Acute and long-term increase in fracture risk after hospitalization for stroke

Fracture Risk Among Stroke Survivors According to Poststroke Disability Status and Stroke Type

BACKGROUND

Stroke survivors face physical and cognitive challenges, leading to an increased dependency and a higher fall risk. We aimed to investigate the impact of poststroke disability and stroke type on fracture risk at various sites compared with matched controls.

METHODS

This retrospective cohort study used data from the Korean National Health Insurance System database (2010-2018), including patients with stroke and 1:1 matched controls. Stroke survivors were grouped based on the presence and severity of their poststroke disability and stroke type. The primary outcome was a newly diagnosed fracture, analyzed by Cox proportional hazard regression analyses adjusting for potential confounders.

RESULTS

Among 223 358 stroke survivors (mean age, 64.8±10.9 years; 61.2% men), 16 344 fractures occurred during a mean follow-up of 3.7±2.5 years. In matched controls (n=322 161; mean age, 65.4±11.2 years; 61.3% men), 20 398 fractures were identified. Stroke survivors had increased overall fracture risk compared with matched controls (adjusted hazard ratio [aHR], 1.40 [95% CI, 1.37-1.43]). Specifically, hip fracture risk was even greater in stroke survivors (incidence rate per 1000 person-years, 4.7 [95% CI, 4.5-4.8]; aHR, 2.42 [95% CI, 2.30-2.55]) than controls (incidence rate, 2.2 [95% CI, 2.1-2.3]). The risk of vertebral fractures (aHR, 1.29 [95% CI, 1.25-1.34]) and other fractures (aHR, 1.19 [95% CI, 1.15-1.23]) was also higher than that of the control group. Hip fracture risk was the highest among stroke survivors with severe poststroke disability (aHR, 4.82 [95% CI, 4.28-5.42]), although vertebral or other fracture risk was the highest among those with mild poststroke disability. No significant difference in fracture risk was found between hemorrhagic and ischemic stroke survivors when stratified by disability status.

CONCLUSIONS

Our findings showed increased subsequent fracture risk among stroke survivors, particularly those with poststroke disability and for hip fracture. Bone health assessment and treatment should be emphasized as an essential part of stroke management.

Osteoporosis and fracture risk assessment in adults with ischaemic stroke

PURPOSE

To study the prevalence of osteoporosis, falls and fractures in adults with ischaemic stroke.

METHODS

Observational cohort study of adults aged ≥ 50 years admitted with ischaemic stroke over a 12-month period were invited to participate in a telephone interview one-year post-stroke to ascertain falls and fracture. A Fracture Risk After Ischaemic Stroke (FRAC-stroke) score was calculated.

RESULTS

Of the 1267 patients admitted to the stroke unit between 1 January 2020 and 31 December 2020, 624 had a modified Rankin Score documented. Of these, 316 adults ≥ 50 years had ischaemic stroke and 131 consented to a telephone interview. Mean age was 72.4 ± 10.7 years and 36.6% were female. 34 patients (25.9%) had a FRAC-stroke score of ≥ 15, equating to ≥ 5% risk of fracture in the year following stroke. Eleven (8.4%) patients (6 female) had a minimal trauma fracture in the 12 months post-stroke. There was a significant difference in patients experiencing falls pre- and post-stroke (19.8% vs 31.3%, p = 0.04). FRAC-stroke score was higher in those who had a fracture post stroke compared those who did not (20.4 vs 8.9, p < 0.001). Receiver operating characteristic analysis found an area under the curve of 0.867 for FRAC-stroke score (95% CI 0.785-0.949, p < 0.005). The optimal cutoff value for FRAC-stroke score predicting fracture was 12 with a sensitivity of 90.9% and specificity of 70%.

CONCLUSION

The FRAC-stroke score is a simple clinical tool that can be used to identify patients at high risk of fracture post-stroke who would most benefit from osteoporosis therapy. Stroke is a risk factor for fracture due to immobilisation, vitamin D deficiency and increased falls risk. This study found that a simple bedside tool, the FRAC-stroke score, can predict fracture after ischaemic stroke. This will allow clinicians to plan treatment of osteoporosis prior to discharge from a stroke unit.

Clinical characteristics of elderly hip fracture patients with chronic cerebrovascular disease and construction of a clinical predictive model for perioperative pneumonia

INTRODUCTION

The recovery of cerebrovascular disease (CVD) will increase the incidence of perioperative pneumonia (POP). However, there is limited research on POP in elderly patients with hip fractures complicated by CVD. Therefore, our research focuses on the following two issues: (1) What are the clinical features of elderly patients with hip fractures combined with CVD? (2) What are the predictive factors for the occurrence of POP in such patients?

HYPOTHESIS

Male, femoral neck fracture and hypoalbuminemia can be predictive factors for the development of POP after hip fracture in CVD patients.

MATERIAL AND METHODS

This is a nested case-control study that included patients aged 65 to 105 years with CVD who had a hip fracture between January 2021 and January 2023. According to the occurrence of POP, they were divided into case group and control group. Collecting data includes demographic information, clinical data, and surgical information. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to select variables. The constructed predictive model was transformed into a nomogram. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA).

RESULTS

We ultimately included 714 patients, 69.3% female, with a median age of 80 years. Asymptomatic cerebral infarction (ACI) is the most common CVD (55.7%). More patients developed intertrochanteric fractures than femoral neck fractures (57.1 vs. 42.9%). In total, 606 patients (84.9%) underwent surgery. The most common perioperative complications were anemia (76.9%) and hypoalbuminemia (71.8%). POP (20.0%) was more common preoperatively (89.5%). Factors such as fracture type, surgical wait time, implant used for surgery, and anesthesia type did not differ between the presence or absence of postoperative pneumonia. 143 patients with POP served as the case group. Five hundred and seventy one patients did not develop POP and served as the control group. The predictors of POP were male (OR 1.699,95%CI 1.150-2.511, p<0.05), femoral neck fracture (OR 2.182,95%CI 1.491-3.192, p<0.05), and hypoalbuminemia (OR 3.062, 95%CI 1.833-5.116, p<0.05). This model has good discrimination, calibration, and clinical practicality.

DISCUSSION

In this study, we constructed a clinical prediction model for the occurrence of POP in CVD combined with hip fracture in the elderly, with risk factors including gender, fracture type and perioperative hypoproteinemia. Therefore, we can take effective preventive measures against the occurrence of POP in patients with these factors in our clinical work.

LEVEL OF PROOF

IV; nested case-control study.

Management of ischaemic stroke survivors in primary care setting: the road to holistic care

The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.

Beyond antithrombotics: recent advances in pharmacological risk factor management for secondary stroke prevention

Patients with ischaemic stroke represent a diverse group with several cardiovascular risk factors and comorbidities, which classify them as patients at very high risk of stroke recurrence, cardiovascular adverse events or death. In addition to antithrombotic therapy, which is important for secondary stroke prevention in most patients with stroke, cardiovascular risk factor assessment and treatment also contribute significantly to the reduction of mortality and morbidity. Dyslipidaemia, diabetes mellitus and hypertension represent common and important modifiable cardiovascular risk factors among patients with stroke, while early recognition and treatment may have a significant impact on patients' future risk of major cardiovascular events. In recent years, there have been numerous advancements in pharmacological agents aimed at secondary cardiovascular prevention. These innovations, combined with enhanced awareness and interventions targeting adherence and persistence to treatment, as well as lifestyle modifications, have the potential to substantially alleviate the burden of cardiovascular disease, particularly in patients who have experienced ischaemic strokes. This review summarises the evidence on the contemporary advances on pharmacological treatment and future perspectives of secondary stroke prevention beyond antithrombotic treatment.

One-year retention of gait speed improvement in stroke survivors after treatment with a wearable home-use gait device

Background

Gait impairments after stroke are associated with numerous physical and psychological consequences. Treatment with the iStride® gait device has been shown to facilitate improvements to gait function, including gait speed, for chronic stroke survivors with hemiparesis. This study examines the long-term gait speed changes up to 12 months after treatment with the gait device.

Methods

Eighteen individuals at least one-year post-stroke completed a target of 12, 30-minute treatment sessions with the gait device in their home environment. Gait speed was measured at baseline and five follow-up sessions after the treatment period: one  week, one  month, three months, six months, and 12 months. Gait speed changes were analyzed using repeated-measures ANOVA from baseline to each follow-up time frame. Additional analysis included comparison to the minimal clinically important difference (MCID), evaluation of gait speed classification changes, and review of subjective questionnaires.

Results

Participants retained an average gait speed improvement >0.21 m/s compared to baseline at all post-treatment time frames. Additionally, 94% of participants improved their gait speed beyond the MCID during one or more post-treatment measurements, and 88% subjectively reported a gait speed improvement.

Conclusion

Treatment with the gait device may result in meaningful, long-term gait speed improvement for chronic stroke survivors with hemiparetic gait impairments.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03649217, identifier NCT03649217.

Comorbidity Patterns in Older Patients Undergoing Hip Fracture Surgery: A Comorbidity Network Analysis Study

Comorbidity network analysis (CNA) is a technique in which mathematical graphs encode correlations (edges) among diseases (nodes) inferred from the disease co-occurrence data of a patient group. The present study applied this network-based approach to identifying comorbidity patterns in older patients undergoing hip fracture surgery. This was a retrospective observational cohort study using electronic health records (EHR). EHR data were extracted from the one University Health System in the southeast United States. The cohort included patients aged 65 and above who had a first-time low-energy traumatic hip fracture treated surgically between October 1, 2015 and December 31, 2018 (n = 1,171). Comorbidity includes 17 diagnoses classified by the Charlson Comorbidity Index. The CNA investigated the comorbid associations among 17 diagnoses. The association strength was quantified using the observed-to-expected ratio (OER). Several network centrality measures were used to examine the importance of nodes, namely degree, strength, closeness, and betweenness centrality. A cluster detection algorithm was employed to determine specific clusters of comorbidities. Twelve diseases were significantly interconnected in the network (OER > 1, p-value < .05). The most robust associations were between metastatic carcinoma and mild liver disease, myocardial infarction and congestive heart failure, and hemi/paraplegia and cerebrovascular disease (OER > 2.5). Cerebrovascular disease, congestive heart failure, and myocardial infarction were identified as the central diseases that co-occurred with numerous other diseases. Two distinct clusters were noted, and the largest cluster comprised 10 diseases, primarily encompassing cardiometabolic and cognitive disorders. The results highlight specific patient comorbidities that could be used to guide clinical assessment, management, and targeted interventions that improve hip fracture outcomes in this patient group.

Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life

BACKGROUND

Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA.

METHODS

Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture.

RESULTS

Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%-80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05-1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21-1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77-3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10-1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49-0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort.

CONCLUSIONS

Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.

Bone adaptation and osteoporosis prevention in hibernating mammals

Hibernating bears and rodents have evolved mechanisms to prevent disuse osteoporosis during the prolonged physical inactivity that occurs during hibernation. Serum markers and histological indices of bone remodeling in bears indicate reduced bone turnover during hibernation, which is consistent with organismal energy conservation. Calcium homeostasis is maintained by balanced bone resorption and formation since hibernating bears do not eat, drink, urinate, or defecate. Reduced and balanced bone remodeling protect bear bone structure and strength during hibernation, unlike the disuse osteoporosis that occurs in humans and other animals during prolonged physical inactivity. Conversely, some hibernating rodents show varying degrees of bone loss such as osteocytic osteolysis, trabecular loss, and cortical thinning. However, no negative effects of hibernation on bone strength in rodents have been found. More than 5000 genes in bear bone tissue are differentially expressed during hibernation, highlighting the complexity of hibernation induced changes in bone. A complete picture of the mechanisms that regulate bone metabolism in hibernators still alludes us, but existing data suggest a role for endocrine and paracrine factors such as cocaine- and amphetamine-regulated transcript (CART) and endocannabinoid ligands like 2-arachidonoyl glycerol (2-AG) in decreasing bone remodeling during hibernation. Hibernating bears and rodents evolved the capacity to preserve bone strength during long periods of physical inactivity, which contributes to their survival and propagation by allowing physically activity (foraging, escaping predators, and mating) without risk of bone fracture following hibernation. Understanding the biological mechanisms regulating bone metabolism in hibernators may inform novel treatment strategies for osteoporosis in humans.

European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack

Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.

Development and validation of a machine learning-based model for postoperative ischemic stroke in middle-aged and elderly patients with hip or knee arthroplasty

Postoperative ischemic stroke in middle-aged and elderly patients with hip or knee arthroplasty remains a major postoperative challenge, little is known about its incidence and risk factors. This study sought to create a nomogram for precise prediction of ischemic stroke after hip or knee arthroplasty. Discharge data of all middle-aged and elderly patients undergoing primary hip or knee arthroplasty from May 2013 to October 2020 were queried. These patients were then followed up over time to determine their risk of ischemic stroke. Clinical parameters and blood biochemical features were analyzed by the use of univariable and multivariable generalized logistic regression analysis. A nomogram to predict the risk of ischemic stroke was constructed and validated with bootstrap resampling. Eight hundred twenty-eight patients were included for analysis; Fifty-one were diagnosed with ischemic stroke. After final regression analysis, age, the neutrophil-to-lymphocyte ratio (NLR), a standard deviation of red blood cell distribution width, American Society of Anesthesiologists, low-density lipoprotein, and diabetes were identified and were entered into the nomogram. The nomogram showed an area under the receiver operating characteristic curve of 0. 841 (95% confidence interval [CI], 0.809-0.871). The calibration curves for the probability of ischemic stroke showed optimal agreement between the probability as predicted by the nomogram and the actual probability (Hosmer-Lemeshow test: P = .818). We developed a practical nomogram that can predict the risk of ischemic stroke for middle-aged and elderly patients with hip or knee arthroplasty. This model has the potential to assist clinicians in making treatment recommendations.

Change in Bone Mineral Density in Stroke Patients with Osteoporosis or Osteopenia

We aimed to investigate the correlation between changes in bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN) and osteoporosis-related factors in stroke patients with osteoporosis or osteopenia, and we suggest the need for active rehabilitation treatment. This study included 63 osteoporosis and 34 osteopenia patients who underwent a BMD test following primary stroke onset. The osteoporosis group was followed up with a BMD test after 12 months of bisphosphonate treatment, and the osteopenia group was followed up without medication. The correlation between BMD changes and functional factors was analyzed, biochemical markers were measured, and hematology tests were performed. In the osteoporosis group, a significant increase was observed in LS BMD (p < 0.05), and in the osteopenia group, there was a significant decrease in FN BMD (p < 0.05). The group with a functional ambulatory category of 1 or more showed a significant improvement in BMD (p < 0.05). Comparative analysis was performed on various indicators, but no significant correlation was found between any variable. In stroke patients with osteoporosis or osteopenia, early appropriate drug treatment is important to prevent bone loss and reduce the risk of fractures, and comprehensive rehabilitation treatment, such as appropriate education and training to prevent falls, is essential.

Vitamin D as therapeutic modulator in cerebrovascular diseases: a mechanistic perspectives

Vitamin D deficiency has been linked to several major chronic diseases, such as cardiovascular and neurodegenerative diseases, diabetes, and cancer, linked to oxidative stress, inflammation, and aging. Vitamin D deficiency appears to be particularly harmful to the cardiovascular system, as it can cause endothelial dysfunctioning and vascular abnormalities through the modulation of various downstream mechanisms. As a result, new research indicates that therapeutic approaches targeting vitamin D inadequacies or its significant downstream effects, such as impaired autophagy, abnormal pro-inflammatory and pro-oxidant reactions, may delay the onset and severity of major cerebrovascular disorders such as stroke and neurologic malformations. Vitamin D modulates the various molecular pathways, i.e., Nitric Oxide, PI3K-Akt Pathway, cAMP pathway, NF-kB Pathway, Sirtuin 1, Nrf2, FOXO, in cerebrovascular disorder. The current review shows evidence for vitamin D's mitigating or slowing the progression of these cerebrovascular disorders, which are significant causes of disability and death worldwide.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

Interleukin-13 Affects the Recovery Processes in a Mouse Model of Hemorrhagic Stroke with Bilateral Tibial Fracture

As one form of stroke, intracerebral hemorrhage (ICH) is a fatal cerebrovascular disease, which has high morbidity and mortality and lacks effective medical treatment. Increased infiltration of inflammatory cytokines coupled with pyroptotic cell death is involved in the pathophysiological process of ICH. However, little is known about whether concomitant fracture patients have the same progression of inflammation and pyroptosis. Hence, we respectively established the mouse ICH model and ICH with bilateral tibial fracture model (MI) to explore the potential cross-talk between the above two injuries. We found that MI obviously reversed the expressions of pyroptosis-associated proteins, which were remarkably up-regulated at the acute phase after ICH. Similar results were observed in neuronal expressions via double immunostaining. Furthermore, brain edema was also significantly alleviated in mice who suffered MI, when compared with ICH alone. To better clarify the potential mechanisms that mediated this cross-talk, recombinant mouse interleukin-13 (IL-13) was used to investigate its effect on pyroptosis in the mouse MI model, in which a lower level of IL-13 was observed. Remarkably, IL-13 administration re-awakened cell death, which was mirrored by the re-upregulation of pyroptosis-associated proteins and PI-positive cell counts. The results of hemorrhage volume and behavioral tests further confirmed its critical role in regulating neurological functions. Besides, the IL-13-treated MI group showed poor outcomes of fracture healing. To sum up, our research indicates that controlling the IL-13 content in the acute phase would be a promising target in influencing the outcomes of brain injury and fracture, and meanwhile, provides new evidence in repairing compound injuries in clinics.

Association between post-traumatic stress disorder symptoms and bone fractures after the Great East Japan Earthquake in older adults: a prospective cohort study from the Fukushima Health Management Survey

Background

It has been reported that psychological stress affects bone metabolism and increases the risk of fracture. However, the relationship between bone fractures and post-traumatic stress disorder (PTSD) is unclear. This study aimed to evaluate the effects of disaster-induced PTSD symptoms on fracture risk in older adults.

Methods

This study evaluated responses from 17,474 individuals aged ≥ 65 years without a history of fractures during the Great East Japan Earthquake who answered the Mental Health and Lifestyle Survey component of the Fukushima Health Management Survey conducted in 2011. The obtained data could determine the presence or absence of fractures until 2016. Age, sex, physical factors, social factors, psychological factors, and lifestyle factors were subsequently analyzed. Survival analysis was then performed to determine the relationship between the fractures and each factor. Thereafter, univariate and multivariate Cox proportional hazard models were constructed to identify fracture risk factors.

Results

In total, 2,097 (12.0%) fractures were observed throughout the follow-up period. Accordingly, univariate and multivariate Cox proportional hazard models showed that PTSD symptoms (total PTSD checklists scoring ≥ 44) [hazard ratio (HR): 1.26; 95% confidence interval (CI): 1.10–1.44; P = 0.001], history of cancer (HR: 1.49; 95% CI: 1.24–1.79; P < 0.001), history of stroke (HR: 1.25; 95% CI: 1.03–1.52; P = 0.023), history of heart disease (HR: 1.30; 95% CI: 1.13–1.50; P < 0.001), history of diabetes (HR: 1.23; 95% CI: 1.09–1.39; P < 0.001), current smoking (HR: 1.29; 95% CI: 1.02–1.63; P = 0.036), and high dissatisfaction with sleep or no sleep at all (HR: 1.33; 95% CI: 1.02–1.74; P = 0.035) promoted a significant increase in fracture risk independent of age and sex.

Conclusions

The present study indicates that disaster-induced PTSD symptoms and insomnia contribute to increased fracture risk among older adults residing in evacuation areas within the Fukushima Prefecture.

Effect of hip fracture on prognosis of acute cerebral infarction

OBJECTIVES

Hip fractures are a worldwide public health problem. The incidence of hip fracture is high among the elderly, and it is an important cause of death and disability in this population. This observational study aimed to investigate the effect of acute hip fracture on the recovery of neurological function and the prognosis of patients with acute cerebral infarction, as well as whether surgical treatment of combined acute fracture can improve the prognosis of patients.

METHODS

Thirty patients with acute cerebral infarction combined with acute hip fracture, who were hospitalized in two hospitals between January 1, 2013 and December 31, 2019, were included. The patients did not undergo surgical treatment. The control group included patients with common acute cerebral infarction without hip fracture admitted in the same period. The neurological function recovery, hospitalization period, half a year recovery rate, incidence of complications, and one-year mortality rate between the two groups were compared. Eleven patients with acute cerebral infarction combined with hip fracture, who underwent surgical treatment, were selected and compared with those in the non-surgery group.

RESULTS

Compared with patients with common acute cerebral infarction, the National Institutes of Health Stroke Scale score of those with acute cerebral infarction combined with hip fracture was higher (7.2±5.4 vs. 5.6%±4.3, p=0.034), the hospitalization period was prolonged (16.1±8.9% vs. 12.2±5.3, p=0.041), and the half a year recovery rate was lower (26.7% vs. 53.3%, p=0.016). Additionally, the incidence of pulmonary infection and lower extremity deep vein thrombosis was increased (30% vs. 11.7%, p=0.03; 6.7% vs. 0, p=0.043). The one-year mortality rate of patients with hip fracture was higher than that of patients with common cerebral infarction (23.3% vs. 6.7%, p=0.027). Compared with the non-surgical group, the good recovery rate after half a year of surgical treatment of the group with cerebral infarction and acute hip fracture had an increasing trend, while the hospitalization cycle, incidence of complications, and one-year mortality rate were all decreased, although this was not statistically significant.

CONCLUSIONS

Acute cerebral infarction combined with hip fracture leads to worse neurological recovery, prolonged hospitalization period, increased complications, decreased patient prognosis, and increased one-year mortality. Surgical treatment improves the prognosis of patients with acute cerebral infarction. These findings may provide insights into the management of acute cerebral infarction.

Does Hip Bone Density Differ between Paretic and Non-Paretic Sides in Hemiplegic Stroke Patients? and Its Relationship with Physical Impairment

Background

Bone loss after stroke escalates the risk of fractures, mainly in the hip, leading to further disability in individuals with stroke. We aimed to investigate the skeletal effect of bone mineral density (BMD) based on the duration of onset of stroke, compare the BMD of the paretic and non-paretic sides, and elucidate the relationship between BMD and disability variables.

Methods

The 31 male hemiplegic stroke patients between 20 and 70 years of age with cerebral infarction or hemorrhage were considered in this study. Subacute and chronic cases included 13 and 18 patients with lag time from the onset of 1 to 6 months and beyond 6 months, respectively. BMD in the lumbar, paretic, and non-paretic hip as well as the disability variables were analyzed retrospectively.

Results

The subacute group showed a significant reduction in the femoral neck BMD on the paretic side compared to that on the non-paretic side based on T-scores (P=0.013). Bone loss was significantly correlated with lower limb muscle strength and overall physical impairment (P<0.05). The chronic group demonstrated significant reduction in femur neck and total femur BMD on the paretic side compared to that on the non-paretic side based on T-scores (P=0.002 and P<0.001, respectively). T-scores of BMD in the chronic phase were not significantly associated with the clinical parameters.

Conclusions

Early screening of bilateral hip BMD in the early stages after stroke, monitoring, and timely implementation of prevention strategies are important to minimize subsequent bone loss and prevent possible complications in patients who experience stroke.

Mechanical loading recovers bone but not muscle lost during unloading

Space travel and prolonged bed rest are examples of mechanical unloading that induce significant muscle and bone loss. The compromised structure and function of bone and muscle owing to unloading make the reloading period a high risk for injury. To explore interactions between skeletal bone and muscle during reloading, we hypothesized that acute external mechanical loading of bone in combination with re-ambulation facilitates the proportional recovery of bone and muscle lost during hind limb suspension (HLS) unloading. Adult male C57Bl/6J mice were randomly assigned to a HLS or time-matched ground control (GC) group. After 2-weeks of HLS, separate groups of mice were studied at day 14 (no re-ambulation), day 28 (14 days re-ambulation) and day 56 (42 days re-ambulation); throughout the re-ambulation period, one limb received compressive mechanical loading and the contralateral limb served as an internal control. HLS induced loss of trabecular bone volume (BV/TV; -51 ± 2%) and muscle weight (-15 ± 2%) compared to GC at day 14. At day 28, the left tibia (re-ambulation only) of HLS mice had recovered approximately 20% of BV/TV lost during HLS, while the right tibia (re-ambulation and acute external mechanical loading) recovered to GC values of BV/TV (~100% recovery). At day 56, the right tibia continued to recover bone for some outcomes (trabecular BV/TV, trabecular thickness), while the left limb did not. Cortical bone displayed a delayed response to HLS, with a 10% greater decrease in BV/TV at day 28 compared to day 14. In contrast to bone, acute external mechanical loading during the re-ambulation period did not significantly increase muscle mass or protein synthesis in the gastrocnemius, compared to re-ambulation alone. Our results suggest acute external mechanical loading facilitates the recovery of bone during reloading following HLS unloading, but this does not translate to a concomitant recovery of muscle mass.

Factors associated with fracture after stroke and TIA: a long-term follow-up

We assessed the long-term incidence of fractures after stroke and TIA and analyzed associated factors. The fracture incidence increases with age and is higher in stroke than in TIA. Dementia is associated with fractures after both. Our results indicate tailored measures are necessary for preventing fractures after stroke or TIA.

INTRODUCTION

In the present study, we aimed to assess the long-term incidence of fractures and analyze associated factors after stroke or transient ischemic attack (TIA).

METHODS

The current cohort study included patients who had received an initial ischemic stroke or TIA diagnosis documented anonymously in the Disease Analyzer database (IQVIA) between 2000 and 2016 by physicians in 1262 general practices in Germany. Univariate Cox and multivariate regression models were carried out.

RESULTS

Three groups (stroke, TIA, no stroke/TIA), each with 12,265 individuals, were selected (mean age 67.3 years, 48.1% female). A fracture was diagnosed in 12.9% of stroke patients and in 11.4% of TIA patients. Among male stroke patients, 11.1% had a fracture (15.4% among female stroke patients). The hazard ratio (HR) for fractures after stroke was 1.26 (CI: 1.15-1.39) and for fractures after TIA, it was 1.14 (CI: 1.03-1.25). In female stroke patients, the HR for fractures was 1.32 (CI: 1.15-1.60), while in males, it was 1.20 (CI: 1.03-1.39). Among TIA patients, females had an elevated HR for fractures (HR: 1.21; CI: 1.06-1.37). In individuals aged ≥ 80 years, an increased risk for fractures was only detected among TIA patients (HR: 1.26; CI: 1.05-1.51). Dementia and non-opioid analgesic therapy were positively associated with fracture after both stroke and TIA.

CONCLUSION

Stroke was positively associated with fracture in patients < 80 years, while TIA was positively associated with fracture in patients ≥ 80 years and females. Dementia and analgesic therapy were also associated with fracture after either stroke or TIA.

Effects of Neurological Disorders on Bone Health

Neurological diseases, particularly in the context of aging, have serious impacts on quality of life and can negatively affect bone health. The brain-bone axis is critically important for skeletal metabolism, sensory innervation, and endocrine cross-talk between these organs. This review discusses current evidence for the cellular and molecular mechanisms by which various neurological disease categories, including autoimmune, developmental, dementia-related, movement, neuromuscular, stroke, trauma, and psychological, impart changes in bone homeostasis and mass, as well as fracture risk. Likewise, how bone may affect neurological function is discussed. Gaining a better understanding of brain-bone interactions, particularly in patients with underlying neurological disorders, may lead to development of novel therapies and discovery of shared risk factors, as well as highlight the need for broad, whole-health clinical approaches toward treatment.

Proton pump inhibitor use and risk of hip fracture in patients with type 2 diabetes

Type 2 diabetes mellitus (T2DM) is associated with a high rate of comorbidity, including osteoporosis and peptic ulcers. Proton pump inhibitors (PPIs) are a group of acid-suppressing drugs commonly used for treating peptic ulcers. However, observational studies have reported an association between PPI therapy and osteoporotic fractures. This study investigated the association between PPI use and hip fracture (HFx) among patients with T2DM. We conducted this population-based propensity-matched retrospective cohort study using the National Health Insurance Research Database in Taiwan. Patients newly diagnosed with T2DM between 2000 and 2008 were identified. After excluding those who previously used PPIs or suffered HFx, 398,885 patients were recruited (44,341 PPI users; 354,544 non-users). HFx risk data from 2000 to 2013 were collected to calculate the cumulative rate of HFx in these two groups. Sensitivity analyses were conducted to evaluate the effects of PPI dose. After propensity score matching of 1:4, 44,431 and 177,364 patients were assigned to the PPI user and non-user groups, respectively. PPI user group showed an increased risk of HFx with an adjusted hazard ratio of 1.41 (95% CI 1.29–1.54) without dose–response relationship. Thus, there is an increased risk of HFx in patients with T2DM receiving long-term PPI treatment.

Association between post-stroke disability and 5-year hip-fracture risk: The Women's Health Initiative

BACKGROUND

Hip fractures are a significant post-stroke complication. We examined predictors of hip fracture risk after stroke using data from the Women's Health Initiative (WHI). In particular, we examined the association between post-stroke disability levels and hip fracture risk.

METHODS

The WHI is a prospective study of 161,808 postmenopausal women aged 50-79 years. Trained physicians adjudicated stroke events and hip fractures. Our study included stroke survivors from the observational and clinical trial arms who had a Glasgow Outcome Scale of good recovery, moderately disabled, or severely disabled and survived more than 7 days post-stroke. Hip fracture-free status was compared across disability levels. Secondary analysis examined hip fracture risk while accounting for competing risk of death.

RESULTS

Average age at time of stroke was 74.6±7.2 years; 84.3% were white. There were 124 hip fractures among 4,640 stroke survivors over a mean follow-up time of 3.1±1.8 years. Mortality rate was 23.3%. Severe disability at discharge (Hazard Ratio (HR): 2.1 (95% Confidence Interval (CI): 1.4-3.2), but not moderate disability (HR: 1.1 (95%CI: 0.7-1.7), was significantly associated with an increased risk of hip fracture compared to good recovery status. This association was attenuated after accounting for mortality. White race, increasing age and higher Fracture Risk Assessment Tool (FRAX)-predicted hip fracture risk (without bone density information) were associated with an increased hip fracture risk. After accounting for mortality, higher FRAX risk and white race remained significant.

CONCLUSION

Severe disability after stroke and a higher FRAX risk score were associated with risk of subsequent hip fracture. After accounting for mortality, only the FRAX risk score remained significant. The FRAX risk score appears to identify stroke survivors at high risk of fractures. Our results suggest that stroke units can consider the incorporation of osteoporosis screening into care pathways.

Beyond the Brain: The Systemic Pathophysiological Response to Acute Ischemic Stroke

Stroke research has traditionally focused on the cerebral processes following ischemic brain injury, where oxygen and glucose deprivation incite prolonged activation of excitatory neurotransmitter receptors, intracellular calcium accumulation, inflammation, reactive oxygen species proliferation, and ultimately neuronal death. A recent growing body of evidence, however, points to far-reaching pathophysiological consequences of acute ischemic stroke. Shortly after stroke onset, peripheral immunodepression in conjunction with hyperstimulation of autonomic and neuroendocrine pathways and motor pathway impairment result in dysfunction of the respiratory, urinary, cardiovascular, gastrointestinal, musculoskeletal, and endocrine systems. These end organ abnormalities play a major role in the morbidity and mortality of acute ischemic stroke. Using a pathophysiology-based approach, this current review discusses the pathophysiological mechanisms following ischemic brain insult that result in end organ dysfunction. By characterizing stroke as a systemic disease, future research must consider bidirectional interactions between the brain and peripheral organs to inform treatment paradigms and develop effective, comprehensive therapeutics for acute ischemic stroke.

Drug treatment strategies for osteoporosis in stroke patients

INTRODUCTION

Osteoporosis and subsequent fractures are well-recognized complications of stroke. However, drug treatment strategies for osteoporosis after stroke have been rarely discussed in the current guidelines for the management of stroke or osteoporosis.

AREAS COVERED

The authors review the epidemiology, characteristics, pathophysiology, and risk prediction of post-stroke osteoporosis and fractures. Then they provide an overview of existing evidence regarding drug treatment strategies for osteoporosis in stroke patients. They also review the effects on bone mineral density (BMD) and fractures for those drugs commonly used in stroke patients.

EXPERT OPINION

Currently, there is scarce evidence. A small randomized control trial suggested that a single use of 4 mg of intravenous zoledronate within 5 weeks of stroke onset was beneficial for preserving BMD, while simultaneous use of calcium and vitamin D supplements may be effective in preventing hypocalcemia. Further studies are needed to address several important issues of post-stroke osteoporosis, including who (the eligibility for treatment), when (the best timing of treatment), what (which drug), and how long (the best duration of treatment). On the other hand, physicians should bear in mind that drugs commonly used for stroke, such as statins or warfarin, may have beneficial or adverse effects on BMD and fracture risks.

The impact of stroke on bone properties and muscle-bone relationship: a systematic review and meta-analysis

To systematically review available evidence related to the characteristics of bone changes post-stroke and the relationship between various aspects of muscle function (e.g., strength, spasticity) and bone properties after stroke onset. An extensive online database search was undertaken (last search in January 2019). Articles that examined the bone properties in stroke patients were included. The quality of the studies was evaluated with the National Institutes of Health (NIH) Study Quality Assessment Tools. Publication bias of meta-analyses was assessed using the Egger's regression asymmetry test. The selection and evaluation of the articles were conducted by two independent researchers. Fifty-nine studies were identified. In subacute and chronic stroke studies, the skeletal sites in the paretic limbs sustained a more pronounced decline in bone quality than did their counterparts in the non-paretic limbs. The rate of changes showed a decelerating trend as post-stroke duration increased, but the timing of achieving the steady rate differed across skeletal sites. The magnitude of bone changes in the paretic upper limb was more pronounced than the paretic lower limb. There was a strong relationship between muscle strength/mass and bone density/strength index. Muscle spasticity seemed to have a negative impact on bone integrity in the paretic upper limb, but its influence on bone properties in the paretic lower limb was uncertain. Substantial bone changes in the paretic limbs occurred particularly in the first few months after stroke onset. Early intervention, muscle strength training, and long-term management strategies may be important to enhance bone health post-stroke. This review has also revealed the knowledge gaps which should be addressed in future research.

Fractures after stroke-A Danish register-based study of 106 001 patients

OBJECTIVES

To estimate the incidence of fractures, possibly caused by falls, in patients aged 65 and older with first episode of stroke, and to estimate the incidence of fracture types for this group of patients. Another objective was to investigate stroke severity and marital status, as risk factors for fractures.

MATERIALS AND METHODS

A large retrospective dataset of 116 519 patients with first episode of stroke was extracted from the Danish Stroke Registry between January 2003 and December 2017. The occurrence of fractures was identified in the Danish National Patient Registry. A univariate analysis was conducted and a multivariate analysis was conducted to determine the relationship between stroke severity and fractures, and marital status and fractures, adjusting for multiple confounders. Cox regression with time-varying covariates was used, taking time-dependent variables into account.

RESULTS

The incidence rate of fractures post-stroke was 41.07 per 1000 person-years between 2003 and 2017 in Denmark. A total of 15 872 (14.86%) sustained a fracture and the mean time at risk until outcome was 3.67 years post-stroke. Femur fracture was the most common fracture type. Mild, moderate, severe, and unknown stroke severity are associated with fractures after stroke compared to very severe stroke, and living alone at the time of stroke is associated with fractures after stroke compared to living with someone.

CONCLUSIONS

The incidence rate of fractures in Denmark was 41.07 per 1000 person-years. Moreover, mild, moderate, and severe stroke severity, and living alone at the time of stroke were found to be risk factors for fracture.

The Incidence and Risk Factors of Hip Fracture after Liver Transplantation (LT): A Nationwide Population-Based Study

Background

Osteoporosis and fragility fracture are the major complications after liver transplantation (LT). The aim of the study was to determine the incidence and risk factors of hip fracture after LT.

Methods

We conducted a retrospective population-based cohort study, enrolling the patients receiving LT between January 1999 and December 2010. Control subjects were randomly matched to every recipient by age and sex by 1 : 10 ratios.

Results

During the follow-up period, 17 recipients (0.77%) and 70 (0.32%) control subjects suffered from hip fractures. The incident rates (per 10000 person-years) were 21.49 for recipients and 7.52 for controls (adjusted hazard ratio = 2.71; 95% confidence interval = 1.21–6.05). The cumulative incidence of hip fracture was significantly higher among the recipients (p < 0.0001). Among the recipients, the subjects aged >65 years at transplantation and with pretransplant steroid use are more susceptible to posttransplant hip fracture. Immunosuppressive agents did not significantly affect the risk of hip fracture among recipients.

Conclusions

Liver transplantation is a risk factor for hip fractures. Aged >65 years at transplantation and pretransplant steroid use are risk factors for posttransplant hip fractures among the recipients.

The Safety of Continuing Antiplatelet Medication Among Elderly Patients Undergoing Urgent Hip Fracture Surgery

Elderly patients with hip fractures who are receiving antiplatelet therapy are commonly encountered in clinical practice. This study sought to elucidate the safety of urgent hip surgery without termination of antiplatelet medication among patients taking a combination of aspirin and dipyridamole, aspirin alone, or dipyridamole alone. This retrospective cohort study included 176 patients 55 years or older who had uncomplicated hip fractures and underwent surgery within 48 hours after admission. On the basis of the preoperative medication regimen, the patients were divided into the following 4 groups: those receiving aspirin and dipyridamole combined (n=29); those receiving aspirin alone (n=63); those receiving dipyridamole alone (n=28); and those not receiving antiplatelet medication (n=56). Main outcomes, including total blood loss, transfusion rate, and 1-year mortality, were analyzed. There was no significant difference in total blood loss, transfusion rate, or 1-year mortality among the 4 groups. The group receiving aspirin and dipyridamole combined preoperatively had increased intraoperative blood loss (mean, 309.14±189.15 mL) compared with the group not receiving antiplatelet medication (mean, 214.64±119.21 mL; P=.005). There was no significant difference in the hazard ratio (P>.05) for 1-year mortality among the 4 groups after adjusting for confounding covariates, including age, sex, Charlson Comorbidity Index, and duration of hospital stay. Patients receiving antiplatelet medication, including aspirin, dipyridamole, or both, who have uncomplicated hip fractures may undergo urgent surgery without a significant difference in total blood loss, transfusion rate, or 1-year mortality compared with patients not receiving anti-platelet medication. [Orthopedics. 2019; 42(5):268-274.].

Derivation and External Validation of a Scoring System for Predicting Fracture Risk After Ischemic Stroke in a Canadian Cohort

Importance

The risk for low-trauma fracture is increased by more than 30% after ischemic stroke, but existing fracture risk scores do not account for history of stroke as a high-risk condition.

Objective

To derive a risk score to predict the probability of fracture within 1 year after ischemic stroke and validate it in a separate cohort.

Design, Setting, and Participants

Prognostic study of a cohort from the Ontario Stroke Registry, a population-based sample of adults in Ontario, Canada, who were hospitalized with ischemic stroke from July 1, 2003, to March 31, 2012, with 1 year of follow-up. A population-based validation cohort consisted of a sample of 13 698 consecutive stroke admissions captured across 5 years: April 2002 to March 2003, April 2004 to March 2005, April 2008 to March 2009, April 2010 to March 2011, and April 2012 to March 2013.

Exposures

Predictor variables were selected based on biological plausibility and association with fracture risk. Age, sex, and modified Rankin score were abstracted from the medical records part of the Ontario Stroke Audit, and other characteristics were abstracted from administrative health data.

Main Outcomes and Measures

Incidence of low-trauma fracture within 1 year of discharge, based on administrative health data.

Results

The Fracture Risk after Ischemic Stroke (FRAC-Stroke) Score was derived in 20 435 patients hospitalized for ischemic stroke (mean [SD] age, 71.6 [14.0] years; 9564 [46.8%] women) from the Ontario Stroke Registry discharged from July 1, 2003, to March 31, 2012, using Fine-Gray competing risk regression. Low-trauma fracture occurred within 1 year of discharge in 741 of the 20 435 patients (3.6%) in the derivation cohort. Age, discharge modified Rankin score (mRS), and history of rheumatoid arthritis, osteoporosis, falls, and previous fracture were associated with the cumulative incidence of low trauma fracture in the derivation cohort. Model discrimination in the validation cohort (n = 13 698) was good (C statistic, 0.70). Discharge mRS was an important discriminator of risk (relative integrated discrimination improvement, 8.7%), with highest risk in patients with mRS 3 and 4 but lowest in bedbound patients (mRS 5). From the lowest to the highest FRAC-Stroke quintile, the cumulative incidence of 1-year low-trauma fracture increased from 1.3% to 9.0% in the validation cohort. Predicted and observed rates of fracture were similar in the external validation cohort. Analysis was conducted from July 2016 to January 2019.

Conclusions and Relevance

The FRAC-Stroke score allows the clinician to identify ischemic stroke survivors at higher risk of low-trauma fracture within 1 year of hospital discharge. This information might be used to select patients for interventions to prevent fractures.

Long-Term Risk of Hip Fracture After Ischemic Stroke

Background and Purpose

Data are lacking on the long-term risk of hip fracture among patients with ischemic stroke. A better understanding of the contemporary incidence of hip fracture after ischemic stroke could benefit patient care by promoting strategies to prevent this disabling complication in stroke survivors.

Methods

We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients ≥66 years of age who were hospitalized with acute ischemic stroke, defined through a validated diagnostic code algorithm. We excluded patients who had a prior or concurrent hip fracture diagnosis at the time of ischemic stroke. The primary outcome was hip fracture requiring hospitalization. Survival statistics were used to calculate crude incidence rates, and the Kaplan-Meier method was used to calculate cumulative rates.

Results

Among the 1 772 550 beneficiaries in our sample, 60 099 were diagnosed with an acute ischemic stroke without prior or concomitant hip fracture. During 4.5 (±2.2) years of follow-up, the incidence of hip fracture was 1.6 (95% confidence interval [CI]: 1.5-1.6) per 100 person-years in patients with acute ischemic stroke versus 0.6 (95% CI: 0.6-0.6) per 100 person-years in patients without acute ischemic stroke. The cumulative 5-year rate of hip fracture was 7.6% (95% CI: 7.2%-8.0%) among patients with acute ischemic stroke versus 2.8% (95% CI: 2.8%-2.9%) among the remaining Medicare beneficiaries.

Conclusion

We found that among elderly Medicare beneficiaries with acute ischemic stroke, nearly 1 in 12 developed a hip fracture over the next 5 years.

The Epidemiology of Fracture in Patients with Acute Ischemic Stroke in Korea

BACKGROUND

Patients who survive an acute phase of stroke are at risk of falls and fractures afterwards. However, it is largely unknown how frequent fractures occur in the Asian stroke population.

METHODS

Patients with acute (< 7 days) ischemic stroke who were hospitalized between January 2011 and November 2013 were identified from a prospective multicenter stroke registry in Korea, and were linked to the National Health Insurance Service claim database. The incidences of fractures were investigated during the first 4 years after index stroke. The cumulative incidence functions (CIFs) were estimated by the Gray's test for competing risk data. Fine and Gray model for competing risk data was applied for exploring risk factors of post-stroke fractures.

RESULTS

Among a total of 11,522 patients, 1,616 fracture events were identified: 712 spine fractures, 397 hip fractures and 714 other fractures. The CIFs of any fractures were 2.63% at 6 months, 4.43% at 1 year, 8.09% at 2 years and 13.00% at 4 years. Those of spine/hip fractures were 1.11%/0.61%, 1.88%/1.03%, 3.28%/1.86% and 5.79%/3.15%, respectively. Age by a 10-year increment (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.17-1.30), women (HR, 1.74; 95% CI, 1.54-1.97), previous fracture (HR, 1.72; 95% CI, 1.54-1.92) and osteoporosis (HR, 1.44; 95% CI, 1.27-1.63) were independent risk factors of post-stroke fracture.

CONCLUSION

The CIFs of fractures are about 8% at 2 years and 13% at 4 years after acute ischemic stroke in Korea. Older age, women, pre-stroke fracture and osteoporosis raised the risk of post-stroke fractures.

Rehabilitation Indices associated with sustaining a minimal trauma fracture within 12 months of a stroke in Western Australia

OBJECTIVE

To identify Rehabilitation Indices associated with a minimal trauma fracture (MTF) within 12 months poststroke.

METHODS

Retrospective case-control study. Stroke survivors with MTF were matched 5:1 with stroke survivors without MTF. Logistic regression determined whether Rehabilitation Indices, such as Physiotherapy Ambulation score (PhysioAmb), were associated with a MTF within 12 months poststroke.

RESULTS

Forty-three stroke survivors (mean age: 79.8; 55.81% female) experienced a MTF (median time to MTF of 1.79 years [IQR 0.70, 4.48]). Those with a MTF within 12 months had lower PhysioAmb (4.53 vs 8.29) and Berg Balance Scale (BBS; 12.25 vs 40.57) scores on admission, lower BBS score on discharge (30.33 vs 49.29) and a greater change in PhysioAmb (+5.67 vs +3.24) and BBS scores (+21.50 vs +8.71) after rehabilitation, all P < 0.05. Greater changes in PhysioAmb score increased the odds of a MTF within 12 months by 18%.

CONCLUSION

Rehabilitation Indices are associated with a MTF within 12 months poststroke.

Assessing the fall risks of community-dwelling stroke survivors using the Short-form Physiological Profile Assessment (S-PPA)

Introduction

Fall is common after stroke. The Short-form Physiological Profile Assessment (S-PPA) was developed to assess the fall risks and underlying physiological factors, and it has been used in healthy older adults and older adults with stroke. This study aimed to establish the psychometric properties of the S-PPA among cognitively intact and ambulant community-dwelling older adults with stroke.

Methods

The S-PPA, Chinese version of the Activities-specific Balance Confidence (ABC-C) scale and 3 balance measures, namely the Berg Balance Scale (BBS), Timed “Up & Go” (TUG) and Functional Reach Test (FRT), were administered. Inter- and intra-rater reliability were assessed at baseline and after a 1-week interval, respectively. The validity of the S-PPA was assessed through correlations with balance measures and the ABC-C and by comparing the S-PPA scores between the stroke and healthy groups and between fallers and non-fallers in the stroke group. A receiver operating characteristic (ROC) curve analysis was used to assess the ability of balance measures to distinguish fall status in the stroke group.

Results

The S-PPA yielded good inter-rater (intraclass correlation coefficient (ICC) = 0.83) and moderate intra-rater reliability (ICC = 0.74), correlated significantly with the 3 balance measures (rho = 0.49–0.70) and ABC-C (rho = 0.35) and revealed significant differences between stroke survivors and controls and between stroke survivors with and without a fall history. However, the ROC analysis revealed that the S-PPA had a poor ability to distinguish the fall statuses of community-dwelling stroke survivors.

Conclusions

The S-PPA is reliable and valid for evaluating fall risks but cannot adequately distinguish the fall statuses of stroke survivors.

A brief history of FRAX

This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008.

INTRODUCTION

Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments.

METHODS

The method used in this paper is literature review.

RESULTS

FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population.

CONCLUSION

FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.

Normal Bone Microstructure and Density But Worse Physical Function in Older Women Treated with Selective Serotonin Reuptake Inhibitors, a Cross-Sectional Population-Based Study

Depression in the elderly is today often treated with selective serotonin reuptake inhibitors (SSRIs) because of their favorable adverse effect profile. However, treatment with SSRIs is associated with increased risk of fractures. Whether this increased risk depends on reduced bone strength or increased fall risk due to reduced physical function is not certain. The aim was therefore to investigate if treatment with SSRIs is associated with impaired bone microstructure, bone density, or physical function in older women. From an ongoing population-based study, 1057 women (77.7 ± 1.5 years) were included. Validated questionnaires were used to assess information regarding medical history, medications, smoking, mental and physical health, and physical activity. Physical function was measured using clinically used tests: timed up and go, walking speed, grip strength, chair stand test, and one leg standing. Bone mineral density (BMD) was measured at the hip and spine with dual-energy X-ray absorptiometry (Hologic Discovery A). Bone geometry and microstructure were measured at the ultradistal and distal (14%) site of radius and tibia using high-resolution peripheral quantitative computed tomography (HR-pQCT; XtremeCT). Treatment with SSRIs was associated with higher BMD at the femoral neck, total hip, and lumbar spine, whereas no associations were found for any HR-pQCT-derived measurements. The use of SSRIs was associated with lower grip strength, walking speed, and fewer chair stand rises. These associations were valid also after adjustments for known risk factors for falls. Treatment with SSRIs was, independently of covariates, associated with worse physical function without any signs of inferior bone geometry and microstructure.

Impact of Bone Fracture on Ischemic Stroke Recovery

Stroke is one of the most devastating complications of bone fracture, occurring in up to 4% of patients after surgical repair for hip fracture. Bone fracture and ischemic stroke have many common risk factors. The impact of bone fracture on stroke recovery has not drawn much attention in the research field. Bone fracture could occur in stroke patients at different times during the recovery phase, which steepens the trajectory of cognitive decline, greatly affects the quality of life, and causes a heavy burden on healthcare resources. In this paper, we reviewed the growing information on the pathophysiological mechanisms by which bone fracture may affect ischemic stroke recovery process.

The Importance of Assessing Nutritional Status to Ensure Optimal Recovery during the Chronic Phase of Stroke

Background

Despite evidence that many of the consequences of stroke that hinder recovery (i.e., obesity, muscle atrophy, and functional declines) have nutritionally modifiable behavior components, little attention has been focused on the significance of nutrition beyond the acute phase of stroke.

Objective

This literature review summarizes the evidence for and against the influence of nutrition on optimal recovery and rehabilitation in chronic (>6 months) stroke.

Results

The literature, which is mainly limited to cross-sectional studies, suggests that a suboptimal nutritional status, including an excess caloric intake, reduced protein intake, and micronutrient deficiencies, particularly the B-vitamins, vitamin D, and omega 3 fatty acids, may have deleterious effects on metabolic, physical, and psychological functioning in chronic stroke survivors.

Conclusions

Careful evaluation of dietary intake, especially among those with eating disabilities and preexisting malnutrition, may aid in the identification of individuals at increased nutritional risk through which early intervention may benefit recovery and rehabilitation and prevent further complications after stroke.

Upright activity and higher motor function may preserve bone mineral density within 6 months of stroke: a longitudinal study

PURPOSE

Bone fragility contributes to increased fracture risk, but little is known about the emergence of post-stroke bone loss. We investigated skeletal changes and relationships with physical activity, stroke severity, motor control and lean mass within 6 months of stroke.

METHODS

This is a prospective observational study. Participants were non-diabetic but unable to walk within 2 weeks of first stroke. Distal tibial volumetric bone mineral density (vBMD, primary outcome), bone geometry and microstructure (high-resolution peripheral quantitative computed tomography) were assessed at baseline and 6 months, as were secondary outcomes total body bone mineral content and lean mass (dual energy X-ray absorptiometry), bone metabolism (serum osteocalcin, N-terminal propeptide of type 1 procollagen (P1NP), C-terminal telopeptide of type 1 collagen (CTX)), physical activity (PAL2 accelerometer) and motor control (Chedoke McMaster) which were also measured at 1 and 3 months.

RESULTS

Thirty-seven participants (69.7 years (SD 11.6), 37.8% females, NIHSS 12.6 (SD 4.7)) were included. The magnitude of difference in vBMD between paretic and non-paretic legs increased within 6 months, with a greater reduction observed in paretic legs (mean difference = 1.5% (95% CI 0.5, 2.6), p = 0.007). At 6 months, better motor control was associated with less bone loss since stroke (r = 0.46, p = 0.02). A trend towards less bone loss was observed in people who regained independent walking compared to those who did not (p = 0.053). Higher baseline daily count of standing up was associated with less change in bone turnover over 6 months: osteocalcin (r = -0.51, p = 0.01), P1NP (r = -0.47, p = 0.01), CTX (r = -0.53, p = 0.01).

CONCLUSION

Better motor control and walking recovery were associated with reduced bone loss. Interventions targeting these impairments from early post-stroke are warranted.

CLINICAL TRIAL REGISTRATION

URL: http://www.anzctr.org.au . Unique identifier: ACTRN12612000123842.

Activation of Alpha-7 Nicotinic Acetylcholine Receptor Reduces Brain Edema in Mice with Ischemic Stroke and Bone Fracture

Stroke is an important risk factor for bone fracture. We showed previously that bone fracture at the acute stage of ischemic stroke worsens, and activation of α-7 nicotinic acetylcholine receptor (α-7 nAchR) improves, stroke recovery by attenuating inflammation. We hypothesized that activation of α-7 nAchR also improves the blood-brain barrier (BBB) integrity. Permanent distal middle cerebral artery occlusion (pMCAO) was performed on C57BL/6J mice followed by tibia fracture 1 day later. Mice were treated with 0.8 mg/kg PHA 568487 (PHA, α-7 nAchR-specific agonist), 6 mg/kg methyllycaconitine (MLA, α-7 nAchR antagonist), or saline 1 and 2 days after pMCAO. Brain water content, the expression of monoamine oxidase B (MAO-B), and tight junction protein (claudin-5) were assessed. We found that tibia fracture increased water content in the ischemic stroke brain (p = 0.006) and MAO-B-positive astrocytes (p < 0.001). PHA treatment reduced water content and MAO-B-positive astrocytes and increased claudin-5 expression in stroke and stroke + tibia fracture mice (p < 0.05), while MLA had the opposite effect. Our findings suggest that in addition to inhibiting inflammation, activation of α-7 nAchR also reduces brain edema, possibly through diminished astrocyte oxidative stress and improved BBB integrity. Thus, the α-7 nAchR-specific agonist could be developed into a new therapy for improving recovery of patients with stroke or stroke + bone fracture.

Thiazide diuretics and the risk of hip fracture after stroke: a population-based propensity-matched cohort study using Taiwan's National Health Insurance Research Database

OBJECTIVES

This study aimed to investigate the association between thiazide use and the risk of hip fracture after stroke.

SETTING

A population-based, propensity-matched cohort study was conducted on the basis of Taiwan's National Health Insurance Research Database.

PARTICIPANTS

Patients with newly diagnosed ischaemic stroke between 2000 and 2011 were included. After propensity score matching, 7470 patients were included, of whom 3735 received thiazides and 3735 did not.

OUTCOME MEASURES

HRs for developing hip fractures within 2 years after stroke were calculated using Cox proportional hazards regression model with adjustments for sociodemographic and coexisting medical conditions.

RESULTS

Overall, patients using thiazides after stroke had a lower risk of hip fracture than those not using thiazides (8.5 vs 13.9 per 1000 person-years, adjusted HR=0.64, 95% CI 0.46 to 0.89, p=0.007). Further sensitivity analysis based on the duration of thiazide use revealed that the risk of hip fracture tended to decrease as the duration of exposure of thiazides increased. However, the effect was significant only in patients with long-term use of thiazides (using thiazides for >365 days within 2 years after stroke), with a 59% reduction in the risk of hip fracture when compared with patients not using thiazide (adjusted HR=0.41, 95% CI 0.22 to 0.79, p=0.008).

CONCLUSIONS

The long-term use of thiazides is associated with a decreased risk of hip fracture after stroke.

A survey to explore what information, advice and support community-dwelling people with stroke currently receive to manage instability and falls

PURPOSE

To describe and determine the benefits of the information and support services currently offered to people with stroke experiencing instability and falls.

METHODS

A cross-sectional survey study. Two hundred and fifty-six surveys were sent out to community stroke groups in Hampshire and the Isle of Wight, as well as to people with stroke on a patient register.

RESULTS

One hundred and twenty-five surveys were returned. A total of 107 participants (86%) reported instability and 62 (50%) had experienced a fall in the preceding year; 29 (28%) had reportedly received information on falls prevention. Forty-four participants (43%) sought help from health professionals following instability and falls; just over half reported that the information they received was useful. One quarter (n = 11) of those seeking help were referred on to falls clinics; all attended and 86% felt attending had been beneficial. However, only one participant was followed up by these clinics.

CONCLUSIONS

Findings suggest that the majority of people with stroke who have experienced instability and falls did not receive any information and support, with very few referred on to falls clinics. Health professionals play a key role in information provision and facilitating access to falls prevention programs. Further research is required to determine the most effective ways to implement current guidelines to manage instability and falls in this high-risk group. Implications for rehabilitation: Many community-dwelling people with stroke did not receive any information, help or support after experiencing instability and falls. Clinicians must stress that falls are a complication, not an expectation, post-stroke. Information on falls prevention and available support services should be offered to individuals prior to discharge from hospital, in GP practices and in rehabilitation settings. All individuals with stroke seeking health professional help following instability and falls should be referred on to falls clinics for individualized multifactorial assessment and intervention to comply with current guidelines.

Simulated space radiation sensitizes bone but not muscle to the catabolic effects of mechanical unloading

Deep space travel exposes astronauts to extended periods of space radiation and mechanical unloading, both of which may induce significant muscle and bone loss. Astronauts are exposed to space radiation from solar particle events (SPE) and background radiation referred to as galactic cosmic radiation (GCR). To explore interactions between skeletal muscle and bone under these conditions, we hypothesized that decreased mechanical load, as in the microgravity of space, would lead to increased susceptibility to space radiation-induced bone and muscle loss. We evaluated changes in bone and muscle of mice exposed to hind limb suspension (HLS) unloading alone or in addition to proton and high (H) atomic number (Z) and energy (E) (HZE) (16O) radiation. Adult male C57Bl/6J mice were randomly assigned to six groups: No radiation ± HLS, 50 cGy proton radiation ± HLS, and 50 cGy proton radiation + 10 cGy 16O radiation ± HLS. Radiation alone did not induce bone or muscle loss, whereas HLS alone resulted in both bone and muscle loss. Absolute trabecular and cortical bone volume fraction (BV/TV) was decreased 24% and 6% in HLS-no radiation vs the normally loaded no-radiation group. Trabecular thickness and mineral density also decreased with HLS. For some outcomes, such as BV/TV, trabecular number and tissue mineral density, additional bone loss was observed in the HLS+proton+HZE radiation group compared to HLS alone. In contrast, whereas HLS alone decreased muscle mass (19% gastrocnemius, 35% quadriceps), protein synthesis, and increased proteasome activity, radiation did not exacerbate these catabolic outcomes. Our results suggest that combining simulated space radiation with HLS results in additional bone loss that may not be experienced by muscle.

Reactive Stepping After Stroke: Determinants of Time to Foot Off in the Paretic and Nonparetic Limb

BACKGROUND AND PURPOSE

Impaired features of reactive stepping, specifically delays in the early time to foot off (TFO) phase, are associated with increased fall rates after stroke. This study aimed to determine differences in, and determinants of, paretic and nonparetic limb TFO, and to determine whether both paretic and nonparetic TFO were associated with perturbation-evoked falls.

METHODS

Retrospective chart review of 105 individuals with stroke was performed within an inpatient rehabilitation setting; each had received a standardized assessment of reactive balance control (in response to a perturbation) at time of discharge.

RESULTS

There were no significant differences in paretic (351 ms) and nonparetic (365 ms) TFO. The capacity to maximally load the nonparetic limb, the amplitude of the perturbation, and the capacity to load the paretic limb were all negatively associated with paretic step TFO, explaining 23.8% of the variance. The amplitude of the perturbation and the preperturbation load under the nonparetic stepping limb were, respectively, negatively and positively associated with nonparetic step TFO, explaining 22.7% of the variance. The likelihood of a perturbation-evoked fall was associated with mean nonparetic limb TFO but not paretic limb TFO.

DISCUSSION AND CONCLUSIONS

Unique stroke-related impairments of dynamic balance control and limb-load asymmetry may differentially influence paretic and nonparetic reactive step TFO, in response to a loss of balance. The amplitude of the perturbation influences reactive step TFO in both limbs. The results of the current study have implications for the future development of standardized clinical assessment methodologies and training strategies to evaluate and remediate reactive stepping and reduce fall risk.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A133).

Post-ischemic stroke rehabilitation is associated with a higher risk of fractures in older women: A population-based cohort study

BACKGROUND

Rehabilitation can improve physical activity after stroke. However, patients may be more prone to falls and fractures because of balance and gait deficits. Few reports have studied the relationship between rehabilitation and subsequent fractures after ischemic stroke.

OBJECTIVE

To investigate whether post-stroke rehabilitation affects fracture risk.

METHODS

We conducted a population-based retrospective cohort study based on the Taiwan National Health Insurance Research Database. Patients with a newly diagnosed ischemic stroke between 2000 and 2012 were included. After propensity score matching, a total of 8,384 patients were enrolled. Half of the patients (4,192) received post-stroke rehabilitation within 1 month; the other half did not receive any post-stroke rehabilitation. Cox proportional hazards regression model was used to calculate hazard ratios (HRs) for fractures among patients with and without rehabilitation within 1 year after ischemic stroke. Patients were further stratified by sex and age (20-64 and ≥65 years).

RESULTS

Patients receiving post-stroke rehabilitation had a higher incidence of fracture (6.2 per 100 person-years) than those who did not (4.1 per 100 person-years) after adjustment for sociodemographic and coexisting medical conditions [HR = 1.53, 95% confidence interval (CI) = 1.25-1.87, p < 0.001]. The analyses performed after stratifying for sex and age showed that only older women undergoing rehabilitation had a significantly higher risk of fracture (HR = 1.62, 95% CI = 1.21-2.17, p = 0.001).

CONCLUSION

Rehabilitation after ischemic stroke is associated with an increased fracture risk in older women.

Reduced bone formation markers, and altered trabecular and cortical bone mineral densities of non-paretic femurs observed in rats with ischemic stroke: A randomized controlled pilot study

Background

Immobility and neural damage likely contribute to accelerated bone loss after stroke, and subsequent heightened fracture risk in humans.

Objective

To investigate the skeletal effect of middle cerebral artery occlusion (MCAo) stroke in rats and examine its utility as a model of human post-stroke bone loss.

Methods

Twenty 15-week old spontaneously hypertensive male rats were randomized to MCAo or sham surgery controls. Primary outcome: group differences in trabecular bone volume fraction (BV/TV) measured by Micro-CT (10.5 micron istropic voxel size) at the ultra-distal femur of stroke affected left legs at day 28. Neurological impairments (stroke behavior and foot-faults) and physical activity (cage monitoring) were assessed at baseline, and days 1 and 27. Serum bone turnover markers (formation: N-terminal propeptide of type 1 procollagen, PINP; resorption: C-terminal telopeptide of type 1 collagen, CTX) were assessed at baseline, and days 7 and 27.

Results

No effect of stroke was observed on BV/TV or physical activity, but PINP decreased by -24.5% (IQR -34.1, -10.5, p = 0.046) at day 27. In controls, cortical bone volume (5.2%, IQR 3.2, 6.9) and total volume (6.4%, IQR 1.2, 7.6) were higher in right legs compared to left legs, but these side-to-side differences were not evident in stroke animals.

Conclusion

MCAo may negatively affect bone formation. Further investigation of limb use and physical activity patterns after MCAo is required to determine the utility of this current model as a representation of human post-stroke bone loss.

Pioglitazone and Risk for Bone Fracture: Safety Data From a Randomized Clinical Trial

CONTEXT

Pioglitazone reduces cardiovascular risk in nondiabetic patients after an ischemic stroke or transient ischemic attack (TIA) but is associated with increased risk for bone fracture.

OBJECTIVE

To characterize fractures associated with pioglitazone by location, mechanism, severity, timing, and sex.

DESIGN, SETTING, AND PATIENTS

Patients were 3876 nondiabetic participants in the Insulin Resistance Intervention after Stroke trial randomized to pioglitazone or placebo and followed for a median of 4.8 years. Fractures were identified through quarterly interviews.

RESULTS

At 5 years, the increment in fracture risk between pioglitazone and placebo groups was 4.9% [13.6% vs 8.8%; hazard ratio (HR), 1.53; 95% confidence interval (CI), 1.24 to 1.89). In each group, ∼80% of fractures were low energy (i.e., resulted from fall) and 45% were serious (i.e., required surgery or hospitalization). For serious fractures most likely to be related to pioglitazone (low energy, nonpathological), the risk increment was 1.6% (4.7% vs 3.1%; HR, 1.47; 95% CI, 1.03 to 2.09). Increased risk for any fracture was observed in men (9.4% vs 5.2%; HR, 1.83; 95% CI, 1.36 to 2.48) and women (14.9% vs 11.6%; HR, 1.32; 95% CI, 0.98 to 1.78; interaction P = 0.13).

CONCLUSIONS

Fractures affected 8.8% of placebo-treated patients within 5 years after an ischemic stroke or TIA. Pioglitazone increased the absolute fracture risk by 1.6% to 4.9% and the relative risk by 47% to 60%, depending on fracture classification. Our analysis suggests that treatments to improve bone health and prevent falls may help optimize the risk/benefit ratio for pioglitazone.