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For Peer Review Only Journal: BMJ Open BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006521 on 17 March 2015. Downloaded from Lifelong Chinese Bound Feet – A Quantitative Ultrasound and Lifestyle Questionnaire Study in Postmenopausal Women For peer review only Journal: BMJ Open Manuscript ID: bmjopen-2014-006521 Article Type: Research Date Submitted by the Author: 15-Sep-2014 Complete List of Authors: Qin, Ling; The Chinese University of Hong Kong, ; The Chinese University of Hong Kong, Department of Orthopaedics and Traumatology Pan, Yi; Second Affiliated Hospital of Kunming Medical University, Department of Endocrinology Zhang, Ming; The Hong Kong Polytechnic University, Department of Mechanical Engineering Xu, Mian; Second Affiliated Hospital of Kunming Medical University, Department of Endocrinology Lao, Hanchang; Second Affiliated Hospital of Kunming Medical University, Department of Orthopaedics O’Laughlin, Michael; The Chinese University of Hong Kong, Department of Orthopaedics and Traumatology Tong, Shan; The Hong Kong Polytechnic University, Department of http://bmjopen.bmj.com/ Mechanical Engineering Zhao, Yanling; Health Promotion Foundation of China, Training Department of International Osteoporosis Diagnosis and Treatment Cheng, JCY; The Chinese University of Hong Kong, Department of Orthopaedics and Traumatology Guo, Xia; The Hong Kong Polytechnic University, Department of Rehabilitation Sciences <b>Primary Subject Sports and exercise medicine on September 29, 2021 by guest. Protected copyright. Heading</b>: Secondary Subject Heading: Sports and exercise medicine ORTHOPAEDIC & TRAUMA SURGERY, Adult orthopaedics < ORTHOPAEDIC Keywords: & TRAUMA SURGERY, Foot & ankle < ORTHOPAEDIC & TRAUMA SURGERY For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 28 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006521 on 17 March 2015. Downloaded from 1 2 3 4 5 Lifelong Chinese Bound Feet – A Quantitative Ultrasound and Lifestyle Questionnaire 6 7 8 Study in Postmenopausal Women 9 10 1* 2 3 2 4 11 Ling Qin PhD; Yi Pan MD; Ming Zhang PhD; Mian Xu MD; Hanchang Lao MD; Michael 12 13 C. O’Laughlin1 BSc; Shan Tong3 MPhil; Yanling Zhao5 MD; Cheng JCY1 MD; Xia Guo6 MD 14 15 For peer review only 16 17 1. Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, 18 19 the Chinese University of Hong Kong, Hong Kong SAR, China. 20 21 2. Department of Endocrinology, the Second Affiliated Hospital of Kunming Medical 22 23 24 University, Kunming, Yunnan Province, China 25 26 3. Department of Mechanical Engineering, the Hong Kong Polytechnic University, Hong Kong 27 28 SAR, China. 29 30 31 4. Department of Orthopaedics, the Second Affiliated Hospital of Kunming Medical University, 32 33 Kunming, Yunnan Province, China http://bmjopen.bmj.com/ 34 35 5. Training Department of International Osteoporosis Diagnosis and Treatment, Health 36 37 38 Promotion Foundation of China, Beijing China 39 40 6. Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hong Kong 41 42 on September 29, 2021 by guest. Protected copyright. 43 SAR, China. 44 45 46 *: Corresponding author: Ling QIN (PhD), e-mail: [email protected] 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 28 BMJ Open: first published as 10.1136/bmjopen-2014-006521 on 17 March 2015. Downloaded from 1 2 Abstract 3 4 5 6 Objective The phenomenon of foot binding or also known as "lotus feet" has an enduring and 7 8 influential history in China. Due to man-made smaller foot size, the life-long foot binding may 9 10 11 impose adverse effect on skeletons and we investigated the bone properties in postmenopausal 12 13 14 women with bound feet that may provide new information to develop appreciate 15 For peer review only 16 countermeasures for prevention of fragility fractures. 17 18 19 Design Population-based cohort study. 20 21 22 Participants This study involved 254 postmenopausal women aged between 65 and 80, including 23 24 25 172 with bounded feet and 82 age- and gender-matched control subjects living in a remote region 26 27 of China. 28 29 30 Outcomes Anthropometric data, SF-36 life-style questionnaire, and heel quantitative ultrasound 31 32 33 (QUS) were collected for the entire study population. A small subset was also invited for http://bmjopen.bmj.com/ 34 35 assessment of bone mineral and microarchitecture at distal tibiae using high-resolution peripheral 36 37 38 quantitative computed tomography (HR-pQCT), gait and balance. 39 40 41 Results Women with bound feet had significantly lower QUS value as compared to age-matched 42 on September 29, 2021 by guest. Protected copyright. 43 women with normal feet, supported by HR-pQCT data as well. However, SF-36 questionnaire 44 45 46 results did not reveal statistically significant differences in any categorical responses, including 47 48 physical functioning, general health vitality and physical component summary score, number of 49 50 previous fractures. No impaired body balance was found in the small set of group. 51 52 53 Conclusions The man-made changes of foot binding led to reduced physical activity and 54 55 56 therefore were prone to osteoporosis. A compensation mechanism for women with bound feet 57 58 with no difference in fragility fracture might be related on not affected capability in body balance 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 28 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-006521 on 17 March 2015. Downloaded from 1 2 tested for the small subset, implying the importance of improving or maintaining body balance in 3 4 overall prevention strategy of fragility fractures confirmed in this unique foot-binding study. 5 6 7 8 Introduction 9 10 11 Few phenomena in history have been brought to such a high level of esteem and popularity with 12 13 14 a perplexing origin, and even fewer have shared such extensive, enduring impacts. For over a 15 For peer review only 16 millennium, Chinese women of all ages and social classes bounded their feet to a fraction of its 17 18 original size, suffering great pain and hardship during the process. Literature documented that 19 20 21 this tradition began in the closing years of the tenth century by either dancers during the Song 22 23 dynasty that valued the aesthetic beauty and graceful movements of small feet or a hedonistic 24 25 26 emperor who ordered his concubines to bind their feet to resemble the shape of a “golden lotus” 27 1,2 28 leaf. One aspect beyond debate, however, is the widespread influence of foot binding and the 29 30 longevity of its practice: spanning over 1000 years and four dynasties in China. The tradition 31 32 th 33 reached its apex during the 18 century, where around over 50% of all women and close to 100% http://bmjopen.bmj.com/ 34 2,3 35 of women in upper class societies bound their feet. 36 37 38 Foot binding was first outlawed in 1912 but persisted in various rural regions of China. Women 39 40 41 with small feet were associated with restricted labor and physical activity that promoted 42 on September 29, 2021 by guest. Protected copyright. 1-3 43 feministic behavior and increased one’s likelihood of marriage. Nowadays, older women aged 44 45 65 or above have become the very last generation still living with bound feet. These women 46 47 48 mainly reside in rural and impoverished provinces of China. However, while the phenomenon is 49 50 well documented, very few previous reports have collected scientific data to study the direct 51 52 effect of lifelong foot binding to one’s bone statues and fragility fractures. 53 54 55 56 One of the observable consequences of lifelong foot binding is the reduced foot size and 57 58 accordingly significant decrease in support area of the foot that greatly hinders the ability for one 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 28 BMJ Open: first published as 10.1136/bmjopen-2014-006521 on 17 March 2015. Downloaded from 1 2 to participate in both social and physical activities throughout one’s lifetime (Figure 1). Physical 3 4 exercise has previously been shown with strong evidence of enhancing bone health.4-7 The 5 6 7 decreased support given by the smaller foot area would be likely to reduce balancing capabilities, 8 9 lead to a greater risk factor of falling and cause higher incidence of fragility fracture due to 10 11 7-9 12 restricted physical activity. We therefore put forward our study hypothesis that women with 13 14 bound feet had adverse impact on musculoskeletal health due to diminished lifelong tendencies 15 For peer review only 16 of physical activity, decrease in ability to balance as a result of smaller foot support area and 17 18 19 therefore higher fall frequency and fall-related fragility fractures. 20 21 22 23 24 25 Methods 26 27 28 29 Participants 30 31 32 This was a project conducted by both clinical scientists and bioengineers from Hong Kong and 33 http://bmjopen.bmj.com/ 34 physicians from Mainland China to reveal the social and physiological impacts of lifelong foot 35 36 37 binding with participants recruited from Luliang County of Yunan Province, China (Supplement 38 39 I). Participants who had any diseases or drug use that were known to affect metabolism of 40 41 musculoskeletal system as well as recent fracture (within 1 year) were excluded. The study was on September 29, 2021 by guest. Protected copyright. 42 43 44 supported by the Chinese Health Promotion Foundation (Appendix A) and human ethics 45 46 approval was obtained from the Second Affiliated Hospital of Kunming Medical Collage for the 47 48 49 part of study conducted in Kunming (Appendix B) and the Chinese University of Hong Kong 50 51 for the part conducted in Hong Kong (Appendix C).
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