Bone loss after stroke over 52 weeks at os calcis: influence of sex, mobility and relation to bone density at other sites

The effect of stroke on the bone mineral density: A systematic review and meta-analysis

OBJECTIVES

Stroke survivors frequently encounter physical complications. This study aimed to evaluate the impact of stroke on bone mineral density (BMD) and assess the risk of post-stroke osteoporosis or osteoporotic fractures.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

We systematically searched Medline, Embase, and the Cochrane Database of Systematic Reviews to identify longitudinal studies reporting the influence of stroke on BMD, osteoporosis, and osteoporotic fractures. Pooled analyses were performed utilizing random-effects models.

RESULTS

This study included 21 studies with 1,029,742 participants. The mean difference of BMD in the paretic femoral neck between follow-up and initial measurements was -0.07 g/cm2 (95% CI, -0.09 to -0.04), and -0.03 g/cm2 (95% CI, -0.05 to -0.01) in the non-paretic femoral neck. A follow-up length exceeding six months was associated with a more pronounced decrease compared to a follow-up of under six months (MD, -0.08; 95% CI, -0.11 to -0.05 vs MD, -0.04; 95% CI, -0.06 to -0.02; P =  0.03). No significant change in lumbar spine BMD was detected post-stroke (MD, -0.00; 95% CI, -0.03 to 0.02), nor was significant change observed in the non-paretic distal radius, proximal humerus, tibia, trochanter, and total hip. Stroke was not associated with an increased risk of osteoporosis or osteoporotic fractures (HR, 1.43; 95% CI, 0.95-2.13).

CONCLUSION

Stroke survivors undergo significant BMD loss in paralyzed limbs, most notably in the femoral neck. However, BMD in the lumbar spine does not exhibit a significant decrease post-stroke. The risk of post-stroke osteoporosis or osteoporotic fractures should be interpreted with caution and needs further investigation.

Mendelian Randomization Study of Lipid Metabolites Reveals Causal Associations with Heel Bone Mineral Density

BACKGROUND

Osteoporosis, which is a bone disease, is characterized by low bone mineral density and an increased risk of fractures. The heel bone mineral density is often used as a representative measure of overall bone mineral density. Lipid metabolism, which includes processes such as fatty acid metabolism, glycerol metabolism, inositol metabolism, bile acid metabolism, carnitine metabolism, ketone body metabolism, sterol and steroid metabolism, etc., may have an impact on changes in bone mineral density. While some studies have reported correlations between lipid metabolism and heel bone mineral density, the overall causal relationship between metabolites and heel bone mineral density remains unclear.

OBJECTIVE

to investigate the causal relationship between lipid metabolites and heel bone mineral density using two-sample Mendelian randomization analysis.

METHODS

Summary-level data from large-scale genome-wide association studies were extracted to identify genetic variants linked to lipid metabolite levels. These genetic variants were subsequently employed as instrumental variables in Mendelian randomization analysis to estimate the causal effects of each lipid metabolite on heel bone mineral density. Furthermore, metabolites that could potentially be influenced by causal relationships with bone mineral density were extracted from the KEGG and WikiPathways databases. The causal associations between these downstream metabolites and heel bone mineral density were then examined. Lastly, a sensitivity analysis was conducted to evaluate the robustness of the results and address potential sources of bias.

RESULTS

A total of 130 lipid metabolites were analyzed, and it was found that acetylcarnitine, propionylcarnitine, hexadecanedioate, tetradecanedioate, myo-inositol, 1-arachidonoylglycerophosphorine, 1-linoleoylglycerophoethanolamine, and epiandrosterone sulfate had a causal relationship with heel bone mineral density (p < 0.05). Furthermore, our findings also indicate an absence of causal association between the downstream metabolites associated with the aforementioned metabolites identified in the KEGG and WikiPathways databases and heel bone mineral density.

CONCLUSION

This work supports the hypothesis that lipid metabolites have an impact on bone health through demonstrating a causal relationship between specific lipid metabolites and heel bone mineral density. This study has significant implications for the development of new strategies to osteoporosis prevention and treatment.

New-onset stroke on the risk of hip fracture: the Kailuan cohort study in China

PURPOSE

Stroke is a documented risk factor for hip fracture(HF). However, no data is currently available on this issue in mainland China, we therefore assessed the risk of hip fracture after new-onset stroke using a cohort study.

METHODS

This study included 165,670 participants without a history of stroke at baseline from the Kailuan study. All participants were followed biennially until December 31, 2021. During follow-up, a total of 8,496 new-onset stroke cases were identified. For each case subject, four control subjects was randomly selected, matched for age (± 1 years) and sex. The final analysis comprised 42,455 pair-matched cases and controls. A multivariate Cox proportional hazard regression model was used to estimate the effect of new-onset stroke on the risk of hip fracture.

RESULTS

During an average follow-up of 8.87 (3.94) years, a total of 231 hip fracture cases occurred, 78 cases in the stroke group and 153 cases in the control group, with incidence rates of 1.12 and 0.50 per 1000 person-years, respectively. The cumulative incidence of the stroke group was higher than that of the controls (P < 0.01). The adjusted hazard ratio (95% confidence interval) of hip fractures in the stroke group was 2.35 (1.77 to 3.12) (P < 0.001) to controls. After stratifying by gender, age, and body mass index, the higher risk was revealed in female (HR 3.10, 95 CI: 2.18 to 6.14, P < 0.001), age < 60 years old (HR 4.12, 95% CI: 2.18 to 7.78, P < 0.001), and non-obesity (BMI<28 kg/m²) (HR 1.74, 95% CI:1.31 to 2.31, P < 0.001) subgroup.

CONCLUSIONS

Stroke significantly increases the risk of hip fracture, strategy for protecting stroke patients from falls and hip fractures should be emphasized in poststroke long-term management, particularly the female, age < 60 years old, and non-obese patients.

Changes in bone mineral density in unconscious immobile stroke patients from the acute to chronic phases of brain diseases

Objectives

Decreased bone mineral density (BMD) is observed in immobile stroke patients. But it is not clarified yet how rapidly BMD reduction occurs or what the most influencing factor to BMD loss is.

Methods

BMDs in the lumbar vertebrae and the proximal femur of the paralyzed side were measured in 100 immobile stroke patients at 1 week (0 month), 1 month, and 2 months after admission. The levels of serum calcium, phosphorous, 25-hydroxyvitamin D, and urine cross-linked N-telopeptide of type I collagen (NTx) were also measured.

Results

The average age of patients was 75.0 ± 11.4 years (31–94 years). No BMD reduction was identified in the lumbar vertebrae in 2 months; however, BMD in the femur significantly decreased in 2 months in female patients (P < 0.05). Serum calcium and phosphorous levels remained within the normal range during hospitalization, and 25-hydroxyvitamin D value rose in 2 months. Urine NTx significantly increased in both males and females in 2 months (male: P < 0.05, female: P < 0.01).

Conclusions

While there was no significant change in lumbar spine BMD in the 2 month period of immobilization after stroke, BMD in the proximal femur showed a significant reduction, particularly in women. The differential loss of BMD in the 2 regions of interest could possibly be due to the physical forces acting on different body parts during mobilization and nutritional factors. More studies are needed with larger study samples and prolonged follow-up to check the accuracy of these observations.

Association between post-stroke disability and 5-year hip-fracture risk: The Women's Health Initiative

BACKGROUND

Hip fractures are a significant post-stroke complication. We examined predictors of hip fracture risk after stroke using data from the Women's Health Initiative (WHI). In particular, we examined the association between post-stroke disability levels and hip fracture risk.

METHODS

The WHI is a prospective study of 161,808 postmenopausal women aged 50-79 years. Trained physicians adjudicated stroke events and hip fractures. Our study included stroke survivors from the observational and clinical trial arms who had a Glasgow Outcome Scale of good recovery, moderately disabled, or severely disabled and survived more than 7 days post-stroke. Hip fracture-free status was compared across disability levels. Secondary analysis examined hip fracture risk while accounting for competing risk of death.

RESULTS

Average age at time of stroke was 74.6±7.2 years; 84.3% were white. There were 124 hip fractures among 4,640 stroke survivors over a mean follow-up time of 3.1±1.8 years. Mortality rate was 23.3%. Severe disability at discharge (Hazard Ratio (HR): 2.1 (95% Confidence Interval (CI): 1.4-3.2), but not moderate disability (HR: 1.1 (95%CI: 0.7-1.7), was significantly associated with an increased risk of hip fracture compared to good recovery status. This association was attenuated after accounting for mortality. White race, increasing age and higher Fracture Risk Assessment Tool (FRAX)-predicted hip fracture risk (without bone density information) were associated with an increased hip fracture risk. After accounting for mortality, higher FRAX risk and white race remained significant.

CONCLUSION

Severe disability after stroke and a higher FRAX risk score were associated with risk of subsequent hip fracture. After accounting for mortality, only the FRAX risk score remained significant. The FRAX risk score appears to identify stroke survivors at high risk of fractures. Our results suggest that stroke units can consider the incorporation of osteoporosis screening into care pathways.

Relationship Between Nutritional Factors and Hip Bone Density in Individuals with Chronic Stroke

The aim of this study was to investigate the relationship between dietary habits and hip bone health in community-dwelling individuals with chronic stroke. The usual dietary intake of 94 individuals with chronic stroke (30 women, mean age: 59.0 years) was assessed by a 3-day food record within a single week. Dual-energy X-ray absorptiometry was used to measure bone mineral density (BMD) at both hips. The results showed that low hip bone mass was found in 59 and 50 of the participants on the affected and unaffected side, respectively. The mean hip BMD was also significantly lower on the affected side than the unaffected side (P < 0.001). The intake of total fat, carbohydrates, calcium, magnesium, iron, zinc, fiber, folic acid, vitamin B1, B2, B3, B6, C, and K was significantly lower than the respective recommended daily intake values (P < 0.05). Multiple regression analyses revealed that after adjusting for the effects of age, sex, body mass index, post-stroke duration, side of paresis, motor impairment, physical activity level, walking endurance, total calories intake, and total number of medications, intake of protein, fiber, and magnesium remained significantly associated with hip T score on the affected side, accounting for 4.2, 4.4, and 3.2% of the variance, respectively. On the other hand, intake of protein and fiber was independently associated with hip T score on the unaffected side, explaining 2.7 and 5.2% of the variance, respectively. The results highlighted the potential relevance of diet modification in maintaining bone health post stroke, which would require further study.

Sex differences in the association between stroke and bone mineral density in elderly Koreans: The Korean National Health and Nutrition Examination Survey, 2008-2010

OBJECTIVES

The aim of this study was to investigate whether osteoporosis is more prevalent in elderly Korean people who have had a stroke and whether the association differs by sex.

STUDY DESIGN

A total of 3806 elderly subjects (1951 men and 1855 women) from the Korea National Health and Nutrition Examination Survey were included in this study. Stroke history was determined by self-administered questionnaire. Bone mineral density (BMD) was measured at the lumbar spine, total hip, and neck of the femur using dual-energy X-ray absorptiometry. It was categorized as normal, osteopenia, or osteoporosis.

RESULTS

In men who had had a stroke, the prevalence of osteoporosis was greater than that of both osteopenia and normal BMD, and the prevalence of osteopenia was greater than that of normal BMD (p<0.001). However, there were no significant differences in BMD level among women who had had a stroke. Men who had had a stroke undertook less vigorous exercise and moderate-or-vigorous exercise than did men who had not had a stroke (p=0.002 and 0.030, respectively). After adjusting for all covariates, the mean BMD at the lumbar spine, total hip and neck of the femur was lower in men who had had a stroke than in men who had not (p=0.034, 0.002, and 0.005, respectively). There were no significant differences in mean BMD at any of the three sites between women who had and women who had not had a stroke.

CONCLUSION

Men who have had a stroke have a higher prevalence of osteopenia and osteoporosis, and have lower BMD at the total hip and femur neck than men who have not had a stroke.

The effects of neuromuscular facilitation techniques on osteoporosis of hemiplegia limbs and serum leptin level in patients or rats with cerebral infarction

PRIMARY OBJECTIVE

This study was to investigate the effect of proprioceptive neuromuscular facilitation techniques (NFT) on osteoporosis and serum leptin level in cerebral infarction patients or rats.

RESEARCH DESIGN

Forty cerebral infarction rats were randomly grouped into control, sham operation, conventional treatment (CT) group and CT+NFT group. Fifty-two stroke patients with hemiplegia were included in this study.

METHODS AND PROCEDURES

The bone mineral densities (BMD) of proximal hemiplegia limbs and serum ALP, BALP, BGP, IL-6 and leptin levels were detected using commercial kits.

MAIN OUTCOMES AND RESULTS

In cerebral infarction rats, the BMD, BGP, BALP, ALP and leptin concentrations in the CT+NFT group was higher compared with the control and CT group, while serum IL-6 level was more reduced by CT+NFT than control and CT. In cerebral infarction patients, both CT and CT+NFT increased the BMD, ALP, BGP and leptin levels. In addition, compared with CT, the BMD, ALP, BGP and leptin levels were markedly increased by CT+NFT. C Conclusion: NFC elevated the BMD of hemiplegia limbs, serum ALP, BGP, IL-6 and leptin levels and, thus, alleviated osteoporosis in rats and patients with cerebral infarction.

Impact and risk factors of post-stroke bone fracture

Bone fracture occurs in stroke patients at different times during the recovery phase, prolonging recovery time and increasing medical costs. In this review, we discuss the potential risk factors for post-stroke bone fracture and preventive methods. Most post-stroke bone fractures occur in the lower extremities, indicating fragile bones are a risk factor. Motor changes, including posture, mobility, and balance post-stroke contribute to bone loss and thus increase risk of bone fracture. Bone mineral density is a useful indicator for bone resorption, useful to identify patients at risk of post-stroke bone fracture. Calcium supplementation was previously regarded as a useful treatment during physical rehabilitation. However, recent data suggests calcium supplementation has a negative impact on atherosclerotic conditions. Vitamin D intake may prevent osteoporosis and fractures in patients with stroke. Although drugs such as teriparatide show some benefits in preventing osteoporosis, additional clinical trials are needed to determine the most effective conditions for post-stroke applications.

Poststroke hip fracture: prevalence, clinical characteristics, mineral-bone metabolism, outcomes, and gaps in prevention

Objective. To assess the prevalence, clinical and laboratory characteristics, and short-term outcomes of poststroke hip fracture (HF). Methods. A cross-sectional study of 761 consecutive patients aged ≥60 years (82.3 ± 8.8 years; 75% females) with osteoporotic HF. Results. The prevalence of poststroke HF was 13.1% occurring on average 2.4 years after the stroke. The poststroke group compared to the rest of the cohort had a higher proportion of women, subjects with dementia, history of TIA, hypertension, coronary artery disease, secondary hyperparathyroidism, higher serum vitamin B12 levels (>350 pmol/L), walking aid users, and living in residential care facilities. The majority of poststroke HF patients had vitamin D insufficiency (68%) and excess bone resorption (90%). This group had a 3-fold higher incidence of postoperative myocardial injury and need for institutionalisation. In multivariate analysis, independent indicators of poststroke HF were female sex (OR 3.6), history of TIA (OR 5.2), dementia (OR 4.1), hypertension (OR 3.2), use of walking aid (OR 2.5), and higher vitamin B12 level (OR 2.3). Only 15% of poststroke patients received antiosteoporotic therapy prior to HF. Conclusions. Approximately one in seven HFs occurs in older stroke survivors and are associated with poorer outcomes. Early implementation of fracture prevention strategies is needed.

Poststroke fractures in a bi-ethnic community

BACKGROUND

Mexican Americans have increased risks of stroke and lower fractures compared with non-Hispanic whites, but little is known about poststroke fracture risk in Mexican Americans. The objective of this study was to describe poststroke fracture risk in a bi-ethnic population and to compare risk by ethnicity.

METHODS

In the Brain Attack Surveillance in Corpus Christi Project, strokes were identified through hospital surveillance (2000-2004) and validated by neurologists (n = 2389). Inpatient claims for fractures were ascertained (2000-2004) and cross-referenced with strokes. Survival free from fracture (any and hip) poststroke was estimated and compared by ethnicity. Cox regression was used to test the association of ethnicity and fracture risk adjusted for confounders. Interaction terms for ethnicity and age were considered.

RESULTS

The mean age was 71 years (SD, 13 yrs); 54% were Mexican American and 52% were women. The mean follow-up was 4 years. There were 105 fractures (33% of the hips). Survival free of any fracture and of hip fracture did not differ by ethnicity. Increasing age, female gender, intracerebral hemorrhage, and greater stroke severity were associated with risk of any fracture, but ethnicity was not. Ethnicity was associated with risk of hip fracture, but this association was modified by age (P = .02), where Mexican Americans were protected from hip fractures at younger but not older ages.

CONCLUSIONS

Stroke patients were at high risk for fractures, with a 10% risk at 5 years. Mexican Americans were protected from hip fractures at younger but not older ages. Both elderly Mexican Americans and non-Hispanic whites should be targeted for poststroke fracture prevention.

Relationship between bone turnover and bone density at the proximal femur in stroke patients

OBJECTIVE

To investigate the relationship between the rate of bone turnover and bone loss at the proximal femur in stroke patients.

METHODS

This study was performed between January 1, 2005 and August 31, 2006 at the Stroke Rehabilitation Unit, Istanbul Physical Medicine and Rehabilitation Training Hospital, Istanbul, Turkey. One hundred six patients who had a stroke for the first time were included in the study. The control group consisted of 33 age- and gender-matched healthy subjects. Bone mineral density (BMD) was measured at the proximal hip region by dual energy X-ray absorptiometry (DXA). Serum osteocalcin (OC) and C telopeptide of type 1 collagen (CTX) levels were measured. Barthel Index (BI) was used for the evaluation of daily activities. Ambulation status of the patients was recorded.

RESULTS

Mean age was 65.1 +/- 9.8 years in the patient group and 51% were male. Mean disease duration was 16.9 +/- 9.1 months. Mean BI score was 60.5 +/- 25.8 on admission. Femoral neck BMD values were 0.873 +/- 0.95 g/cm(2) and 0.816 +/- 0.180 g/cm(2) for control subjects and hemiplegic sides of the patient group, respectively. Femur total BMD values were 0.948 +/- 0.119 g/cm(2) and 0.872 +/- 0.187 g/cm(2) for control group and hemiplegic sides of the patients, respectively. Femoral neck and femur total BMD values in the hemiplegic side were lower than those of controls' (P < .05). There was no statistically significant difference between the proximal femur BMD values of the intact and hemiplegic sides. Negative correlation was found between the proximal femur BMD values of both the intact and hemiplegic sides, and serum OC and CTX levels. Bone resorption rate was higher among the patients with stroke; however, bone formation rate was normal in this group. Serum CTX levels showed correlation with ambulation status. Femoral neck BMD values on the intact side were lower in the patient group with disease duration of more than 1 year compared to those with shorter disease duration.

CONCLUSION

As a result of this study bone turnover was inversely correlated with bone density at the hip of both hemiplegic and intact sides in stroke patients. Evaluation of bone turnover might be helpful to predict bone loss and to find out the stroke patients with bone loss who can not be decided to begin antiresorptive treatment with bone density measurement.

Bone resorption in stroke and institutionalized subjects

Stroke increases the risk of hip fracture on the affected side. Although bone is lost by 1 year, rapidity of onset and relationship with immobility are uncertain. Using the bone resorption marker urinary cross-linked N telopeptide of type I collagen (uNTx), we examined bone resorption in the first 4 weeks after stroke, relating uNTx with bone density and mobility in subjects over 60 years. Two separate control groups acted as comparators, healthy (HC) and institutionalized (IC) controls, the latter to control for the effects of institutionalization. uNTx, urinary calcium (both related to creatinine and log-transformed), heel bone mineral density (BMD), Tinetti scores, and Barthel scores for prestroke function were measured. Log uNTx/Cr was lower in males compared with females, but this difference was not evident in stroke or IC subjects. Log uNTx/Cr was inversely related with BMD in females from both control groups and in male stroke subjects. Tinetti scores were divided into tertiles and were lower in stroke than IC subjects (P < 0.01). Log uNTx/Cr was similar in stroke and IC subjects in the lowest Tinetti tertile. Log uNTx/Cr was higher in stroke subjects of both sexes in the lowest tertile compared with the higher two tertiles combined (P < 0.05) and higher in all tertiles compared with HC subjects (P < 0.05). Subjects with a prestroke Barthel index of < or = 17 had higher log uNTx/Cr compared with HCs. Log uCa/Cr was higher only in male stroke patients. Bone resorption in stroke starts early, and measures to reduce this are merited.

Bone health in stroke

In 2004 the Stroke Association stated ‘Each year over 130,000 people in England and Wales have a stroke. Of all people who suffer from a stroke, about a third are likely to die within the first 10 days, about a third are likely to make a recovery within one month and about a third are likely to be left disabled and needing rehabilitation. Stroke has a greater disability impact than any other medical condition. A quarter of a million people are living with long-term disability as a result of stroke in the UK.’