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Department of Orthopedics, Lund University, Skåne University Hospital, Carl-Bertil Laurells gata 9 21428 Malmö, SwedenDepartment of Orthopaedic Surgery and Traumatology, J.B. Winsløws Vej 4 5000 Odense University Hospital, Odense, Denmark
Department of Orthopaedic Surgery and Traumatology, J.B. Winsløws Vej 4 5000 Odense University Hospital, Odense, DenmarkDepartment of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24 6000 Kolding, Denmark
Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23 2400 Copenhagen, DenmarkDepartment of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B 2200 Copenhagen, Denmark
Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B 2200 Copenhagen, DenmarkDepartments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital – Amager and Hvidovre, Kettegård Allé 30 2650 Hvidovre, DenmarkDepartment of Physical and Occupational Therapy, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Bispebjerg Bakke 23 2400 Copenhagen, Denmark
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.
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A PA score below WHO recommendations was associated with higher ASA, worse HRQoL and weaker hand grip strength.
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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.
]. 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 [
]. 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 [
The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.
]. 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 [
]. 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 [
]. 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 [
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 [
]. 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 [
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 [
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 [
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 [
]. 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 [
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.
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 [
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 [
]. 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 [
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.
Characteristic
Total
Activity score ≤10
Activity score ≥11
p-value
N
207 (%)
123 (59.4)
84 (40.6)
Men
122 (58.9)
68 (55.3)
54 (64.3)
0.196
Women
85 (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 years
18 (8.7)
8 (6.5)
10 (11.9)
0.04
40-49 years
48 (23.2)
23 (18.7)
25 (29.8)
50-59 years
141 (68.1)
92 (74.8)
49 (58.3)
ASA-Grade
ASA I
58 (28.0)
19 (15.4)
39 (46.4)
<0.001
ASA II
81 (39.1)
47 (38.2)
34 (40.5)
ASA III
62 (30.0)
52 (42.3)
10 (11.9)
ASA IV
6 (2.9)
5 (4.1)
1 (1.2)
BMI
n=204
n=120
n=84
BMI <18.5
20 (9.7)
17 (13.8)
3 (3.6)
0.037
BMI 18.5-25
108 (52.2)
57 (46.3)
48 (57.1)
BMI >25
76 (36.7)
46 (38.3)
33 (39.3)
Type of trauma
Low-energy trauma
142 (68.6)
100 (81.3)
42 (50)
<0.001
Moderate-high energy trauma
65 (31.4)
23 (18.7)
42 (50)
DEXA score
n=185
n=109
n=76
Normal, T-score > -1
18 (9.7)
9 (8.2)
9 (11.8)
0.027
Osteopenia, T-score -1 to -2.5
105 (56.8)
55 (50.5)
50 (65.8)
Osteoporosis, T-score < -2.5
62 (33.5)
45 (41.3)
17 (22.4)
New Mobility Score (0-9 points):
N=207
n=123
n=84
0-8 points
33 (15.9)
30 (24.4)
3 (3.6)
< 0.001
9 points
174 (84.1)
93 (75.6))
81 (96.4)
Type of fracture
Intracapsular
124 (59.9)
69 (56.1)
55 (65.5)
0.2
Extracapsular
76 (36.7)
48 (39)
28 (33.3)
Subtrochanteric
7 (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.
Men reported significantly higher EQ values compared to women. An activity score ≥11 indicate fulfilment of WHO recommendations for weekly physical activity
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=53
90 (75-94), n=51
0.02
Self-rated health EQ, VAS 0-100, Women
75 (50-89), n=74
60 (41-80), n=49
90 (78-98), n=25
< 0.001
Data are reported as mean (SD) or as median (25-75% quartiles).
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 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.
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 4Distribution of pre-fracture sedentary time score during a normal day by gender.
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 [
], 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 [
]. 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 [
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 [
]. 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 [
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 [
]. 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 [
]. 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 [
]. 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.
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
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.
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.
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Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age.
The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations.
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.
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
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.
Men reported significantly higher EQ values compared to women. An activity score ≥11 indicate fulfilment of WHO recommendations for weekly physical activity
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