Stroke and Osteoporosis

Nurdjaman Nurimaba
Neurological Department
Medical Faculty
Padjadjaran University
Bandung

INTRODUCTION
STROKE CLASSIFICATION
STROKE

80 %
AT Stroke

85 %

15 %

Ischemic

Hemorrhagic

20 %

50 %

50 %

Cardio
embolic

ICH

SAB

Introduction
Stroke is a major cause of mortality and
morbidity in elderly
Incidence of stroke increases extensively with
age
Risk factors for stroke : age and smoking
Complication after stroke : Paresis and
immobility
All condition also risk factor for osteoporosis

Osteoporosis

Hemiosteoporosis in stroke have been

investigated and listed as :
1. Age
2. Immobilization
3. Vit D deficiency due to malnutrition, sunlight

deprivation, an immobilization induced

hypercalcemia
4. Compensatory hyperparathyroidism
(Sato et al, 1996)

 Low bone density on the hemiparetic side

following stroke, with greater proportional
losses in the upper limbs than the lower limbs
(Naffchi et al, 1975; Handy et al 1993; Takamoto et al,
1995)

Takamoto et al (1995) Recorded a loss of BMD

on the paretic and non paretic sides at the
upper femur, with significant loss on the stroke
side

 Handy et al, 1993

Found that the BMD of the hemiparetic upper
limb was 12,8 % lower than of the unaffected
side
Iversen et al, 1989
Reported that in the hemiplegic upper limb,
BMD was 10 % lower than in the unaffected
upper limb and they claimed that the reason for
this discrepancy was the decrease in level of
activity because of stroke, time since stroke
was 11,3 and 29,1 weeks

Bone mineral density of the paretic and non paretic

limb at admission and discharge
Paretic Side
Admission

Non Paretic Side

Discharge

Lumbar
Spine

0,99 0,16 0.98 0,17

Femoral
Neck

0,95 0,24 0,90 0,13

Distal
Radius

0,32 0,11 0,28 0,09

* = p < 0,01

** = p < 0,05

Admission

Discharge

5*

0,97 0,21

0,93 0,19

2**

12***

0,36 0,10

0,35 0,09

3,5**

*** = p < 0,001

Yovuzer et al, International Journal of Rehabilitation Research (2002)

Complication
Reduced balance
Perceptual disturbances
Cognitive impairment

FRACTURE

Ramnermark et al, 1998

Stroke patient have up to a 4 fold increased risk
of hip fracture
Hip fracture occurs late after stroke (median 30
months)

 Burger et al, 1994

In study about 40 % stroke patient had
more than one vertebral fracture
Poplinger et al, 1985
8 % hip fracture had a previous history of
stroke and 79 % experienced their fracture
on the stroke side

 Fracture after stroke a probably cause by

two main factor :
High incidence of falls
Progressing hemiosteoporosis on paretic side
(Ranemark et al, 1999)

Fracture in patient with stroke make

rehabilitation more difficult and may
significantly reduced the expected
success (Huddaway et al, 1999)

Prevention
Falls, Fracture and Osteoporosis after stroke,
time to think about protection ?
(Kenneth E.S. Poole et al, Stroke 2002;33;1432-1436 )

Background : Osteoporosis is a significant

complication of stroke, sustain increase in hip fracture.
Summary of comment : Morbidity and mortality from
hip fracture maybe reduce by preventing bone loss at
an early stage. Bisphosphonates are the drug of
choice in preventing osteoclastic bone resorption.

Effective dosing regiment for osteoporosis

have include a single annual or semi
annual injection of Bisphosphonates as
well as weekly oral dosing.
Conclusion : Intravenous
Bisphosphonates given in the early phase
of stroke rehabilitation is indicated

Other potential interventions :

Mechanical hip protector : recommended in elderly
patient who are at high risk for hip fracture.
Cochrane review of trial from Scandinavia, Japan,
Australia and UK reported an occurrence of hip
fracture of 2,2 % in those assigned hip protectors vs
6,2 % of those not.

Vitamin D Insufficiency
In practical terms, long standing stroke patient
should in the most cases be given Vit D3 (800 to
2000 U/day), and calcium supplementation if
they are at risk of deficiency particularly so if they
are elderly. This combination reduced hip
fracture by 43 % compare with placebo.

HATUR NUHUN