Post-stroke hip fractures

Comparative Analysis of Fall Risk Assessment Features in Community-Elderly and Stroke Survivors: Insights from Sensor-Based Data

Fall-risk assessment studies generally focus on identifying characteristics that affect postural balance in a specific group of subjects. However, falls affect a multitude of individuals. Among the groups with the most recurrent fallers are the community-dwelling elderly and stroke survivors. Thus, this study focuses on identifying a set of features that can explain fall risk for these two groups of subjects. Sixty-five community dwelling elderly (forty-nine female, sixteen male) and thirty-five stroke-survivors (twenty-two male, thirteen male) participated in our study. With the use of an inertial sensor, some features are extracted from the acceleration data of a Timed Up and Go (TUG) test performed by both groups of individuals. A short-form berg balance scale (SFBBS) score and the TUG test score were used for labeling the data. With the use of a 100-fold cross-validation approach, Relief-F and Extra Trees Classifier algorithms were used to extract sets of the top 5, 10, 15, 20, 25, and 30 features. Random Forest classifiers were trained for each set of features. The best models were selected, and the repeated features for each group of subjects were analyzed and discussed. The results show that only the stand duration was an important feature for the prediction of fall risk across all clinical tests and both groups of individuals.

Post-stroke hip fracture in older people: A narrative review

Background/Aims:

A hip fracture is a serious and common complication after stroke. Individuals often experience particular gait problems post-stroke and may have difficulty with everyday activities such as walking. Therefore, the interventions for falls prevention in older patients should be re-examined when applied to the post-stroke population. This study reviews the risk factors for falls and hip fractures that are specific to the post-stroke population and the measures that may be taken to prevent hip fractures and/or falls in this patient group.

Method:

A narrative review of articles written in English in the scientific literature on the risk factors, natural history and prevention of hip fractures in post-stroke patients.

Results:

The interventions that were reviewed showed some benefit to post-stroke patients. These included interventions designed to increase physical activity, water-based exercise, general falls prevention programmes, and the use of force platforms and body weight supported treadmills. More solid evidence was found to support strategies such as the symmetrical use of limbs, which provides appropriate support and an environment where an individual can regain more normal movement patterns. This can be achieved by training in a low-gravity environment using water-based exercises or a body-weight supported treadmill. To perform more symmetrical movements, biofeedback (visual feedback) or a force platform can be used in addition to symmetrical exercises.

Conclusions:

In a post-stroke population, it is better to pay special attention to the prevention of falls and hip fracture than to rehabilitate after a fracture has occurred. Evaluation and management of the risk factors that contribute to falls should be a priority in post-stroke rehabilitation, focusing on as many risk factors as possible in hip fracture prevention programmes. A variety of techniques should be used to facilitate functional recovery, emphasising symmetry and optimal movement patterns.

Mobility and one-year mortality of stroke patients after hip-fracture surgery

BACKGROUND

History of stroke is a risk factor for hip fracture. We investigated one-year mortality and change of mobility differences between stroke patients and non-stroke patients after hip-fracture surgery.

METHODS

We retrospectively evaluated 548 patients who had hip-fracture surgery from May 2003 to Dec 2008 and were older than 50 years at the time of surgery. We identified 77 patients with a history of stroke and 471 patients with no history of stroke. We compared postoperative change of mobility and 1-year mortality for the two groups.

RESULTS

Although stroke patients had lower preinjury mobility (p < 0.001) and higher American Society of Anesthesiologists score (p < 0.001), 1-year mortality and the decrease of mobility were similar to those for non-stroke patients.

CONCLUSIONS

History of stroke did not affect 1-year mortality and the decrease of mobility after hip fracture.

LEVEL OF EVIDENCE

Therapeutic level III.

Sit-to-Stand in People with Stroke: Effect of Lower Limb Constraint-Induced Movement Strategies

Background. Weight-bearing asymmetry and impaired balance may contribute to the increased fall risk in people with stroke when rising to stand from sitting. Objective. This study investigated the effect of constraint-induced movement (CIM) strategies on weight-bearing symmetry and balance during sit-to-stand in people with stroke. Methods. A nonrandom convenience sample of fifteen people with stroke performed the sit-to-stand task using three CIM strategies including a solid or compliant (foam) block strategy, with the unaffected limb placed on the block, and an asymmetrical foot position strategy, with the unaffected limb placed ahead of the affected limb. Duration of the task, affected limb weight-bearing, and centre of pressure and centre of mass displacement were measured in the frontal and sagittal plane. Results. Affected limb weight-bearing was increased and frontal plane centre of pressure and centre of mass moved toward the affected limb compared to baseline with all CIM strategies. Centre of mass displacement in the sagittal plane was greater with the compliant block and asymmetrical foot strategies. Conclusions. The CIM strategies demonstrated greater loading of the affected limb and movement of the centre of pressure and centre of mass toward the affected limb. The compliant block and asymmetrical foot conditions may challenge sagittal plane balance during sit-to-stand in people with stroke.

Bone mineral density in adults disabled through acquired neurological conditions: a review

This article is a review of the changes in bone mineral density (BMD), which occur in a number of acquired neurological conditions resulting in disability. For each of spinal cord injury, stroke, multiple sclerosis, Parkinson's disease, and traumatic brain injury, the following aspects are discussed, where information is available: prevalence of low BMD according to World Health Organization diagnostic categories and recommended diagnostic method, prevalence based on other diagnostic tools, comparison of BMD with a control population, rate of decline of BMD following onset of the neurological condition, factors influencing decline; mechanism of bone loss, and fracture rates. The common risk factors of immobilization and vitamin D deficiency would appear to cross all disability groups, with the most rapid phase of bone loss occurring in the acute and subacute phases of each condition.

The impact of hip fracture (HF) on the functional status (FS) of older persons in Rio de Janeiro, Brazil: results of a prospective cohort study

There is no prospective study investigating the impact of hip fracture (HF) on functional status (FS) in Brazil. The objective of this study was to investigate the impact of a HF on the FS of older persons 1 year after the fracture and the factors associated with decline in FS 1 year after the fracture. Two hundred and forty-six patients who were admitted to one of four hospitals after HF participated. The sample for this study consisted of 160 patients who were still alive and had information on functional limitations after 1 year. The Brazil Old Age Schedule (BOAS) was used to assess FS before and 1 year after HF. Logistic regression analyses were used to identify predictors of decline 1 year after fracture. Of the patients, 46.3% did not achieve their prior FS. Older age, being underweight, total length of stay and the use of psychotics/sedatives and anxiolitics were associated in multivariate analyses with decline in FS. Working before the fracture was protective of decline in FS. We conclude that HF severely compromised the FS of older persons in Rio de Janeiro, Brazil.

Reduced hip bone mineral density is related to physical fitness and leg lean mass in ambulatory individuals with chronic stroke

Following a stroke, the reduced level of physical activity and functional use of the paretic leg may lead to bone loss and muscle atrophy. These factors and the high incidence of falls may contribute to hip fractures in the stroke population. This study was the first to examine total proximal femur bone mineral content (BMC) and bone mineral density (BMD) and their relationship to stroke-specific impairments in ambulatory individuals with chronic stroke (onset >1 year). We utilized dual-energy X-ray absorptiometry (DXA) to acquire proximal femur and total body scans on 58 (23 women) community-dwelling individuals with chronic stroke. We reported total proximal femur BMC (g) and BMD (g/cm2) derived from the proximal femur scans, and lean mass (g) and fat mass (g) for each leg derived from the total body scans. Each subject was evaluated for ambulatory capacity (Six-Minute Walk Test), knee extension strength (hand-held dynamometry), physical fitness [maximal oxygen uptake (VO2max)] and spasticity (Modified Ashworth Scale). Results showed that the paretic leg had significantly lower proximal femur BMD, lean mass and percent lean mass, but higher fat mass than the non-paretic leg for both men and women. Proximal femur BMD of the paretic leg was significantly related to ambulatory capacity (r=0.33, P=0.011), muscle strength (r=0.39, P=0.002), physical fitness (r=0.57, P<0.001), but not related to spasticity (r=-0.23, P=0.080). Multiple regression analysis showed that lean mass in the paretic leg was a major predictor (r2=0.371, P<0.001) of the paretic proximal femur BMD. VO2max was a significant predictor of both paretic proximal femur BMD (r2=0.325, P<0.001) and lean mass in the paretic leg (r2=0.700, P<0.001). Further study is required to determine whether increasing physical fitness and lean mass are important to improve hip bone health in chronic stroke.

Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

OBJECTIVES

To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers.

DESIGN

Cross-sectional, observational study.

SETTING

Community.

PARTICIPANTS

Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 +/- 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire.

RESULTS

Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P = .018) and ADL ability (P = .010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls.

CONCLUSIONS

The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability.

Effect of previous cerebrovascular accident on outcome after hip fracture

OBJECTIVE

To evaluate the effect of previous cerebrovascular accident on outcome after hip fracture.

STUDY DESIGN

Prospective, consecutive.

PATIENTS

From July 1987 to March 1997, 862 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed.

INTERVENTION

All patients had operative fracture treatment.

MAIN OUTCOME MEASUREMENTS

Postoperative complications, in-hospital mortality, hospital length of stay, hospital discharge status, one-year mortality and place of residence, and return to preinjury ambulatory level, basic and instrumental activities of daily living status.

RESULTS

Sixty-three patients (7.3 percent) had a history of cerebrovascular accident; the fracture was on the hemiplegic side in forty-six (86.8 percent) of the fifty-three patients with hemiplegia. Patients who had a history of cerebrovascular accident were more likely to be male and have an American Society of Anesthesiologists (ASA) rating of III or IV. They were also more likely to have three or more comorbidities, be a home ambulator, and be dependent on basic and instrumental activities of daily living before hip fracture. Hospital length of stay was significantly higher for patients who had a history of cerebrovascular accident. There were no differences in the incidence of hospital mortality or one-year mortality between patients who did and did not have a history of cerebrovascular accident before hip fracture. In addition, at one-year follow-up, when controlling for prefracture level of function, there were no differences in the rate of functional recovery between the two groups of patients.

CONCLUSIONS

The functional recovery of elderly hip fracture patients who had a prior cerebrovascular accident was similar to that of patients who had no history of a prior cerebrovascular accident.

Hemiosteoporosis after severe stroke, independent of changes in body composition and weight

BACKGROUND AND PURPOSE

Fractures are a serious complication after stroke, and the risk of hip fractures among stroke patients is increased 2 to 4 times versus a reference population. Fractures after stroke are probably caused by the development of hemiosteoporosis and the high incidence of accidental falls. The aim of this study was to investigate the development of hemiosteoporosis in relation to other changes in body composition during the first year after severe stroke.

METHODS

The study included 24 patients with extensive paresis after stroke. Bone mineral content (BMC) and fat and lean mass were assessed 1, 4, 7, and 12 months after stroke onset by a dual-energy x-ray absorptiometer.

RESULTS

The loss of total body BMC was significant during the first year after stroke (-1.6%; P<0.05), but there were no significant changes in total lean or fat mass. At inclusion, there were no significant differences between sides in lean or fat mass or BMC, but during follow-up, BMC of the affected side decreased significantly compared with the same side at inclusion (-7.5%; P<0.01). Side differences in fat mass became significant between legs (9.3%; P<0.001) and whole sides (4. 8%; P<0.01). There were only minor side changes in lean mass. Loss of BMC was independent of weight changes.

CONCLUSIONS

During the first year after severe stroke, patients developed pronounced hemiosteoporosis. This was not associated with general changes in lean or fat mass. The development of hemiosteoporosis was independent of weight changes after stroke.

Secondary osteoporosis

Generalized osteoporosis currently represents a heterogeneous group of conditions with many different causes and pathogenetic mechanisms, that often are variably associated. The term "secondary" is applied to all patients with osteoporosis in whom the identifiable causal factors are other than menopause and aging. In this heterogeneous group of conditions, produced by many different pathogenetic mechanisms, a negative bone balance may be variably associated with low, normal or increased bone remodeling states. A consistent group of secondary osteoporosis is related to endocrinological or iatrogenic causes. Exogenous hypercortisolism may be considered an important risk factor for secondary osteoporosis in the community, and probably glucocorticoid-induced osteoporosis is the most common type of secondary osteoporosis. Supraphysiological doses of corticosteroids cause two abnormalities in bone metabolism: a relative increase in bone resorption, and a relative reduction in bone formation. Bone loss, mostly of trabecular bone, with its resultant fractures is the most incapacitating consequence of osteoporosis. The estimated incidence of fractures in patients prescribed corticosteroid is 30% to 50%. Osteoporosis is considered one of the potentially serious side effects of heparin therapy. The occurrence of heparin-induced osteoporosis appeared to be strictly related to the length of treatment (over 4-5 months), and the dosage (15,000 U or more daily), but the pathogenesis is poorly understood. It has been suggested that heparin could cause an increase in bone resorption by increasing the number of differentiated osteoclasts, and by enhancing the activity of individual osteoclasts. Hyperthyroidism is frequently associated with loss of trabecular and cortical bone; the enhanced bone turnover that develops in thyrotoxicosis is characterized by an increase in the number of osteoclasts and resorption sites, and an increase in the ratio of resorptive to formative bone surfaces, with the net result of bone loss. Despite these findings, the occurrence of pathological fractures in patients with hyperthyroidism is relatively low, and probably due to the fact that deficiencies in bone mass may be reversed by treatment of the thyroid disease. Most, but not all, studies on insulin-dependent diabetes mellitus (IDDM) report an association with osteopenia. In IDDM, the extent of bone loss is usually slight, which helps explain the discrepancy between the frequency of decreased bone mineral density, and the frequency of osteoporotic fractures in long-standing diabetes. Contradictory results have been obtained in non-insulin-dependent diabetes mellitus (NIDDM) patients. Increased rates of bone loss at the radius and lumbar spine were demonstrated either in patients with two-thirds gastric resection and Billroth II reconstruction, or in those with one-third resection and Billroth I anastomosis, and the metabolic bone disease following gastrectomy may consist also of osteomalacia or mixed pattern of osteoporosis-osteomalacia, with secondary hyperparathyroidism. Miscellaneous causes of secondary osteoporosis are also immobilization, pregnancy and lactation, and alcohol abuse.