Decrease of physical activity level in adolescents with limb fractures: an accelerometry-based activity monitor study

Validity of the activPAL and ActiGraph for measuring sitting time and steps in hospitalised orthopaedic patients with altered weight bearing

PURPOSE

To determine the criterion validity of the activPAL and ActiGraph for measuring steps and sitting/sedentary time, compared to observation, in people hospitalised following orthopaedic lower limb injury who were weight bearing (WB) (i.e., walking) or non-weight bearing (NWB) (i.e., hopping).

MATERIALS AND METHODS

Participants wore an activPAL and ActiGraph on the hip/thigh/unaffected (UA)/affected ankle (AA) while completing bouts of walking and sitting. Lin's concordance correlation coefficient, Bland-Altman methods, and ratio of agreement were used to compare device-measured to observed (videoed) step count, sitting/sedentary time.

RESULTS

In 42 participants, the ActiGraph demonstrated excellent concordance with the observed step count when worn on the ankle (LCC 0.91-0.92) compared to the hip (LCC 0.56) in participants that were WB. The ActiGraph AA achieved the highest concordance (LCC 0.71) with observed steps in participants NWB. The activPAL had poor concordance with observed steps, particularly at slow gait speeds, in participants that were WB (LCC 0.38-0.46), however was less influenced by gait speed and had good concordance in NWB participants (LCC 0.52-0.69). The activPAL (LCC 0.79-0.88) and ActiGraph UA (LCC 0.94) showed excellent concordance with observed sitting and sedentary time, respectively.

CONCLUSIONS

The ActiGraph worn at the ankle provided the most valid measure of steps in people who are WB and NWB following orthopaedic injury, while the activPAL was best for measuring sitting time.Implications for rehabilitationTo accurately measure both steps and sitting time in people with lower limb orthopaedic injuries, a combination of activity monitors should be used (i.e., ActiGraph for steps, activPAL for sitting time).The ActiGraph device when worn on the ankle demonstrated the strongest agreement with observed step count in people who were weight bearing and non-weight bearing.Caution is needed when using thigh- or hip-worn devices in people who walk slowly.

Physiology of sedentary behavior

Sedentary behaviors (SB) are characterized by low energy expenditure while in a sitting or reclining posture. Evidence relevant to understanding the physiology of SB can be derived from studies employing several experimental models: bed rest, immobilization, reduced step count, and reducing/interrupting prolonged SB. We examine the relevant physiological evidence relating to body weight and energy balance, intermediary metabolism, cardiovascular and respiratory systems, the musculoskeletal system, the central nervous system, and immunity and inflammatory responses. Excessive and prolonged SB can lead to insulin resistance, vascular dysfunction, shift in substrate use toward carbohydrate oxidation, shift in muscle fiber from oxidative to glycolytic type, reduced cardiorespiratory fitness, loss of muscle mass and strength and bone mass, and increased total body fat mass and visceral fat depot, blood lipid concentrations, and inflammation. Despite marked differences across individual studies, longer term interventions aimed at reducing/interrupting SB have resulted in small, albeit marginally clinically meaningful, benefits on body weight, waist circumference, percent body fat, fasting glucose, insulin, HbA1c and HDL concentrations, systolic blood pressure, and vascular function in adults and older adults. There is more limited evidence for other health-related outcomes and physiological systems and for children and adolescents. Future research should focus on the investigation of molecular and cellular mechanisms underpinning adaptations to increasing and reducing/interrupting SB and the necessary changes in SB and physical activity to impact physiological systems and overall health in diverse population groups.

Wearable technology in orthopedic trauma surgery - An AO trauma survey and review of current and future applications

The use of wearable sensors to track activity is increasing. Therefore, a survey among AO Trauma members was conducted to provide an overview of their current utilization and determine future needs and directions. A cross sectional expert opinion survey was administered to members of AO Trauma. Respondents were surveyed concerning their experience, subspeciality, current use characteristics, as well as future needs concerning wearable technology. Three hundred and thirty-three survey sets were available for analysis (Response Rate 16.2%). 20.7% of respondents already use wearable technology as part of their clinical treatment. The most prevalent technology was accelerometry combined with smartphones (75.4%) to measure general patient activity. To facilitate the use of wearable technology in the future, the most pressing issues were cost, patient compliance and validity of results. Wearable activity monitors are currently being used in trauma surgery. Surgeons employing these technologies mostly measure simple activity or activity associated parameters. Cost was the greatest perceived barrier to implementation. Further research, especially concerning the interpretation of the outcome values obtained, is required to facilitate wearable activity monitoring as an objective patient outcome measurement tool.

Management of "torus" or "buckle" fractures of the distal radius: a systematic review

BACKGROUND

Torus fractures, also known as buckle fractures, of the distal radius are a very common reason for presentation to emergency departments. Traditional approaches to their management involved immobilisation in a circumferential cast but the evidence now supports the use of removable splints with or without radiological and clinical follow-up. Unfortunately current practice conflicts with the evidence base and there is no guideline which highlights all the evidence as one clear, concise management protocol.

METHODS

An online review of Pubmed, EMBASE, Biomed, and the Cochrane library using keyword searches combining "radius", "torus", "buckle" and "fracture" was performed. All prospective, retrospective or randomised trials involving the management of distal radius torus fractures in patients aged 0-18 years were included. Our outcomes focused on 5 aspects of patient care: immobilisation method and duration, clinical follow-up, radiological follow-up and the use of diagnostic ultrasound.

RESULTS

The initial search identified 143 papers which following application of the inclusion and exclusion criteria 21 articles were deemed eligible. A Cochrane review and 8 systematic reviews were also identified and manually searched for missed articles and this yielded a further 3 articles.

CONCLUSIONS

Current research indicates that torus fractures should be managed with a removable splint supplied in A&E and worn for 3 weeks. There is no need for fracture clinic follow-up or repeat radiological imaging once patients are given adequate information at the time of diagnosis. This would represent both an economical and resource saving for patients, parents and the health service.

Independent of physical activity, volumetric muscle loss injury in a murine model impairs whole-body metabolism

Volumetric muscle loss (VML) injuries result in a non-recoverable loss of muscle tissue and function due to trauma or surgery. Reductions in physical activity increase the risk of metabolic comorbidities over time, and it is likely that VML may reduce whole-body activity. However, these aspects remain uncharacterized following injury. Our goal was to characterize the impact of VML on whole-body physical activity and metabolism, and to further investigate possible muscle-specific metabolic changes. Adult male C57Bl/6J (n = 28) mice underwent a standardized VML injury to the posterior compartment of the hind limb, or served as injury naïve controls. Mice underwent longitudinal evaluation of whole-body physical activity and metabolism in specialized cages up to three times over the course of 8 weeks. At terminal time points of 4- and 8-weeks post-VML in vivo muscle function of the posterior compartment was evaluated. Additionally, the gastrocnemius muscle was collected to understand histological and biochemical changes in the muscle remaining after VML. The VML injury did not alter the physical activity of mice. However, there was a noted reduction in whole-body metabolism and diurnal fluctuations between lipid and carbohydrate oxidation were also reduced, largely driven by lower carbohydrate utilization during active hours. Following VML, muscle-specific changes indicate a decreased proportion of fast (i.e., type IIb and IIx) and a greater proportion of slow (i.e., type I and IIa) fibers. However, there were minimal changes in the capillarity and metabolic biochemical activity properties of the gastrocnemius muscle, suggesting a miss-match in capacity to support the physiologic needs of the fibers. These novel findings indicate that following VML, independent of changes in physical activity, there is whole-body diurnal metabolic inflexibility. Supporting future investigations into the chronic and overlooked co-morbidities of VML injury.

Do levels of sedentary behaviour and physical activity differ according to weight-bearing status after lower limb fracture? A prospective cohort study

Background/purpose:

To determine whether sedentary behaviour and physical activity differ according to initial weight-bearing status 2 weeks and 6 months after lower limb (LL) fracture.

Methods:

Two weeks and 6 months following LL fracture, 47 adults aged 18–69 wore ActiGraph and activPAL accelerometers for 10 days. Sitting time, steps, and moderate-intensity physical activity (MPA) were compared between weight-bearing (WB) and non-weight-bearing (NWB) groups.

Results:

Two weeks post-discharge, the NWB group sat significantly more than the WB group (median: 14.1 h/day vs. 13.3 h/day; p = 0.04). These differences were apparent for female and middle-aged participants. At 6 months, there were no significant differences between weight-bearing groups for sitting time, steps or MPA.

Conclusion:

Weight-bearing restriction had an early impact on sitting time, but this impact lessened over time. While considering the need for rest, advice about reducing sitting time may be particularly important for people who are NWB post-fracture.

Do teenagers return to normal physical activity levels after limb fractures? A longitudinal, accelerometry-based, activity monitoring study

PURPOSE

This study aimed to elucidate whether levels of physical activity (PA) return to normal after bone healing or whether long-term behavioural changes in PA are to be expected in children and teenagers who have sustained limb fractures.

METHODS

In all, 100 children and teenagers with a first episode of limb fracture and 100 sex- and age-matched healthy controls (CTRL) were recruited for a prospective study. PA in limb fracture patients was assessed at 18-month follow-up using accelerometer measurements, and values were compared with those of CTRL. Time spent in PA at different levels of intensity was determined for each participant and expressed in minutes and as a percentage of total validly measured time.

RESULTS

Mean levels of PA at different levels of intensity by previously injured children and teenagers were similar than CTRL (42 sets of paired data). However, time spent in moderate-to-vigorous PA (MVPA) was lower than 60 minutes among limb-fracture patients at 18-month follow-up.

CONCLUSION

The amount of skeletal loading in children and teenagers returns to normal values by 18 months after limb fracture. Even if time spent in MVPA is not significantly lower in children and teenagers with limb fractures, it no longer reached the international recommendations for school-aged children (MVPA > 60 minutes), which may be interpreted as a lifestyle modification or a behavioural change to avoid new trauma.

LEVEL OF EVIDENCE

II.

What is the real impact of upper limb cast immobilisation on activity-related energy expenditure in children?

Background

Upper limb fractures and subsequent cast immobilisation constitute a potential cause of reduction in childhood levels of physical activity (PA), with subsequent decrease of energy consumption. The main objective of this study was thus to quantify the decrease of activity-related energy expenditure (AEE) due to upper limb cast immobilisation.

Methods

We conducted a longitudinal matched case-control study that included 35 children and teenagers with a first episode of upper limb fracture and 35 healthy cases. PA was assessed during cast immobilisation by accelerometer. AEE was the calculated using an equation based on the total counts per day measured by accelerometers.

Results

AEE in children and teenagers with upper limb fractures was estimated to be 7.4 % lower than healthy controls. The mean difference corresponded to 1.35 kcal/kg per mean valid recorded time (750  min), that is, the waking hours. When converted in kcal per mean subjects’ weight, the difference in AEE amounted 63.5 kcal/day, which corresponds approximately to 26  min of walking at a speed of 4  km/hours. In comparison with the mean AEE in healthy controls (18.2 kcal/kg), the noted decrease (1.35 kcal/kg) represents only 7.4 % of AEE.

Conclusion

Reduction of AEE in children and teenagers with upper limb fractures may lead to a slight positive energy balance, as there is usually no compensatory reduction of energy intake. An increase of light PA has to be counselled in this situation or patients should be advised to reduce their energy intake during the immobilisation period.

Level of evidence

Level I: high-quality prospective study (all patients were enrolled at the same point in their disease with ≥80 % follow-up of enrolled patients).

Activity-related energy expenditure during lower limb cast immobilization in children

Physical inactivity, which may result from immobilization, is recognized as a risk factor for the development of obesity. We aimed to quantify the decrease in activity-related energy expenditure (AEE) because of lower limb cast immobilization. We carried out a longitudinal matched case-control study: 34 adolescents with a first episode of lower limb fracture and 34 healthy cases. Physical activity was assessed during cast immobilization by an accelerometer from which we calculated the decrease in AEE. AEE in adolescents with lower limb fractures was estimated to be 16.0% lower than healthy controls. When converted into kcal per mean participants' weight, the difference in AEE amounted to 125 kcal/day, which corresponds to 5.2 h of slow walking. A significant reduction of AEE in adolescents with lower limb fractures may lead to a significantly positive energy balance as there is usually no compensatory reduction of energy intake. An increase of walking seems unrealistic in this situation and patients should be advised at the emergency unit to reduce their energy intake during the immobilization period.

LEVEL OF EVIDENCE

Level III, prospective case-control study.

Reduced Physical Activity in People Following Ankle Fractures: A Longitudinal Study

STUDY DESIGN

Longitudinal observational cohort.

BACKGROUND

The impact of ankle fracture on physical activity and sitting time and the course of recovery of physical activity are unclear.

OBJECTIVES

To assess the course of recovery of physical activity after ankle fracture and the extent to which this population may be less physically active and more sedentary than the general population.

METHODS

A cohort of individuals with ankle fracture was derived from a randomized trial and assessed with the International Physical Activity Questionnaire-Short Form (IPAQ-SF) at immobilization removal and 1, 3, and 6 months later. Total metabolic equivalent (MET) minutes per week were calculated to evaluate the course of recovery of physical activity. Sitting time (minutes per day) and the percentage of those who met the World Health Organization physical activity guidelines were calculated. Normative data were derived from a population-based cohort study that assessed physical activity using the IPAQ-SF.

RESULTS

In people with ankle fracture (n = 214), physical activity increased in the first month (from a median of 99 at immobilization removal to 979 MET min/wk) and leveled off by 6 months (1386 MET min/wk). Only 22% of the ankle fracture cohort met World Health Organization guidelines at immobilization removal, compared to 80% of the cohort from the general population (P<.001). This difference diminished over time. Sitting time in the ankle fracture cohort was higher than population norms at all time points (P<.001).

CONCLUSION

People with ankle fracture are less physically active and more sedentary than the general population. Strategies to increase physical activity must be considered. LEVEL OF EVIDENCE Prognosis, level 4.

Prognosis of physical function following ankle fracture: a systematic review with meta-analysis

STUDY DESIGN

Systematic review and meta-analysis of longitudinal studies.

OBJECTIVES

To quantify the prognosis of physical function following ankle fracture.

BACKGROUND

Information about the course of recovery of physical function after ankle fracture is essential for patient care and health care policy. The existing data have not previously been included in a meta-analysis.

METHODS

Studies were identified using searches of electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro, AMED, SPORTDiscus) and gray literature to September 2012. Studies of people with traumatic ankle fracture were included. Two reviewers independently screened references for inclusion, then extracted data and evaluated risk of bias. The outcome of interest was physical function (physical activity and activity limitation). Outcomes were converted to a common 100-point scale, on which higher scores indicated better outcomes. Meta-regression was conducted using generalized estimating equations.

RESULTS

Thirty-one studies (37 articles) were included. Adults with ankle fracture, present with significant activity limitation in the short term (mean at 1 month, 31.9; 95% confidence interval [CI]: 18.8, 45.1), recovered markedly but incompletely in the short to medium term (mean at 6 months, 78.3; 95% CI: 70.1, 85.1), and showed little further improvement in the long term (mean at 24 months, 86.6; 95% CI: 78.2, 95.0). Studies with older participants and predominantly male participants tended to report worse functional outcomes.

CONCLUSION

Adults typically experience a rapid initial recovery of physical function after ankle fracture (approximately 80% function at 6 months), but, on average, recovery remains incomplete 24 months after injury. PROSPERO registration number: 42012002979.

LEVEL OF EVIDENCE

Prognosis, level 2a.

Is bone mineral mass truly decreased in teenagers with a first episode of forearm fracture? A prospective longitudinal study

BACKGROUND

Forearm fractures are common in the pediatric population and are mostly treated by cast immobilization. The purposes of this study were first to determine whether forearm fractures in adolescents are associated with abnormal bone mineral density (BMD) or content (BMC) at the time of fracture, and second, to quantify the bone mineral loss at various sites due to cast-mediated immobilization.

METHODS

This longitudinal case-control study recruited 50 adolescents (age, 12.8 ± 1.8 y) who underwent cast-mediated immobilization for a forearm fracture and 50 healthy controls (13.0 ± 1.8 y). Using 2 dual-energy x-ray absorptiometries, BMD and BMC were measured at various skeletal sites (total body, lumbar spine, total upper limb, and forearm) at fracture time and at cast removal.

RESULTS

At the fracture time, BMD/BMC Z-scores at the lumbar spine and areal BMD at the peripheral wrist were not different among the injured and the healthy subjects. At cast removal, significant BMD decreases were observed in adolescents with fracture at the level of the radial and the ulnar diaphyses (-5.6% and -3.8%, respectively) and the total upper limb (-5.6%) compared with the noninjured side. Significant decreases in the BMC values were observed at the level of the radial diaphysis (-6.4%), ultradistal ulna (-10.2%), total upper limb, and total ulna (-8.2% and -4.9%, respectively).

CONCLUSIONS

These data demonstrate that total body, lumbar spine, or wrist bone mineral mass and density (BMC and BMD) are not reduced at the fracture time in adolescents sustaining a first episode of upper limb fracture when compared with healthy subjects. These findings suggest that forearm fractures are not related to osteopenia in youth. In addition, cast-mediated immobilization results in a significant bone mineral loss at the upper limb, which may explain the increased risk of sustaining a second fracture. Finally, bone callus formation may interfere when assessing bone mineral mass after cast removal and may lead to an erroneous underestimation of bone mineral mass decrease.

LEVEL OF EVIDENCE

Level IV.

Recovery of physical activity levels in adolescents after lower limb fractures: a longitudinal, accelerometry-based activity monitor study

Background

In adolescents, loss of bone mineral mass usually occurs during phases of reduced physical activity (PA), such as when an injured extremity spends several weeks in a cast. We recorded the PA of adolescents with lower limb fractures during the cast immobilization, at 6 and at 18 months after the fracture, and we compared these values with those of healthy controls.

Methods

Fifty adolescents with a first episode of limb fracture and a control group of 50 healthy cases were recruited for the study through an advertisement placed at the University Children’s Hospital of Geneva, Switzerland. PA was assessed during cast immobilization and at 6- and 18-month follow-up by accelerometer measurement (Actigraph® 7164, MTI, Fort Walton Beach, FL, USA). Patients and their healthy peers were matched for gender and age. Time spent in PA at each level of intensity was determined for each participant and expressed in minutes and as a percentage of total valid time.

Results

From the 50 initial teenagers with fractures, 44 sustained functional evaluations at 6 months follow-up, whereas only 38 patients were studied at 18 months. The total PA count (total number of counts/min) was lower in patients with lower limb fractures (-62.4%) compared with healthy controls (p<0.0001) during cast immobilization. Similarly, time spent in moderate-to-vigorous PA was lower by 76.6% (p<0.0001), and vigorous PA was reduced by 84.4% (p<0.0001) in patients with cast immobilization for lower limb injuries compared to healthy controls values. At 6 and 18 months after the fracture, the mean PA level of injured adolescents was comparable to those of healthy teenagers (-2.3%, and -1.8%, respectively).

Importantly, we observed that time spent in vigorous PA, which reflects high-intensity forces beneficial to skeletal health, returned to similar values between both groups from the six month follow-up in adolescents who sustained a fracture. However, a definitive reduction in time spent in moderate PA was observed among patients with a lower limb fracture at 18 months, when comparing with healthy controls values (p = 0.0174).

Conclusions

As cast immobilization and reduced PA are known to induce bone mineral loss, this study provides important information to quantify the decrease of skeletal loading in adolescents with limb fractures. The results of this study demonstrate that the amount of skeletal loading returns to normal values in adolescents with lower limb fractures after bone healing and is probably linked to an overall better pattern of functional recovery among this age group. When comparing both populations of adolescents, a definitive decrease in time spent in moderate-to-vigorous PA was observed among patients with a lower limb fracture at 18 months and may suggest a modification of lifestyle. The high rate of missing data (26.5%) due to above all non compliance with monitor wearing among teenagers complicates the data analysis, and requires a more cautious interpretation of the results. Future studies using accelerometer to monitor PA in adolescents should therefore include strategies for improving the rate of adherence and minimizing the ratio of missing data.