|Year : 2019 | Volume
| Issue : 4 | Page : 1479-1484
Assessment of osteoporosis in hemiplegic patients with stroke
Abd E. I. El-Hewala1, Samar G Soliman2, Dina R Al Sharaki2, Dina S Fotoh2
1 Department of Rheumatology, Physical Medicine and Rehabilitation, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||01-Mar-2016|
|Date of Decision||31-Mar-2016|
|Date of Acceptance||04-Apr-2016|
|Date of Web Publication||31-Dec-2019|
Dina S Fotoh
Shebein El Kom
Source of Support: None, Conflict of Interest: None
The aim of this work was to find out the proportion of patients with stroke who are at risk of osteoporosis (OP) and to examine the relationships between bone mineral densities (BMDs) and severity of stroke and functional assessment.
Loss of BMDs and fractures in patients after stroke are among the most serious health complications. Neurogenic OP is explained by the neural connection between brain and bone, which is mediated centrally by classic neurotransmitters and several neuropeptides. Moreover, mechanical stress on bone is one of the determinants of bone morphology, BMD, and bone strength. So reduction of mechanical stress on bone in patients with stroke inhibits osteoblast-mediated bone formation and accelerates osteoclast-mediated bone resorption, leading to what has been called disuse OP.
Patients and methods
A total of 100 patients with stroke diagnosed on clinical evaluation, including the mode of onset, the neurologic examination, and brain computed tomography scans, were included in this study. All patients were subjected to laboratory investigations, including the measurement of complete blood count, total and ionized serum calcium, and parathyroid hormone, and radiological investigations, including assessment of BMD of the lumbar spine (L2–L4), total hip, and distal forearm by dual-energy radiographic absorptiometry on both paretic and nonparetic sides.
There were significant differences between BMDs at the spine and hip on the paretic side and duration of stroke, Lawton instrumental activity of daily living, and Scandinavian stroke scale (P < 0.001). There was a statistically significant increase in BMD regarding Barthel index (P < 0.001). There was also significant decrease in BMD on the paretic side in comparison with the nonparetic side (P < 0.001).
OP was more severe on the paretic side in patients with stroke compared with the nonaffected side. There was a significant negative correlation between BMD and age and duration of stroke.
Keywords: dual-energy radiography absorptiometry technique, osteoporosis, stroke
|How to cite this article:|
El-Hewala AE, Soliman SG, Al Sharaki DR, Fotoh DS. Assessment of osteoporosis in hemiplegic patients with stroke. Menoufia Med J 2019;32:1479-84
|How to cite this URL:|
El-Hewala AE, Soliman SG, Al Sharaki DR, Fotoh DS. Assessment of osteoporosis in hemiplegic patients with stroke. Menoufia Med J [serial online] 2019 [cited 2020 Jan 17];32:1479-84. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1479/274216
| Introduction|| |
A stroke is a cerebrovascular accident, cerebrovascular insult, which is the loss of brain function owing to a disturbance in the blood supply to the brain. This disturbance is due to either ischemia (lack of blood flow) or hemorrhage. As a result, the affected area of the brain cannot function normally, which might result in an inability to move one or more limbs on one side of the body, failure to understand or formulate speech, or a vision impairment of one side of the visual field .
Osteoporosis (OP) is a disease characterized by reduced bone mass and increased skeletal fragility. Normal bone growth and remodeling entail a tightly coupled process of bone resorption and new bone formation. OP-related bone loss occurs when bone resorption exceeds bone formation. The WHO defined OP as a systemic skeletal disease characterized by low bone mass with microarchitectural deterioration of bone tissue, thus increasing bone fragility and susceptibility to fracture. For screening purposes, OP was defined by the WHO as a bone mineral density (BMD) at any site equal to or greater than 2.5 SD below the fracture-resistant mean peak bone mass of young adulthood .
Correlation between immobilization and localized OP is well documented in patients with chronic stroke. Previous studies have found reduced BMD on the affected side in hemiplegic patients. As a consequence, fractures usually occur on the affected side. Although the higher incidence of fractures, including hip fractures, is reported in the immediate poststroke period .
Hemiplegia from a stroke can result in immobilization hypercalcemia, which inhibits parathyroid hormone (PTH) secretion and 1, 25-[OH] D production. Bone remodeling may have almost reached equilibrium, resulting in a steady rate of bone loss .
An important type of stroke-induced OP is neurogenic OP, which is explained by the neural connection between brain and bone, which is mediated centrally by classic neurotransmitters and several neuropeptides, and peripherally by many of the same neurotransmitters and neuropeptides .
Demineralization of neurogenic OP is area dependent, occurs exclusively in the areas below the level of injury, affecting mainly paralyzed extremities, and increasing from proximal to distal. Moreover, bone loss between trabecular and cortical bone compartment differs in mechanism, that is, in the epiphyses is due to decrease in trabecular, but in diaphysis, cortical bone is maintained and bone is lost through endocortical resorption by reducing cortical wall thickness .
| Patients and methods|| |
After following the committee's ethical guidelines of our university, an informed consent was obtained from all individuals participating in the study. A total of 100 patients with stroke diagnosed upon the clinical evaluation, including the mode of onset, the neurologic examination, and brain computed tomography scans, were included in this study. The patients were attending the outpatient clinics of Physical Medicine and Rehabilitation, Internal Medicine, and Neuropsychiatry Departments at the Menoufiya University Hospitals from the year 2013 to 2014.
All patients who were approached agreed to participate in this study, and informed consent was obtained.
All the patients who were included in this study passed the acute stage of stroke with disease duration more than one month either with right-sided or left-sided hemiparesis due to stroke of any cause (i.e. thrombotic, embolic, and hemorrhagic).
Exclusion criteria were history of drugs affecting BMD such as glucocorticoids, hemiparesis due to hereditary or congenital causes such as spastic CP, any disease affecting bone quality such as osteosarcoma and osteomyelitis or systemic bone diseases, neurologic deficit, terminal illness such as chronic renal failure, and hyperparathyrodism.
Patients were questioned about their current age and the age of onset of stroke. Clinical examination of all patients was performed in the form of general, locomotor, and neurological examinations; BMI (in kg/m 2) was calculated .
Locomotor examination included the assessment of the following:
Assessment of the severity of stroke by Scandinavian Stroke Scale .
The Brunnstrom staging classification categorized according to seven stages .
Assessment of spasticity by modified Ashworth scale scored on a six-point scale ranging from 0 (no increase in muscle tone) to 4 (affected part rigid in flexion and extension) .
Functional assessment including assessment of the activity of daily living by the Barthel index (0–100)  and by the Lawton Instrumental (IADL) with a summary score from 0 to 8 .
Laboratory investigations were performed in the form of complete blood count, total and ionized serum calcium level, PTH level, renal function tests, and vitamin D using a 25-hydroxyvitamin D radioimmunoassay .
Regarding radiological assessment in the form of assessment of BMD, each patient received a bone density measurement of the lumbar spine (L1–L4), total hip, and distal forearm by dual-energy radiographic absorptiometry technique using DEXA machine (GE-Lunar Prodigy, Madison, MA, USA) .
The data were collected, tabulated, and analyzed by SPSS (statistical package for the social sciences) version 17.0 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done: descriptive statistics, included percentage, mean and SD, and analytic statistics, including χ2 test, Mann–Whitney U-test, Spearman correlation (r), and Kruskal–Wallis test. The difference was considered significant if P value was less than 0.05, nonsignificant if P value was greater than 0.05, and highly significant if P value was less than 0.001.
| Results|| |
This study included 100 patients with stroke diagnosed upon clinical evaluation, including the mode of onset, the neurologic examination, and brain computed tomography scans with disease duration more than 1 month either with right-sided or left-sided hemiparesis. Our patients were recruited from outpatient clinic of the Physical Medicine and Rehabilitation Department, Menoufiya University Hospital.
Descriptive statistics of personal data among the studied cases included age, with a mean of 42.06 years, and sex, with 61 (61%) male patients and 39 (39%) females [Table 1].
|Table 1: Descriptive statistics of personal data among the studied cases|
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Correlation between age and sex and severity of OP on the affected side shows significant decrease in BMD as the age increases, as shown in [Table 2], but there were no statistically significant differences between sex and BMD.
[Table 3] shows a significant negative correlation between BMD at the spine and hip and the duration of stroke and visual analog scale (VAS), with no significant differences regarding spasticity.
|Table 3: Correlation between bone mineral densities and clinical parameters in the affected side|
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[Table 4] shows a significant positive correlation between BMD and Barthel index on the affected side.
|Table 4: Correlation between bone mineral densities and Barthel index on the affected side|
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[Table 5] shows a positive correlation between BMD regarding t and Z score among the studied cases and Scandinavian stroke scale on the affected side.
|Table 5: Correlation between bone mineral densities and Scandinavian stroke scale on the affected side|
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Correlation between BMD and laboratory investigations, including serum Ca+, vitamin D, and PTH, shows a significant positive correlation between BMD, vitamin D, and PTH and negative correlation with serum Ca+, as shown in [Table 6].
|Table 6: Correlation between bone mineral densities and vitamin D, serum Ca+, and parathyroid hormone in the affected side|
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Comparison between BMD regarding t and Z scores on the paretic and nonparetic sides shows a significant prevalence of OP on the affected side, especially the forearm more than the hip and spine, as compared with the normal one, as shown in [Table 7].
|Table 7: Comparison between bone mineral density as regarding t and Z scores on the affected and normal sides|
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| Discussion|| |
Stroke was defined by the WHO (1978) as a clinical syndrome of vascular origin, manifested by rapidly developing signs of focal or global disturbance of cerebral function lasting more than 24 h or leading to death .
OP is defined as a progressive systemic disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk .
In our study, we found that there was a significant negative correlation between age and BMD, including t and Z score, with no significant differences regarding sex.
This came in agreement with Dennis et al.  and Peltonen and Asplund  who studied 100 patients with stroke for more than 1-month duration, and BMD was measured using DEXA at both hips and lumbar spine. They found a significant negative correlation between BMD and age, with no significant differences between BMD and sex.
In contrast to our study, Jorgensen et al.  found no statistically significant differences regarding age and BMD in patients with stroke. They might have a small number of studied patients, which was not sufficient to indicate the positive correlation between age and development of OP on the affected side.
In our study, we found a significant negative correlation between BMD at the spine and hip and duration of stroke and between BMD and VAS, with no significant differences regarding spasticity.
Our results came in agreement with Sato et al.  who reported that there were significant differences between severity of OP and the duration of stroke and VAS, with no significant differences regarding spasticity.
In contradiction to our results, Hamdy et al.  found no significant differences between BMD and duration of stroke on the paretic side. They might have studied the patients for short duration not sufficient to indicate the positive effect of duration of hemiplegia on the development of OP.
In our study, there was a significant positive correlation between BMDs, in terms of t and Z scores, and Barthel index on the affected side.
This came in line with Brunnstrom  and Nguyen et al.  who found a positive correlation between BMD on the paretic side and Barthel index.
In the present study, there was a positive correlation between BMDs, in terms of t and Z scores among the studied cases, and Scandinavian stroke scale on the affected side, with no significant differences on the nonparetic side.
This came in agreement with Jorgensen et al.  and Pang et al.  who conducted their studies on patients with stroke and reported the significant differences between BMDs on the paralyzed side and Scandinavian stroke scale.
In our study, there was a significant positive correlation between BMDs and laboratory investigations, including vitamin D and PTH, and a negative correlation with serum Ca+ among the studied cases.
This came in agreement with Sato et al. , who reported that there was a significant correlation between BMDs and these laboratory measures, because decreased BMD is associated with hypercalcemia, leading to hypoparathyrodism and hypovitaminosis D.
In the current study, there was a statistically significant decrease in BMDs, with respect to t and Z scores, on the paretic side compared with the nonparetic side among the studied cases owing to severe motor impairment and disuse on the paretic side.
This came in agreement with Hamdy et al. , Hodkinson and Brain , and Bergmann et al.  who conducted a study on 38 patients with stroke. They made a comparison between BMDs on the paretic and nonparetic side and noted more pronounced demineralization on the paretic side, especially the forearm, owing bone load reduction, when compared with the lower limbs, and this could reflect the mechanical stress on the lower limbs when the patient stands up and attempts to walk, which is well known to promote bone mineralization.
In contrast to our study, the study performed by Villareal et al.  on 85 patients with stroke passing the acute stage reported no significant reduction in BMDs between paretic and nonparetic sides in patients with stroke. They may have studied small samples not sufficient to indicate the effect of immobilization on BMD.
| Conclusion|| |
Our results showed that there was significant prevalence of OP on the paretic side in patients with stroke, especially the upper limbs more than the lower limbs owing to absence of mechanical stress on the upper limbs. There was a significant negative correlation between BMDs, with respect to t and Z score, and duration of stroke. There was also a significant negative correlation between BMD and serum Ca+ and a positive correlation between BMD and vitamin D and PTH. Moreover, we can recommend from our study that physical activity plays a very important role in patients after stroke. Physical exercise can improve BMD and balance and reduce the risk of falls. Early starts of pharmacological treatment plus exercise are recommended procedures in the early poststroke stages, to diminish as much as possible subsequent bone loss. Patients with long-standing stroke should in most cases be given vitamin D3 (800–2000 Ul/day) and calcium supplementation, as this reduces hip fractures by 43%.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]