Secondary fracture prevention in primary care: a narrative review

The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.

The "Can Do, Do Do" Framework Applied to Assess the Association between Physical Capacity, Physical Activity and Prospective Falls, Subsequent Fractures, and Mortality in Patients Visiting the Fracture Liaison Service

The "can do, do do" framework combines measures of poor and normal physical capacity (PC, measured by a 6 min walking test, can do/can't do) and physical activity (PA, measured by accelerometer, do do/don't do) into four domains and is able to categorize patient subgroups with distinct clinical characteristics, including fall and fracture risk factors. This study aims to explore the association between domain categorization and prospective fall, fracture, and mortality outcomes. This 6-year prospective study included patients visiting a Fracture Liaison Service with a recent fracture. Outcomes were first fall (at 3 years of follow-up, measured by fall diaries), first subsequent fracture, and mortality (at 6 years). Cumulative incidences of all three outcomes were calculated. The association between domain categorization and time to the three outcomes was assessed by uni- and multivariate Cox proportional hazard analysis with the "can do, do do" group as reference. The physical performance of 400 patients with a recent fracture was assessed (mean age: 64 years; 70.8% female), of whom 61.5%, 20.3%, and 4.9% sustained a first fall, sustained a subsequent fracture, or had died. Domain categorization using the "can do, do do" framework was not associated with time to first fall, subsequent fracture, or mortality in the multivariate Cox regression analysis for all groups. "Can't do, don't do" group: hazard ratio [HR] for first fall: 0.75 (95% confidence interval [CI]: 0.45-1.23), first fracture HR: 0.58 (95% CI: 0.24-1.41), and mortality HR: 1.19 (95% CI: 0.54-6.95). Categorizing patients into a two-dimensional framework seems inadequate to study complex, multifactorial outcomes. A personalized approach based on known fall and fracture risk factors might be preferable.

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Physical strength and mental health mediate the association between pain and falls (recurrent and/or injurious) among community-dwelling older adults in Singapore

OBJECTIVE

This study aims to understand if poor physical strength and depression mediate the association between pain and recurrent and/or injurious falls in a community of older adults.

METHODS

Data was obtained from a nationally representative longitudinal cohort study conducted in Singapore, PHASE (Wave I and II), which collected information from community-dwelling older adults above 60 years old. A hurdle negative binomial regression and binomial logistic regression were used to assess the association between pain and recurrent falls, and pain and injurious falls respectively. A subsequent mediation analysis was conducted.

RESULTS

Almost half of the participants (N = 1144, 39.7%) reported having either mild, moderate, or severe pain at baseline, 166 (5.4%) participants experienced injurious falls and 144 (4.7%) participants experienced recurrent falls at Wave II. After adjusting for covariates, the presence of pain significantly influenced recurrent (OR 2.8; 95% CI: 1.8, 4.4) and injurious falls (OR: 1.8; 95% CI: 1.3, 2.5). Mediation analyses demonstrated that poor physical strength and depression had a significant mediation effect between all pain characteristics on recurrent falls. Poor physical strength partially mediates the effects of pain and injurious falls as well. However, the mediating effect of poor physical strength and depression was not observed between other pain characteristics and injurious falls.

CONCLUSIONS

The findings highlighted differences in the underlying mechanisms between pain characteristics affecting recurrent and injurious falls. These insights will be useful for identifying patients most at risk for recurrent or injurious falls, and for tailoring future community-based fall intervention programmes.

Association of motor index scores with fall incidence among community-dwelling older people

BACKGROUND

Several kinds of motor dysfunction have been studied for predicting future fall risk in community-dwelling older individuals. However, no study has tested the ability of the fine motor index (FINEA) and gross motor index (GROSSA) to predict the risk of falling, as well as the specific fall type.

OBJECTIVE

We investigated the associations of FINEA/GROSSA scores with fall risk, explained falls, and unexplained falls.

METHODS

A total of 6267 community-dwelling adults aged ≥ 50 years from the Irish Longitudinal Study on Aging (TILDA) cohort were included. First, the associations of FINEA and GROSSA scores with the history of total falls, explained falls and unexplained falls were assessed in a cross-sectional study and further verified in a prospective cohort after 2 years of follow-up by Poisson regression analysis.

RESULTS

We found that high FINEA and GROSSA scores were positively associated with almost all fall histories (FINEA scores: total falls: adjusted prevalence ratio [aPR] = 1.28, P = 0.009; explained falls: aPR = 1.15, P = 0.231; unexplained falls: aPR = 1.88, P < 0.001; GROSSA scores: total falls: aPR = 1.39, P < 0.001; explained falls: aPR = 1.28, P = 0.012; unexplained falls: aPR = 2.18, P < 0.001) in a cross-sectional study. After 2 years of follow-up, high FINEA scores were associated with an increased incidence of total falls (adjusted rate ratio [aRR] = 1.42, P = 0.016) and explained falls (aRR = 1.51, P = 0.020) but not with unexplained falls (aRR = 1.41, P = 0.209). High GROSSA scores were associated with an increased incidence of unexplained falls (aRR = 1.57, P = 0.041) and were not associated with either total falls (aRR = 1.21, P = 0.129) or explained falls (aRR = 1.07, P = 0.656). Compared with individuals without limitations in either the FINEA or GROSSA, individuals with limitations in both indices had a higher risk of falls, including total falls (aRR = 1.35, P = 0.002), explained falls (aRR = 1.31, P = 0.033) and unexplained falls (aRR = 1.62, P = 0.004).

CONCLUSION

FINEA scores were positively associated with accidental falls, while GROSSA scores were positively associated with unexplained falls. The group for whom both measures were impaired showed a significantly higher risk of both explained and unexplained falls. FINEA or GROSSA scores should be investigated further as possible tools to screen for and identify community-dwelling adults at high risk of falling.

Handgrip strength effectiveness and optimal measurement timing for predicting functional outcomes of a geriatric hip fracture

Handgrip strength (HGS) now draws attention as one of the predictors of outcomes following geriatric hip fracture; however, its effectiveness and the optimal time to assess HGS remain unknown. Herein, we aimed to determine the usefulness of HGS in predicting the outcomes of geriatric hip fracture and to find the most effective time to measure HGS in both the low muscle strength and normal hip fracture groups. The study was performed prospectively for 79 geriatric hip fracture patients. HGS was measured during the admission period and the one-week postoperative period. Walking ability and quality of life were assessed using Koval scores and the European Quality of Life Five Dimension (EQ-5D) scale at the admission period and postoperatively at 3, 6, and 12 months, respectively. The relationship between pre/postoperative HGS and functional outcomes was assessed, and the functional score between the "low muscle strength" and "normal muscle strength" groups was compared. The association between HGS asymmetry and low strength with functional limitations was determined. For the preoperative HGS, the Koval score showed a significant relationship in the postoperative 6-month (r = -0.295, P = 0.008) and 12-month (r = -0.266, P = 0.019) periods; also, the EQ-5D score showed a significant relationship in the postoperative 6-month and 12-month periods (r = 0.344, P < 0.001, and r = 0.386, P = 0.001, respectively). For the postoperative HGS, the Koval score showed a significant relationship in the 6-month (r = -0.432, P < 0.001) and 12-month (r = -0.344, P = 0.002) postoperative periods. Also, the EQ-5D score showed a significant relationship in the 3-month (r = 0.340, P = 0.010), 6-month (r = 0.476, P < 0.001), and 12-month (r = 0.471, P < 0.001) postoperative periods. The incidence of preoperative and postoperative low HGS was 78.5% and 70.9%, respectively. The "low-strength" group had poor Koval scores and EQ-5D at postoperative month 12 and poor functional outcomes earlier in the follow-up (postoperative 6- and 12-month Koval scores and postoperative 3-, 6-, and 12-month EQ-5D), respectively (P = 0.008 and P = 0.003; P = 0.003, P = 0.001, and P = 0.001). The effect of HGS asymmetry and low strength on functional limitations remained undetermined. Both preoperative and postoperative HGS reflected functional outcomes of patients with hip fracture during the 12-month follow-up. Postoperative HGS had a higher prognostic value than preoperative HGS.

The interdisciplinary fracture liaison service improves health-related outcomes and survival of older adults after hip fracture surgical repair

Due to the high burden of fragility fractures, we developed an interdisciplinary FLS care pathway for early management and monitoring of older adults discharged from a high-volume trauma center after hip fracture repair. Interdisciplinary FLS effectively improves up to 1-year adherence to treatments for secondary prevention of fragility fractures, reduces health facility admission, and improves long-term survival.

PURPOSE

To compare adherence to secondary fragility fracture prevention, falls, healthcare facility admissions, and mortality between hip fracture older adults who entered the fracture liaison services pathway of care (FLS-CP) and those managed according to the usual traumatologist model of care (U-CP).

METHODS

Prospective observational study enrolling subjects aged ≥ 65 years discharged by high-volume trauma center after hip fracture repair from February 2016 to February 2017, who consecutively entered FLS-CP or U-CP according to their preference and goals.

RESULTS

Compared to U-CP, those in FLS-CP had higher initiation rate and up to 1-year adherence to secondary prevention of fragility fracture, including vitamin D and calcium (87.7% vs 36.9%; p &lt; 0.0001), specific anti-osteoporosis drugs (75.1% vs 8.0%; p &lt; 0.0001), and complete anti-fracture therapy (72.3% vs 5.7%; p &lt; 0.0001). Older adults belonging to FLS-CP showed a lower likelihood of healthcare facility admission (RR 0.597; 95% CI 0.398-0.895; p = 0.0125), with a longer re-hospitalization-free survival (176.4 vs 88.7 days; p = 0.0152) than those in U-CP. One-year incidence of falls and fractures was similar between groups, with a lower tendency of the subjects in the FLS-CP to be multiple fallers (19% vs 34.8%; OR 0.057; 95% CI 0.004-0.876; p = 0.0690). The FLS-CP group experienced a lower 1-year (87.2% vs 74.3%; p = 0.001) and 3-year mortality (67.9% vs 55.6%; p = 0.0245) and a lower adjusted 5-year mortality hazard ratio (50.2% vs 58%; HR = 0.76; 95% CI 0.60; 0.96).

CONCLUSION

The FLS-CP may improve initiation and adherence to secondary prevention of fragility fractures, reduces healthcare facility admission, and improves long-term survival.

Correlation between Physical Performance and Stabilometric Parameters in Older Adults

Background and Objectives: Falls are a common and serious threat to the health and independence of older adults. The decrease in functional capacity during aging means an increased risk of falls. To date, it is not known whether there is a relationship between balance and functional tests. The aim of the study was to evaluate the correlation between eyes-open and eyes-closed static balance with different functional tests. Materials and Methods: A correlation study was designed with 52 healthy subjects over 65 years of age. Results: Regarding the open eyes stabilometric parameters, significant correlations observed between the surface and the functional tests were weak in all cases. The correlations observed between length and the functional tests performed were moderate, except for that of the Timed Up and Go test (TUG) which was weak. No significant correlation between TUG and surface was found. Regarding the closed eyes stabilometric parameters, statistically significant moderate correlations were found between the surface and the Short Physical Performance Battery (SPPB) and the Five Times Sit to Stand test (5XSST). In the case of the length with eyes closed, a statistically significant moderate correlation (rho = 0.40-0.69) was found with the SPPB and 5XSST variables, and weak correlations with the 4 m Walk Speed test (4WS) and TUG variables. Conclusions: There is a mild to moderate correlation between some functional tests and stabilometric parameters in adults over 65 years old.

Association between incident falls and subsequent fractures in patients attending the fracture liaison service after an index fracture: a 3-year prospective observational cohort study

OBJECTIVES

To evaluate the risk of subsequent fractures in patients who attended the Fracture Liaison Service (FLS), with and without incident falls after the index fracture.

DESIGN

A 3-year prospective observational cohort study.

SETTING

An outpatient FLS in the Netherlands.

PARTICIPANTS

Patients aged 50+ years with a recent clinical fracture.

OUTCOME MEASURES

Incident falls and subsequent fractures.

RESULTS

The study included 488 patients (71.9% women, mean age: 64.6±8.6 years). During the 3-year follow-up, 959 falls had been ascertained in 296 patients (60.7%) (ie, fallers), and 60 subsequent fractures were ascertained in 53 patients (10.9%). Of the fractures, 47 (78.3%) were fall related, of which 25 (53.2%) were sustained at the first fall incident at a median of 34 weeks. An incident fall was associated with an approximately 9-fold (HR: 8.6, 95% CI 3.1 to 23.8) increase in the risk of subsequent fractures.

CONCLUSION

These data suggest that subsequent fractures among patients on treatment prescribed in an FLS setting are common, and that an incident fall is a strong predictor of subsequent fracture risk. Immediate attention for fall risk could be beneficial in an FLS model of care.

TRIAL REGISTRATION NUMBER

NL45707.072.13.

Multivariable prediction models for long-term outcomes after hip fracture: A protocol for a systematic review

Background: Hip fracture results in high mortality and, for many survivors, long-term functional limitations. Multivariable prediction models for hip fracture outcomes have the potential to aid clinical-decision making as well as risk-adjustment in national audits of care. The aim of this study is to identify, critically appraise and synthesise published multivariable prediction models for long-term outcomes after hip fracture. Protocol: The systematic review will include a literature search of electronic databases (MEDLINE, Embase, Scopus, Web of Science and CINAHL) for journal articles. Search terms related to hip fracture, prognosis and outcomes will be included. Study selection criteria includes studies of people with hip fracture where the study aimed to predict one or more long-term outcomes through derivation or validation of a multivariable prediction model. Studies will be excluded if they focus only on the predictive value of individual factors, or only include patients with periprosthetic fractures, fractures managed non-surgically or younger patients. Covidence software will be used for data management. Two review authors will independently conduct study selection, data extraction and appraisal. Data will be extracted based on the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist. Risk of bias assessment will be conducted using the Prediction model Risk of Bias Assessment Tool (PROBAST). Characteristics and results of all studies will be narratively synthesised and presented in tables. Where the same model has been validated in multiple studies, a meta-analysis of discrimination and calibration will be conducted. Conclusions: This systematic review will aim to identify multivariable models for hip fracture outcome prognosis that have been derived using high quality methods. Results will highlight if current models have the potential for further assessment for use in both clinical decision making and improving methods of national hip fracture audits. PROSPERO registration: CRD42022330019 (25th May 2022).

Comparative Analysis of Preoperative and Postoperative Muscle Mass around Hip Joint by Computed Tomography in Patients with Hip Fracture

Purpose

This study was conducted in order to assess changes in hip muscles by comparing results of preoperative and postoperative computed tomography (CT) in older patients who underwent surgery for treatment of hip fracture.

Materials and Methods

A total of 50 patients (aged ≥65 years) who underwent surgery for treatment of intertrochanteric fractures (25 patients) and femoral neck fractures (25 patients) between February 2013 and February 2019 and underwent preoperative and postoperative pelvic CT were enrolled in the study. The cross-sectional area, attenuation and estimates of muscle mass of the gluteus medius, gluteus minimus, iliopsoas, and rectus femoris on the uninjured side were measured. Basic patient data (sex, age, height, weight, body mass index [BMI], bone mineral density [BMD], Harris hip score [HHS], and length of follow-up) were collected from medical records.

Results

No significant differences in sex, age, height, weight, BMI, BMD, HHS, and length of follow-up were observed between the two groups. No significant difference in the cross-sectional areas and attenuations of gluteus medius and gluteus minimus was observed after surgery; however, a statistically significant decrease was observed in those of iliopsoas and rectus femoris after surgery. Lower estimates with statistical significance of muscle mass of the iliopsoas and rectus femoris were observed on postoperative CT.

Conclusion

Muscle mass of the hip flexor (iliopsoas, rectus femoris) showed significant decreases on postoperative CT compared with preoperative CT. Based on these findings, selective strengthening exercise for hip flexor should be beneficial in rehabilitation of hip fractures.

Identification of hip fracture patients at risk for postoperative mobilisation complications via handgrip strength assessment

INTRODUCTION

Treatment of older adult hip fracture patients can be challenging and requires early postoperative mobilisation to prevent complications. Simple clinical tools to predict mobilisation/weight-bearing difficulties after hip fracture surgery are scarcely available and analysis of handgrip strength could be a feasible approach. In the present study, we hypothesised that patients with reduced handgrip strength show incapability to follow postoperative weight-bearing instructions.

MATERIALS AND METHODS

Eighty-four patients aged ≥ 65 years with a proximal femur fracture (trochanteric, n = 45 or femoral neck, n = 39), who were admitted to a certified orthogeriatric center, were consecutively enrolled in a prospective study design. Five days after surgery (intramedullary nailing or arthroplasty), a standardised assessment of handgrip strength and a gait analysis (via insole forcesensors) was performed.

RESULTS

Handgrip strength showed positive correlation with average peak force during gait on the affected limb (0.259), postoperative Parker Mobility Score (0.287) and Barthel Index (0.306). Only slight positive correlation was observed with gait speed (0.157). These results were congruent with multivariate regression analysis.

CONCLUSION

Assessment of handgrip strength is a simple and reliable tool for early prediction of postoperative mobilisation complications like the inability to follow weight-bearing instructions in older hip fracture patients. Follow-up studies should evaluate if these findings also match with other fracture types and result in personalised adjustment of current aftercare patterns. In addition, efforts should be made to combine objectively collected data as handgrip strength or gait speed in a prediction model for long-term outcome of orthogeriatric patients.

Effects of 8 Weeks of Balance Training, Virtual Reality Training, and Combined Exercise on Lower Limb Muscle Strength, Balance, and Functional Mobility Among Older Men: A Randomized Controlled Trial

BACKGROUND

Poor muscle strength, balance, and functional mobility have predicted falls in older adults. Fall prevention guidelines recommend highly challenging balance training modes to decrease falls; however, it is unclear whether certain modes are more effective. The purpose of this study was to determine whether traditional balance training (BT), virtual reality balance training (VR), or combined exercise (MIX) relative to a waitlist control group (CON) would provoke greater improvements in strength, balance, and functional mobility as falls risk factor proxies for falls in older men.

HYPOTHESIS

We hypothesized that 8 weeks of MIX will provoke the greatest improvements in falls risk factors, followed by similar improvements after BT and VR, relative to the CON.

STUDY DESIGN

Single-blinded randomized controlled trial NCT02778841 (ClinicalTrials.gov identifier).

LEVEL OF EVIDENCE

Level 2.

METHODS

In total, 64 community-dwelling older men (age 71.8 ± 6.09 years) were randomly assigned into BT, VR, MIX, and CON groups and tested at baseline and at the 8-week follow-up. The training groups exercised for 40 minutes, 3 times per week, for 8 weeks. Isokinetic quadriceps and hamstrings strength on the dominant and nondominant legs were primary outcomes measured by the Biodex Isokinetic Dynamometer. Secondary outcomes included 1-legged stance on firm and foam surfaces, tandem stance, the timed-up-and-go, and gait speed. Separate one-way analyses of covariance between groups were conducted for each outcome using baseline scores as covariates.

RESULTS

(1) MIX elicited greater improvements in strength, balance, and functional mobility relative to BT, VR, and CON; (2) VR exhibited better balance and functional mobility relative to BT and CON; and (3) BT demonstrated better balance and functional mobility relative to CON.

CONCLUSION

The moderate to large effect sizes in strength and large effect sizes for balance and functional mobility underline that MIX is an effective method to improve falls risk among older adults.

CLINICAL RELEVANCE

This study forms the basis for a larger trial powered for falls.

Rib Fracture Mortality: Are there clues in the core?

BACKGROUND

Sarcopenia is associated with increased morbidity and mortality in the trauma patient. The primary objective of this study was to determine the relationship of psoas cross sectional area with hospital mortality in patients with rib fractures over the age of 55 years.

MATERIALS AND METHODS

We retrospectively reviewed 1223 patients presenting to a Level 1 Trauma Center between 1/1/2002 and 1/31/2019. Psoas cross sectional area was measured using a polygonal tracing tool. Patients were stratified into four quartiles based on sex-specific values.

RESULTS

There was increased in-hospital mortality for patients with a lower psoas cross sectional area (10 %, 8%, 6%, and 4%, Q1-Q4 respectively; P=0.021). The logistic regression model determined for every increase in psoas cross sectional area by 1 cm² the odds of in-hospital mortality decreased by 4%.

CONCLUSIONS

In-hospital mortality is multifactorial; however, psoas cross sectional area may provide a clue in predicting adverse outcomes after traumatic rib fractures.

Effects of physical exercise in sarcopenia. A systematic review

From the third decade of life and due to multiple causes, muscle mass and strength are gradually lost, which affects the function of the musculoskeletal system. This combined loss of muscle mass and strength with aging is called sarcopenia, and is associated with greater morbidity and mortality in the elderly. Early treatment is therefore essential, and physical exercise is the therapeutic approach that has given the best results. This literature review intended to analyze the effect of physical exercise, excluding the role that other treatments proposed, including the nutritional approach, could play in the treatment of sarcopenia, refers to 12 articles. In studies including high intensity strength exercises in isolation, either alone or combined with aerobic exercise, improvements were seen in muscle mass, muscle strength, and functional test times. There is also a significant increase in fat-free mass in individuals who exercised more frequently (more than two sessions per week). Current evidence shows that strength-resistance training and its combination in multimodal programs with aerobic exercise show significantly beneficial effects on anthropometric and muscle function parameters. Programs of prescribed exercises including strength exercises adequate to the characteristics should therefore be adapted to the characteristics of each individual and replace the usual practice of prescribing aerobic exercises (walking) only.

Motivational interviewing with community-dwelling older adults after hip fracture (MIHip): protocol for a randomised controlled trial

INTRODUCTION

Community-dwelling people recovering from hip fracture have the physical capacity to walk in their community but lack the confidence to do so. The primary aim of this trial is to determine whether motivational interviewing increases time spent walking at 12 months in community-dwelling people after hip fracture compared with an attention placebo control group. Secondary aims are to evaluate cost effectiveness, patient and health service outcomes and to complete a process evaluation.

METHODS AND ANALYSIS

An assessor-blinded parallel group randomised controlled design with embedded health economic evaluation and process evaluation will compare the effects of n=270 participants randomly allocated to an experimental group (motivational interviewing) or a control group (dietary advice). For inclusion, participants are aged ≥65 years, living at home independently within 6 months of discharge from hospital after hip fracture and able to walk independently and communicate with conversational English. Key exclusion criteria are severe depression or anxiety, impaired intellectual functioning and being medically unstable to walk. Participants allocated to the experimental group will receive 10 (8 weekly and 2 booster) telephone-based sessions of motivational interviewing to increase walking over 16 weeks. Participants allocated to the control group will receive an equivalent dose of telephone-based dietary advice. The primary outcome is daily time spent walking over 7 days assessed at weeks 0, 9, 26 and 52. Secondary outcomes include measures of psychological-related function, mobility-related function, community participation, health-related quality of life and falls. Health service utilisation and associated costs will be assessed. Process evaluation will assess the fidelity of the motivational interviewing intervention and explore contextual factors through semistructured interviews.

ETHICS AND DISSEMINATION

Ethical approval obtained from Eastern Health (E19-002), Peninsula Health (50261/EH-2019), Alfred Health (617/20) and La Trobe University (E19/002/50261). The findings will be disseminated in peer-reviewed journals, conference presentations and public seminars.

TRIAL REGISTRATION NUMBER

ACTRN12619000936123.

High intensity power training in middle-aged women with Charcot–Marie–Tooth disease: a case series

Background/aims

High-intensity power training has been shown to be effective in improving muscular capabilities, functional performance and health-related quality of life in populations with physical impairments. However, the effectiveness of high-intensity power training in people with Charcot–Marie–Tooth disease remains uncertain. This case series investigated the effects of high-intensity power training on muscle performance, function and health-related quality of life in middle-aged women with Charcot-Marie-Tooth disease.

Methods

Four women (age 51–58 years) with Charcot–Marie–Tooth disease type 1A participated in 8 weeks of supervised high-intensity power training.

Results

All participants improved strength of the right hip abductors (46.7–109.7%) and left hip abductors (27.3–128.6%), maximal gait speed (2.3–9.1%), static balance (0.7–4.9%), tandem walk (−3.3 to −58.5%), and mental component scores on the Short Form 36 Health Status Survey (0.8–27.6%). Adherence to high-intensity power training was 100% and only one minor adverse event related to the intervention was reported.

Conclusions

Although promising, larger controlled studies are indicated to confirm the safety and efficacy of high-intensity progressive resistance and power training in this cohort.

Keeping adults physically active after Falls Management Exercise (FaME) programmes end: development of a physical activity maintenance intervention

Background

Falls prevention exercise programmes help to improve muscle strength, balance and physical function, and reduce falling rates in older adults. Improvements in muscle strength, balance and physical function are reversed if older adults do not continue to be physically active after falls prevention exercise programmes end. This paper describes the design process of an intervention that aimed to maintain physical activity in older adults exiting falls prevention exercise programmes.

Methods

The development of the Keeping Adults Physically Active (KAPA) intervention and its implementation plan was guided by Bartholomew’s Intervention Mapping approach. The intervention mapping approach involved (1) performing a needs assessment and developing intervention objectives using previous literature; (2) identifying theory-based intervention strategies from a systematic review and the National Institute of Clinical Excellence guidelines; and (3) designing the KAPA intervention and its implementation plan with the guidance from an expert steering group.

Results

The KAPA intervention comprised of six group sessions of motivational interviewing, delivered monthly by trained and mentor-supported falls prevention practitioners. Intervention sessions lasted up to 90 min and were delivered in community settings over a 6-month duration. Participant manuals, illustrated exercise books, physical activity diaries and pedometers supported the KAPA intervention.

Conclusions

The intervention development process, consisting of Bartholomew’s Intervention Mapping approach and the input from an expert steering group, was successful in creating the evidence-based KAPA intervention ready to be evaluated in a feasibility trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00844-w.

Performance during reactive handrail grasping during forward walking by young and older adults with and without prior knowledge of the direction of movement is correlated with grip strength

It has been suggested that the most frequent cause of falls in assisted-living facilities is due to incorrect weight shifting. Lateral instability and weakness have also been linked to falls risk. The objective of this study was to evaluate balance responses to weight shifting during walking and to investigate age-related changes in movement and strength. Thirty-two participants (16 young, 16 older) completed 12 straight walking trials and 6 trials in each condition where a weight shift was required to grasp a handrail. Instructions were to walk down the pathway and, if cued, grasp the handrail as quickly as possible. Conditions included left and right grasping trials, with and without prior knowledge about the movement direction. Kinematic data were recorded and center of mass (COM) was calculated to examine whole body movements. A clinical balance test, strength, and body composition measures were captured to facilitate exploration into the relationship of these measures with reactive movements used during weight transfers. Young adults had quicker lateral COM velocities and reached peak velocity earlier. Males completed the task quicker than females and, for everyone, having knowledge about direction enabled quicker responses. Grip strength was correlated to most performance metrics in this study; more-so than body composition. Slower reactive movements might reflect a more cautious strategy in the older adults or it may highlight changes that occur with increased age and strength changes.

Early Maximal Strength Training Improves Leg Strength and Postural Stability in Elderly Following Hip Fracture Surgery

Introduction:

Hip fractures predominantly occur in the geriatric population and results in increased physical inactivity and reduced independency, largely influenced by a downward spiral of ambulatory capacity, related to loss of skeletal muscle strength and postural stability. Thus, effective postoperative treatment, targeting improvements in muscle strength, is sought after.

Materials & Methods:

Twenty-one hip fracture patients (>65 yr) were randomized to 8 weeks of either conventional physiotherapy control group (CG), or leg press and hip abduction maximal strength training (MST) 3 times per week. MST was performed applying heavy loads (85-90% of 1 repetition maximum; 1RM) and 4-5 repetitions in 4 sets. Maximal strength (bi- and unilateral 1RM), postural stability (unipedal stance test; UPS), and DEXA-scan bone mineral content/ density (BMC/BMD) were measured before and after the 8-week rehabilitation.

Results:

Both MST and conventional physiotherapy improved bilateral leg press 1RM by 41 ± 27 kg and 29 ± 17 kg, respectively (both p < 0.01), while unilateral leg press 1RM only increased after MST (within group and between groups difference: both p < 0.05). MST also resulted in an increase in abduction 1RM in both the fractured (5 kg, 95%CI: 2-7; p < 0.01) and healthy limb (6 kg, 95%CI: 3-9; p < 0.01), while no such improvement was apparent in the CG (between groups difference: p < 0.01). Finally, MST improved UPS of the fractured limb (p < 0.05). No differences were observed in BMC or BMD following the 8 weeks.

Discussion:

Early postoperative MST improved lower extremities maximal muscle strength more than conventional physiotherapy and was accompanied by improvements in postural stability.

Conclusion:

Implementing MST in early rehabilitation after hip fracture surgery should be considered as a relevant treatment to curtail the downward spiral of reduced ambulatory capacity typical for this patient group, possibly reducing the risk of recuring falls and excess mortality.

Trial Registration:

https://clinicaltrials.gov/ct2/show/NCT03030092

Physical Therapy Management of Older Adults With Hip Fracture

Hip fracture is a leading cause of profound morbidity in individuals aged 65 years and older, ranking in the top 10 causes of loss of disability-adjusted life-years for older adults. Worldwide, the number of people with hip fracture is expected to rise significantly due to the aging population and other factors. Physical therapist management is recommended within medical, surgical, and multidisciplinary clinical practice guideline (CPGs) and is considered to be the standard of care in rehabilitation for people with hip fracture. The goal of this CPG was to review the evidence relevant to physical therapist management and to provide evidence-based recommendations for physical therapy diagnosis, prognosis, intervention, and assessment of outcome in adults with hip fracture. J Orthop Sports Phys Ther 2021;51(2):CPG1-CPG81. doi:10.2519/jospt.2021.0301.

Sarcopenia, Currently a Hot Topic: A Narrative Review

Aging is associated with a progressive decline of skeletal muscle quantity and quality leading to a gradual slowing of movement, a decline in strength and power, and a condition known as sarcopenia. Sarcopenia is a syndrome a risk of adverse outcomes such as physical disability, poor quality of life and death. Agerelated losses in skeletal muscle mass and function have had a significant important in health care issue. In this study, we reviewed the recently introduced criteria for the Eastern and Western diagnosis of sarcopenia. A narrative review of evidence- and non-evidence-based papers was conducted, using a relevant methodological framework. This review is included the following: 1) definitions and diagnostic criteria over time; 2) pathophysiology of muscle loss; 3) management especially protein or amino acid supplementation, medications, and physical exercise.

Impact of Bone Fracture on Muscle Strength and Physical Performance-Narrative Review

PURPOSE OF REVIEW

Low muscle strength and poor physical performance are associated with high risk of fracture. Many studies assessed clinical and functional outcomes of fractures. Fewer studies analyzed the impact of fractures on muscle strength and physical performance.

RECENT FINDINGS

Vertebral fractures (especially multiple and severe ones) are associated with back pain, back-related disability, lower grip strength, lower strength of lower limbs, lower gait speed, and poor balance. Patients with hip fracture have slower gait and lower quadriceps strength. Non-vertebral fractures were associated with lower strength of the muscles adjacent to the fracture site (e.g., grip strength in the case of distal radius fracture, knee extensors in the case of patellar fracture) and poor physical function dependent on the muscles adjacent to the fracture site (e.g., limited range of motion of the shoulder in the case of humerus fracture, gait disturbances in the case of the ankle fracture). Individuals with a fracture experience a substantial deterioration of muscle strength and physical performance which exceeds that related to aging and is focused on the period close to the fracture occurrence. After fracture, muscle strength increased and physical performance improved. The rate of normalization depended partly on the therapeutic approach and on the rehabilitation program. A subgroup of patients, mainly the elderly, never returns to the pre-fracture level of physical performance. The permanent decline of physical function after fracture may be related to the limitation of movements due to pain, low physical activity, poor health before the fracture, and reduced efficacy of retraining after immobilization.

Validity and reliability of the self-rated fall risk questionnaire in older adults with osteoporosis

BACKGROUND

Several risk assessments have been developed to evaluate fall risk in older adults, but it has not been conclusively established which of these tools is most effective for assessing fall risk in this vulnerable population. Recently, the U.S. Centers for Disease Control and Prevention (CDC) developed the self-rated Fall Risk Questionnaire (self-rated FRQ), a 12-item questionnaire designed to screen older adults who are at risk of falling and has been widely used in many centers. This study aimed to determine the validity and reliability of the self-rated FRQ in older adults with osteoporosis.

METHODS

This prospective study was conducted at the Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from December 2019 to March 2020. Sixty-eight men or postmenopausal women aged > 65 years who were diagnosed with osteoporosis either by bone mineral density T-score or by occurrence of fragility fracture were evaluated with the self-rated FRQ, the Thai falls risk assessment test (Thai-FRAT), the timed get-up-and-go test (TUG test), the Berg Balance Scale (BBS), and the 5 times sit-to-stand test (5TSTS test). Validity of the self-rated FRQ was assessed by evaluating the correlations (r) between the self-rated FRQ score and the scores from the other four assessments. Reliability of the self-rated FRQ was evaluated by measuring test-retest reliability and internal consistency.

RESULTS

The self-rated FRQ was moderately strongly correlated with the BBS, TUG test, and 5TSTS test (r = 0.535 to 0.690; p < 0.001), and fairly correlated with the Thai-FRAT (r = 0.487; p < 0.001). Test-retest reliability of the self-rated FRQ was high, with a Kappa of 1. Internal consistency of the self-rated FRQ was excellent (Cronbach's alpha: 0.936).

CONCLUSIONS

The self-rated FRQ was found to be a valid and reliable tool for evaluating fall risk in older adults with osteoporosis. Since assessment of fall risk requires a multifaceted measurement tool, the self-rated FRQ is an appropriate tool that can be integrated into the fall risk assessment algorithm in older adults with osteoporosis.

Comprehensive Geriatric Care to Improve Mobility after Hip Fracture: An RCT

BACKGROUND

Comprehensive geriatric care (CGC) for older adults during hospitalization for hip fracture can improve mobility, but it is unclear whether CGC delivered after a return to community living improves mobility compared with usual post-discharge care.

OBJECTIVE

To determine if an outpatient clinic-based CGC regime in the first year after hip fracture improved mobility performance at 12 months.

METHODS

A two-arm, 1:1 parallel group, pragmatic, single-blind, single-center, randomized controlled trial at 3 hospitals in Vancouver, BC, Canada. Participants were community-dwelling adults, aged ≥65 years, with a hip fracture in the previous 3-12 months, who had no dementia and walked ≥10 m before the fracture occurred. Target enrollment was 130 participants. Clinic-based CGC was delivered by a geriatrician, physiotherapist, and occupational therapist. Primary outcome was the Short Physical Performance Battery (SPPB; 0-12) at 12 months.

RESULTS

We randomized 53/313 eligible participants with a mean (SD) age of 79.7 (7.9) years to intervention (n = 26) and usual care (UC, n = 27), and 49/53 (92%) completed the study. Mean 12-month (SD) SPPB scores in the intervention and UC groups were 9.08 (3.03) and 8.24 (2.44). The between-group difference was 0.9 (95% CI -0.3 to 2.0, p = 0.13). Adverse events were similar in the 2 groups.

CONCLUSION

The small sample size of less than half our recruitment target precludes definitive conclusions about the effect of our intervention. However, our results are consistent with similar studies on this population and intervention.

Evaluation of Fall and Fracture Risk Among Men With Prostate Cancer Treated With Androgen Receptor Inhibitors: A Systematic Review and Meta-analysis

Importance

A high incidence of fall and fracture in a subset of patients treated with androgen receptor inhibitors (ARIs) has been reported, although the relative risk (RR) of fall and fracture for patients who receive ARI treatment is unknown.

Objective

To evaluate whether treatment with ARIs is associated with an elevated relative risk for fall and fracture in patients with prostate cancer.

Data Sources

Cochrane, Scopus, and MedlinePlus databases were searched from inception through August 2019.

Study Selection

Randomized clinical trials comparing patients with prostate cancer treated with any ARI or placebo were included.

Data Extraction and Synthesis

Two independent reviewers used a standardized data extraction and quality assessment form. A mixed effects model was used to estimate the effects of ARI on relative risk, with included studies treated as random effects and study groups treated as fixed effects in the pooled analysis. Sample size for each study was used to weight the mixed model. Statistical analysis was performed from August to October 2019.

Main Outcomes and Measures

The primary outcome was RR of fall and fractures for patients receiving ARI treatment.

Results

Eleven studies met this study's inclusion criteria. The total population was 11 382 men (median [range] age: 72 [43-97] years), with 6536 in the ARI group and 4846 in the control group. Participants in the ARI group could have received enzalutamide, apalutamide, or darolutamide in combination with androgen deprivation therapy or other enzalutamide combinations; patients in the control group could have received placebo, bicalutamide, or abiraterone. The reported incidence of fall was 525 falls (8%) in the ARI group and 221 falls (5%) in the control group. The incidence of fracture was 242 fractures (4%) in the ARI group and 107 fractures (2%) in the control group. Use of an ARI was associated with an increased risk of falls and fractures: all-grade falls (RR, 1.8; 95% CI, 1.42-2.24; P < .001); grade 3 or greater fall (RR, 1.6; 95% CI, 1.27-2.08; P < .001); all-grade fracture (RR, 1.59; 95% CI, 1.35-1.89; P < .001), and likely grade 3 or greater fracture (RR, 1.71; 95% CI, 1.12-2.63; P = .01).

Conclusions and Relevance

Use of ARI was associated with an increase in falls and fractures in patients with prostate cancer as assessed by a retrospective systematic review and meta-analysis. Further studies are warranted to identify and understand potential mechanisms and develop strategies to decrease falls and fractures associated with ARI use.

Risk factors for recurrent falls in older adults: A systematic review with meta-analysis

Older adults who fall recurrently (i.e., 2 or more falls/year) are at risk of functional decline and mortality. Understanding which risk factors for recurrent falls are most important will inform secondary fall prevention strategies that can reduce recurrent falls risk. Thus, we conducted a systematic review with meta-analysis to determine the relative risk of recurrent falls for different types of falls risk factors. MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched on April 25, 2019 (Prospero Registration: CRD42019118888). We included peer-reviewed prospective studies which examined risk factors that contributed to recurrent falls in adults aged ≥ 60 years. Using the falls risk classification system of Lord and colleagues, we classified each risk factor into one of the following domains: 1) balance and mobility; 2) environmental; 3) psychological; 4) medical; 5) medication; 6) sensory and neuromuscular; or 7) sociodemographic. We calculated the summary relative risk (RR) for each domain and evaluated the risk of bias and quality of reporting. Twenty-two studies were included in this systematic review and meta-analysis. Four domains predicted recurrent falls: balance and mobility (RR:1.32;95 % CI:[1.10, 1.59]), medication (RR:1.53;95 % CI:[1.11, 2.10]), psychological (RR:1.35;95 % CI:[1.03, 1.78]), and sensory and neuromuscular (RR:1.51;95 % CI:[1.18, 1.92]). Each of these four domains can be viewed as a marker of frailty. The risk of bias was low, and the study quality was high (minimum:19/22). Older adults with markers of frailty are up to 53 % more likely to experience recurrent falls. Strategies that identify and resolve frailty markers should be a frontline approach to preventing recurrent falls.

Effects of an intervention to reduce fear of falling and increase physical activity during hip and pelvic fracture rehabilitation

BACKGROUND

fear of falling and reduced fall-related self-efficacy are frequent consequences of falls and associated with poorer rehabilitation outcomes. To address these psychological consequences, geriatric inpatient rehabilitation was augmented with a cognitive behavioural intervention ("Step by Step") and evaluated in a RCT.

METHODS

one hundred fifteen hip and pelvic fracture patients (age = 82.5 years, 70% female) admitted to geriatric inpatient rehabilitation were randomly allocated to the intervention or control group. The intervention consisted of eight additional individual sessions during inpatient rehabilitation, one home visit and four telephone calls delivered over 2 months after discharge. Both groups received geriatric inpatient rehabilitation. Primary outcomes were fall-related self-efficacy (short falls efficacy scale-international) and physical activity as measured by daily walking duration (activPAL3™ sensor) after admission to rehabilitation, before discharge and 1-month post-intervention.

RESULTS

in covariance analyses, patients in the intervention group showed a significant improvement in fall-related self-efficacy (P = 0.025, d = -0.42), but no difference in total daily walking duration (P = 0.688, d = 0.07) 1-month post-intervention compared to the control condition. Further significant effects in favour of the intervention group were found in the secondary outcomes "perceived ability to manage falls" (P = 0.031, d = 0.41), "physical performance" (short physical performance battery) (P = 0.002, d = 0.58) and a lower "number of falls" (P = 0.029, d = -0.45).

CONCLUSIONS

the intervention improved psychological and physical performance measures but did not increase daily walking duration. For the inpatient part of the intervention further research on the required minimum intensity needed to be effective is of interest. Duration and components used to improve physical activity after discharge should be reconsidered.

A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture.

PURPOSE/INTRODUCTION

To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice.

METHODS

The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses.

RESULTS

One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%).

CONCLUSION

A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society

BACKGROUND

The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities.

METHODOLOGY

A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS.

RESULTS/CONCLUSION

A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Effects of physical exercise in sarcopenia. A systematic review

From the third decade of life and due to multiple causes, muscle mass and strength are gradually lost, which affects the function of the musculoskeletal system. This combined loss of muscle mass and strength with aging is called sarcopenia, and is associated with greater morbidity and mortality in the elderly. Early treatment is therefore essential, and physical exercise is the therapeutic approach that has given the best results. This literature review intended to analyze the effect of physical exercise, excluding the role that other treatments proposed, including the nutritional approach, could play in the treatment of sarcopenia, refers to 12 articles. In studies including high intensity strength exercises in isolation, either alone or combined with aerobic exercise, improvements were seen in muscle mass, muscle strength, and functional test times. There is also a significant increase in fat-free mass in individuals who exercised more frequently (more than two sessions per week). Current evidence shows that strength-resistance training and its combination in multimodal programs with aerobic exercise show significantly beneficial effects on anthropometric and muscle function parameters. Programs of prescribed exercises including strength exercises adequate to the characteristics should therefore be adapted to the characteristics of each individual and replace the usual practice of prescribing aerobic exercises (walking) only.

Early Mobilization Versus Splinting After Surgical Management of Distal Radius Fractures

BACKGROUND

After the surgical management of distal radius fractures (DRF) in older patients, further treatment with a splint often follows. It is unclear whether early mobilization might be superior to splinting in this group of patients, as it is in others. In this prospective, randomized, controlled trial, we attempted to determine whether early mobilization yields better outcomes.

METHODS

50 patients over age 70 with DRF were included in the trial. Group A (the splint group) was treated with postoperative immobilization, group B with early mobilization. Clinical follow-up examinations were performed at 2, 6, and 12 weeks and at 6 and 12 months. X-rays were obtained preoperatively, postoperatively, at 6 weeks, and at 6 months. The primary outcome parameter was the modified Mayo Wrist Score (MMWS) at 6 weeks.

RESULTS

At 6 weeks, the functional outcome was better to a statistically significant extent in group B (MMWS; 65/100 vs. 55/100 [q25 : 55/40 - q75 : 70/70; p = 0.025]). No difference between the two groups was demonstrable in their further clinical course. The estimated regression model revealed a statistically significant effect of the method of treatment (p = 0.023). There were no differences in hand strength or in x-ray findings.

DISCUSION

Early mobilization is associated with better wrist function on initial follow-up, without any demonstrable disadvantage with respect to secondary dislocation. The psychological benefit and protective function of wrist splinting in patients who are in danger of falling should nonetheless be investigated in further studies.

Factors associated with screening positive for high falls risk in fragility fracture patients: a cross-sectional study

Background

We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk.

Methods

The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression.

Results

Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50–64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk.

Conclusions

Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted.

Factors influencing performances and indicating risk of falls using the true Timed Up and Go test time of patients with hip fracture upon acute hospital discharge

OBJECTIVE

To examine the influence and risk of falls of individual factors on timed up and go test (TUG) times using standardized instructions in patients with hip fracture upon discharge from an acute orthopaedic hip fracture unit.

METHODS

Following instructions, the TUG was performed three times with a rollator (standardized aid), as fast as safely possible. Up to a 1-min rest was given after the first and second TUG trial. Multivariable linear regression analysis was used to investigate the factors influencing TUG-times and corresponding logistic analysis was used to investigate factors indicating risk of falls, using a cut-off of 24 s for TUG.

RESULTS

A total of 181 patients (122 women), 60 years or older, with a mean (SD) age of 78.1 (9.1) years were studied. The fastest of three TUG trials performed within a mean of 10.0 (5.2) post-surgery days and used in analyses reached a mean of 25.6 (11.0) s. Multivariable regression analysis showed that greater age (B = 0.24; 2.4s more per decade older), a low pre-fracture function level (New Mobility Score <7 points, B = 6.4s more than high level), having a trochanteric fracture (B = 6.2 s, vs. cervical), and the post-surgery day of testing (B = 0.42, 4.2s per 10 days later) were independently associated with using more time for performing the TUG. Correspondingly, the same four factors indicated an increased risk of falls in the logistic analysis. The linear model explained 28% of the variance on TUG, while the accuracy of the logistic model to predict patients having TUG≥24 s was 69%.

CONCLUSION

The age, pre-fracture function, fracture type and post-surgery day of TUG testing were identified as strong factors influencing TUG performances and TUG-times indicating risk of falls in patients with hip fracture. We suggest that these factors be considered when interpreting TUG test results and in further rehabilitation and fall prevention efforts.

Comparative Effectiveness of Functional Tests in Fall Prediction After Hip Fracture

OBJECTIVES

To assess the validity of 4 functional tests in predicting falls within the first year after hip fracture.

DESIGN

Prospective study of functional tests shortly after hip surgery and incident falls during 12 months' follow-up.

SETTING AND PARTICIPANTS

The sample comprised 173 adults with acute hip fracture, aged 65 years and older (79% women, 77% community dwelling, mean age 84.2 years), who participated in a clinical trial of vitamin D or home exercise.

METHODS

We assessed 4 functional tests [Timed Up and Go test (TUG), grip strength, and knee flexor and extensor strength in the nonoperated leg] by trained study physiotherapists at baseline (1-12 days after hip fracture surgery). During 12 months' follow-up, we ascertained all fall events by monthly personal phone calls, a telephone hotline, and a patient diary. Then we compared TUG and strength test performance at baseline between future single fallers, recurrent fallers, and nonfallers over the 12-month follow-up. All analyses adjusted for age, body mass index, gender, 25-hydroxyvitamin D status at baseline, days of follow-up, and treatment allocation (the original trial tested vitamin D treatment and/or a home exercise program).

RESULTS

Ninety-two of 173 (53%) participants fell and experienced 212 falls. Participants who became recurrent fallers (n = 54) had significantly longer TUG times at baseline than those who did not fall (n = 81) in the following 12 months (mean TUG for recurrent fallers = 71.6 seconds, SD = 8.2 seconds, vs mean TUG for nonfallers = 51.4 seconds, SD = 6.9 seconds; P = .02). There were no significant differences in TUG times between single fallers and nonfallers. For all 3 strength tests, there were no significant differences between single fallers, recurrent fallers, and nonfallers.

CONCLUSIONS AND IMPLICATIONS

In this population of frail older adults recruited shortly after hip fracture surgery, only the TUG test discriminated between future recurrent fallers and nonfallers over a 12-month follow-up. Because of the high incidence and serious consequences of falls in older adults after a hip fracture, it is very important to identify practical and clinically related tests to predict repeated falls in the first year after a hip fracture, which is of great public health importance.

A randomised feasibility study assessing an intervention to keep adults physically active after falls management exercise programmes end

Background

Physical inactivity contributes to disability and falls in older adults. Falls prevention exercise (FaME) programmes improve physical activity and physical function and reduce falling rates. Improvements in physical function are reduced, and falls rates increase, if physical activity is not maintained. This research investigated the feasibility and acceptability of an intervention that aimed to maintain physical activity in older adults exiting FaME.

Methods

The Keeping Adults Physically Active (KAPA) intervention comprised of six group sessions of motivational interviewing, delivered monthly by trained and mentor-supported postural stability instructor's after the FaME programme ceased. The KAPA intervention included participant manuals, illustrated exercise books, physical activity diaries and pedometers. A feasibility study was conducted in 8 FaME classes. The study design was a two-arm, cluster randomised, multi-site feasibility study comparing the KAPA intervention with usual care. A sample of 50 community-dwelling adults aged 65 years old or older were recruited. Recruitment, retention and attendance rates, self-reported physical activity and participant interviews were used to examine the feasibility and acceptability of the KAPA intervention.

Results

Fifty of the sixty-seven (74.6%) participants invited into the study agreed to take part, 94.2% of the available KAPA sessions were attended and 92.3% of the recruited participants provided outcome data. The KAPA participants expressed positive views about the venues and postural stability instructors and reported enjoying the group interactions. Intervention participants discussed increasing their physical activity in response to the peer-support, illustrated home exercise booklet, physical activity diaries and pedometers. Most discussed the written tasks to be the least enjoyable element of the KAPA intervention. The proportion of participants reporting at least 150 minutes of moderate to vigorous physical activity per week rose from 56.3 to 62.5% in the intervention arm and from 41.4 to 52.0% in the usual care arm.

Conclusions

The participants found the KAPA intervention acceptable. Participants reported the exercise booklet, peer support and the physical activity monitoring tools encouraged them to keep active. A full-scale trial is needed to assess whether physical activity can be significantly maintained in response to the KAPA intervention.

Trial registration

Retrospectively registered on ClinicalTrials.gov (NCT03824015).

Inflammatory markers associated with fall recurrence and severity: The Bambuí Cohort Study of Aging

BACKGROUND

The aim of this study was to analyze the association between inflammatory markers and recurrent and severe falls in 1304 community-dwelling older adults from the Bambuí Cohort Study of Aging.

METHODS

Information about falls in the previous 12 months was collected, and classified based on recurrence (two or more falls) and severity (requirement of medical attention). The screened biomarkers included interleukins (IL-1β, IL-6, IL-10, and IL-12, TNF), chemokines (CXCL8, CXCL9, CXCL10, CCL2, and CCL5), and high-sensitive C-reactive protein (hs-PCR). Potential confounders included sociodemographic, behavioral, and health indicators. Associations were evaluated through logistic regression, using odds ratios (OR) and 95% confidence intervals (95% CI), with Stata 13.1.

RESULTS

The prevalence of recurrent and severe falls was 10.7% and 9.0%, respectively. After adjustments, elevated levels of IL-12 (OR: 1.92; 95% CI: 1.09-3.37) and CXCL9 (OR: 1.67; 95% CI: 1.05-2.66) were found to be associated with recurrent falls, while elevated levels of TNF (OR: 1.58; 95% CI: 1.01-2.50), IL-12 (OR: 2.04; 95% CI: 1.13-3.70), CXCL10 (OR: 1.75; 95% CI: 1.04-2.92), and CCL5 (OR: 1.90; 95% CI: 1.18-3.07) were associated with severe falls.

CONCLUSIONS

The results highlight a wide range of biomarkers not yet explored in the literature and suggest that inflammation may be an important component of recurrent and severe falls.

Prevalence and clinical impact of sarcopenia in osteoporotic hip fracture: Single center retrospective cohort study

OBJECTIVE

The study aimed to identify the prevalence of sarcopenia in patients with osteoporotic hip fractures, investigate the anthropometric differences between sarcopenic and non-sarcopenic patients, and evaluate and compare the surgical outcomes between the two groups.

METHODS

The study included 135 patients (35 men and 100 women; mean age: 74.1 years (range; 25-96)) who received surgical treatment for hip fracture between March 2014 and October 2016 and underwent whole-body dual-energy X-ray absorptiometry (DEXA). The skeletal muscle mass index (SMI) for diagnosis of sarcopenia was measured using whole-body DEXA. The following data were collected to compare the preoperative details of the sarcopenic and non-sarcopenic groups: SMI, age, sex, type of fracture, type of operation, BMI, obesity, American society of Anesthesiologists (ASA) class, pre-injury mobility score, BMD, and follow-up period. We compared clinical outcomes, including Harris Hip Score (HSS) and the walking ability at the last follow-up visit and radiologic outcomes, including non-union and the time to union.

RESULTS

The average HHS and Parker's mobility score at the last follow-up were 81.7 and 6.9 in the sarcopenic group, and 77.6 and 6.3 in the non-sarcopenic group, respectively (p=0.149 and 0.122). Non-union was identified 0 (0%) in sarcopenic group and 4 (10%) in non-sarcopenic group (p=0.288). The mean union timer of the patients in the sarcopenia group was 4.0 months and that of patients in the non-sarcopenic group was 4.4 months (p=0.210). Multiple regression analysis did not show any significant association between sarcopenia and postoperative surgical outcomes, including HHS, mobility score at the last follow up, non-union, and time to union.

CONCLUSION

Although the present study showed that the prevalence of sarcopenia in hip fracture patients was 45.9% (62/135), there was no clinical association between sarcopenia and postoperative. Based on these results, the clinical impact of sarcopenia may be confined to increased risk of hip fracture occurrence and surgical outcomes of hip fracture may not be affected by sarcopenia.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

The association of malnutrition with falls and harm from falls in hospital inpatients: Findings from a 5-year observational study

BACKGROUND

Inpatient falls continue to be a significant clinical issue, and while malnutrition is a known risk factors for falls, few studies have investigated its association with inpatient falls. This study aimed to explore the independent association between malnutrition and fall risk as well as harm from falls in hospital inpatients.

METHODS

Malnutrition identified in annual malnutrition audits was combined with inpatient fall data captured through the electronic patient incident reporting system in the 12 months following audit days. Audit data were available for 1,849 inpatients across 2011-2015, and covariate associations between age, gender, BMI, malnutrition, falls and harmful falls were analysed. The reporting of this paper is in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations (see Appendix S1).

RESULTS

The prevalence of malnutrition was 32.4% (n = 543), and 171 (9.2%) inpatients experienced a fall with 0.7% (n = 13) categorised as harmful. In bivariate analysis, patients who fell were more likely to be older (median 79.0 vs. 70.0 years; p < .0001) or malnourished (40.9% vs. 31.5%; p = .021). Malnutrition (p < .0001) and having a lower BMI (p = .026) were significant predictors of harmful falls. Regression modelling demonstrated that only increasing age increased the likelihood of having an inpatient fall (OR 1.022 95% CI 1.021-1.046; p < .0001). Malnourished inpatients were almost 8 times more likely to have a harmful fall than those not malnourished (OR 7.94 95% CI 1.457-43.338; p = .017), independent of age and BMI.

CONCLUSIONS

Malnourished patients are more likely to experience a harmful fall. Assessment of malnutrition should be incorporated into fall risk assessments as a way of highlighting those patients at greater risk and to link to nutritional care pathways.

Agreement and predictive power of six fall risk assessment methods in community-dwelling older adults

A large number of fall risk assessment methods are available with a variety of performances for screening the risk of falling in older adults, but their agreement for assessing the risk of falling remains unknown. This observational prospective cohort study describes the agreement and predictive power of methods to classify the risk of falling in older adults using prospective data and published cut-off values. Fifty-two participants aged 74 years (interquartile range 69-80) were assessed using the Berg Balance Scale, polypharmacy, Falls Risk Assessment Score, Fall Risk Assessment Tool, Fall Efficiency Scale, and Posturography. Nine participants (17 %) reported at least one fall after six months. Cochran's test showed different proportions of participants classified as at high risk of falling among all methods (Q = 69.560, p < 0.001). A slightly better-then-chance agreement was estimated between all FRA methods (Light's κ = 0.074, 95%CI [0.021; 0.142]). We found both global and pairwise agreement levels that question the agreement among fall risk assessment methods for screening community-dwelling older adults.

Fall-risk increasing drugs and recurrent injurious falls association in older patients after hip fracture: a cohort study protocol

Polypharmacy and fall-risk increasing drugs (FRIDS) have been associated with injurious falls. However, no information is available about the association between FRIDS and injurious falls after hospital discharge due to hip fracture in a very old population. We aim to assess the association between the use of FRIDS at discharge and injurious falls in patients older than 80 years hospitalized due to a hip fracture. A retrospective cohort study using routinely collected health data will be conducted at the Orthogeriatric Unit of a teaching hospital. Patients will be included at hospital discharge (2014), with a 2-year follow-up. Fall-risk increasing drugs will be recorded at hospital discharge, and exposure to drugs will be estimated from usage records during the 2-year follow-up. Injurious falls are defined as falls that lead to any kind of health care (primary or specialized care, including emergency department visits and hospital admissions). A sample size of 193 participants was calculated, assuming that 40% of patients who receive any FRID at discharge, and 20% who do not, will experience an injurious fall during follow up. This protocol explains the study methods and the planned analysis. We expect to find a relevant association between FRIDS at hospital discharge and the incidence of injurious falls in this very old, high risk population. If confirmed, this would support the need for a careful pharmacotherapeutic review in patients discharged after a hip fracture. However, results should be carefully interpreted due to the risk of bias inherent to the study design.

Fall-risk increasing drugs and prevalence of polypharmacy in older patients discharged from an Orthogeriatric Unit after a hip fracture

BACKGROUND

Polypharmacy and fall-risk increasing drugs (FRIDS) have been associated with injurious falls. We aimed to estimate the prevalence of polypharmacy and FRIDS in older patients discharged from an Orthogeriatric Unit after a hip fracture surgery.

METHODS

This study describes the baseline findings of a 2-year retrospective cohort study. We included patients older than 80 years discharged from an Orthogeriatric Unit who were able to walk before surgery. Patient's baseline variables, total number of drugs, and FRIDS at hospital discharge were collected.

RESULTS

We included 228 patients. The mean number of drugs and FRIDS prescribed at discharge was 11.6 ± 3.0 and 2.9 ± 1.6, respectively. Polypharmacy was prevalent in all patients except in three: 23.3% (5-9 drugs) and 75.9% (≥ 10 drugs). Only 11 patients had no FRIDS and 35.5% were on > 3 FRIDS. The most prevalent FRIDS were: agents acting on the renin-angiotensin system (43.9%) and anxiolytics (39.9%). The number of FRIDS was higher in patients with extreme polypharmacy (3.4 ± 1.5) than in those on 5-9 drugs (1.5 ± 1.0, p < 0.05). Independent people in performing instrumental activities had lower risk of extreme polypharmacy (≥ 10 drugs) or > 3 FRIDS: OR 0.39 (95% CI 0.18-0.83) and OR 0.41 (95% CI 0.20-0.84), respectively. People living in a nursing home had higher risk of > 3 FRIDS: OR 4.03 (95% CI 1.12-14.53).

CONCLUSIONS

Polypharmacy and fall-risk increasing drugs are prevalent in patients discharged from orthogeriatric care after surgery for a hip fracture. Interventions on drug use at hospital discharge could have a potential impact on falls in this high-risk population.

The Effect of Intensive Abductor Strengthening on Postoperative Muscle Efficiency and Functional Ability of Hip-Fractured Patients: A Randomized Controlled Trial

BACKGROUND

Hip fractures are common in the elderly and many patients fail to regain prefracture hip abductor strength or functional status. The purpose of this clinical trial was to compare the effects of an intensive abductor muscle exercise program versus a standard physiotherapy intervention in hip-fractured patients.

MATERIALS AND METHODS

Ninety six femoral neck-fractured patients were randomized into equal-sized groups. A 12-week standard physiotherapy program was implemented in the control group(S-PT) whereas an intensive exercise program, emphasizing on abductors' strengthening, was implemented in the research group(I-PT). Abductors' isometric strength of the fractured hip, abductor ratio% in the fractured compared to contralateral hip, and functional level were assessed at the 3^rd (postintervention) and 6^th (followup) months.

RESULTS

Postintervention, abductors' isometric strength was 35.7% greater (P < 0.0005) and abductor ratio% was 2.5% higher (P < 0.0005) in I-PT group, compared to S-PT group. With regard to functional assessments, I-PT group was 29.1% faster during Timed Up and Go (TUG) test and achieved a 26.7% higher Lower Extremity Functional Scale Greek version's (LEFS-Greek) total score, compared to S-PT group (P < 0.0005). At followup, abductors' isometric strength was 37.0% greater (P < 0.0005) and abductor ratio% was 7.1% higher (P < 0.0005) in I-PT group, compared to S-PT group. In addition, I-PT group was 45.9% faster during TUG test (P < 0.0005) and achieved an 11.2% higher LEFS-Greek total score, compared to S-PT group (P = 0.013).

CONCLUSIONS

Compared to the standard physiotherapy intervention, the intensive abductor-strengthening program significantly increased both abductors' isometric strength of the fractured hip and abductor ratio% and resulted in patients' enhanced functional level.

CLINICAL TRIAL IDENTIFIER

ISRCTN30713542.

Review of perioperative falls

Falls are a known public health problem, and there is increasing recognition of the importance of perioperative falls for risk prediction and quality assessment. Our objective was to review existing literature regarding the occurrence, injuries, and risk factors of preoperative and postoperative falls. A systematized search of PubMed entries between 1947 and November 2015 produced 24 articles that met inclusion criteria. Most studied orthopaedic surgery patients older than 65 yr. Four were rated 'good' quality. Interrater reliability for the quality assessment was moderate (κ = 0.77). In the 3-12 months before surgery, the proportion of preoperative patients who fell ranged from 24 to 48%. Injuries were common (70%). The rate of postoperative falls ranged from 0.8 to 16.3 per 1000 person-days, with a gradual decline in the months after surgery. Injuries from postoperative falls occurred in 10-70% of fallers, and 5-20% experienced a severe injury. Risk factors were not well studied. Prospective studies reported a higher percentage of falls and fall-related injuries than retrospective studies, suggesting that there may be underdetection of falls and injuries with retrospective studies. Perioperative falls were more common than falls reported in the general community, even up to 12 months after surgery. Surgery-related falls may therefore occur beyond the hospitalization period. Future studies should use a prospective design, validated definitions, and broader populations to study perioperative falls. In particular, investigations of risk factors and follow-up after hospitalization are needed.

REGISTRY NUMBER

PROSPERO registration number CRD42015029971.