Advertisement

Physical Activity in Young Hip Fracture Patients is Associated with Health-Related Quality of Life and Strength; Results from a Multicenter Study

  • Anna Gaki Lindestrand
    Correspondence
    Corresponding author.
    Affiliations
    Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23 2400 Copenhagen, Denmark
    Search for articles by this author
  • Sebastian Strøm Rönnquist
    Affiliations
    Department of Orthopedics, Lund University, Skåne University Hospital, Carl-Bertil Laurells gata 9 21428 Malmö, Sweden

    Department of Orthopaedic Surgery and Traumatology, J.B. Winsløws Vej 4 5000 Odense University Hospital, Odense, Denmark
    Search for articles by this author
  • Bjarke Viberg
    Affiliations
    Department of Orthopaedic Surgery and Traumatology, J.B. Winsløws Vej 4 5000 Odense University Hospital, Odense, Denmark

    Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24 6000 Kolding, Denmark
    Search for articles by this author
  • Søren Overgaard
    Affiliations
    Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23 2400 Copenhagen, Denmark

    Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B 2200 Copenhagen, Denmark
    Search for articles by this author
  • Henrik Palm
    Affiliations
    Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23 2400 Copenhagen, Denmark
    Search for articles by this author
  • Cecilia Rogmark
    Affiliations
    Department of Orthopedics, Lund University, Skåne University Hospital, Carl-Bertil Laurells gata 9 21428 Malmö, Sweden
    Search for articles by this author
  • Morten Tange Kristensen
    Affiliations
    Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B 2200 Copenhagen, Denmark

    Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital – Amager and Hvidovre, Kettegård Allé 30 2650 Hvidovre, Denmark

    Department of Physical and Occupational Therapy, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Bispebjerg Bakke 23 2400 Copenhagen, Denmark
    Search for articles by this author
Open AccessPublished:January 20, 2023DOI:https://doi.org/10.1016/j.injury.2023.01.037

      Highlights

      • We found that 6 out of 10 younger hip fracture patients had a PA score below WHO recommendations, this is twice as many as in the general population.
      • A PA score below WHO recommendations was associated with higher ASA, worse HRQoL and weaker hand grip strength.
      • About 90% had a DXA scan indicating osteopenia or osteoporosis, regardless of PA.

      Abstract

      Background

      The World Health Organization recommends a minimum of 150 min of moderate intensity exercise per week or 75 min of strenuous activity weekly for adults. Younger hip fracture patients are often assumed less active than the general population, however, knowledge on physical activity (PA) and health-related quality of life (HRQoL) in younger hip fracture patients is limited.

      Objectives

      We aimed to 1) investigate the variation in pre-fracture PA for adult patients with hip fractures under the age of 60; and 2) to quantify the association with patient characteristics, including outcomes of HRQOL and handgrip strength.

      Design and methods

      A prospective multicenter cohort study of 207 adult hip fracture patients under 60 years admitted to four study hospitals from July 2015 to December 2018. Data was collected through medical records, questionnaires, physical tests and interviews. PA level was assessed using a validated questionnaire from the Swedish National Board of Health and Welfare, providing a total score from 3 to 19. A score ≥11 corresponds to fulfillment of the WHO recommendation for weekly PA. Handgrip strength was measured in kilograms using a handheld dynamometer following a standardized protocol. Recall pre-fracture HRQoL was assessed using the EQ-5D-3L questionnaire.

      Results

      59% had a PA score ≤10 out of these 46% had an ASA grade of 3 or 4, 38% had a BMI over 25 and 81% had a low energy fracture. A PA score ≤10 was associated with a lower HRQoL compared to those who had a PA score ≥11. PA score ≤10 points was associated with weaker hand grip strength and a worse health status (higher ASA-grade) p<0.001.

      Conclusion

      We found that close to two-thirds of the patients had a pre-fracture PA level below WHO recommendations. Being more active was associated with better handgrip strength, HRQoL, and ASA score. Our findings indicate that individuals under 60 years who sustain a hip fracture form a heterogeneous group, some severely comorbid and others highly active and seemingly healthy. This suggests a more nuanced approach to rehabilitation, as the more active patient might need a more individualized plan than the standard program can offer.

      Keywords

      Introduction

      A hip fracture is a serious injury, associated with loss of mobility, reduced quality of life, and mortality [
      • Ekegren CL
      • Edwards ER
      • Page R
      • Hau R
      • de Steiger R
      • Bucknill A
      • et al.
      Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age.
      ,
      • Leu T
      • Chang W
      • Lin JC
      • Lo C
      • Liang W
      • Chang Y
      • et al.
      Incidence and excess mortality of hip fracture in young adults: a nationwide population-based cohort study.
      ]. Young and middle-aged patients constitute one tenth of the total hip fracture population but the literature is still scarce concerning this group of patients compared to the elderly [
      • Rogmark C
      • Kristensen MT
      • Viberg B
      • Rönnquist SS
      • Overgaard S
      • Palm H.
      Hip fractures in the non-elderly- Who, why and whither?.
      ]. There are many preconceived notions about the younger hip fracture patient, some of these being that they are less active than the general population and at greater risk of fracture due to comorbidities.
      Physical activity (PA) and maintaining strength are some of the most important modifiable preventative factors for osteoporosis and fracture [
      • Carter MI
      • Hinton PS.
      Physical activity and bone health.
      ]. Regular physical activity promotes healthier bones and can help maintain bone mineral density in adulthood and beyond [
      • Weaver CM
      • Gordon CM
      • Janz KF
      • Kalkwarf HJ
      • Lappe JM
      • Lewis R
      • et al.
      The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.
      ], and active adults can decrease their risk of hip fracture by 20-60% from that of sedentary adults [
      • Farahmand BY
      • Persson PG
      • Michaëlsson K
      • Baron JA
      • Alberts A
      • Moradi T
      • et al.
      Physical activity and hip fracture: a population-based case-control study. Swedish Hip Fracture Study Group.
      ,
      • Stattin K
      • Michaëlsson K
      • Larsson SC
      • Wolk A
      • Byberg L.
      Leisure-Time Physical Activity and Risk of Fracture: A Cohort Study of 66,940 Men and Women.
      ,
      • Trimpou P
      • Landin-Wilhelmsen K
      • Odén A
      • Rosengren A
      • Wilhelmsen L.
      Male risk factors for hip fracture-a 30-year follow-up study in 7495 men.
      ]. However, the type of activity, frequency, intensity, and duration of activity required for bone health are not well defined. The World Health Organization (WHO) has recommendations on PA, as PA in adults confer benefits for several health outcomes, including all-cause mortality, cardiovascular disease mortality, incident type-2-diabetes, mental health, and sleep [

      WHO Guidelines on Physical Activity and Sedentary Behaviour. Guideline published on the World Health Organization website 25 november 2020. Available from: https://www.who.int/publications/i/item/9789240015128

      ]. The WHO recommends a minimum of 150 min of moderate intensity exercise per week or 75 min of strenuous activity weekly for individuals older than 18 years [

      WHO Guidelines on Physical Activity and Sedentary Behaviour. Guideline published on the World Health Organization website 25 november 2020. Available from: https://www.who.int/publications/i/item/9789240015128

      ]. The National Board of Health in both Sweden and Denmark has introduced these recommendations as the national guidelines on PA for the general population in respective country.
      However, knowledge on variation in PA and its association to strength and health related quality of life (HRQoL) among younger patients treated due to acute hip fracture is limited.
      We aimed to 1) investigate the variation in self-reported pre-fracture PA for adult patients with hip fracture under the age of 60 years; and 2) to quantify the association with patient characteristics, including handgrip strength and HRQoL.

      Materials and methods

      Study design, setting and participants

      The present study is a part of the prospective multicenter cohort study of Hip Fractures in adults Under 60 years of age (HFU-60), and full details of the initial dataset are reported elsewhere [
      • Strøm Rönnquist S
      • Viberg B
      • Kristensen MT
      • Palm H
      • Jensen JB
      • Madsen CF
      • et al.
      Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.
      ].
      Patients aged 18 to 59 years, that underwent surgery for an acute non-pathological hip fracture at Orthopedic Departments located at one of the four study hospitals; Skåne University Hospital Malmö, Sweden, Lillebaelt Kolding Hospital, Hvidovre University Hospital and Odense University Hospital in Denmark were eligible for inclusion in the study [
      • Strøm Rönnquist S
      • Viberg B
      • Kristensen MT
      • Palm H
      • Jensen JB
      • Madsen CF
      • et al.
      Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.
      ]. Skåne University Hospital started the inclusion in July 2015, followed by the other centers in the first half of 2016. Inclusion was closed at all departments at December 31st 2018.
      A total of 218 patients agreed to participate in the main study [
      • Strøm Rönnquist S
      • Viberg B
      • Kristensen MT
      • Palm H
      • Jensen JB
      • Madsen CF
      • et al.
      Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.
      ], of whom 207 reported a PA score and were included in the present study (Figure 1).
      Figure 1
      Figure 1Flowchart of inclusion and analysis of physical activity, HGS and HRQoL.

      Study variables

      Physical Activity

      The PA level was assessed using a validated questionnaire by The Swedish National Board of Health and Welfare [
      • Olsson S.J.G
      • Ekblom Ö
      • Andersson E
      • Börjesson M
      • Kallings L.V.
      Categorical answer modes provide superior validity to open answers when asking for level og physical activity: A cross-sectional study.
      ]. It contains the following questions:
      • 1
        During a regular week, how much time do you spend exercising on a level that makes you short of breath for example running, fitness class, or ball games?
      • 2
        During a regular week, how much time are you physically active in ways that are not exercise, for example walks, bicycling or gardening? Add together all activities lasting at least 10 min.
      The patient could answer in categorical modes, where each category corresponds to a number (1-7), providing a total score from 3 to 19. The score was calculated by multiplying the result from exercise time by two and then adding the product to the result from everyday PA. A score ≥11 corresponds to fulfillment of the WHO recommendation for weekly PA [
      • Olsson S.J.G
      • Ekblom Ö
      • Andersson E
      • Börjesson M
      • Kallings L.V.
      Categorical answer modes provide superior validity to open answers when asking for level og physical activity: A cross-sectional study.
      ].
      Sedentary behavior was assessed with a single item question; How much time do you spend sitting during a normal day, when excluding sleep. The patient can answer in categorical modes, where each category corresponds to a number, equal to a score from 1 to 7, reflecting hours of daily sitting time [
      • Kallings LV
      • Olsson SJG
      • Ekblom Ö
      • Ekblom-Bak E
      • Börjesson M.
      The SED-GIH: A Single-Item Question for Assessment of Stationary Behavior- A Study of Concurrent and Convergent Validity.
      ].

      Health related quality of life

      Pre-fracture HRQoL was assessed using the European Quality of Life-5-Dimension-3-Levels and Visual Analogue Scale questionnaire (EQ-5D and EQ-VAS).The EQ-5D is a generic, validated, cross-disciplinary standardized health utility instrument used to assess HRQoL after hip fracture [

      EuroHRQoL Research Foundation. EQ-5D-3L UserGuide, 2018. Available from: https://euroHRQoL.org/publications/user-guides.

      ]. The EQ-5D provides a health status instrument consisting of a 3-level response (no problems, some problems and extreme problems) for 5 health domains related to daily life and activities (mobility, self-care, usual activities, pain and discomfort and anxiety and depression). The EQ-VAS records the patient's self-rated health on a vertical visual analogue scale where the endpoints are labelled “Best imaginable health state” (100 points) and “Worst imaginable health state” (0 points). The patient was asked to indicate his/her health before fracturing their hip by ticking the box next to the most appropriate statement in each of the five dimensions and on the VAS scale.

      Hand grip strength

      Handgrip strength (HGS) was used as a proxy for general strength and measured using a handheld dynamometer, following a standardized protocol. All patients were given a minimum of 3 trials (a 4th and 5th trial were given if the 3rd and 4th, respectively, exceeded the previous result) using the dominant hand. All values were documented in kilograms and the highest was used for analysis [
      • Kristensen MT
      • Hulsbæk S
      • Faber LL
      • Kronborg L.
      Knee Extension Strength Measures Indicating Probable Sarcopenia Is Associated with Health-Related Outcomes and a Strong Predictor of 1-Year Mortality in Patients Following Hip Fracture Surgery.
      ].

      Bone mineral density

      Dual energy X-ray Absorption (DXA) scans were performed at each hospital. Measurements were made at the lumbar spine and unfractured hip by local clinical standard regimes within 3 months post-fracture [
      • Weaver CM
      • Gordon CM
      • Janz KF
      • Kalkwarf HJ
      • Lappe JM
      • Lewis R
      • et al.
      The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.
      ]. A total of 184 patients’ DXA scan results (i.e. T-score) were included in the analysis. Median time to DXA investigation from hip fracture surgery was 5 (IQR 3-24) days, 85% of the analyzed patients had DXA scans within 1 month.

      Descriptive variables

      Patient characteristics – age, sex, American Society of Anesthesiologists grade (ASA) for health status, Body Mass Index (BMI), trauma mechanism, New Mobility Score (NMS) and fracture type – was collected through interviews and review of medical records [
      • Strøm Rönnquist S
      • Viberg B
      • Kristensen MT
      • Palm H
      • Jensen JB
      • Madsen CF
      • et al.
      Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.
      ]. Trauma mechanism was assessed and classified; as either low-energy (fall from standing or a seated position) or as moderate to high energy trauma, if a higher degree of energy caused the fracture.
      NMS is a composite score of the patient's ability to perform; outdoor walking, indoor walking and shopping, providing a score from 0-3 for each function, resulting in a total score from 0-9. A score of 9 equals an independent pre-fracture walking ability [

      Kristensen MT, Kehlet H. Most patients regain prefracture basic mobility after hip fracture surgery in a fast-

      ].

      Ethical considerations

      HFU-60 was approved by ethical review boards in Sweden (Regionala etikprövningsnämnden Lund (Diarienummer: 2015/28)) and Denmark (Videnskabsetisk Komité for Region Syddanmark (Projekt ID: s-20150137)), registered at ClinicalTrials.gov (NCT03848195), and conducted in accordance with the Helsinki declaration. All participants gave written informed consent.

      Statistics

      PA data were dichotomized as ≤10 (not fulfilling) versus ≥11 (fulfilling) according to WHO recommendations for weekly PA and used for evaluation of the relationship with patient characteristics and outcomes of handgrip strength, EQ-5D-3L and EQ-VAS. Chi-square test was used for categorical data, while Students t-test and the Mann-Whitney test, were used as appropriate, depending on the distribution of continuous data. Statistical analysis was performed in SPSS, version 25.0 and excel.

      Results

      The 207 participants were between 23 and 59 years old, and 59% were men. 142 (69%) fractured their hip due to low-energy trauma, 167 (90%) had DXA scans equivalent to osteoporosis or osteopenia. 52% had a normal BMI and 84% had a high pre-fracture functional level evaluated with the NMS. The majority of participants (68%) were between 50-59 years old (Table 1). HGS, EQ-5D and EQ-VAS data were available in respectively 192, 183 and 178 of the 207 participants (Figure 1)
      Table 1Characteristics of participants.
      CharacteristicTotalActivity score ≤10Activity score ≥11p-value
      N207 (%)123 (59.4)84 (40.6)
      Men122 (58.9)68 (55.3)54 (64.3)0.196
      Women85 (41.1)55 (44.7)30 (35.7)
      Age, median (25-75%)53 (48-57)55 (49-57)51 (45-55)<0.001
      20-39 years18 (8.7)8 (6.5)10 (11.9)

      0.04
      40-49 years48 (23.2)23 (18.7)25 (29.8)
      50-59 years141 (68.1)92 (74.8)49 (58.3)
      ASA-Grade
      ASA I58 (28.0)19 (15.4)39 (46.4)

      <0.001

      ASA II81 (39.1)47 (38.2)34 (40.5)
      ASA III62 (30.0)52 (42.3)10 (11.9)
      ASA IV6 (2.9)5 (4.1)1 (1.2)
      BMIn=204n=120n=84
      BMI <18.520 (9.7)17 (13.8)3 (3.6)

      0.037
      BMI 18.5-25108 (52.2)57 (46.3)48 (57.1)
      BMI >2576 (36.7)46 (38.3)33 (39.3)
      Type of trauma
      Low-energy trauma142 (68.6)100 (81.3)42 (50)

      <0.001

      Moderate-high energy trauma65 (31.4)23 (18.7)42 (50)
      DEXA scoren=185n=109n=76
      Normal, T-score > -118 (9.7)9 (8.2)9 (11.8)

      0.027

      Osteopenia, T-score -1 to -2.5105 (56.8)55 (50.5)50 (65.8)
      Osteoporosis, T-score < -2.562 (33.5)45 (41.3)17 (22.4)
      New Mobility Score (0-9 points):N=207n=123n=84
      0-8 points33 (15.9)30 (24.4)3 (3.6)< 0.001
      9 points174 (84.1)93 (75.6))81 (96.4)
      Type of fracture
      Intracapsular124 (59.9)69 (56.1)55 (65.5)

      0.2

      Extracapsular76 (36.7)48 (39)28 (33.3)
      Subtrochanteric7 (3.4)6 (4.9)1 (1.2)
      Data are reported as numbers (%), otherwise as stated. An activity score ≥11 indicate fulfilment of WHO recommendations for weekly physical activity. A New Mobility Score of 9 indicate a pre-fracture independent walking ability
      123 (59%) participants had a PA score below the WHO recommendations for weekly PA (≤10 points). These patients were significantly older, had more often; a BMI <18.5, a lower BMD, a lower pre-fracture functional level (NMS <9), a higher ASA (46% ASA≥3) and a low-energy trauma as cause of fracture, compared to those fulfilling recommendations (Table 1). Within the 3 age groups (20-39, 40-49 and 50-59) presented in Table 1, a similar proportion of participants fulfilled recommendations versus not in the 2 youngest age groups. On the contrary, within the 50–59-year group, the larger proportion (n=92, 65%) that didn't, were slightly and significantly older (mean (95%CI) of 1.3 (0.3-2.3), p=0.1, years) compared to those (n=49, 35%) fulfilling recommendations. Participants not fulfilling recommendations also had lower handgrip strength, EQ-5D index and EQ-VAS, regardless of sex (Table 2).
      Table 2Association between physical activity hand grip strength and health related quality of life.
      OutcomesAllActivity score ≤10Activity score ≥11P-value
      Handgrip strength:
      Handgrip strength, kg, Men45.8 (13.9), n=11540.0 (12.5), n=6352.7 (12.4), n=52< 0.001
      Handgrip Strength, kg, Women27.7 (7.4), n=7726.0 (7.6), n=4930.6 (6.3), n=280.008
      EQ-5D:
      EQ-5D-3L index, men1.0 (0.76-1.0)
      Men reported significantly higher EQ values compared to women. An activity score ≥11 indicate fulfilment of WHO recommendations for weekly physical activity
      , n=105
      0.82 (0.66-1.00), n=551.0 (0.82-1.0), n=500.002
      EQ-5D-3L index, women0.82 (0.71-1.0), n=780.77 (0.51-0.82), n=501.0 (0.79-1.0), n=280.001
      Self-rated health EQ, VAS 0-100, Men85 (70-91)
      Men reported significantly higher EQ values compared to women. An activity score ≥11 indicate fulfilment of WHO recommendations for weekly physical activity
      , n=104
      80 (50-90), n=5390 (75-94), n=510.02
      Self-rated health EQ, VAS 0-100, Women75 (50-89), n=7460 (41-80), n=4990 (78-98), n=25< 0.001
      Data are reported as mean (SD) or as median (25-75% quartiles).
      low asterisk Men reported significantly higher EQ values compared to women. An activity score ≥11 indicate fulfilment of WHO recommendations for weekly physical activity
      The distribution of the PA score showed that 22 (18%) men achieved the highest possible score of 19 points (Figure 2). In comparison, women had the largest congregation at 9 points (n=17) and only 6 (7%) women reported the highest PA score. On the other hand, men also constituted a slightly larger proportion than women in the lowest degrees of PA (Figure 2). Regarding weekly physical exercise, 39 (32%) men reported the highest degree of strenuous PA (>120 min/week) in comparison with 11 (13%) women (Figure 3).
      Figure 2
      Figure 2Distribution of pre-fracture weekly Physical Activity score by gender. A score of 11 or higher corresponds to fulfillment of the WHO recommendation for weekly PA.
      Figure 3
      Figure 3Distribution of pre-fracture weekly “short of breath” physical exercise by gender.
      Among the men with the highest PA score, 14 (64%) were diagnosed with a low BMD.
      Among the men who recorded the highest degree of strenuous exercise, 27 (69%) had DXA scan results equivalent to osteopenia or osteoporosis and 14 (36%) reported a sedentary score ≥3 (equal to ≥7 hours of the day spent sitting). Correspondingly for the women, who reported the highest degree of strenuous exercise, 9 (82%) were diagnosed with a low BMD, and 4 (44%) recorded a sedentary score ≥3.
      Regarding sedentary time about one-third of patients (n=68) were found in the two highest categories (>10 hours a day), and almost equally distributed among the sexes (Fig. 4).
      Figure 4
      Figure 4Distribution of pre-fracture sedentary time score during a normal day by gender.

      Discussion

      We found that close to two thirds of younger patients with a hip fracture had a weekly PA level below WHO recommendations before fracturing their hip. This was in turn associated with a worse health status, a lower pre-fracture functional level, a low BMI, a lower BMD and muscle strength and a worse pre-fracture HRQOL, when compared to those complying with WHO recommendations.
      In the general adult population in the study countries approximately 30% do not comply with the WHO recommendations for PA [,

      Danskernes Sundhed Den nationale sundhedsprofil 2017. Sundhedsstyrelsen 2018. Available from: https://www.sst.dk/da/udgivelser/2018/danskernes-sundhed-den-nationale-sundhedsprofil-2017

      ], i.e. it was twice as many amongst our study participants. More than 80% of participants with a low PA level fractured their hip due to a low-energy trauma. The more active patients were a bit more likely to be men and slightly younger compared to the less active patients. A majority of participants in both activity groups were in the eldest age group, suggesting that age alone does not account for the difference in PA score. Still, within this age group a larger proportion of participants did not fulfill recommendations, while this was more equally distributed in the younger age groups. A fairly large group of men were top scorers on physical activity and especially on weekly physical exercise, and they reported a higher HRQOL.
      Participants were also likely to have poor bone quality, regardless of trauma and PA scores, with 90% of patients diagnosed with either osteopenia or osteoporosis on DXA investigation. Importantly, a larger proportion of participants with the worst bone health were seen in the low PA group, >40% with osteoporosis, in comparison with 22% among compliers to PA recommendations, a finding that also is supported by the literature [
      • Carter MI
      • Hinton PS.
      Physical activity and bone health.
      ]. Even though a high PA does not rule out osteopenia/-porosis, our findings add to the hypothesis of PA as a potential and important factor in counteracting the age related loss of bone mineral density and thereby reducing the risk of fracture due to low-energy trauma [
      • Strøm Rönnquist S
      • Viberg B
      • Kristensen MT
      • Palm H
      • Jensen JB
      • Madsen CF
      • et al.
      Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.
      ,
      • Carter MI
      • Hinton PS.
      Physical activity and bone health.
      ].
      Physical activity helps to build muscle and bone mass and maintain BMD [
      • Weaver CM
      • Gordon CM
      • Janz KF
      • Kalkwarf HJ
      • Lappe JM
      • Lewis R
      • et al.
      The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.
      ]. On the other hand, physical activity can also predispose to injuries and fracture. Endurance athletes such as runners and non-weight-bearing sports such as cycling and swimming have been associated with a low BMD, and sometimes even lower than their inactive peers [
      • Karantana A
      • Boulton C
      • Bouliotis G
      • Shu KS
      • Scammell BE
      • Moran CG.
      Epidemiology and outcome of fracture of the hip in women aged 65 years and under: a cohort study.
      ]. The high-functioning group of men in the present study who were high scorers on strenuous exercise might fall into this category of so-called endurance athletes, which could explain the high prevalence of low BMD seen in this group. Also, a third of the men in this group reported a high sedentary score, indicating that a large part of the day was spent sitting down which also has a negative effect on bone health.
      Despite being in seemingly better health, many of the more active participants still had T-scores indicating poor bone health, and thereby a higher risk of fracture.
      PA alone does not seem to maintain an adequate BMD, it is also important to look at other factors like environment, genetics, somatic disease and diet.
      Most participants, regardless of PA scores, had a high pre-fracture functional level according to NMS score. The majority of participants with a lower pre-fracture functional level (NMS score <9) was found in the less active group (PA≤10). At the same time, the more active participants seem to have a better general health as indicated by lower ASA grade, better muscle strength and higher functional level.
      That is, HGS was significantly lower in the group with a low PA score in both sexes, indicating worse muscular fitness and general health. Compared to normative values in two Danish cohorts, participants with a high PA had similar strength (HGS) for men and slightly lower for women when looking at age groups from 20-59 years, while participants with low PA had markedly lower muscle strength [
      • Aadahl M
      • Beyer N
      • Linneberg A
      • Thuesen BH
      • Jørgensen T.
      Grip strength and lower limb extension power in 19-72 year old Danish men and women: the Health2006 study.
      ,
      • Suetta C
      • Haddock B
      • Alcazar J
      • Noerst T
      • Hansen OM
      • Ludvig H
      • et al.
      The Copenhagen Sarcopenia Study: lean mass, strength, power, and physical function in a Danish cohort aged 20-93 years.
      ].
      The self-rated EQ-5D-3L index and EQ-VAS showed significantly better HRQOL in the more active participants for both sexes, when compared to the less active. Overall, women reported a lower self-rated health compared to men in the present study, a trend that is also seen in the general population [,

      Danskernes Sundhed Den nationale sundhedsprofil 2017. Sundhedsstyrelsen 2018. Available from: https://www.sst.dk/da/udgivelser/2018/danskernes-sundhed-den-nationale-sundhedsprofil-2017

      ]. In support of our overall findings related to PA, a large population-based Danish study also reported an association between PA and self-rated health, and additionally to muscle strength [
      • Hansen AW
      • Beyer N
      • Flensborg-Madsen T
      • Grønbæk M
      • Helge JW.
      Muscle strength and physical activity are associated with self-rated health in an adult Danish population.
      ]. Similarly, a large UK population-based study including 40-60 year-old men and women found a positive association across all types of PA and HRQOL [
      • Anokye N.K.
      • Trueman P.
      • Green C.
      • et al.
      Physical activity and health related quality of life.
      ]. The findings of the present study also suggest a positive relationship between PA and HRQOL.
      Although validated questionnaires were used, one limitation of our study could be the risk of recall bias when reporting of pre-fracture PA, HRQoL and function. I.e. self-reported PA could be overestimated. Thus, complying to PA recommendations when objectively monitored seems much lower as compared to self-reported [
      • Anokye N.K.
      • Trueman P.
      • Green C.
      • et al.
      Physical activity and health related quality of life.
      ]. However, for patients with an acute injury there is no alternative to self-reported PA. Another limitation could be that data for HRQOL, DXA and strength measures were missing for some participants with PA data, which could introduce some selection bias. Still, the participants with missing data were almost equally distributed between genders and PA levels. We therefore consider our findings valid.
      The strengths of the study are that data was collected prospectively for a relatively large cohort of young patients with hip fractures in four public hospitals in two countries responsible for all types of acute fracture care in their catchment areas. Thereby we consider them representative of this patient group, at least in high- and middle-income countries

      Conclusions

      Close to two-thirds of younger patients sustaining a hip fracture had a weekly pre-fracture PA level below WHO recommendations. This is twice as many as in the general population. Being less active was associated with worse ASA grade, handgrip strength and HRQOL. As there are preconceived notions that hip fractures in younger age is either due to high energy trauma or only seen in individuals with severe comorbidities, we need to nuance the understanding of this highly heterogenous group of patients, especially when it comes to rehabilitation and follow-up. The younger hip fracture patients with a high pre-fracture PA level might need a more individualized rehabilitation plan to fully regain their function and activity level, than what the usual rehabilitation program can offer.

      Uncited References

      [
      • Kettunen J
      • Impivaara O
      • Kujala U
      • Linna M
      • Mäki J
      • Räty H
      • et al.
      Hip fractures and femoral bone density in male former athletes.
      ,
      • Lin JC
      • Wu CC
      • Lo C
      • Liang WM
      • Cheng CF
      • Wang CB
      • et al.
      Mortality and complications of hip fracture in young adults: a nationwide population-based cohort study.
      ,
      • Coughlin T.A
      • Nightingale J.M
      • Forward D.P
      • Norrish A.R
      • Ollivere B.J
      Patient-reported outcomes in young patients with isolated fracture of the hip.
      ,

      Lofthus, C.M., Osnes, E.K., Meyer, H.E. et al. Young patients with hip fracture: a population-based study of bone mass and risk factors for osteoporosis. Osteoporos Int17, 1666–1672

      ,
      • Scofield K.L.
      • Hecht S.
      Bone Health in Endurance Athletes.
      ,
      • Cauley JA
      • Giangregorio L.
      Physical activity and skeletal health in adults.
      ,
      • Parsons NR
      • Costa ML
      • Achten J
      • Griffin XL.
      Baseline quality of life in people with hip fracture: results from the multicentre WHiTE cohort study.
      ,
      • Nagle KB
      • Brooks MA.
      A Systematic Review of Bone Health in Cyclists.
      ,
      • Han S
      • Jang HD
      • Nah S
      • Han K
      • Lim H
      • Kim WS
      • et al.
      Effects of changes in regular physical activity status on hip fracture: A nationwide population-based cohort study in Korea.
      ,
      • Omari A
      • Madsen CM
      • Lauritzen JB
      • Jørgensen HL
      • Vojdeman FJ.
      Comorbidity and mortality after hip fracture in nineteen thousand six hundred and eighty two patients aged eighteen to sixty five years in Denmark from 1996 to 2012.
      ,
      • Wang M.T.
      • Yao S.H.
      • Wong P.
      • et al.
      Hip fractures in young adults: a retrospective cross-sectional study of characteristics, injury mechanism, risk factors, complications and follow-up.
      ,
      • Kanis JA
      • Odén A
      • McCloskey EV
      • Johansson H
      • Wahl DA
      • Cooper C
      IOF Working Group on Epidemiology and Quality of Life. A systematic review of hip fracture incidence and probability of fracture worldwide.
      ]

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      References

        • Ekegren CL
        • Edwards ER
        • Page R
        • Hau R
        • de Steiger R
        • Bucknill A
        • et al.
        Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age.
        Injury. 2016; 47 (Oct): 2182-2188
        • Leu T
        • Chang W
        • Lin JC
        • Lo C
        • Liang W
        • Chang Y
        • et al.
        Incidence and excess mortality of hip fracture in young adults: a nationwide population-based cohort study.
        BMC Musculoskeletal Disorders. 2016; 17: 326
        • Rogmark C
        • Kristensen MT
        • Viberg B
        • Rönnquist SS
        • Overgaard S
        • Palm H.
        Hip fractures in the non-elderly- Who, why and whither?.
        Injury Int J. Care Injured. 2018; 49: 1445-1450
        • Carter MI
        • Hinton PS.
        Physical activity and bone health.
        Mo Med. 2014; 111: 59-64
        • Weaver CM
        • Gordon CM
        • Janz KF
        • Kalkwarf HJ
        • Lappe JM
        • Lewis R
        • et al.
        The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.
        Osteoporos Int. 2016 Apr; 27 (Epub 2016 Feb 8. Erratum in: Osteoporos Int. 2016 Apr;27(4):1387): 1281-1386https://doi.org/10.1007/s00198-015-3440-3
        • Farahmand BY
        • Persson PG
        • Michaëlsson K
        • Baron JA
        • Alberts A
        • Moradi T
        • et al.
        Physical activity and hip fracture: a population-based case-control study. Swedish Hip Fracture Study Group.
        Int J Epidemiol. 2000 Apr; 29: 308-314
        • Stattin K
        • Michaëlsson K
        • Larsson SC
        • Wolk A
        • Byberg L.
        Leisure-Time Physical Activity and Risk of Fracture: A Cohort Study of 66,940 Men and Women.
        J Bone Miner Res. 2017 Aug; 32: 1599-1606
        • Trimpou P
        • Landin-Wilhelmsen K
        • Odén A
        • Rosengren A
        • Wilhelmsen L.
        Male risk factors for hip fracture-a 30-year follow-up study in 7495 men.
        Osteoorosis Int. 2010; 21: 409-416
      1. WHO Guidelines on Physical Activity and Sedentary Behaviour. Guideline published on the World Health Organization website 25 november 2020. Available from: https://www.who.int/publications/i/item/9789240015128

        • Strøm Rönnquist S
        • Viberg B
        • Kristensen MT
        • Palm H
        • Jensen JB
        • Madsen CF
        • et al.
        Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.
        Osteoporos Int. 2022 Jan 14; (Epub ahead of print. PMID:35029719)https://doi.org/10.1007/s00198-021-06281-y
        • Kettunen J
        • Impivaara O
        • Kujala U
        • Linna M
        • Mäki J
        • Räty H
        • et al.
        Hip fractures and femoral bone density in male former athletes.
        Bone. 2010; 46: 330-335
        • Olsson S.J.G
        • Ekblom Ö
        • Andersson E
        • Börjesson M
        • Kallings L.V.
        Categorical answer modes provide superior validity to open answers when asking for level og physical activity: A cross-sectional study.
        Scandinavian Journal of Public Health. 2016; 44: 70-76
        • Lin JC
        • Wu CC
        • Lo C
        • Liang WM
        • Cheng CF
        • Wang CB
        • et al.
        Mortality and complications of hip fracture in young adults: a nationwide population-based cohort study.
        BMC Musculoskelet Disord. 2014 Oct 31; 15: 362
      2. Folkhälsans Utveckling Årsrapport 2020, Folkhälsomyndigheten. Available from: https://www.folkhalsomyndigheten.se/folkhalsorapportering-statistik/tolkad-rapportering/folkhalsans-utveckling/

      3. Danskernes Sundhed Den nationale sundhedsprofil 2017. Sundhedsstyrelsen 2018. Available from: https://www.sst.dk/da/udgivelser/2018/danskernes-sundhed-den-nationale-sundhedsprofil-2017

        • Coughlin T.A
        • Nightingale J.M
        • Forward D.P
        • Norrish A.R
        • Ollivere B.J
        Patient-reported outcomes in young patients with isolated fracture of the hip.
        Bone Joint J. 2020; 102-B: 766-771
        • Kallings LV
        • Olsson SJG
        • Ekblom Ö
        • Ekblom-Bak E
        • Börjesson M.
        The SED-GIH: A Single-Item Question for Assessment of Stationary Behavior- A Study of Concurrent and Convergent Validity.
        Int. J. Environ. Res. Health. 2019; 16: 4766
        • Kristensen MT
        • Hulsbæk S
        • Faber LL
        • Kronborg L.
        Knee Extension Strength Measures Indicating Probable Sarcopenia Is Associated with Health-Related Outcomes and a Strong Predictor of 1-Year Mortality in Patients Following Hip Fracture Surgery.
        Geriatrics (Basel). 2021 Jan 15; 6: 8https://doi.org/10.3390/geriatrics6010008.19
      4. EuroHRQoL Research Foundation. EQ-5D-3L UserGuide, 2018. Available from: https://euroHRQoL.org/publications/user-guides.

      5. Lofthus, C.M., Osnes, E.K., Meyer, H.E. et al. Young patients with hip fracture: a population-based study of bone mass and risk factors for osteoporosis. Osteoporos Int17, 1666–1672

        • Aadahl M
        • Beyer N
        • Linneberg A
        • Thuesen BH
        • Jørgensen T.
        Grip strength and lower limb extension power in 19-72 year old Danish men and women: the Health2006 study.
        BMJ Open. 2011; 2e000192
        • Karantana A
        • Boulton C
        • Bouliotis G
        • Shu KS
        • Scammell BE
        • Moran CG.
        Epidemiology and outcome of fracture of the hip in women aged 65 years and under: a cohort study.
        J Bone Joint Surg Br. 2011 May; 93: 6
        • Scofield K.L.
        • Hecht S.
        Bone Health in Endurance Athletes.
        Current Sports Medicine Reports. 2012; 11: 328-3323
        • Cauley JA
        • Giangregorio L.
        Physical activity and skeletal health in adults.
        Lancet Diabetes Endocrinol. 2020 Feb; 8: 150-162
        • Parsons NR
        • Costa ML
        • Achten J
        • Griffin XL.
        Baseline quality of life in people with hip fracture: results from the multicentre WHiTE cohort study.
        Bone Joint Res. 2020 Aug 19; 9: 468-476
        • Hansen AW
        • Beyer N
        • Flensborg-Madsen T
        • Grønbæk M
        • Helge JW.
        Muscle strength and physical activity are associated with self-rated health in an adult Danish population.
        Prev Med. 2013 Dec; 57: 792-798
        • Nagle KB
        • Brooks MA.
        A Systematic Review of Bone Health in Cyclists.
        Sports Health. 2011; 3: 235-243https://doi.org/10.1177/1941738111398857
        • Han S
        • Jang HD
        • Nah S
        • Han K
        • Lim H
        • Kim WS
        • et al.
        Effects of changes in regular physical activity status on hip fracture: A nationwide population-based cohort study in Korea.
        PLoS One. 2021 Apr 8; 16e0249819
        • Omari A
        • Madsen CM
        • Lauritzen JB
        • Jørgensen HL
        • Vojdeman FJ.
        Comorbidity and mortality after hip fracture in nineteen thousand six hundred and eighty two patients aged eighteen to sixty five years in Denmark from 1996 to 2012.
        International Orthopaedics. 2019; 43: 2621-2627
        • Wang M.T.
        • Yao S.H.
        • Wong P.
        • et al.
        Hip fractures in young adults: a retrospective cross-sectional study of characteristics, injury mechanism, risk factors, complications and follow-up.
        Arch Osteoporos. 2017; 12: 46
        • Suetta C
        • Haddock B
        • Alcazar J
        • Noerst T
        • Hansen OM
        • Ludvig H
        • et al.
        The Copenhagen Sarcopenia Study: lean mass, strength, power, and physical function in a Danish cohort aged 20-93 years.
        J Cachexia Sarcopenia Muscle. 2019 Dec; 10: 1316-1329
        • Anokye N.K.
        • Trueman P.
        • Green C.
        • et al.
        Physical activity and health related quality of life.
        BMC Public Health. 2012; 12: 624
        • Kanis JA
        • Odén A
        • McCloskey EV
        • Johansson H
        • Wahl DA
        • Cooper C
        IOF Working Group on Epidemiology and Quality of Life. A systematic review of hip fracture incidence and probability of fracture worldwide.
        Osteoporos Int. 2012 Sep; 23 (Epub 2012 Mar 15PMID:22419370PMCID: PMC3421108): 2239-2256https://doi.org/10.1007/s00198-012-1964-3
      6. Kristensen MT, Kehlet H. Most patients regain prefracture basic mobility after hip fracture surgery in a fast-