medication, how the subjects reached information sources about osteoporosis, menopausal status, and a history of osteoporotic fracture were questioned. To consider a participant as being aware of osteoporosis, we asked if they have heard about osteoporosis before, and the ones who had heard about it previously were considered aware. A questionnaire developed from a previous study (14), with a content reliability of 0.89, was performed on participants. The 30-item questionnaire comprises questions that cause, signs/symptoms, risk factors, prognosis, diagnosis, treatment, complications, and prevention of osteoporosis. Patients responded to the questions as “agree,” “disagree,” or “unsure.” Knowledge scores were created assigning 1 point to every correct answer and 0 points to every incorrect or “unsure” answer. The items were summed for a possible range of 0 to 30, with higher scores reflecting greater knowledge.

Statistical Analysis

The SPSS software version 24.0 (SPSS IBM Corp.; Armonk, NY, USA) was used for statistical analyses. The Kolmogorov-Smirnov test was used to determine the normality of data distribution. Demographics and descriptive data are presented as median (interquartile range Q1-Q3) or mean standard deviation. Pearson’s chi-squared and Fisher’s Exact tests were used to compare between categorical variables. Group comparisons of baseline characteristics were performed with independent samples t-test, as appropriate. Statistical significance was defined as p<0.05. The factors on osteoporosis awareness were assessed univariate and multivariate logistic regression. Covariates [age, gender (F), education (high school and above), presence of comorbid disease, corticosteroid administration] were tested. The correlation between the age and knowledge level of patients was evaluated using Spearman’s correlation analysis.

Results

A total of 88 adult patients with MS (22 male, 66 female) were included in the study. The median age of the patients was 39.85±9.67 (range, 20-64) years. Baseline characteristics are shown in Table 1. The awareness of osteoporosis in patients with MS was 81.8% (n=72). Thirty-seven patients (42.04%) had known that MS disease was a risk factor for developing osteoporosis. Awareness of osteoporosis was higher in those who received corticosteroid treatment and had comorbid diseases (respectively p=0.011 and p=0.009). The median knowledge score of all subjects was 13 (8,25-17). The knowledge score levels were higher in those who had heard of osteoporosis than those who had not heard, respectively 14 (10-18) to 4 (0-13,75) (p<0.001). There was a significant difference between the osteoporosis knowledge scores of patients with received corticosteroid treatment before (p=0.003). The factors related to osteoporosis knowledge score levels are shown in Table 2. When the sources of osteoporosis information were questioned in patients, the results were as follows: doctors (34.1%), television-internet (25%) and relatives (23.9%) and were in the first place, followed by friends (9.1%) newspapers and magazines (4.5%) and others (3.4%). When education levels were divided as primary school and high school and above, no significant relationship was found between educational levels and the level of knowledge of osteoporosis (p=0.154). However, the effect of education level was shown in the multiple regression analysis. Univariate and multivariate regression analyses of osteoporosis awareness are shown in Table 3. It was observed that as the age of the patients increased, their level of knowledge also increased (p=0.008, Spearman’s rho=0.281). Table 4 presents descriptive data for the knowledge items.

Discussion

In this study, we determined that although there was high awareness of osteoporosis in patients with MS, the knowledge level of osteoporosis was poor in most of this population.

In our study, the awareness of osteoporosis in patients with MS was 81.8%. Osteoporosis awareness varies in different studies. In a study conducted in a Greek female population, it was reported that 96% of the participants knew the definition of osteoporosis (15). Nguyen et al. (14) reported that awareness of osteoporosis in the Vietnamese women population is 81.6%. Gemalmaz and Oge (16) found awareness of osteoporosis in the Turkish women population as 60.8% in their study. In another study evaluating osteoporosis awareness and osteoporosis knowledge level in Turkish patients with neuromuscular disease, osteoporosis awareness was 97.9% (17). Our study results were comparable to these studies in terms of osteoporosis awareness. The fact that our patients with MS were regularly followed up in a particular unit may also have contributed to the high awareness of osteoporosis in these patients.

Osteoporosis awareness was higher in those who received corticosteroid treatment and had comorbid diseases. This may be related to increased health literacy in patients to understand other diseases and corticosteroid side effects. It may also be related to informing the patients by other physicians.

We found that osteoporosis knowledge scores were lower in MS patients who had not heard of osteoporosis disease before. Similar to our result, it has been shown that hearing of osteoporosis disease increases the level of osteoporosis knowledge in different osteoporosis awareness studies (18,19). Although there was a high rate of awareness in our study group, this was not accompanied by actual knowledge. While osteoporosis awareness of the patients was 81.8%, osteoporosis knowledge levels of patients were inadequate. The knowledge level was especially low in terms of two critical aspects of the disease: causes and signs of osteoporosis. The low-level knowledge about osteoporosis may be related to not being informed by the physician following the patient. This situation indicates that information should also be given frequently by physicians. Also, although the definition of osteoporosis was unknown well enough, the subjects answered questions about the complications of osteoporosis at a high rate. This may be related to the difficulty of understanding some medical terms, and because of the emphasized fracture risk of osteoporosis by the information sources.

In our study, patients with awareness of osteoporosis were older, but it was not statistically significant. Contrary to our study, several studies have shown a significant inverse relationship between age and osteoporosis knowledge level (20-22). The fact that our study included only MS patients and the relatively lower mean age in our study group compared to these studies may have led to this result.

Some studies showed that when the education level of patients increased the level of knowledge about osteoporosis increased (15,16). In another study involving 1,114 osteoporotic patients, there was no significant difference between education level and awareness of osteoporosis (5). In our study, awareness of osteoporosis and knowledge scores did not differ by education. However, the effect of education level was shown in the multiple regression analysis. When the patients are compared according to their education level, the lack of difference between the levels of knowledge score may be related to the small number of patients with low education levels in the study.

Different results were reported in the literature when access to information sources regarding osteoporosis was examined. Radio-television, newspapers, friends-relatives, and doctors were reported as information resources (14,16,23). In our study, when the sources of information about osteoporosis were examined, doctors ranked first and television ranked second in MS patients. In addition, it has also been found that having a relative with osteoporosis disease leads to higher awareness of osteoporosis. The fact that our patients with MS are regularly followed up in a unit may have contributed to the fact that the most frequent source of information is doctors.

Fourteen patients had a history of fractures, and 72% predicted that hip fracture might occur because of osteoporosis. However, there was no effect of fracture history on osteoporosis awareness and osteoporosis knowledge level in patients with MS. Fractures are the most important complications that may lead to morbidity and mortality in patients with MS (3,24). The assessment of risk factors for osteoporosis is essential for preventing fractures in patients with MS (12,13,25). Education may play an important role in determining and preventing risk factors.

Our study had some limitations. First, there was no control group to compare patients with MS in our study. In addition, we enrolled patients who were admitted to the outpatient clinic who were monitored regularly. We could not standardize and exclude the effect of regular follow-up on awareness and knowledge levels because our study had a cross-sectional design. Future studies evaluating the awareness and knowledge levels of this population with a larger sample size are needed.

Conclusion

In this study, although awareness of osteoporosis was high in MS patients, the level of osteoporosis knowledge was insufficient. Awareness and knowledge levels of osteoporosis were higher in those who received corticosteroid treatment. In addition, osteoporosis awareness was higher in those who had comorbid diseases. Increasing knowledge about osteoporosis may be important for preventing osteoporosis and reducing its complications in MS patients.