RETRACTED: Changes in the supporting muscles of the fractured hip in elderly women

Low Hand Grip Strength, Mid-Upper Arm Muscle Area, Calf Circumference, Serum Albumin Level, and Muscle Fiber Diameter as Risk Factors for Independent Walking Inability in Patients with Hip Fracture 6 Weeks after Bipolar Hemiarthroplasty Surgery

Background

Bipolar hemiarthroplasty, one of the main treatment modalities for hip fracture, does not always promise the ability to walk independently after surgery. Patients with the same fracture characteristics and comorbidities, implants, and operators may also have different outcomes. Sarcopenia is thought to be one of the causes of the inability to walk independently after this operation; however, it has not been widely studied and is often overlooked.

Methods

This study used a case-control design with 23 patients in the case group (patients unable to walk independently) and 23 patients in the control group (patients able to walk independently). Sampling was carried out consecutively according to the inclusion and exclusion criteria based on the medical records of patients with hip fractures after bipolar hemiarthroplasty at our hospital. In the preoperative period, hand grip strength (HGS), mid-upper arm muscle area (MUAMA), calf circumference (CC), serum albumin level, and total lymphocyte count were measured. A muscle biopsy was performed intraoperatively from the gluteus muscle with the amount of 200-350 mg. The patient's walking ability was assessed in the polyclinic using the Timed Up and Go test 6 weeks postoperatively. The statistical tests used were descriptive statistics, proportion comparison analysis with the chi-square test, and multiple logistic regression test.

Results

Univariate analysis using chi-square test proved HGS, MUAMA, CC, serum albumin level, and muscle fiber diameter as risk factors for inability to walk independently 6 weeks after bipolar hemiarthroplasty (p = 0.003, p = 0.003, p = 0.006, p = 0.044, and p = 0.000, respectively). Logistic regression test proved 3 direct risk factors for the inability to walk independently 6 weeks after bipolar hemiarthroplasty, namely MUAMA, serum albumin level, and muscle fiber diameter, as the strongest predictive factor (adjusted odds ratio, 63.12).

Conclusions

Low MUAMA, serum albumin levels, and muscle fiber diameter are direct risk factors for the inability to walk independently in hip fracture patients 6 weeks after bipolar hemiarthroplasty.

Peri-implant femoral fractures in hip fracture patients treated with osteosynthesis: a retrospective cohort study of 1965 patients

BACKGROUND AND PURPOSE

There are few studies on incidence rates, treatment and outcomes for peri-implant femoral fractures (PIFF) in the proximity of osteosynthesis. The purpose of this study was to investigate the incidence of PIFF following osteosynthesis of proximal femoral fractures.

PATIENTS AND METHODS

This retrospective cohort study comprised a consecutive series of hip fracture patients aged 50 years or older and operated with osteosynthesis between 2003 and 2015. Patients were followed-up until 2018, removal of implants or death, for a mean of 4 years (range 0-15). Data on age, sex, housing, hip complications, and reoperations were recorded. The risk of PIFFs was assessed using Cox proportional hazards regression analysis. In patients with two fractures during the study period, only the first fracture was included.

RESULTS

A total of 1965 osteosynthesis procedures were performed, of which 382 were cephalomedullary nails (CMN), 933 sliding hip devices (SHD) and 650 pins. Mean age was 80 years (range 50-104), 65% of patients were women. A total of 41 PIFFs occurred during the study period. The cumulative incidence of peri-implant fractures was 0.8% for CMN, 2.7% (HR 2.995% CI, 0.87-9.6, p = 0.08) for SHD and 2.0% (HR 2.3 95% CI, 0.6-8.1, p = 0.2) for pins. PIFFs occurred after a mean of 27 months (range 0-143). The 1-year mortality was 34% following PIFF. The majority was treated surgically (66%, 27/41) and the reoperation rate was 15% (4/27).

CONCLUSION

In this retrospective cohort study, in contrast to previous reports, we found a tendency to a higher cumulative incidence of PIFFs for SHD compared to modern CMN. Our results show cumulative incidences of PIFFs comparable to those described for periprosthetic femur fractures after hip arthroplasty for femoral neck fracture.

VITamin D and OmegA-3 TriaL (VITAL): Effects of Vitamin D Supplements on Risk of Falls in the US Population

CONTEXT

It is unclear whether vitamin D supplementation reduces risk of falls, and results from randomized controlled trials (RCTs) are conflicting.

OBJECTIVE

The objective of this work is to determine whether 2000 IU/day of supplemental vitamin D3 decreases fall risk.

DESIGN

VITamin D and OmegA-3 TriaL (VITAL) is a double-blind, placebo-controlled RCT including 25 871 adults, randomly assigned November 2011 to March 2014 and treated for 5.3 years (median).

SETTING

This is a nationwide study.

PARTICIPANTS

Men 50 years or older and women 55 years or older (mean age, 67.1 years) without cancer or cardiovascular disease at baseline participated in this study.

INTERVENTIONS

Interventions included vitamin D3 (cholecalciferol; 2000 IU/day) and/or omega-3 fatty acids (1 g/day) or respective placebos in a 2 × 2 factorial design.

MAIN OUTCOME MEASURES

Main outcome measures include 2 or more falls and falls resulting in a doctor or hospital visit.

RESULTS

Baseline serum total 25-hydroxyvitamin D (25[OH]D) level was 77 nmol/L; characteristics were well-balanced between groups. Numbers of participants with 2 or more falls were similar between active and placebo groups (9.8% vs 9.4%). Over 5 years, there were no differences in the proportion having 2 or more falls (odds ratio [OR] = 0.97; 95% CI, 0.90-1.05, P = .50), falls resulting in a doctor visit (OR = 1.03; 95% CI, 0.94-1.13, P = .46), or resulting in a hospital visit (OR = 1.04; 95% CI, 0.90-1.19, P = .61) between groups. Results did not differ between those with baseline 25(OH)D less than 50 vs 50 nmol/L or greater or other cut points.

CONCLUSION

Daily supplemental vitamin D3 vs placebo did not decrease fall risk in generally healthy adults not selected for vitamin D insufficiency. This large RCT does not indicate that supplemental vitamin D should be used for primary prevention of falls in the US population.

Molecular-Based Treatment Strategies for Osteoporosis: A Literature Review

Osteoporosis is an unavoidable public health problem in an aging or aged society. Anti-resorptive agents (calcitonin, estrogen, and selective estrogen-receptor modulators, bisphosphonates, anti-receptor activator of nuclear factor κB ligand antibody along with calcium and vitamin D supplementations) and anabolic agents (parathyroid hormone and related peptide analogs, sclerostin inhibitors) have major roles in current treatment regimens and are used alone or in combination based on the pathological condition. Recent advancements in the molecular understanding of bone metabolism and in bioengineering will open the door to future treatment paradigms for osteoporosis, including antibody agents, stem cells, and gene therapies. This review provides an overview of the molecular mechanisms, clinical evidence, and potential adverse effects of drugs that are currently used or under development for the treatment of osteoporosis to aid clinicians in deciding how to select the best treatment option.

Anticipatory postural adjustments and spatial organization of motor cortex: evidence of adaptive compensations in healthy older adults

During anticipated postural perturbations induced by limb movement, the central nervous system generates anticipatory postural adjustments (APAs) in the trunk and hip musculature to minimize disturbances to equilibrium. Age-related changes in functional organization of the nervous system may contribute to changes in APAs in healthy older adults. Here we examined if altered APAs of trunk/hip musculature in older adults are accompanied by changes in the representation of these muscles in motor cortex. Twelve healthy older adults, 5 with a history of falls and 7 nonfallers, were compared with 13 young adults. APAs were assessed during a mediolateral arm raise task in standing. Temporal organization of postural adjustments was quantified as latency of APAs in the contralateral external oblique, lumbar paraspinals, and gluteus medius relative to activation of the deltoid. Spatial organization was quantified as extent of synergistic coactivation between muscles. Volume and location of the muscle representations in motor cortex were mapped using transcranial magnetic stimulation. We found that older adults demonstrated significantly delayed APAs in the gluteus medius muscle. Spatial organization of the three muscles in motor cortex differed between groups, with the older adults demonstrating more lateral external oblique representation than the other two muscles. Separate comparisons of the faller and nonfaller subgroups with young adults indicated that nonfallers had the greatest delay in gluteus medius APAs and a reduced distance between the representational areas of the lumbar paraspinals and gluteus medius. This study indicates that altered spatial organization of motor cortex accompanies altered temporal organization of APA synergies in older adults.

NEW & NOTEWORTHY Anticipatory postural adjustments are a critical component of postural control. Here we demonstrate that, in healthy older adults with and without a history of falls, delayed anticipatory postural adjustments in the hip musculature during mediolateral perturbations are accompanied by altered organization of trunk/hip muscle representation in motor cortex. The largest adaptations are evident in older adults with no history of falls.

Asymmetry in CT Scan Measures of Thigh Muscle 2 Months After Hip Fracture: The Baltimore Hip Studies

BACKGROUND

Hip fracture is an important problem for older adults with significant functional consequences. After hip fracture, reduced muscle loading can result in muscle atrophy.

METHODS

We compared thigh muscle characteristics in the fractured leg with those in the nonfractured leg in participants from the Baltimore Hip Studies 7th cohort using computed tomography (CT) scan imaging.

RESULTS

At 2 months postfracture, a single 10-mm axial CT scan was obtained at the midthigh level in 47 participants (26 men and 21 women) with a mean age of 80.4 years (range 65-96), and thigh muscle cross-sectional area (CSA), CSA of intermuscular adipose tissue (IMAT), as well as mean radiological attenuation were measured. Total thigh muscle CSA was less on the side of the fracture by 9.2 cm(2) (95% CI: 5.9, 12.4 cm(2)), whereas the CSA of IMAT was greater by 2.8 cm(2) (95% CI: 1.9, 3.8 cm(2)) on the fractured side. Mean muscle attenuation was lower on the side of the fracture by 3.61 HU (95% CI: 2.99, 4.24 HU).

CONCLUSIONS

The observed asymmetry is consistent with the effect of disuse and inflammation in the affected limb along with training effects in the unaffected limb due to the favoring of this leg with ambulation during the postfracture period.

Asymmetry in CT Scan Measures of Thigh Muscle 2 Months After Hip Fracture: The Baltimore Hip Studies

BACKGROUND

Hip fracture is an important problem for older adults with significant functional consequences. After hip fracture, reduced muscle loading can result in muscle atrophy.

METHODS

We compared thigh muscle characteristics in the fractured leg to those in the nonfractured leg in participants from the Baltimore Hip Studies 7th cohort using computed tomography scan imaging.

RESULTS

At 2 months postfracture, a single 10mm axial computed tomography scan was obtained at the midthigh level in 43 participants (23 men, 20 women) with a mean age of 79.9 years (range: 65-96 years), and thigh muscle cross-sectional area, cross-sectional area of intermuscular adipose tissue, and mean radiologic attenuation were measured. Total thigh muscle cross-sectional area was less on the side of the fracture by 9.46cm(2) (95% CI: 5.97cm(2), 12.95cm(2)) while the cross-sectional area of intermuscular adipose tissue was greater by 2.97cm(2) (95% CI: 1.94cm(2), 4.01cm(2)) on the fractured side. Mean muscle attenuation was lower on the side of the fracture by 3.66 Hounsfield Units (95% CI: 2.98 Hounsfield Units, 4.34 Hounsfield Units).

CONCLUSIONS

The observed asymmetry is consistent with the effect of disuse and inflammation in the affected limb along with training effects in the unaffected limb due to the favoring of this leg with ambulation during the postfracture period.

Methods for Dynamic Characterization of the Major Muscles Activating the Lower Limb Joints in Cycling Motion

The functional activation, through electrical stimulation, of the lower limb consisting of several deficient muscles requires well-patterned and coordinated activation of these muscles. This study presents a method for characterizing the parameters of the major muscle groups controlling the ankle and knee joints in cycling motion, the latter having particular significance in the rehabilitation of locomotion. To lower mechanical indeterminacy in the joints the system is reduced by grouping the muscles acting in synergism. The joint torques were calculated by inverse dynamics methods from cycling motion data, including kinematics and foot/pedal reaction loads (forces, moments). The mechanical indeterminacy was resolved by applying optimization criteria and the individual muscle torques were parceled-out from the joint torques. System identification of the individual muscles, part of which being bi-articular, in this non-isometric condition was performed from the relationship between the evaluated force and the measured EMG of each the muscles, using both first and second order linear transfer functions. Feasibility of the presented method was demonstrated through the computation of the coefficients of the muscles involved and validating the results on the experimental data obtained from one subject.

Hip strength: ankle proprioceptive threshold ratio predicts falls and injury in diabetic neuropathy

INTRODUCTION

We determined lower limb neuromuscular capacities associated with falls and fall-related injuries in older people with declining peripheral nerve function.

METHODS

Thirty-two subjects (67.4 ± 13.4 years; 19 with type 2 diabetes), representing a spectrum of peripheral neurologic function, were evaluated with frontal plane proprioceptive thresholds at the ankle, frontal plane motor function at the ankle and hip, and prospective follow-up for 1 year.

RESULTS

Falls and fall-related injuries were reported by 20 (62.5%) and 14 (43.8%) subjects, respectively. The ratio of hip adductor rate of torque development to ankle proprioceptive threshold (Hip(STR) /AnkPRO ) predicted falls (pseudo-R(2)  = .726) and injury (pseudo-R(2)  = .382). No other variable maintained significance in the presence of Hip(STR) /AnkPRO .

CONCLUSIONS

Fall and injury risk in the population studied is related inversely to Hip(STR) /AnkPRO . Increasing rapidly available hip strength in patients with neuropathic ankle sensory impairment may decrease risk of falls and related injuries.

25(OH) vitamin D is associated with greater muscle strength in healthy men and women

PURPOSE

The purpose of the study was to examine the relation between serum 25-hydroxy vitamin D (25(OH)D) levels and muscle strength in 419 healthy men and women over a broad age range (20-76 yr).

METHODS

Isometric and isokinetic strength of the arms and legs was measured using computerized dynamometry, and its relation to vitamin D was tested in multivariate models controlling for age, gender, resting HR, systolic blood pressure, diastolic blood pressure, body mass index, maximal oxygen uptake (VO(2max)), physical activity counts, and season of vitamin D measurement.

RESULTS

Vitamin D was significantly associated with arm and leg muscle strength when controlling for age and gender. When controlling for other covariates listed previously, vitamin D remained directly related to both isometric and isokinetic arm strength but only to isometric leg strength.

CONCLUSION

These data suggest that there may be a differential effect of vitamin D on upper and lower body strength. The mechanism for this difference remains unclear but could be related to differences in androgenic effects or to differences in vitamin D receptor expression. Our study supports a direct relation between vitamin D and muscle strength and suggests that vitamin D supplementation be evaluated to determine whether it is an effective therapy to preserve muscle strength in adults.

Relationship between 25-hydoxyvitamin D, muscle strength, and incidence of injury in healthy adults: a systematic review

The purpose of this systematic review is to answer the following clinical questions in healthy adults: is vitamin D status related to (1) muscle strength? (2) or incidence of injury? A literature search was performed using Pubmed, SPORTDiscus, and Web of Science to capture relevant articles that have examined these outcomes. Inclusion criteria required studies to address at least one of the 2 questions stated above, enroll healthy human subjects with a mean age of 18 to 65 years of age, and include serum 25-hydoxyvitamin D measures. Study characteristics such as vitamin D status, study design, and study population were documented. Measured assessors and outcomes from all studies were extracted to answer at least one of the two questions. When applicable, data were used to compute effect sizes at a 95% confidence interval for comparisons across studies to answer the 2 questions. The results of these studies indicate a weak to moderate effect of higher 25-hydoxyvitamin D levels on greater muscle strength and reduced incidence of injury. Randomized controlled clinical trials examining these questions are scarce when compared with the popularity of vitamin D testing; therefore, future trials are necessary to advance our understanding and to clarify the effect vitamin D has on extraskeletal outcomes in healthy adults.

Differential features of muscle fiber atrophy in osteoporosis and osteoarthritis

We demonstrated that osteoporosis is associated with a preferential type II muscle fiber atrophy, which correlates with bone mineral density and reduced levels of Akt, a major regulator of muscle mass. In osteoarthritis, muscle atrophy is of lower extent and related to disease duration and severity.

INTRODUCTION

Osteoarthritis (OA) and osteoporosis (OP) are associated with loss of muscle bulk and power. In these diseases, morphological studies on muscle tissue are lacking, and the underlying mechanisms of muscle atrophy are not known. The aim of our study was to evaluate the OP- or OA-related muscle atrophy and its correlation with severity of disease. Muscle levels of Akt protein, a component of IGF-1/PI3K/Akt pathway, the main regulator of muscle mass, have been determined.

METHODS

We performed muscle biopsy in 15 women with OP and in 15 women with OA (age range, 60-85 years). Muscle fibers were counted, measured, and classified by ATPase reaction. By statistical analysis, fiber-type atrophy was correlated with bone mineral density (BMD) in the OP group and with Harris Hip Score (HHS) and disease duration in the OA group. Akt protein levels were evaluated by Western blot analysis.

RESULTS

Our findings revealed in OP a preferential type II fiber atrophy that inversely correlated with patients' BMD. In OA, muscle atrophy was of lower extent, homogeneous among fiber types and related to disease duration and HHS. Moreover, in OP muscle, the Akt level was significantly reduced as compared to OA muscles.

CONCLUSIONS

This study shows that in OP, there is a preferential and diffuse type II fiber atrophy, proportional to the degree of bone loss, whereas in OA, muscle atrophy is connected to the functional impairment caused by the disease. A reduction of Akt seems to be one of the mechanisms involved in OP-related muscle atrophy.

Strategy for prevention of hip fractures in patients with Parkinson's disease

Hypovitaminosis D and K due to malnutrition or sunlight deprivation, increased bone resorption due to immobilization, low bone mineral density (BMD) and an increased risk of falls may contribute to an increased risk of hip fractures in patients with Parkinson's disease. The purpose of the present study was to clarify the efficacy of interventions intended to prevent hip fractures in elderly patients with Parkinson's disease. PubMed was used to search the literature for randomized controlled trials (RCTs) regarding Parkinson's disease and hip fractures. The inclusion criteria were 50 or more subjects per group and a study period of 1 year or longer. Five RCTs were identified and the relative risk and 95% confidence interval were calculated for individual RCTs. Sunlight exposure increased serum hydroxyvitamin D [25(OH)D] concentration, improved motor function, decreased bone resorption and increased BMD. Alendronate or risedronate with vitamin D supplementation increased serum 25(OH)D concentration, strongly decreased bone resorption and increased BMD. Menatetrenone (vitamin K(2)) decreased serum undercarboxylated osteocalcin concentration, decreased bone resorption and increased BMD. Sunlight exposure (men and women), menatetrenone (women), alendronate and risedronate with vitamin D supplementation (women) significantly reduced the incidence of hip fractures. The respective RRs (95% confidence intervals) according to the intention-to-treat analysis were 0.27 (0.08, 0.96), 0.13 (0.02, 0.97), 0.29 (0.10, 0.85) and 0.20 (0.06, 0.68). Interventions, including sunlight exposure, menatetrenone and oral bisphosphonates with vitamin D supplementation, have a protective effect against hip fractures elderly patients with Parkinson's disease.

Efficacy of antiresorptive agents for preventing fractures in Japanese patients with an increased fracture risk: review of the literature

The aim of the present review was to clarify the efficacy of currently available potent antiresorptive agents for preventing fractures in Japanese patients with an increased fracture risk. PubMed was used to search the literature for randomized controlled trials (RCTs), with the following search terms: fracture, etidronate, alendronate, risedronate, minodronate, raloxifene, bazedoxifene and Japan. The inclusion criteria were papers written in English, ≥50 subjects per group and a study period of ≥1 year. Fourteen RCTs met these criteria. The efficacy of antiresorptive agents for preventing vertebral, nonvertebral and hip fractures was investigated. There was evidence that raloxifene reduced the incidence of clinical vertebral fractures, while etidronate, alendronate and minodronate (but not bazedoxifene) reduced the incidence of morphometric vertebral fractures in patients with postmenopausal or involutional osteoporosis. Head-to-head trials showed that alendronate and raloxifene had similar efficacy for preventing vertebral fractures in patients with postmenopausal osteoporosis, while risedronate was not inferior to etidronate for reducing the incidence of morphometric vertebral fractures in patients with involutional osteoporosis. Alendronate reduced the incidence of hip fractures in patients with Parkinson's disease, and risedronate reduced the incidence of nonvertebral fractures and hip fractures in patients with Alzheimer's disease or stroke. In conclusion, the present review confirmed the efficacy of etidronate, minodronate and raloxifene for the prevention of vertebral fractures, the efficacy of alendronate for vertebral and hip fractures, and the efficacy of risedronate for vertebral, nonvertebral and hip fractures in Japanese patients with an increased fracture risk.

Sunlight exposure is important for preventing hip fractures in patients with Alzheimer's disease, Parkinson's disease, or stroke

OBJECTIVES

Hypovitaminosis D as a result of malnutrition or sunlight deprivation, increased bone resorption, low bone mineral density (BMD), or an increased risk of falls may contribute to an increased risk of hip fractures in patients with neurological diseases, including Alzheimer's disease, Parkinson's disease, and stroke. The purpose of this study was to clarify the efficacy of sunlight exposure for reducing the risk of hip fractures in patients with such neurological diseases.

METHODS

The English literature was searched using PubMed, and randomized controlled trials evaluating the efficacy of sunlight exposure for reducing the risk of hip fractures in patients with Alzheimer's disease, Parkinson's disease, and stroke were identified. The relative risk and the 95% confidence interval were calculated for individual randomized controlled trials, and a pooled data analysis (meta-analysis) was performed.

RESULTS

Three randomized controlled trials were identified. Sunlight exposure improved hypovitaminosis D and increased the BMD. The relative risk (95% confidence interval) of hip fractures was 0.22 (0.05, 1.01) for Alzheimer's disease, 0.27 (0.08, 0.96) for Parkinson's disease, and 0.17 (0.02, 1.36) for stroke. The relative risk (95% confidence interval) calculated for the pooled data analysis was 0.23 (0.10, 0.56) (P = 0.0012), suggesting a significant risk reduction rate of 77%.

CONCLUSION

The present meta-analysis added additional evidence indicating the efficacy of sunlight exposure for reducing the risk of hip fractures in patients with Alzheimer's disease, Parkinson's disease, and stroke.

Fat content of hip muscles: an anteroposterior gradient

BACKGROUND

Despite the importance of the hip muscles in protecting against hip fracture and in the outcome of hip arthroplasty, the variability in their fat content has not been previously studied. Our objectives were to evaluate the variability in the fat content of the hip muscles in a population without myopathy or a need for hip surgery with the use of computed tomography (CT), to study the relationship between hip muscle fat content and physical performance, and to identify medical conditions and lifestyle habits associated with an increase in hip muscle fat content.

METHODS

Ten normal subjects without a relevant medical history and ninety-nine consecutive nonsurgical patients without myopathy (age, twenty-one to ninety-four years) underwent a nonenhanced CT scan of the pelvis. Patients were asked to perform physical tests (six-meter walk, repeated chair stands, and Trendelenburg test), and their level of physical activity and medical history were recorded. Evaluation of the fat content of the hip muscles was based on the analysis of four reproducible and representative CT slices with use of custom software.

RESULTS

The fat content varied among the muscles, with an anteroposterior gradient from the hip flexors (mean, 2%) to the hip extensors (mean, 10%). This gradient increased after fifty years of age. Fat content also varied considerably among patients. Higher fat content was associated with poorer performance on physical tests, even after adjustment for the cross-sectional area of the muscle (p < 0.05). Higher fat content was also associated with greater age, higher body-mass index, and lower physical activity (p < 0.001).

CONCLUSIONS

The observed variability in the fat content of individuals without myopathy or a need for hip surgery should be useful for comparison with future studies of specific populations of patients, such as those with muscle weakness secondary to hip fracture or hip surgery. Simple lifestyle changes such as dietary restriction, increased physical activity, and vitamin D supplementation may decrease muscle fat content and improve physical performance in the elderly.

Efficacy of oral bisphosphonates for preventing hip fracture in disabled patients with neurological diseases: a meta-analysis of randomized controlled trials among the Japanese population

OBJECTIVE

Neurological diseases such as amyotrophic lateral sclerosis (ALS), stroke, and Parkinson's disease cause disability and immobilization that increases the risk of hip fracture. The purpose of the present study was to clarify the efficacy of oral bisphosphonates for preventing hip fracture in disabled patients with such neurological diseases.

METHODS

A literature search (PubMed) was done from 1995 to the present for randomized controlled trials (RCTs), and a meta-analysis was conducted.

RESULTS

Seven RCTs met the criteria, including two of etidronate (ALS and stroke), two of alendronate (stroke and Parkinson's disease), and three of risedronate (stroke and Parkinson's disease). All of the RCTs were performed on Japanese patients. According to the results of pooled data analysis, the relative risk (95% confidence interval) of hip fracture in patients receiving etidronate, alendronate, and risedronate treatment compared with placebo or active control treatment was 0.16 (0.03-0.87), 0.29 (0.10-0.80), and 0.24 (0.10-0.58), respectively, suggesting a reduction of risk by more than 70% with oral bisphosphonates. There was no statistical evidence of heterogeneity among RCTs, and publication bias was not identified by the funnel plot and Begg's rank correlation test. No severe adverse events due to oral bisphosphonate treatment were reported.

LIMITATION

It remains uncertain whether the findings are relevant for Western patients with an increased risk of hip fracture due to neurological diseases.

CONCLUSION

A meta-analysis of RCTs suggested that oral bisphosphonate treatment prevents hip fracture in disabled Japanese patients with neurological diseases, including ALS, stroke, and Parkinson's disease. Oral bisphosphonate treatment was well tolerated by such patients.

Relationship between fatty degeneration of thigh muscles and vitamin D status in the elderly: a preliminary MRI study

OBJECTIVE

The purpose of this study was to study the relationship between fatty degeneration of thigh muscles and vitamin D status in elderly adults.

SUBJECTS AND METHODS

For six months, 121 patients 65 years old or older were evaluated. Myopathy, muscular impairment, and conditions influencing vitamin D status other than diet and sunlight were exclusion criteria. Twenty patients (10 men and 10 women; mean age, 77.6 years) underwent MRI. Thigh muscles were scanned from the hip to the knee with T1- and T2-weighted spin-echo sequences. Skeletal muscles were evaluated for fatty degeneration and atrophy from grade 0 to 3 (grade 0 = normal appearance, grade 3 = severe changes). The relationship between muscular fatty degeneration, 25-hydroxyvitamin D (25-OHD) levels, and scores on Tinetti scales for balance and gait were examined.

RESULTS

In the evaluation of the extensor muscles for fatty degeneration and atrophy, grade 0 was present in three patients (15%), grade 1 in 11 (55%), and grade 2 in six (30%). In the flexor muscles, grade 0 was found in one patient (5%), grade 1 in five (25%), and grade 2 in 14 (70%); grade 3 changes were not seen. Muscular fatty degeneration negatively correlated with 25-OHD levels (r = -0.50, p < 0.01) and the Tinetti scores (balance: r = -0.40, p < 0.05; gait: r = -0.50, p < 0.05). In 11 vitamin D-deficient patients (55%), there was selective complete atrophy of at least one thigh muscle. The gracilis and sartorius muscles were spared.

CONCLUSION

In elderly adults, fatty degeneration of thigh muscles was associated with vitamin D deficiency and impaired balance and gait. Selective complete fatty degeneration of single muscles was observed.

Muscle strength and mobility in vitamin D-insufficient female geriatric patients: a randomized controlled trial on vitamin D and calcium supplementation

BACKGROUND AND AIMS

Insufficient vitamin D status, commonly found in older people, has been associated with muscle weakness which, in old age, impairs mobility and is a risk factor for falling. In a randomized, double-blind placebo-controlled trial, we tested the hypothesis that vitamin D + calcium supplementation improves muscle strength and mobility, compared with calcium mono-therapy in vitamin D-insufficient female geriatric patients.

METHODS

Seventy female geriatric patients >65 years of age with serum 25-hydroxyvitamin D3 (25OHD) concentrations between 20 and 50 nmol/L, visiting an outpatient geriatric department, were included. Participants received either cholecalciferol 400 IU/day + calcium 500 mg/day (D/Cal group) or a placebo + calcium 500 mg/day (Plac/Cal group) for 6 months. At baseline and 6 months, muscle strength, power and functional mobility were tested.

RESULTS

At baseline, 25OHD was significantly (p<0.05) associated with knee extension strength (r=0.42), handgrip strength (r=0.28), leg extension power (r=0.34), Timed Get Up and Go (r=-0.31) and Modified Cooper test (r=0.44). At 6 months, a significant difference in 25OHD (77.2 vs 41.6 nmol/L, p<0.001) and 1,25OHD was found between the two groups. Significantly improving vitamin D status in the D/Cal group compared with the Plac/Cal group did not result in a significant difference in strength or functional mobility between the two groups.

CONCLUSIONS

Daily 400 IU vitamin D + 500 mg calcium supplementation is not enough to significantly improve strength or mobility in vitamin D-insufficient female geriatric patients.

Prevention of hip fractures by exposure to sunlight and pharmacotherapy in patients with Alzheimer's disease

BACKGROUND AND AIMS

Hypovitaminosis D and K due to malnutrition or sunlight deprivation, compensatory hyperparathyroidism, increased bone resorption, low bone mineral density (BMD), and an increased risk of falls may contribute to an increased risk of hip fractures in patients with Alzheimer's disease. The purpose of the present study was to clarify the efficacy of interventions against hip fractures in patients with Alzheimer's disease.

METHODS

With respect to randomized controlled trials (RCTs) regarding Alzheimer's disease and hip fractures, the literature was searched with PubMed.

RESULTS

Three RCTs were identified, and the relative risk (RR) and 95% confidence interval (CI) were calculated for individual RCTs. Exposure to sunlight with calcium supplementation, menatetrenone (vitamin K2) plus calcium and vitamin D supplementation, and risedronate plus calcium and vitamin D supplementation improved hypovitaminosis D and hyperparathyroidism, contributing to a reduction in bone resorption. Risedronate itself strongly decreased bone resorption. Menatetrenone also decreased the serum level of undercarboxylated osteocalcin. The three interventions increased metacarpal BMD and reduced the incidence of hip fractures. The respective RRs (95% CI) were 0.22 (0.049-0.999), 0.13 (0.031-0.554), and 0.26 (0.100- 0.690).

CONCLUSIONS

The present study clarified the efficacy of three interventions, including exposure to sunlight, menatetrenone, and risedronate with calcium and/or vitamin D supplementation against hip fractures in patients with Alzheimer's disease.

Vitamin D-deficiency and post-fracture changes in lower extremity function and falls in women with hip fractures

We determined the prevalence of vitamin D deficiency and lower extremity function in women with hip fractures. Women with extremely low vitamin D levels had reduced lower extremity muscle function and increased falls 1 year later. Ensuring vitamin D sufficiency after a hip fracture may improve function and reduce falls.

INTRODUCTION

Hip fractures are the most devastating of fractures, commonly leading to loss of independent ambulation and living. In this retrospective analysis we determined the prevalence of vitamin D deficiency in women with hip fractures and the association between 25-hydroxyvitamin D [25(OH)D] levels and functional impairment one year later.

METHODS

One hundred ten community-dwelling women with hip fractures were recruited from Boston, MA (n = 30) and Baltimore, MD (n = 80) before 1998 and 25(OH)D levels were measured by radioimmunoassay. In a subset of women from Baltimore, a performance measure of the lower extremities using the lower extremity gain scale (LEGS) was measured at 2, 6, and 12 months. Falls, grip strength, chair rise time, walking speed, and balance were also determined.

RESULTS

Vitamin D insufficiency defined as a 25(OH)D <or=32 ng/mL was present in 96% of the women with hip fractures and 38% had extremely low levels <or=9 ng/mL. At 1 year post-fracture, compared to women with a 25(OH)D >9 ng/mL, those with 25(OH)D <or=9 ng/mL had poorer LEGS performance (p < 0.0001) and higher fall rates, without group differences in grip strength or balance.

CONCLUSION

Vitamin D sufficiency may have important effects on lower extremity function following hip fractures, without excessive healthcare costs.

Efficacy of risedronate against hip fracture in patients with neurological diseases: a meta-analysis of randomized controlled trials

OBJECTIVE

Neurological diseases, including Alzheimer's disease, stroke, and Parkinson's disease have been reported to increase the risk for fractures. The purpose of the present study was to clarify the efficacy of risedronate against hip fracture in patients with neurological diseases.

METHODS

The literature was searched with PubMed from 1995 to the present, with respect to strictly conducted randomized controlled trials (RCTs) with narrow confidence intervals (CIs), and a meta-analysis was conducted.

RESULTS

Four RCTs met the criteria; one RCT for Alzheimer's disease (n = 461, mean age = 78 years), two RCTs for stroke (n = 267, mean age = 76 years for men; n = 345, mean age = 71 years for women), and one RCT for Parkinson's disease (n = 223, mean age = 71 years). According to the results of RCTs, the relative risks (95% CI) for hip fracture with risedronate treatment compared with placebo treatment were 0.26 (0.10, 0.69) for Alzheimer's disease, 0.20 (0.04, 0.89) for stroke in men, 0.14 (0.02, 1.16) for stroke in women, and 0.34 (0.09, 1.21) for Parkinson's disease. Overall, the relative risk (95% CI) for hip fracture with risedronate treatment was 0.25 (0.13, 0.48), suggesting 75% of risk reduction rate with risedronate treatment in patients with one of the three neurological diseases (heterogeneity: 0.58, p = 0.9016 and overall effect: 17.36, p < 0.0001). No severe adverse events were reported in the risedronate and placebo groups.

CONCLUSION

The results of a meta-analysis of strictly conducted RCTs suggest that there is efficacy against hip fracture and safety with risedronate treatment in patients with neurological diseases including Alzheimer's disease, stroke, and Parkinson's disease.

Vitamin D Status of Patients Admitted to a Hospital Rehabilitation Unit

OBJECTIVE

The primary objective was to determine the association between vitamin D status, baseline function, and short-term inpatient rehabilitation progress.

DESIGN

This was a prospective convenience sampling of 100 patients in a tertiary general hospital rehabilitation unit (RU). The cohort comprised men and women of mixed race with a variety of diagnoses (mean age 70 yrs). Patient histories and demographic information were obtained by patient interview and chart review. Serum 25-hydroxyvitamin D (25OHD) (nmol/L) was measured on or after the day of admission. The Functional Independence Measurement (FIM) instrument, a validated survey tool, was used to measure function at admission and discharge.

RESULTS

Eleven percent of the patients were overtly vitamin D deficient, with serum 25OHD concentrations <20 nmol/L. Ninety-four percent of the patients had serum 25OHD concentrations below the recommended minimum optimal concentration of 80 nmol/L. Using the Spearman rank correlation test, low serum 25OHD was weakly but significantly associated with low total FIM scores: r = 0.25 (P < 0.012) and r = 0.23 (P < 0.021) for admission and discharge total FIM score, respectively. Patients with serum 25OHD concentrations greater than the median value of 41.3 nmol/L had significantly higher FIM efficiency scores (discharge total FIM score - admission total FIM score/length of stay [LOS]) than the subgroup of patients below the median (2.0 +/- 1.1 vs. 1.6 +/- 0.9, respectively; P < or = 0.026). Serum 25OHD was not significantly correlated with FIM efficiency or the unadjusted change in total FIM score (discharge total FIM score - admission total FIM score), but it was significantly correlated with LOS (the lower the serum 25OHD concentration, the longer the LOS, and vice versa; r = -0.235, P < 0.018). Thus, the difference in FIM efficiency between patients with serum 25OHD above and below the median was the result of the significant inverse correlation between serum 25OHD and LOS; as a group, patients with serum 25OHD above the median had a 19% shorter LOS than the group with serum 25OHD below the median value (11.4 +/- 4.9 vs. 14.1 +/- 5.6 days, respectively; P = 0.005).

CONCLUSIONS

Most patients in a hospital RU had a suboptimal serum 25OHD concentration, reflecting what has previously been observed in hospitalized patients in general and also the population at large. Although no specific physical deficits or attributes could be directly attributed to low serum 25OHD, the baseline functional status of RU patients, LOS, and progress attributable to inpatient rehabilitation (FIM efficiency) were favorably affected by higher serum 25OHD concentrations.

Partition between volitional and induced forces in electrically augmented dynamic isometric muscle contractions

Augmentation of force in partially deficient muscles can be achieved by combining electrical stimulation (ES) with their volitional activation (hybrid activation). However, while the overall torque results from the combination of the volitional and the electrically-induced torque components, the exact share between these components is not known. In a previous work, we described a method to resolve the share between the torque components under isometric static contractions. In this work, we extend our analysis to the case of isometric dynamic contractions. Five healthy subjects were instructed to contract their Tibialis Anterior (TA) muscles according to a typical gait-like dynamic torque pattern, that was visually displayed to them, while monitoring their actual ankle torque and TA electromyography (EMG). These experiments were done with and without augmented activation by means of ES. A computational algorithm was developed to dissociate the volitional from the overall torque, based on EMG signal processing and on precalibration of the dynamic system of the volitional torque versus EMG. The results indicated the quantitative relations between decrease in the volitional torque and the required increase in ES enhancement. The developed method also demonstrated what ES intensity profile is necessary to produce a desired overall torque output. This provides the means for designing an adaptive rehabilitation device for the hybrid activation of deficient muscles.

Relationship between 1,25-dihydroxycholecalciferol levels and functional outcome after hip fracture in elderly patients

A prospective study was performed in 109 patients with osteoporotic hip fracture to verify the relationship between 1,25-dihydroxycholecalciferol levels at admission and functional recovery in elderly patients with hip fracture. 47.7% of all the patients had 1,25-dihydroxycholecalciferol levels below the reference values of our laboratory. At 1 year of the fracture only 33 patients (30.3%) had recovered the functional level they had before the fracture. In the bivariate analysis, a statistically significant relationship was found between reduced 1,25-dihydroxycholecalciferol levels and a poorer functional recovery 1 year after the fracture was sustained. A multivariate analysis showed a significant relationship between 1,25-dihydroxycholecalciferol levels and absolute dependence of the patient 1 year after the fracture (P = 0.005; OR 6.97: CI- 1.77-27.41).

Vitamin D Deficiency and Osteoporosis in Rehabilitation Inpatients

OBJECTIVE

To determine vitamin D status and bone mineral density (BMD) in patients admitted to a subacute rehabilitation facility.

DESIGN

Cross-sectional cohort study.

SETTING

Subacute rehabilitation facility.

PARTICIPANTS

Fifty-three community-dwelling patients admitted from June through February 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

BMD, 25-hydroxyvitamin D (25[OH]D), C-telopeptide (CTX), osteocalcin, and dietary milk intake.

RESULTS

Prevalence of vitamin D deficiency (25[OH]D <20 ng/mL) was 49.1%, while a total of 83% of patients were either vitamin D deficient or insufficient (25[OH]D <30 ng/mL). The prevalence of osteopenia (T score, <-1) was 52.8%; osteoporosis (T score, <-2.5) was 17.0%. CTX (bone resorption marker) was elevated in 60.4% of patients. Osteocalcin (bone formation marker) was elevated in 13.2% of patients. Measurements of bone resorption and formation positively correlated (R2 = .22) indicating increased bone remodeling.

CONCLUSIONS

Vitamin D deficiency and osteopenia and osteoporosis were highly prevalent in patients admitted for rehabilitation. Elevated bone resorption and remodeling were evident. This could be due to vitamin D deficiency that should be corrected before antiresorptive therapy is considered. The study emphasizes the need for vigilance for vitamin D status and BMD testing in patients admitted to rehabilitation facilities.

Muscle enhancement using closed-loop electrical stimulation: volitional versus induced torque

In cases of partial deficiency of muscle activation capacity, force augmentation can be achieved by hybrid activation, i.e., by combining electrical stimulation (ES) with volitional activation. In this activation modality the shares of the volitional and induced torques within the overall hybrid torque are unknown. The purpose of this study was to suggest a computational approach to parcel out the volitional and stimulation induced components of joint torque generated during combined voluntary and electrical activation of the Tibialis Anterior muscle (TA). For this purpose, isometric contraction of the TA was studied on 5 healthy subjects, using an activation protocol involving ES alone, volitional activation alone and hybrid activation. Ankle torque and TA EMG were measured. A computational algorithm was developed to dissociate the volitional from the overall torque, based on EMG filtering and on pre-measured calibration curves of volitional torque versus EMG. The results indicated that for a certain hybrid torque there is a linear decaying relationship between the induced torque and the volitional torque shares. Moreover, based on a defined enhancement ratio, the results indicate that within the range of stimulation intensities, there exist regions of increased facilitation, in which the stimulation efficiency is higher under combined compared to isolated conditions.

Prevalence of Vitamin D inadequacy among postmenopausal North American women receiving osteoporosis therapy

PURPOSE

To evaluate serum 25-hydroxyvitamin D [25(OH)D] concentrations and factors related to vitamin D inadequacy in postmenopausal North American women receiving therapy to treat or prevent osteoporosis.

METHODS

Serum 25(OH)D and PTH were obtained in 1536 community-dwelling women between November 2003 and March 2004. Multivariate logistic regression was used to assess risk factors for suboptimal (<30 ng/ml) 25(OH)D.

RESULTS

Ninety-two percent of study subjects were Caucasian, with a mean age of 71 yr. Thirty-five percent resided at or above latitude 42 degrees north, and 24% resided less than 35 degrees north. Mean (sd) serum 25(OH)D was 30.4 (13.2) ng/ml: serum 25(OH)D was less than 20 ng/ml in 18%; less than 25 ng/ml in 36%; and less than 30 ng/ml in 52%. Prevalence of suboptimal 25(OH)D was significantly higher in subjects who took less than 400 vs. 400 IU/d or more vitamin D. There was a significant negative correlation between serum PTH concentrations and 25(OH)D. Risk factors related to vitamin D inadequacy included age, race, body mass index, medications known to affect vitamin D metabolism, vitamin D supplementation, exercise, education, and physician counseling regarding vitamin D.

CONCLUSIONS

More than half of North American women receiving therapy to treat or prevent osteoporosis have vitamin D inadequacy, underscoring the need for improved physician and public education regarding optimization of vitamin D status in this population.

Age-related changes in hip abductor and adductor joint torques

OBJECTIVE

To test the hypothesis that older age significantly affects hip abduction and adduction joint torque-time generating capability in women.

DESIGN

Cross-sectional study, wherein subjects were tested in a supported standing position.

SETTING

University human performance laboratory.

PARTICIPANTS

Seventy-six healthy, adult women (38 young; 38 old).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The dependent variables were peak isometric torque and its corresponding torque rate and average peak isokinetic torque. Age group differences were assessed by analysis of variance.

RESULTS

Isometric peak torques were significantly lower in older women (P</=.001) for hip abduction (34%) and adduction (24%). Decreases with age were also significant for isometric rates of torque for both muscle groups (P</=.001). Average isokinetic peak torque of hip abduction and adduction showed even greater declines in older women versus the young (P</=.001) with losses of 44% and 56%, respectively.

CONCLUSIONS

The hip abductor and adductor torques showed relatively marked age-related changes. To enhance balance assessment and treatment, and to reduce the risk of falls and related injuries in older women, greater focus should be placed on understanding the role of joint torque-time changes on frontal plane balance control.

Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study

This study of 9605 community-dwelling residents supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in elderly in a northern European region known to be deficient in vitamin D, especially during winter periods.

INTRODUCTION

We evaluated the effect of two programs for the prevention of osteoporotic fractures leading to acute hospital admission in a population of elderly community-dwelling residents.

MATERIALS AND METHODS

This was a factorial, cluster-randomized, pragmatic, intervention study. We included 9605 community-dwelling residents aged 66+ years. We offered a prevention program of a daily supplement of 1000 mg of elemental calcium as calcium carbonate and 400 IU (10 microg) of vitamin D3 to a total of 4957 participants. Another program with evaluation and suggestions for the improvement of the domestic environment was offered to a total of 5063 participants. Both programs included revision of the resident's current pharmaceutical treatment. We achieved information on osteoporotic fractures in the study population from the Danish Hospital Registration Database. We defined osteoporotic fractures as low energy fractures of the proximal humerus, distal forearm, vertebral column, pelvis, cervical femur, and intertrochanteric femur.

RESULTS

Active participation was 50.3% in the Calcium and Vitamin D Program and 46.4% in the Environmental and Health Program. We observed a 16% reduction in fracture incidence rate (relative risk [RR], 0.84; CI, 0.72-0.98; p < 0.025) among male and female residents offered the Calcium and Vitamin D Program (intention-to-prevent analysis).

CONCLUSIONS

This study supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in community-dwelling elderly people in a northern European region known to be deficient in vitamin D, especially during winter periods.

Muscular Atrophy in the Hemiplegic Thigh in Patients After Stroke

OBJECTIVES

This study evaluated muscular atrophy in the hemiplegic limbs by assessing the muscle volume of the thighs in stroke patients.

DESIGN

Muscle volume of the bilateral thighs was determined by computed tomographic scanning in 50 hemiplegic patients after stroke.

RESULTS

The average muscle volume in the hemiplegic side was significantly lower than that in the nonhemiplegic side. When the patients were divided into the two groups aged <65 yr old and >/=65 yr, age-dependent reduction in the muscle volume was significant only in the nonhemiplegic side. In addition, the ratio of the muscle volume in hemiplegic side to that in non-hemiplegic side was lower in the younger group than in the older group, with close to significance (P = 0.07). Muscle volume in both hemiplegic and nonhemiplegic sides correlated positively with Barthel index and negatively with patient age.

CONCLUSION

Muscle volume decreases in the hemiplegic side in stroke patients.

Lateral Stability and Falls in Older People

Aging changes in specific neuromusculoskeletal factors affecting protective stepping and other balance functions may precipitate lateral instability and falls. Identification of these factors provides directives for novel therapeutic interventions to reduce fall risk in older people.

Hip fractures among the elderly: causes, consequences and control

This review examines all pertinent literature sources published in the English language between 1966 to the present concerning hip fracture epidemiology, hip fracture injury mechanisms, and hip fracture management strategies. These data reveal hip fractures have several causes, but among these, the impact of falls and muscle weakness, along with low physical activity levels seems to be the most likely explanation for the rising incidence of hip fracture injuries. Related determinants of suboptimal nutrition, drugs that increase fall risk and lower the safety threshold and comorbid conditions of the neuromuscular system may also contribute to hip fracture disability. A number of interventions may help to prevent hip fracture injuries, including, interventions that optimize bone mass and quality, interventions that help prevent falls and falls dampening interventions. Rehabilitation outcomes may be improved by comprehensive interventions, prolonged follow-up strategies and ensuring that all aging adults enjoy optimal health.