Stroke and OsteoporosisStroke and Osteoporosis

Nurdjaman NurimabaNurdjaman NurimabaNeurological DepartmentNeurological Department

Medical FacultyMedical FacultyPadjadjaran UniversityPadjadjaran University

BandungBandung

INTRODUCTIONINTRODUCTION

STROKE CLASSIFICATION

STROKE

85 %

Ischemic

15 %

Hemorrhagic

80 %

AT Stroke

20 %

Cardio embolic

50 %

ICH

50 %

SAB

IntroductionIntroduction

• 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 Bone mineral density of the paretic and non paretic limb at admission and dischargelimb at admission and discharge

Paretic Side Non Paretic Side

Admission Discharge % Admission Discharge %

Lumbar Spine

0,99 ± 0,16 0.98 ± 0,17 1

Femoral Neck

0,95 ± 0,24 0,90 ± 0,13 5* 0,97 ± 0,21 0,93 ± 0,19 2**

Distal Radius

0,32 ± 0,11 0,28 ± 0,09 12*** 0,36 ± 0,10 0,35 ± 0,09 3,5**

* = p < 0,01 ** = p < 0,05 *** = p < 0,001

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

• Reduced balance

• Perceptual disturbances FRACTURE

• Cognitive impairment

• 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)

Complication

• 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)

PreventionPrevention• 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.

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