Osteoporosis International

, Volume 18, Issue 9, pp 1243–1252

Muscle weakness, spasticity and disuse contribute to demineralization and geometric changes in the radius following chronic stroke

Original Article

Abstract

Summary

Bone health status of the radius in individuals with chronic stroke was evaluated using peripheral quantitative computed tomography. Bone mineral density and cortical thickness on the affected side were compromised when compared with the unaffected side. Muscle weakness, spasticity, and disuse were identified as contributing factors to such changes.

Introduction

Following a stroke, demineralization and geometric changes occur in bone as a result of disuse and residual impairments, and these can contribute to an increased risk of fragility fractures.

Methods

This study used peripheral quantitative computed tomography (pQCT) to evaluate volumetric bone mineral density and geometry at the midshaft radius in people living with chronic stroke. Older individuals with chronic stroke were recruited. Each subject underwent a pQCT scan of the midshaft radius at the 30% site on both upper limbs. Muscle strength, motor function, spasticity, and chronic disuse were also evaluated. Data from 47 subjects (19 women) were assessed.

Results

A significant difference was found between the two limbs for cortical bone mineral content, cortical bone mineral density, cortical thickness, and polar stress-strain index. There was no significant side-to-side difference in total bone area. Percent side-to-side difference in muscle strength, spasticity, and chronic disuse were significant determinants of percent side-to-side difference in cortical bone mineral content and cortical thickness.

Conclusions

The findings suggest that following chronic stroke, endosteal resorption of the midshaft radius occurred with a preservation of total bone area. Muscle weakness, spasticity, chronic disuse significantly contributed to demineralization and geometric changes in the radius following chronic stroke.

Keywords

Bone density Cerebrovascular accident Osteoporosis Rehabilitation 

References

  1. 1.
    Wolf SL, Lecraw DE, Barton LA et al (1989) Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurology 104:125–132CrossRefGoogle Scholar
  2. 2.
    Hamdy RC, Krishnaswamy G, Cancellaro V et al (1993) Changes in bone mineral content and density after stroke. Am J Phys Med Rehabil 72:188–191PubMedCrossRefGoogle Scholar
  3. 3.
    Prince RL, Price RI, Ho S (1988) Forearm bone loss in hemiplegia: a model for the study of immobilization osteoporosis. J Bone Miner Res 3:305–310PubMedGoogle Scholar
  4. 4.
    Liu M, Tsuji T, Higuchi Y et al (1999) Osteoporosis in hemiplegic stroke patients as studied with dual-energy X-ray absorptiometry. Arch Phys Med Rehabil 80:1219–1226PubMedCrossRefGoogle Scholar
  5. 5.
    Ramnemark A, Nyberg L, Lorentzon R et al (1999) Progressive hemiosteoporosis on the paretic side and increased bone mineral density in the nonparetic arm the first year after severe stroke. Osteoporos Int 9:269–275PubMedCrossRefGoogle Scholar
  6. 6.
    Kanis J, Oden A, Johnell O (2001) Acute and long-term increase in fracture risk after hospitalization for stroke. Stroke 32:702–706PubMedGoogle Scholar
  7. 7.
    Ramnemark A, Nyberg L, Borssen B et al (1998) Fractures after stroke. Osteoporos Int 8:92–95PubMedCrossRefGoogle Scholar
  8. 8.
    Dennis MS, Lo KM, McDowall M et al (2002) Fractures after stroke. Frequency, types and associations. Stroke 33:728–734PubMedCrossRefGoogle Scholar
  9. 9.
    Garrett NA, Brasure M, Schmitz KH et al (2004) Physical inactivity. Direct cost to a Health Plan. Am J Prev Med 27:304–309PubMedGoogle Scholar
  10. 10.
    Jorgensen L, Jacobsen BK (2001) Functional status of the paretic arm affects the loss of bone mineral in the proximal humerus after stroke: a 1-year prospective study. Calcif Tissue Int 68:11–15PubMedGoogle Scholar
  11. 11.
    Pang MYC, Eng JJ (2005) Muscle strength is a determinant of bone mineral content in the hemiparetic upper extremity: implications for stroke rehabilitation. Bone 37:103–111PubMedCrossRefGoogle Scholar
  12. 12.
    Iwamoto J, Takeda T, Ichimura S (2001) Relationships between physical activity and metacarpal cortical bone mass and bone resorption in hemiplegic patients. J Orthop Sci 6:227–233PubMedCrossRefGoogle Scholar
  13. 13.
    Sahin L, Ozoran K, Gunduz OH et al (2001) Bone mineral density in patients with stroke. Am J Phys Med Rehabil 80:592–596PubMedCrossRefGoogle Scholar
  14. 14.
    Sato Y, Fujimatsu Y, Kikuyama M et al (1998) Influence of immobilization on bone mass and bone metabolism in hemiplegic elderly patients with long-standing stroke. J Neurol Sci 156:205–210PubMedCrossRefGoogle Scholar
  15. 15.
    Frost HM (2003) Absorptiometry and “osteoporosis”: problems. J Bone Miner Metab 21:255–260PubMedCrossRefGoogle Scholar
  16. 16.
    Burr DB, Turner Ch (2003) Biomechanics of bone. In: Favus MJ (ed) Primer on the metabolic bone diseases and disorders of mineral metabolism, 5th edn. American Society for Bone and Mineral Research, Washington DC, pp 58–64Google Scholar
  17. 17.
    Ashe MC, Fehling P, Eng JJ et al (in press) Bone structural changes to chronic disuse following stroke. J Musculoskelet and Neuron InteractGoogle Scholar
  18. 18.
    Riggs LB, Melton LJ, Robb RA et al (2004) A population-based study of age and sex differences in bone volumetric density, size, geometry and structure at different skeletal sites. J Bone Miner Res 19:1945–1954PubMedCrossRefGoogle Scholar
  19. 19.
    Pang MYC, Eng JJ, Dawson AS et al (2005) A community-based Fitness and Mobility Exercise program for older adults with chronic stroke: a randomized controlled trial. J Am Geriatr Soc 53:1667–1674PubMedCrossRefGoogle Scholar
  20. 20.
    Folstein MF, Folstein, SE, McHugh PR (1975) Mini-mental state: a practical method for grading the state of patients for the clinician. J Psychiat Res 12:189–198PubMedCrossRefGoogle Scholar
  21. 21.
    Kelly-Hayes M, Robertson JT, Broderick JP et al (1998) The American Heart Association Stroke Outcome Classification: executive summary. Circulation 97:2474–2478PubMedGoogle Scholar
  22. 22.
    Liu-Ambrose TY, Khan KM, Eng JJ et al (2004) Both resistance and agility training increase cortical bone density in 75- to 85-year-old women with low bone mass: a 6-month randomized controlled trial. J Clin Densitom 7:390–398PubMedCrossRefGoogle Scholar
  23. 23.
    Pang MYC, Ashe MC, Eng JJ et al (2006) A 19-week exercise program for people with chronic stroke enhances bone geometry at the tibia: a peripheral quantitative computed tomography study. Osteoporos Int 17:1615–1625PubMedCrossRefGoogle Scholar
  24. 24.
    Fess EE (1992) Grip strength. In: Casanova JS (ed) Clinical assessment recommendations, 2nd edn. American Society of Hand Therapists, Chicago, pp 41–45Google Scholar
  25. 25.
    McCrea PH, Eng JJ, Hodgson AJ (2003) Time and magnitude of torque generation is impaired in both arms following stroke. Muscle Nerve 28:46–53PubMedCrossRefGoogle Scholar
  26. 26.
    Bohannon RW (1997) Measurement and nature of muscle strength in patients with stroke. J Neuro Rehabil 11:115–125Google Scholar
  27. 27.
    Mathiowetz V (2002) Comparison of Rolyan and Jamar dynamometers for measuring grip strength. Occup Ther Int 9:201–209PubMedCrossRefGoogle Scholar
  28. 28.
    Wolf SL, Catlin PA, Ellis M et al (2001) Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke. Stroke 32:1635–1639PubMedGoogle Scholar
  29. 29.
    Morris DM, Uswatte G, Crago JE et al (2001) The reliability of the Wolf Motor Function Test for assessing upper extremity function after stroke. Arch Phys Med Rehabil 82:750–755PubMedCrossRefGoogle Scholar
  30. 30.
    Bohannon BW, Smith MB (1987) Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Phys Ther 67:206–207PubMedGoogle Scholar
  31. 31.
    van der Lee JH, Beckerman H, Knol DL et al (2004) Clinimetric properties of the Motor Activity Log for the assessment of arm use in hemiparetic patients. Stroke 35:1410–1414PubMedCrossRefGoogle Scholar
  32. 32.
    Hughes VA, Frontera WR, Dallal GE et al (1995) Muscle strength and body composition: associations with bone density in older subjects. Med Sci Sports Exerc 27:967–974PubMedCrossRefGoogle Scholar
  33. 33.
    Di Monaco M, Di Monaco R, Manca M et al (2000) Handgrip strength is an independent predictor of distal radius bone mineral density in postmenopausal women. Clin Rheumatol 19:473–476PubMedCrossRefGoogle Scholar
  34. 34.
    Eser P, Schiessl H, Willnecker J (2004) Bone loss and steady state after spinal cord injury: a cross-sectional study using pQCT. J Musculoskel Neuron Interact 4:197–198Google Scholar
  35. 35.
    Russo CR, Laurentani F, Bandinelli S et al (2003) Aging bone in men and women: beyond changes in bone mineral density. Osteoporos Int 14:531–538PubMedCrossRefGoogle Scholar
  36. 36.
    Ahlborg HG, Johnell O, Turner CH et al (2003) Bone loss and bone size after menopause. New Engl J Med 349:327–334PubMedCrossRefGoogle Scholar
  37. 37.
    Hangartner TN, Gilsanz V (1996) Evaluation of cortical bone by computed tomography. J Bone Miner Res 11:1518–1525PubMedCrossRefGoogle Scholar
  38. 38.
    Adami S, Gatti D, Braga V et al (1999) Site-specific effects of strength training on bone structure and geometry of ultradistal radius in postmenopausal women. J Bone Miner Res 14:120–124PubMedCrossRefGoogle Scholar
  39. 39.
    Wilmet E, Ismail AA, Heilporn A et al (1995) Longitudinal study of the bone mineral content and of soft tissue composition after spinal cord section. Paraplegia 33:674–677PubMedGoogle Scholar
  40. 40.
    Taub E, Miller NE, Novack TA et al (1993) Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 74:347–354PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2007

Authors and Affiliations

  • M. Y. C. Pang
    • 1
    • 2
    • 3
    • 4
  • M. C. Ashe
    • 2
    • 3
    • 4
  • J. J. Eng
    • 2
    • 3
    • 4
  1. 1.Department of Rehabilitation SciencesHong Kong Polytechnic UniversityHong KongChina
  2. 2.School of Rehabilitation SciencesUniversity of British ColumbiaVancouverCanada
  3. 3.Rehabilitation Research LaboratoryGF Strong CentreVancouverCanada
  4. 4.Vancouver Coastal Health Research InstituteVancouverCanada

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