Physical Inactivity and Pain in Older Men and ... - GNM Healthcare

Clinical Section / Original Paper Received: October 5, 2009 Accepted: February 26, 2010 Published online: May 28, 2010

Gerontology DOI: 10.1159/000315490

Physical Inactivity and Pain in Older Men and Women with Hip Fracture History Anu Salpakoski a, b Erja Portegijs g Mauri Kallinen c Sanna Sihvonen d Ilkka Kiviranta c, e Markku Alen f Taina Rantanen a, b Sarianna Sipilä a

a

Gerontology Research Centre and b Department of Health Sciences, University of Jyväskylä, c Central Finland Health Care District and d University of Applied Sciences, Jyväskylä, e Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, and f Department of Medical Rehabilitation, Oulu University Hospital and Institute of Health Sciences, University of Oulu, Oulu, Finland; g Social Medicine, Academic Medical Center Amsterdam, Amsterdam, The Netherlands

Key Words Proximal femoral fracture ⴢ Musculoskeletal pain ⴢ Physical activity

Abstract Hip fracture patients often suffer from pain for several months after surgery. This may lead to physical inactivity and subsequent mobility limitation and disability. The purpose of this study was to investigate the association between severe musculoskeletal pain and the level of physical activity in older people with a history of hip fracture. Data were collected from 60- to 85-year-old (n = 78) community-dwelling people, 0.7–7.5 years after hip fracture. Physical activity was assessed with the Yale Physical Activity Survey (YPAS). According to the YPAS summary index distribution, the participants were divided into the physically inactive and physically active groups. Musculoskeletal pain in the lower back, hip or knee region was assessed by the Visual Analog Scale. Pain was defined as severe pain if the subject rated the pain 66 mm or over (upper third of the scale) in at least one of the relevant body regions in the lower body. Thirty-three sub-

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jects (42%) experienced severe pain in the lower body, of whom 23 (70%) reported severe pain in the operated hip. Twenty-three patients (30%) used pain medication prescribed by a physician. The level of musculoskeletal pain was significantly higher in the physically inactive (62%) than in the physically active (31%) group (p = 0.011). Logistic regression analysis showed that people with severe pain had over three times (OR: 3.5, 95% CI: 1.30–9.39) the risk for physical inactivity compared to those with less or no pain. Multivariate adjustments for balance confidence, time since fracture, number of chronic diseases and type of surgery did not materially change the estimate (OR: 3.0, 95% CI: 1.00–9.30). Pain is an important associated factor of physical inactivity in older people with a hip fracture history. Pain management may be important in restoring and sustaining the level of physical activity after hip fracture. Further prospective and experimental studies are, however, needed to explore the causality between pain and physical activity as well as the role of pain management and physical activity interventions in preventing mobility limitation and disability among older people recovering from hip fracture. Copyright © 2010 S. Karger AG, Basel

Anu Salpakoski Department of Health Sciences, Gerontology Research Centre University of Jyväskylä, P.O.Box 35, FI–40014 Jyväskylä (Finland) Tel. +358 14 260 4550 or +358 40 738 4536, Fax +358 14 260 4600 E-Mail anu.salpakoski @ jyu.fi

Introduction

An extensive body of knowledge exists on the beneficial effects of a physically active lifestyle, including protection against adverse health events and disability. In older disabled people, even a small amount of physical activity, such as walking eight blocks per week, predicted better mobility 1 year later [1]. In people with mobility limitation, physical activity reduced the risk for all-cause mortality and institutionalization [2]. The total amount and intensity of physical activity declines with age [3, 4] and less than 30% of older people achieve the recommended weekly amount of physical activity. In particular, the oldest old and those suffering from chronic diseases tend to restrict their physical activity [4, 5]. Reasons for a low level of physical activity among older people include poor health [3], pain [6] and fear of falling [7]. Although poor health and mobility limitation decrease physical activity, they do not correlate fully as some people remain active even in the face of disability. Previous studies have clearly demonstrated that hip fracture patients comprise a special group of people at high risk for mobility limitation and activity restriction [8, 9]. Earlier studies have shown that only 40% of survivors return to their pre-fracture ambulatory level [8] and less than 20% to their pre-fracture level for more demanding mobility tasks, including walking outdoors and negotiating stairs [9]. Because the incidence of hip fractures increases with age, the total number of fractures is expected to rise with population aging [10]. Understanding the key determinants of physical inactivity among this clinical population is of great value in supporting the rehabilitation process after a hip fracture. Musculoskeletal pain is frequent among communitydwelling older people [11] and predicts the progression of disability [12]. Older people with a history of hip fracture often suffer from persistent pain. It has been reported that nearly half of 80-year-old hip fracture patients experience moderate to severe hip pain 3 months after surgical treatment for proximal femoral fracture [13]. The number of people with a high degree of hip pain is important as hip pain months after a hip fracture independently predicts mobility limitation [9] and, thus, potentially contributes to an increasingly physically inactive lifestyle. People who have suffered a hip fracture also often have poor balance confidence [14] and low muscle strength [15], both of which may contribute to the avoidance of physical activities. To promote functional capacity and physical activity and to prevent disability among older people with a hip 2

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fracture history, it is necessary to better understand the factors and determinants that explain physical inactivity. The purpose of this study was to examine the association between physical activity and musculoskeletal pain in the lower body among community-dwelling men and women with a hip fracture history.

Materials and Methods Study Design and Participants This cross-sectional study utilized the baseline data of a larger randomized controlled study investigating the effects of a rehabilitation program, including resistance training on lower limb muscle strength, mobility and balance in older men and women with hip fracture history (IRCTN34271567). A detailed description of the study design and recruitment of the subjects has been published earlier elsewhere [16]. Briefly, patient records at the Central Hospital of Central Finland were gathered during the years 2004–2005 to recruit community-dwelling men and women aged 60–85 who had been operated on for a femoral neck or trochanteric fracture during the past 8 months to 7.5 years. Information about the study was sent by letter to all of the patients who were still alive (n = 452) and resident in the local health care district. One hundred and ninety-three patients answered the letter and 132 of them expressed initial interest in the study. Patients were interviewed over the telephone to ensure their interest in and suitability for the study. The exclusion criteria were inability to move outdoors without assistance from another person, amputation of a lower limb, severe progressive or neurological diseases, and severe memory problems (diagnosed dementia or MMSE ! 19). Seventy-eight (53 women, 25 men) subjects attended the laboratory examinations (fig. 1). The ethical committee of the Central Finland Health Care District approved the study protocol and the study was conducted in accordance with the ethical principles stated in the Declaration of Helsinki. Subjects gave their written informed consent prior to participating in the study. Measurements All subjects were requested to avoid exercise or extra waking hours a day before the laboratory measurements and to refrain from the intake of alcohol for 36 h before the measurement. Subjects were allowed to eat a light breakfast, but were to avoid drinking coffee or tea on the morning prior to the measurements. Daily medication was to be taken as normal. The measurements were performed in our university laboratory. One specially trained nurse and some specially trained physiotherapists performed the measurements. Each measure performed one and the same set of measurements on all subjects. No adverse events occurred during the laboratory measurements. Physical Activity. Physical activity was assessed by interview using the Yale Physical Activity Survey (YPAS) [17]. The survey was specifically developed to assess physical activity in the older population. The YPAS comprehensively describes overall physical activity and also provides information on whether activities are light or moderate in intensity [18]. The interview includes a physical activity dimension summary index, which is the sum of

Salpakoski /Portegijs /Kallinen /Sihvonen / Kiviranta /Alen /Rantanen /Sipilä

five weighted sub-indices. Participants were asked how many times they performed vigorous physical activity (weighting of 5) and leisure walking (weighting of 4) during the past month and the duration of each physical activity session. The frequency, duration score and weighting of each respective activity were multiplied. Additionally, participants were asked to estimate the duration of the time spent moving around indoors and outdoors (weighting of 3), standing (weighting of 2) and sitting (weighting of 1) on an average day in the past month. The duration score for an activity was multiplied by its weighting. For the data analysis, the participants were divided into three equal groups according to the summary index distribution. The lowest tertile contained the most physically inactive individuals (PI score ^ 24). Middle and highest tertiles were combined into a single group of physically active individuals (PA score 1 24). The YPAS has shown adequate validity in relation to several physiological variables which typically reflect physical activity level. For example, the association between the physical activity summary index and estimated VO2max in healthy older populations has varied between an r value of 0.33 and 0.58. The correlation coefficient between the summary index and percentage of body fat has been reported to be –0.43, and –0.31 between the summary index and BMI [17, 19]. In subindices the correlations between the vigorous index and estimated VO2max, and between the sitting index and resting diastolic blood pressure have been reported to be rather high (r = 0.60 and r = 0.53, respectively) [19]. The test-retest correlation of the summary index has varied between 0.31 and 0.65 [17, 20, 21]. Musculoskeletal Pain in Lower Body. Pain in the lower back, hip or knee region on both sides of the body during the last week was assessed with the Visual Analog Scale. A line 100 mm long was used without numbers. The left end of the line (0 mm) represented ‘no pain’ and the right end (100 mm) ‘worst imaginable pain’ [22]. The subject had severe pain (SP) if she or he rated the pain as 66 mm or over (upper third of the scale) in at least one of the relevant body regions. Pain below 66 mm was rated as less or no pain (LNP). The visual analog scale is a widely used method of assessing pain in research and clinical practice. It has also been found to be a highly reliable and valid measure of pain intensity among older people [23, 24]. Covariates. Body weight was measured in kilograms using a beam scale with the participant wearing light indoor clothing. Body height was measured with a scale stadiometer while the participant was standing in stocking feet. Height was measured to the nearest centimeter. BMI was calculated as weight (kg) divided by height (m) squared (kg/m2). Fat-free mass was assessed using a computerized single-frequency bioimpedance device (BC-418; Tanita Corp., Tokyo, Japan) using the manufacturer’s equation. The body composition analyzer includes a stainless steel hand and foot contact with a standard eight electrode placement, two in each foot and two in each palm. During the measurements, participants were instructed to stand still on a scale platform with bare feet while holding the handgrips. Precision (coefficient of variation) of repeated measurements has been reported to be on average 0.3% for fat mass percentage [25]. Health Status. A physician and a research nurse performed a thorough clinical examination. The presence of chronic conditions and the use of prescription medication were confirmed according to a prestructured questionnaire. In addition, current prescriptions and medical records were obtained from the local

Physical Inactivity and Pain after a Hip Fracture

Patients informed n = 452

• No response (n = 259) Responded to the letter n = 193

• Poor health and unable to move outdoors without assistance (n = 46)

• Died recently (n = 1) • Confined to wheel chair (n = 2) • Unwilling to participate (n = 12) Interviewed n = 132

• Poor health and unable to move outdoors without assistance (n = 28)

• Confined to wheelchair (n = 3) • New hip fracture (n = 1) Invited to the laboratory n = 100

• Did not participate; poor health (n = 8) • Unwilling to participate (n = 2) • New hip fracture (n = 2) • Wrong dg; subtrochanteric fracture (n = 1) • Neurological disease (n = 8) Measured n = 78

Fig. 1. Study flow diagram.

hospital and health care centers. The number of chronic diseases present for at least 3 months was calculated as an indicator of comorbidity. The diseases included in the analyses were cardiovascular diseases (e.g. ischemic heart disease, hypertension), respiratory diseases (e.g. asthma, bronchitis), neurological diseases (e.g. epilepsy, cerebrovascular dysfunction), musculoskeletal diseases (e.g. knee or hip osteoarthritis), rheumatic diseases, endocrinological diseases (e.g. diabetes, thyroid gland dysfunction), liver or kidney diseases, and cancer. The use of pain medication prescribed by a physician was recorded as a dichotomous variable (yes/no). The characteristics of each hip fracture and the surgical procedure used were collected from the medical records of the orthopedic department of the hospital. Time since fracture was defined as the number of days between the date of the hip fracture and the date of the measurement. Additionally, contraindications for participation in the muscle strength assessment were evaluated by the physician conducting the clinical examination, in accordance with the criteria laid down by the American College of Sports Medicine [26]. Contraindications included unstable coronary artery disease, uncontrolled hypertension, recent intracra-

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Table 1. Characteristics of subjects by physical activity groups (mean 8 SD)

Physical activity

Age Body height, cm Body weight, kg BMI Fat-free mass, kg Time since fracture, years ABC balance, score Knee extension force (fractured side), N Knee extension force (nonfractured side), N Women, % Osteosynthesis, % Chronic diseases, n Osteoarthritis, % Severe musculoskeletal pain, % Prescribed pain medication, %

p

PI (n = 20–26)

PA (n = 46–51)

75.087.5 16289.5 71.1814.2 27.185.1 45.689.8 2.881.8 80.4835.1 206.9879.3 241.38113.7 73 47 3.882.1 19 62 35

75.386.4 16488.5 70.9811.4 26.283.5 48.789.1 3.682.1 102.2831.1 259.18114.4 295.18117.8 65 42 2.981.8 29 31 25

0.953* 0.134* 0.945 0.457* 0.052* 0.140* 0.007 0.085* 0.070 0.458 0.692 0.099* 0.335 0.011 0.402

* Mann-Whitney U test.

nial hemorrhage, aneurysm of the abdominal aorta as well as musculoskeletal disorders which could potentially progress as a result of testing. In addition, acute conditions such as infections (e.g. acute respiratory or urinary tract infection) were evaluated to ascertain safe participation in the measurements. Five participants were found to have contraindications for participation in the strength tests. Muscle Strength. Maximal isometric knee extension force (N) was measured in the fractured and nonfractured leg using an adjustable dynamometer chair (Good Strength; Metitur Ltd., Palokka, Finland). The ankle was attached to a strain-gauge with the knee angle fixed at 60° from full extension. The leg was extended as forcefully as possible and participants were encouraged to make a maximal effort during the measurement. The contraction was maintained for 2–3 s. The rest period between the trials was 30 s. The measurement was repeated at least three times, until no further improvement occurred and the best performance was used in the analysis. In our earlier study, the coefficient of variation between two consecutive knee extension measurements was 6% [27]. Balance confidence was assessed with the Activities-Specific Balance Confidence Scale (ABC), which measures confidence in carrying out specific activities without falling or becoming unsteady [28]. The scale consists of 16 items in which subjects are asked to report their confidence in their ability to keep their balance when performing different activities, including activities outside the home. All answers are rated from 1 (no confidence) to 10 (total confidence). The ABC summary scale ranges from 16 to 160, with a small value indicating poor balance confidence. The ABC scale has been used in studies among older persons and it has acceptable psychometric properties [29–31]. Among healthy older adults, Cronbach’s alpha was 0.96 and retest reliability was r = 0.92 [28].

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Statistical Analyses Means and standard deviations were calculated for continuous variables. An independent samples t-test was used to compare the means of the study groups (PA/PI and SP/LNP). Normality of the continuous variables was tested with the KolmogorovSmirnov test. Differences between the study groups for the nonnormally distributed variables were tested with a nonparametrical Mann-Whitney U test. Differences between the groups in the dichotomous variables (gender, type of the surgery, osteoarthritis, prescribed pain medication and pain) were analyzed with the Pearson ␹2 test. Logistic regression modeling was used to determine odds ratios (ORs) and 95% confidence intervals (CI 95%) for pain as a predictor of physical inactivity. The model was first adjusted one by one with each covariate. The final model was adjusted for all of the following covariates: balance confidence, time since fracture, number of chronic diseases and type of surgery (osteosynthesis). Initially, we adjusted the model for age and gender, but this did not change the results in our selected clinical population. To retain the statistical power of the final model, we did not include age or gender in the final model. Statistical analyses were performed using SPSS for Windows software version 15.0 and p ! 0.05 was considered statistically significant.

Results

The mean age of the subjects was 75.2 8 6.7 years and on average 3.3 8 2.0 years had elapsed since the hip fracture. Causes of hip fractures were falls at ground level (68%), from a higher level (17%) or other causes, such as bicycle or car accidents (15%). The hip fracture had been Salpakoski /Portegijs /Kallinen /Sihvonen / Kiviranta /Alen /Rantanen /Sipilä

Physically active

Physically inactive p < 0.001

Less or no pain

60

60

50

50

40 30

p < 0.001

p < 0.001

20

Severe pain

70

Score

Score

70

p = 0.112

40 30

p = 0.392 p = 0.448

20 p = 0.033 p < 0.001

10

p = 0.244 p = 0.001

0 Vigorous Leisure Moving Standing Sitting Summary physical walking around index activity Physical activity subindices

10

p = 0.003 p = 0.002

0 Vigorous Leisure Moving Standing Sitting Summary physical walking around index activity Physical activity subindices

Fig. 2. Physical activity according to YPAS subindices.

Fig. 3. Musculoskeletal pain according to YPAS subindices.

surgically fixed by osteosynthesis in 36 patients (46%) and by arthroplasty in 42 patients (54%). When all subjects were included, the mean YPAS summary index score was 37.1 8 20.0. According to the activity dimension indices, the mean score for the vigorous activity index was 7.8 8 12.9, 12.7 8 14.4 for the leisure walking index, 7.5 8 2.9 for the moving index, 6.1 8 2.0 for the standing index and 3.0 8 0.9 for the sitting index. Table 1 shows the detailed characteristics of the subjects by physical activity level. No statistically significant difference was observed for age, height, weight, BMI, fatfree mass, time since fracture, knee extension strength, health status or gender distribution between the groups. The level of musculoskeletal pain was significantly higher in the PI group than in the PA group. Balance confidence was better in the PA group than in the PI group. Figure 2 presents the subindices of the YPAS in the two physical activity groups, showing the overall lack of physical activity in the PI group. The subjects in the PA group had significantly higher scores in the vigorous physical activity (11.5 8 14.4 vs. 0.6 8 2.2, p ! 0.001), leisure walking (18.3 8 14.7 vs. 1.9 8 3.2, p ! 0.001), moving around (8.0 8 3.0 vs. 6.5 8 2.2, p = 0.033) and standing indexes (6.7 8 1.9 vs. 5.0 8 1.7, p ! 0.001), whereas the PI group had a significantly higher sitting score (2.8 8 0.9 vs. 3.5 8 0.8, p = 0.001). Thirty-three (42%) out of the 78 subjects experienced SP in the lower back, hip or knee region, of whom 23

(70%) reported SP in the operated hip. Twenty-three patients (30%) used pain medication prescribed by a physician. Significantly more subjects in the SP group than in the LNP group had prescribed pain medication (48 vs. 16%, p = 0.002). Table 2 shows the detailed characteristics of the subjects in two pain groups. No statistically significant difference was observed in age, body height, body weight, fat-free mass, time since fracture, health status, gender distribution or muscle strength between the subjects with SP compared to those with LNP. However, the participants suffering from SP had a significantly lower balance confidence score and higher BMI compared to those in the LNP group. Figure 3 presents the subindices of the YPAS in the two pain groups. The subjects in the LNP group had a significantly higher score for standing (6.7 8 2.0 vs. 5.3 8 1.7, p = 0.003) and a lower score for sitting (2.8 8 0.8 vs. 3.4 8 0.9, p = 0.002) compared to those in the SP group. Logistic regression analyses were performed in order to study the associations between physical activity and severe musculoskeletal pain (table 3). Subjects with SP had three and a half times (OR 3.5, CI 95% 1.30–9.39) the risk for PI compared to those with less or no pain. Multivariate adjustments for balance confidence, time since fracture, number of chronic diseases and type of surgery did not materially change the estimate (OR 3.0, CI 95% 1.00–9.30).


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Table 2. Characteristics of subjects by pain groups (mean 8 SD)

Musculoskeletal pain

Age Body height, cm Body weight, kg BMI Fat-free mass, kg Time since fracture, years ABC balance, score Knee extension force (fractured side), N Knee extension force (nonfractured side), N Women, % Osteosynthesis, % Chronic diseases, n Osteoarthritis, % Prescribed pain medication, %

p

LNP (n = 38–45)

SP (n = 28–33)

75.785.9 16588.5 69.2812.0 25.483.5 48.289.3 3.682.2 103.0830.1 248.48109.4 280.68124.8 62 38 3.281.9 20 16

74.687.7 16289.3 73.7812.3 28.184.4 47.189.4 2.981.8 82.9836.1 230.48101.9 271.38110.1 76 58 3.382.1 33 49

0.804* 0.063* 0.136 0.024* 0.702* 0.184* 0.010 0.443* 0.749 0.206 0.083 0.725* 0.183 0.002

* Mann-Whitney U test

Table 3. ORs and 95% CIs for physical inactivity from binominal regression models

Model I OR (95% CI) n Severe pain ABC, score, 10 points Time since fracture, year Chronic diseases, n Osteosynthesis

Model II OR (95% CI)

Model III OR (95% CI)

Model IV OR (95% CI)

77 76 77 76 3.5 (1.30–9.39) 2.8 (1.00–8.14) 3.2 (1.19–8.81) 3.9 (1.39–10.80) 0.8 (0.72–1.00) 0.8 (0.64–1.09) 1.3 (0.98–1.64)

Model V OR (95% CI)

Model VI OR (95% CI)

77 3.9 (1.39–10.83)

76 3.0 (1.00–9.30) 0.9 (0.75–1.07) 0.8 (0.63–1.14) 1.2 (0.91–1.59) 1.1 (0.35–3.35)

1.6 (0.58–4.53)

The model was first adjusted one by one with each covariate. The final model was adjusted for all of the following covariates: balance confidence, time since fracture, number of chronic diseases and type of surgery (osteosynthesis).

Discussion

In this study, we found that a substantial number of people with a hip fracture history (aged 60–84 years and living in the community) experienced SP in the lower back, hip or knee region. Of them, over two thirds reported pain in the operated hip. Pain correlated with an inactive lifestyle even after controlling for balance confidence, time since fracture, number of chronic conditions and type of surgical procedure. This result is in line with an earlier study showing that pain has a major association with the low physical activity in older populations [6]. Earlier prospective studies have also suggested 6

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that musculoskeletal pain is a major cause of mobility limitation and disability in older people [11, 12] and leads to poor recovery of mobility after a hip fracture [9]. Among a nonclinical old population there was a doseresponse relationship between pain severity, number of painful sites and risk for inactivity [32]. The mechanism underlying the association between pain and physical activity is, most likely, multifactorial and largely unknown. After hip replacement or surgical fixation after a hip fracture, joint range of motion and weight bearing on the operated leg are limited for several weeks. Consequently, long-term or even permanent muscle weakness and modifications in standing and walking Salpakoski /Portegijs /Kallinen /Sihvonen / Kiviranta /Alen /Rantanen /Sipilä

patterns may occur. These changes or adaptations may lead to pain-inducing loading on the lower back and joints in the lower limbs, resulting in activity restriction. Hurwitz et al. [33] showed that subjects suffering from hip osteoarthritis had an asymmetric and consistently different gait pattern compared to healthy subjects. These gait adaptations were related to pain and limitations in the joint range of motion. Musculoskeletal pain leading to a low level of physical activity decreases muscle strength and physical performance. It may also be that low level of physical activity in concert with related muscle weakness may induce musculoskeletal pain. In some cases physical activity may exacerbate the pain, which is removed by short-term disuse or inactivity. Two extensive meta-analyses, however, suggest that physical activity reduces pain in older people with a musculoskeletal disorder [34, 35]. In addition to pain, pain-related fear and disability beliefs may have an influence on physical inactivity [6, 36]. These earlier studies and our own analyses suggest the following series of events. Hip fracture is a traumatic experience and leads to loss of balance confidence while also causing pain. Impaired balance confidence and pain reduce mobility and lead to behavioral changes such as adopting a physically inactive lifestyle. Physical inactivity further impairs physical fitness, decreases muscle strength and induces pain. From this point of view, relieving pain may be a key factor in maintaining physical activity at a sufficient level in older people with hip fracture history. Earlier studies have shown that nearly half of older people experience moderate to severe hip pain 3 months after surgical repair of a proximal femoral fracture [13] and that a large number of fracture patients continue to suffer from severe hip pain 6–12 months after discharge [37]. The percentage of subjects operated on with osteosynthesis was greater in those with SP, although the difference was not significant. Earlier studies, however, suggest that the type of surgery performed appears to play an important role in pain intensity. Months after surgery, patients operated on with arthroplasty, seem to experience less pain than patients with internal fixation [38]. In this study, the level of physical activity was measured with the YPAS. The YPAS captures the type and intensity of activities that are common among older populations and seems to provide a comprehensive description of the overall level of physical activity, especially in older persons who engage in moderate-intensity physical activities [18, 19]. Repeatability may be better in activities with higher intensities than in the more common lower intensity activities because habitual low intensity activi-

ties may be more difficult to recall and they have larger day-to-day variability [17, 19, 20]. All together, the YPAS is a good tool for research studies that aim to quantify the types of physical activities habitually performed by older adults [39]. Comparing our results to those of earlier studies, our participants with a hip fracture history had substantially lower values than those reported in healthy older men and women without mobility limitations by DiPietro et al. [17] and lower scores in the YPAS summary index and subindices than those reported by Semanik et al. [40] in older women with rheumatoid arthritis. The mean score for sitting was higher among subjects with a hip fracture history compared to persons with rheumatoid arthritis [40] or healthy older subjects [17]. The results of this study are limited to communitydwelling cognitively intact older people with a hip fracture history who were willing to participate in a randomized controlled study with exercise rehabilitation intervention. The present analysis is based on a crosssectional design utilizing the baseline data of the trial. Therefore, conclusions on the causal relationship between pain and physical activity cannot be drawn. Due to the inclusion criteria of the present study (e.g. able to move outdoors without assistance and no cognitive impairment), our subjects were younger and had better mobility than hip fracture patients in general. Therefore, the results cannot be generalized to hip fracture patients residing in nursing homes, individuals who are more frail or those unable to participate in an assessment of physical testing requiring voluntary effort. Because the participants represent the highest end of the distribution of hip fracture patients, it is very likely that this truncated distribution underestimates the association between pain and physical inactivity. Despite this, our participants had markedly poorer postural balance, balance confidence [14], muscle strength and walking speed [41] than ageand sex-matched controls. Our results may apply to other clinical populations suffering from lower limb morbidities; however, this needs further study. Other factors, such as depression, may also underlie the association between pain and physical inactivity [42, 43]. Unfortunately, we do not have data for depressive mood in this sample. Despite intensive recruitment, the sample size of this study was relatively small. Of the 452 potential subjects we informed about the study, only every sixth person participated. This is in line with earlier studies investigating clinical populations in randomized controlled trial studies, especially if frequent travelling is required [44, 45].


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Despite intensive efforts at prevention, hip fractures will continue to be among the major threats to the health and disability of older people. However, very little is known about pain and physical activity after discharge from stationary treatment [37]. The present study showed that a substantial proportion of patients continue to suffer from SP, which restricts their physical activity years after a hip fracture. Physical activity can increase the level of independence and, thus, the quality of life [46]. The primary goal of geriatric rehabilitation after a hip fracture or after other major injury is to return the patient to the pre-injury level of functioning and physical activity [47]. Pain and physical inactivity were found to be associated in a small subset of patients with hip fracture still living in the community 3 years after surgical repair of their hip fracture. Interventions to either reduce pain, promote

physical activity, or both, should be tested in this cohort in robustly designed factorial trials to determine which of these interventions are most important and whether they are interactive for long-term mobility and function as an aim to improve quality of life for these individuals. Further studies are needed to develop effective strategies for promoting physical activity and preventing mobility limitation and disability among the older clinical population.

Acknowledgements This study was supported by the Finnish Ministry of Education, the Social Insurance Institution of Finland and the Finnish Concordia Fund. The funders had no further interest or involvement in the design, methods, subject recruitment, data collection or preparation of the manuscript.

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