JAMA article reports dramatic reduction in hip fracture in stroke patients with b12 and folate

A recent article from Japan by Sato et al reported an impressive 80% reduction in hip fractures in a two year trial with B 12 and folic acid in patients with poststroke hemiplegia.Interestingly there were no fewer falls in the treatment group and no change in measured bone density. A reviewer ( Dr. Steven R. Cummings) in ACP Journal Club commented "The huge reduction in risk defies explanation by current paradigms of pathogenesis and prevention of fractures." Actually, we can always make up some pathophysiology to "explain" the facts. Certainty on the face of it, one has to ask why fewer fractures if no fewer falls and no change in bone density. It may well be that the treatment somehow (maybe collagen cross-linkage improvement) may strengthen bone without a measurable difference in bone density. It is well recognized that the bone density measurement does not tell the whole story about likelihood of fracture given a fall, it is just the typically used clinical measure. So should we give B12 and folate try in stroke patients with hemiplegia? It seems safe and after all a RCT resides on top of the EBM epistomologic hierarchy so why not?