Exercise, nutrition and managing hip fracture in older persons

Peri-operative protein or amino acid supplementation for total joint arthroplasty: a systematic review and meta-analysis

PURPOSE

Osteoarthritis (OA) affects weight-bearing joints, such as hips and knees, and its prevalence is rising due to factors like obesity and aging. Muscle atrophy, exacerbated by aging and surgery, increases the risk of joint instability and falls. Orthopedic surgeons explore dietary interventions to counteract these effects, with protein supplementation (PS) showing promise. This systematic review and meta-analysis assessed the effectiveness of PS in arthroplasty patients, comparing findings with sports medicine and sarcopenia literature.

METHODS

Following PRISMA guidelines, we searched PubMed, Web of Science, Scopus, and Embase (February 2025) for protein and amino acid supplementation studies in total knee or hip arthroplasty (TKA and THA) patients. The quality assessment used the Cochrane risk of bias and the Newcastle-Ottawa Scale. Meta-analysis calculated effect sizes for muscle atrophy and strength outcomes.

RESULTS

Nineteen studies (903 patients) evaluated oral or intravenous protein/amino acid supplementation over a mean follow-up of 55.2 days. Essential amino acids (EAA) significantly reduced muscle atrophy in quadriceps femoris muscle mass (SMD: 0.69; 95% CI: 0.44 to 0.95) and hamstring muscle mass (SMD: 1.04; 95% CI: 0.52 to 1.55). However, effects on intramuscular adipose tissue (IMAT) and muscle thickness (MT) were inconsistent. Muscle strength outcomes varied, with no significant effect on quadriceps muscle strength (QMS) or handgrip strength (HGS). Intravenous amino acid infusion improved muscle protein synthesis and reduced perioperative blood loss.

CONCLUSIONS

Protein and amino acid supplementation can reduce muscle atrophy in hip or knee arthroplasty patients. While effects on muscle strength and function are mixed, intravenous supplementation offers benefits. Further standardized research is needed to confirm these findings.

TRIAL REGISTRATION

PROSPERO registration code (CRD42024555899).

Association of Sarcopenia with Osteopenia and Osteoporosis in Community-Dwelling Older Korean Adults: A Cross-Sectional Study

Sarcopenia and bone disorders, such as osteopenia and osteoporosis, are common musculoskeletal disorders in older adults. Therefore, this study aimed to establish the association between sarcopenia and bone disorders such as osteoporosis and osteopenia according to sex. We analyzed 3077 participants from the 2008-2011 Korean National Health and Nutrition Examination Survey aged 65 years or older. After adjusting for all covariates, such as physical examinations, exercise, and nutrient intake (model 4), the odds ratios for the association between sarcopenia and bone disorders were 2.051 (95% confidence interval [CI]: 1.498-2.808) in osteopenia and 2.258 (95% CI: 1.584-3.218) in osteoporosis. However, when sex was analyzed separately, the odds ratio was significantly different in men (osteopenia-2.068, 95% CI: 1.462-2.924; osteoporosis-3.247, 95% CI: 1.953-5.399), but not in women. Therefore, the results of this study show an association between sarcopenia and bone disorders in older Korean adults. Sarcopenia is significantly related to osteopenia and osteoporosis, especially in men, when stratified by sex.

Cutoff Value for a Nutritional Indicator Related to Gait Independence in Elderly Fracture Patients: A Preliminary Study

OBJECTIVE

Previous studies have reported the relationship between nutritional status and gait independence in elderly fracture patients. However, the degree to which nutritional indicators are related to gait independence is unclear. The purpose of this study is to calculate a cutoff value for a nutritional indicator related to gait independence in patients with hip and vertebral compression fractures.

METHOD

This study included 69 patients (33 hip fracture, 36 vertebral compression fracture) who underwent rehabilitation at a convalescent rehabilitation ward. The relationships between nutritional indexes (Mini-Nutritional Assessment-Short Form [MNAⓇ-SF] and skeletal muscle mass index [SMI] ) at admission and gait independence at discharge were analyzed using logistic regression. In addition, receiver operating characteristic analysis was performed to calculate a cutoff value that predicts gait independence.

RESULTS

Among the nutritional indicators used in this study, only MNAⓇ-SF was significantly able to predict gait independence at discharge, and this association was maintained, even after adjustment for confounders. The calculated MNAⓇ-SF cutoff values were 5.5 (sensitivity 100%, specificity 46.3%) and 7.5 points (sensitivity 67.9%, specificity 78.0%).

CONCLUSION

This study suggests that MNAⓇ-SF may be an index for predicting gait independence in patients with hip or vertebral compression fractures in the convalescent rehabilitation ward. The cutoff values calculated in this study were simple and useful index for physical therapists to interpret the results of MNAⓇ-SF.

Effect of Individual Nutrition Therapy and Exercise Regime on Gait Speed, Physical Function, Strength and Balance, Body Composition, Energy and Protein, in Injured, Vulnerable Elderly: A Multisite Randomized Controlled Trial (INTERACTIVE)

It is imperative that the surgical treatment of hip fractures is followed up with rehabilitation to enhance recovery and quality of life. This randomized controlled trial aimed to determine if an individualised, combined exercise–nutrition intervention significantly improved health outcomes in older adults, after proximal femoral fracture. We commenced the community extended therapy while in hospital, within two weeks post-surgery. The primary outcome was gait speed and secondary outcomes included physical function, strength and balance, body composition, energy and protein intake. Eighty-six and 89 participants were randomized into six months individualised exercise and nutrition intervention and attention-control groups, respectively. There were no statistically significant differences in gait speed between the groups at six and 12 months. There were no major differences between groups with respect to the secondary outcomes, except estimated energy and protein intake. This may be explained by the sample size achieved. Participants in the intervention group had greater increment in energy (235 kcal; 95% CI, 95 to 375; p = 0.01) and protein intake (9.1 g; 95% CI, 1.5 to 16.8; p = 0.02), compared with those in the control group at six months but not significant at 12 months. This study has demonstrated that providing early, combined exercise and nutrition therapy can improve dietary energy and protein intake in older adults with hip fractures.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation

Fractures of femur proximal extremity (FFPE) are the most common fragility fractures requiring hospitalization, with a high risk of mortality, low independence in the activities of daily living and severe consequences on health-related quality of life. Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines. Early surgery (within 48 h from hospital admission) allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes. Therefore, time for surgery could be considered as a comorbidity marker. The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature, but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery. In light of these considerations, the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs. Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes, the feasibility of a comprehensive approach in clinical practice is still a challenge. In particular, the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings. Therefore, the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE, highlighting the benefits, feasibility and limitations of this approach.

Feasibility and preliminary effect of anabolic steroids in addition to strength training and nutritional supplement in rehabilitation of patients with hip fracture: a randomized controlled pilot trial (HIP-SAP1 trial)

Background

Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation and a Cochrane Review recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery.

Methods

Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14weeks. Secondary outcomes were physical performance, patient reported outcomes and body composition.

Results

Seven hundred seventeen patients were screened, and 23 randomised (mean age 73.4years, 78% women). Target sample size was 48. Main limitations for inclusion were not home-dwelling (18%) and cognitive dysfunction (16%). Among eligible patients, the main reason for declining participation was Overwhelmed and stressed by situation (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95%CI -0.25;0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95%CI -0.05;0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. Eighteen adverse reactions were identified (anabolic=10, control=8).

Conclusions

Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid.

Trial registration

Clinicaltrials.gov NCT03545347.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02273-z.

Characteristics of incidence hip fracture cases in older adults participating in the longitudinal AGES-Reykjavik study

Poor physical function and body composition my partly predict the risk of falls leading to fracture regardless of bone mineral density.

INTRODUCTION

To examine the relationship between body composition, physical function, and other markers of health with hip fractures in older community-dwelling Icelandic adults.

METHODS

A prospective cohort of 4782 older adults from the AGES-Reykjavik study. Baseline recruitment took place between 2002 and 2006, and information on hip fractures occurring through 2012 was extracted from clinical records. Using multivariate regression analyses, baseline measures of bone health, physical function, and body composition were compared between those who later experienced hip fractures and to those who did not. Associations with the risk of fractures were quantified using Cox regression.

RESULTS

Mean age was 76.3 years at baseline. After adjustment for age, regression showed that male hip fracture cases compared with non-cases had (mean (95% confidence interval)) significantly lower thigh muscle cross-sectional area - 5.6 cm2 (- 10.2, - 1.1), poorer leg strength - 28 N (- 49, - 7), and decreased physical function as measured by longer timed up and go test 1.1 s (0.5, 1.7). After adjustment for age, female cases had, compared with non-cases, lower body mass index - 1.5 kg/m2 (- 2.1, - 0.9), less lean mass - 1.6 kg (- 2.5, - 0.8), thigh muscle cross-sectional area - 4.4 cm2 (- 6.5, - 2.3), and worse leg strength - 16 N (- 25, - 6). These differences largely persisted after further adjustment for bone mineral density (BMD), suggesting that body composition may contribute to the risk of fracture independent of bone health. When examining the association between these same factors and hip fractures using Cox regression, the same conclusions were reached.

CONCLUSIONS

After accounting for age and BMD, older adults who later experienced a hip fracture had poorer baseline measures of physical function and/or body composition, which may at least partly contribute to the risk of falls leading to fracture.

Preliminary effect and feasibility of physiotherapy with strength training and protein-rich nutritional supplement in combination with anabolic steroids in cross-continuum rehabilitation of patients with hip fracture: protocol for a blinded randomized controlled pilot trial (HIP-SAP1 trial)

BACKGROUND

A 2014 Cochrane review evaluating the effect of anabolic steroids after hip fracture concluded that the quality of the studies was insufficient to draw conclusions on the effects and recommended further high-quality trials in the field. Therefore, the aim of this pilot trial is to determine the preliminary effect and feasibility of a 12-week multimodal intervention consisting of physiotherapy (with strength training), protein-rich nutritional supplement and anabolic steroid on knee-extension muscle strength and function 14 weeks after hip fracture surgery.

METHODS

We plan to conduct a randomized, placebo-controlled pilot trial with 48 patients operated for acute hip fracture. The patients are randomized (1:1) to either (1) physiotherapy with protein-rich nutritional supplement plus anabolic steroid or (2) physiotherapy with protein-rich nutritional supplement plus placebo. Outcome assessments will be carried out blinded at baseline (3-10 days after surgery) and at 14 weeks after entering the trial. Primary outcome is the change from baseline to follow-up in maximal isometric knee-extension muscle strength in the fractured limb. Secondary outcomes are physical performance test, patient-reported outcomes, and measures of body composition.

DISCUSSION

If the trial is found feasible and the results show an indication of anabolic steroid being a relevant addition to further enhance the recovery of muscle strength and function in an enhanced recovery after surgery program, this trial will constitute the basis of a larger confirmatory trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03545347. Preregistered on 4 June 2018.

Southampton Arm Fracture Frailty and Sarcopenia Study (SAFFSS): a study protocol for the feasibility of assessing frailty and sarcopenia among older patients with an upper limb fracture

INTRODUCTION

Falls are a major health problem for older people; 35% of people aged 65+ years fall every year, leading to fractures in 10%-15%. Upper limb fractures are often the first sign of osteoporosis and routine screening for osteoporosis is recommended by the National Institute for Health and Care Excellence to prevent subsequent hip fractures. However, both frailty and sarcopenia (muscle weakness) are associated with increased risk of falling and fracture but are not routinely identified in this group. The aim of this study is to evaluate the feasibility of assessing and managing frailty and sarcopenia among people aged 65+ years with an upper limb fracture.

METHODS AND ANALYSIS

This study will be conducted in three fracture clinics in one acute trust in England. 100 people aged 65+ years with an upper arm fracture will be recruited and assessed using six validated frailty measures and two sarcopenia tools. The prevalence of the two conditions and the best tools to use will be determined. Those with either condition will be referred to geriatric clinical teams for comprehensive geriatric assessment (CGA). We will document the proportion who are referred for CGA and those who receive CGA. Other outcome measures including falls, fractures and healthcare resource use over 6 months will be collected. In-depth interviews with a purposive sample of patients who undergo the frailty and sarcopenia assessments and healthcare professionals in fracture clinics and geriatric services will be carried out to their acceptability of assessing frailty and sarcopenia in a busy environment.

ETHICS AND DISSEMINATION

The study was given the relevant ethical approvals from NHS Research Ethics Committee (REC No: 18/NE/0377), the University Hospital Southampton NHS Foundation Trust, and the University of Southampton, Faculty of Medicine Ethics Committee and Research Governance Office. Findings will be published in scientific journals and presented to local, national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN13848445.

The Association of Aromatic Amino Acids with Incident Hip Fracture, aBMD, and Body Composition from the Cardiovascular Health Study

In 5187 persons from the Cardiovascular Health Study, there was no significant association of dietary intakes of aromatic amino acids (AAA) with areal BMD of the hip or body composition. However, those who had the lowest dietary intakes of AAA were at increased risk for incident hip fractures. Prior studies of the association of protein intake with osteoporosis are conflicting and have not directly examined the relationship of aromatic amino acids (AAA) with fractures, areal bone mineral density (aBMD), and body composition. We sought to determine the relationship of dietary intakes of AAA with osteoporosis parameters in elderly men and women. 5187 men and women aged ≥ 65 years from the Cardiovascular Health Study (CHS) with dietary intakes of AAA (tryptophan, phenylalanine, tyrosine) estimated by food frequency questionnaire (FFQ) were included. We examined the relationship between a one-time estimate of daily dietary AAA intake with risk of incident hip fractures over a median of 13.2 years of fracture follow-up. A subset (n = 1336) who had dual energy X-ray absorptiometry (DXA) performed were included in a cross-sectional analysis of the association of dietary AAA intake with aBMD of the total hip and measurements of body composition. In multivariable models adjusted for demographic and clinical variables, medication use, and diet, higher dietary AAA intake was not significantly associated with incident hip fractures. All hazard ratios (HR) were less than one (tryptophan, HR 0.14, 95% CI 0.01 to 1.89; phenylalanine, HR 0.60, 95% CI 0.23 to 1.55; tyrosine, HR 0.59, 95% CI 0.27 to 1.32), but confidence intervals were wide and included no difference. However, in post hoc analyses, the lowest quartile of intake for each AAA was associated with an increased risk for hip fracture compared to higher quartiles (p ≤ 0.047 for all). Dietary AAA intakes were not significantly associated with total hip aBMD or any measurements of body composition. Overall, there was no significant association of dietary AAA intake with hip fractures, aBMD of the hip, or body composition. However, there may be a subset of elderly individuals with low dietary intakes of AAA who are at increased for hip fractures.

Ambient Sensors for Elderly Care and Independent Living: A Survey

Elderly care at home is a matter of great concern if the elderly live alone, since unforeseen circumstances might occur that affect their well-being. Technologies that assist the elderly in independent living are essential for enhancing care in a cost-effective and reliable manner. Elderly care applications often demand real-time observation of the environment and the resident’s activities using an event-driven system. As an emerging area of research and development, it is necessary to explore the approaches of the elderly care system in the literature to identify current practices for future research directions. Therefore, this work is aimed at a comprehensive survey of non-wearable (i.e., ambient) sensors for various elderly care systems. This research work is an effort to obtain insight into different types of ambient-sensor-based elderly monitoring technologies in the home. With the aim of adopting these technologies, research works, and their outcomes are reported. Publications have been included in this survey if they reported mostly ambient sensor-based monitoring technologies that detect elderly events (e.g., activities of daily living and falls) with the aim of facilitating independent living. Mostly, different types of non-contact sensor technologies were identified, such as motion, pressure, video, object contact, and sound sensors. Besides, multicomponent technologies (i.e., combinations of ambient sensors with wearable sensors) and smart technologies were identified. In addition to room-mounted ambient sensors, sensors in robot-based elderly care works are also reported. Research that is related to the use of elderly behavior monitoring technologies is widespread, but it is still in its infancy and consists mostly of limited-scale studies. Elderly behavior monitoring technology is a promising field, especially for long-term elderly care. However, monitoring technologies should be taken to the next level with more detailed studies that evaluate and demonstrate their potential to contribute to prolonging the independent living of elderly people.

Role of Dietary Protein and Muscular Fitness on Longevity and Aging

Muscle atrophy is an unfortunate effect of aging and many diseases and can compromise physical function and impair vital metabolic processes. Low levels of muscular fitness together with insufficient dietary intake are major risk factors for illness and mortality from all causes. Ultimately, muscle wasting contributes significantly to weakness, disability, increased hospitalization, immobility, and loss of independence. However, the extent of muscle wasting differs greatly between individuals due to differences in the aging process per se as well as physical activity levels. Interventions for sarcopenia include exercise and nutrition because both have a positive impact on protein anabolism but also enhance other aspects that contribute to well-being in sarcopenic older adults, such as physical function, quality of life, and anti-inflammatory state. The process of aging is accompanied by chronic immune activation, and sarcopenia may represent a consequence of a counter-regulatory strategy of the immune system. Thereby, the kynurenine pathway is induced, and elevation in the ratio of kynurenine to tryptophan concentrations, which estimates the tryptophan breakdown rate, is often linked with inflammatory conditions and neuropsychiatric symptoms. A combined exercise program consisting of both resistance-type and endurance-type exercise may best help to ameliorate the loss of skeletal muscle mass and function, to prevent muscle aging comorbidities, and to improve physical performance and quality of life. In addition, the use of dietary protein supplementation can further augment protein anabolism but can also contribute to a more active lifestyle, thereby supporting well-being and active aging in the older population.

"I struggle to count my blessings": recovery after hip fracture from the patients' perspective

Background

Recovery outlooks of physical functioning and quality of life after hip fracture have not changed significantly over the past 25 years. Previous research has mainly dealt with causalities and acute treatment, while the recovery process from the patients’ perspective has been less comprehensively described. Expanded knowledge of what the patients consider important in their recovery process may have important consequences for how these patients are treated in the future and thereby on future patient outcomes. The aim presently is therefore to explore how elderly patients with hip fracture enrolled in an ongoing RCT have experienced their recovery process.

Method

The study was qualitative in design. Eight frail elderly in recovery after hip fracture (aged 69–91) were interviewed in their home four months after their fracture. The interviews covered issues related to their experiences of facilitators and barriers throughout the different stages in the recovery process. The patients were already enrolled in an ongoing randomized controlled trial, examining the effects of habitual functional training during their short term stays at nursing homes. The patients were chosen strategically according to age, gender, and participation in rehabilitation. The interviews were recorded, transcribed and subjected to a method of systematic text condensation inspired by Giorgi’s phenomenological method.

Results

The results revealed that the patients’ experiences of the recovery process fell into three main themes: “Feeling vulnerable”, “A span between self-reliance and dependency” and “Disruption from a normal life”. The feeling of gloominess and vulnerability persisted throughout. Being in recovery was also experienced as a tension between self-reliance and dependency; a disrupted life where loss of mobility and the impact of age was profoundly present.

Conclusion

Being in recovery after hip fracture was experienced as a life breaking event. Based on these findings, increased focus on individualized treatment to each patient through each stage of the recovery process should be emphasized.

Impact of beverage consumption, age, and site dependency on dual energy X-ray absorptiometry (DEXA) measurements in perimenopausal women: a prospective study

INTRODUCTION

The aim of this study was to determine the best site for bone mineral density (BMD) measurements based on T-scores, age, and beverage consumption.

MATERIAL AND METHODS

In this prospective study, 271 women stratified by age (average age: 61.9 years) underwent dual energy X-ray absorptiometry (DEXA) scanning of their lumbar spine, hips, and forearms. Osteoporosis was defined as a BMD of 2.5 standard deviations or more below the mean peak bone mass based on a reference population of adult women (translated as a T-score ≤ -2.5), as measured by DEXA. Participants were also evaluated regarding alcohol and caffeine consumption by a semiquantitative questionnaire.

RESULTS

A significant discrepancy was observed in the classification of osteoporosis at different locations, with hip and forearm showing the best correlation (Pearson's r = 0.627, p < 0.001). In addition, for participants over 50 years of age, hip and forearm showed the best correlation. Significant correlations were also noted between forearm T-scores and caffeine consumed and, to a lesser extent, the level of alcohol consumption. In the group ≤ 50 years of age, lumbar spine and forearm T-scores were only associated with alcohol consumption. In the group over 50 years of age, hip and forearm T-scores were only associated with caffeine consumption.

CONCLUSIONS

Bone mineral density measurements at the hip and forearm correlated with caffeine consumption in elderly Taiwanese women. This is an important finding since age and caffeine consumption are known risk factors for osteoporosis.

A multidisciplinary approach to improve the quality of care for patients with fragility fractures

BACKGROUND

Fragility fractures have become a worldwide epidemic associated with significant morbidity and mortality. As the world population ages, the number of patients that experience these fractures is also expected to rise. A multidisciplinary team was assembled that was coordinated by the Acute Inpatient Medical Service and included orthopedic surgeons, geriatricians, anesthesiologists, cardiologists, nurses, trauma surgeons, emergency medicine physicians, physiatrists, and physical therapists. This team was formed with the expectation that geriatric fragility fracture complications, specifically hip fractures, could be reduced by identifying and implementing best practices using guidelines from the American Academy of Orthopedic Surgery and those from the International Geriatric Fracture Society.

METHODS

We implemented a clinical pathway with a standardized approach with reduction in care variation and followed that by instituting performance improvement measures. The difference in outcome measurements as reported by TQIP for the year prior to implementation and the year following creation of the fragility fracture program was evaluated.

RESULTS

Benchmarking data demonstrated improved outcomes for patients with fragility fractures. Length of stay was significantly below national average, mortality remained below national average, and complication rates for UTIs and pressure ulcers were both reduced from 2014 to 2015 and below the national average.

CONCLUSION

The clinical pathway we adopted for the care of patients with fragility fractures has resulted in reduced lengths of stay, below average mortality, and improved discharge disposition.

The effects of habitual functional training on physical functioning in patients after hip fracture: the protocol of the HIPFRAC study

Background

The survivors after hip fracture often report severe pain and loss of physical functioning. The poor outcomes cause negative impact on the person’s physical functioning and quality of life and put a financial burden on society. Rehabilitation is important to improve physical functioning after hip fracture. To maintain the continuity in rehabilitation we have an assumption that it is of utmost importance to continue and progress the functional training that already started at the hospital, while the patients are transferred to short-term stays in a nursing home before they are returning to home. The aim presently is to examine the effects of a functional training program, initiated by the physiotherapist and performed by the nurses, on physical functioning while the patients are at short term stays in primary health care.

Methods/design

Inclusion and randomization will take place during hospital stay. All patients 65 years or above who have sustained a hip fracture are eligible, except if they have a score on Mini Mental State (MMS-E) of less than 15, could walk less than 10 m prior to the fracture, or are terminally ill. The intervention consists of additional functional training as part of the habitual daily routine during short term stays at nursing homes after discharge from hospital. The primary outcome is physical functioning measured by the Short Physical Performance Battery (SPPB). Secondary outcomes are Timed “Up & Go” (TUG), hand grip strength, activPAL accelerometer, and self-reported measures like new Mobility Score (NMS), Walking Habits, University of California Los Angeles (UCLA) activity scale, Fall efficacy scale (FES), EuroQol health status measure (EQ-5D-5 L), and pain.

Discussion

Issues related to internal and external validity in the study are discussed. The outline for the arguments in this protocol is organized according to the guidelines of the Medical Research Council (MRC) guidance on how to develop and evaluate complex interventions.

Trial registration

ClinicalTrials.gov NCT02780076.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Fall and Fracture Risk in Sarcopenia and Dynapenia With and Without Obesity: the Role of Lifestyle Interventions

Due to their differing etiologies and consequences, it has been proposed that the term "sarcopenia" should revert to its original definition of age-related muscle mass declines, with a separate term, "dynapenia", describing muscle strength and function declines. There is increasing interest in the interactions of sarcopenia and dynapenia with obesity. Despite an apparent protective effect of obesity on fracture, increased adiposity may compromise bone health, and the presence of sarcopenia and/or dynapenia ("sarcopenic obesity" and "dynapenic obesity") may exacerbate the risk of falls and fracture in obese older adults. Weight loss interventions are likely to be beneficial for older adults with sarcopenic and dynapenic obesity but may result in further reductions in muscle and bone health. The addition of exercise including progressive resistance training and nutritional strategies, including protein and vitamin D supplementation, may optimise body composition and muscle function outcomes thereby reducing falls and fracture risk in this population.

Handgrip strength is an independent predictor of functional outcome in hip-fracture women: a prospective study with 6-month follow-up

The objective of this study was to investigate the contribution of handgrip strength in predicting the functional outcome after hip fracture in women.We prospectively investigated white women (N = 193 of 207) who were consecutively admitted to a rehabilitation hospital after a hip fracture. We measured handgrip strength with a Jamar dynamometer (Lafayette Instrument Co, Lafayette, IN), on admission to rehabilitation. Ability to function in activities of daily living was assessed by the Barthel index both on discharge from rehabilitation and at a 6-month follow-up.We found significant correlations between handgrip strength measured before rehabilitation and Barthel index scores assessed both on discharge from rehabilitation (ρ = 0.52, P < 0.001) and after 6 months (ρ = 0.49, P < 0.001). Significant associations between handgrip strength and Barthel index scores persisted after adjustment for age, comorbidities, pressure ulcers, medications in use, concomitant infections, body mass index, hip-fracture type, and Barthel index scores assessed both preinjury and on admission to rehabilitation (P = 0.001). Further adjustments for both Barthel index scores and Timed Up-and-Go test assessed at rehabilitation ending did not erase the significant association between handgrip strength and the Barthel index scores at the 6-month evaluation (P = 0.007). To define successful rehabilitation, we categorized the Barthel index scores as either high (85 or higher) or low (<85). The adjusted odds ratio for 1 SD increase in grip strength was 1.73 (95% confidence interval [CI] 1.05-2.84, P = 0.032) for having a high Barthel index score at the end of inpatient rehabilitation and 2.24 (95% CI 1.06-5.18) for having a high Barthel index score at the 6-month follow-up.Handgrip strength assessed before rehabilitation independently predicted the functional outcome both after inpatient rehabilitation and at a 6-month follow-up in hip-fracture women.

Post-operative rehabilitation and nutrition in osteoarthritis

Osteoarthritis (OA) is a degenerative process involving the progressive loss of articular cartilage, synovial inflammation and structural changes in subchondral bone that lead to loss of synovial joint structural features and functionality of articular cartilage. OA represents one of the most common causes of physical disability in the world. Different OA treatments are usually considered in relation to the stage of the disease. In the early stages, it is possible to recommend physical activity programs that can maintain joint health and keep the patient mobile, as recommended by OA Research Society International (OARSI) and European League Against Rheumatism (EULAR). In the most severe and advanced cases of OA, surgical intervention is necessary. After, in early postoperative stages, it is essential to include a rehabilitation exercise program in order to restore the full function of the involved joint. Physical therapy is crucial for the success of any surgical procedure and can promote recovery of muscle strength, range of motion, coordinated walking, proprioception and mitigate joint pain. Furthermore, after discharge from the hospital, patients should continue the rehabilitation exercise program at home associated to an appropriate diet. In this review, we analyze manuscripts from the most recent literature and provide a balanced and comprehensive overview of the latest developments on the effect of physical exercise on postoperative rehabilitation in OA. The literature search was conducted using PubMed, Scopus, Web of Science and Google Scholar, using the keywords 'osteoarthritis', 'rehabilitation', 'exercise' and 'nutrition'. The available data suggest that physical exercise is an effective, economical and accessible to everyone practice, and it is one of the most important components of postoperative rehabilitation for OA.