Skip to main content

Advertisement

SpringerLink
Log in

Predictors of low bone mineral density of the stroke-affected hip among ambulatory individuals with chronic stroke

  • Original Article
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Summary

Risk of hip fracture is greater poststroke than in an age-matched healthy population, in part because of declining hip BMD. We found that individuals may be at risk of loss of hip BMD from muscle atrophy, asymmetrical gait, and poor affected-side ankle dorsiflexor strength. These impairments may be targeted during rehabilitation.

Introduction

This study aimed to determine predictors of low hip BMD on the stroke-affected side in people living in the community.

Methods

Forty-three participants (female; 27.9 %), mean age 62.4 ± 13.5 and 17.9 ± 32.8 months, poststroke with motor impairments underwent dual energy X-ray absorptiometry scans. Gait characteristics, isometric strength, body composition, and fasting plasma lipids were measured.

Results

At entry, 34.9 % (15/43) of the participants had low total hip BMD on the stroke-affected side. Of those with low BMD, 93.3 % (14/15) had a step length symmetry ratio >1, indicating greater reliance on the non-paretic leg for weight bearing. Logistic regression analysis revealed that lower affected-side ankle dorsiflexor strength (ß = 0.700, p = 0.02), lower total body fat-free mass index (ß = 0.437, p = 0.02), and greater step length symmetry ratio during walking (ß = 1.135 × 103, p = 0.03) were predictors of low hip BMD.

Conclusion

Low BMD of the stroke-affected side hip is prevalent in over a third of individuals with lower limb motor impairments. These individuals may be at particular risk of accelerated loss of BMD at the hip from asymmetrical gait pattern and poor affected-side ankle dorsiflexor strength. These impairments are intervention targets that may be addressed during rehabilitation which includes resistance training and addresses gait impairments.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Ramnemark A, Nyberg L, Borssen B, Olsson T, Gustafson Y (1998) Fractures after stroke. Ostoporos Int 8:92–95

    Article  CAS  Google Scholar 

  2. Ramnemark A, Nilsson M, Borssen B, Gustafson Y (2000) Stroke, a major and increasing risk factor for femoral neck fracture. Stroke 31:1572–1577

    Article  PubMed  CAS  Google Scholar 

  3. Cummings SR, Kelsey JL, Nevitt MC, O'Dowd K (1985) Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev 7:178–208

    PubMed  CAS  Google Scholar 

  4. Chiu KY, Pun WK, Luk KD, Chow SP (1992) A prospective study on hip fractures in patients with previous cerebrovascular accidents. Injury 23:297–299

    Article  PubMed  CAS  Google Scholar 

  5. Ovbiagele B, Goldstein LB, Higashida RT, Howard VJ, Johnston SC, Khavjou OA, Lackland DT, Lichtman JH, Mohl S, Sacco RL, Saver JL, Trogdon JG (2013) Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke 44:2361–2375

    Article  PubMed  Google Scholar 

  6. Tosteson AN, Burge RT, Marshall DA, Lindsay R (2008) Therapies for treatment of osteoporosis in US women: cost-effectiveness and budget impact considerations. Am J Manag Care 14:605–615

    PubMed  Google Scholar 

  7. Melton LJI, Gabriel SE, Crowson CS, Tosteson AN, Johnell O, Kanis JA (2003) Cost-equivalence of different osteoporotic fractures. Osteoporos Int 14:383–388

    Article  PubMed  Google Scholar 

  8. Burge RT, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475

    Article  PubMed  Google Scholar 

  9. Jones G, Nguyen T, Sambrook P, Kelly P, Eisman J (1994) Progressive loss of bone in the femoral neck in elderly people: longitudinal findings from the Dubbo osteoporosis epidemiology study. BMJ 309:691–695

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  10. Jorgensen L, Jacobsen BK, Wilsgaard T, Magnus JH (2000) Walking after stroke: does it matter? Changes in bone mineral density within the first 12 months after stroke. A longitudinal study. Osteoporos Int 11:381–387

    Article  PubMed  CAS  Google Scholar 

  11. Ramnemark A, Nyberg L, Lorentzon R, Englund U, Gustafson Y (1999) Progressive hemiosteoporosis on paretic side and increased bone mineral density in non-paretic arm first year after severe stroke. Osteoporos Int 9:269–275

    Article  PubMed  CAS  Google Scholar 

  12. Nevitt MC, Cummings SR, for the Study of Osteoporotic Fractures Research Group (1993) Type of fall and risk of hip and wrist fractures: the study of osteoporotic fractures. J Am Geriatr Soc 41:1226–1234

    PubMed  CAS  Google Scholar 

  13. Cummings SR, Black DM, Nevitt MC, Browner WS, Cauley J, Ensrud K, Geneant HK, Palermo L, Scott J, Vogt TM (1993) Bone density at various sites for prediction of hip fractures. Lancet 341:72–75

    Article  PubMed  CAS  Google Scholar 

  14. Pang MYC, Eng JJ, McKay HA, Dawson AS (2005) Reduced hip bone mineral density is related to physical fitness and leg lean mass in ambulatory individuals with chronic stroke. Osteoporos Int 16:1769–1779

    Article  PubMed  PubMed Central  Google Scholar 

  15. Poli A, Bruschi F, Cesana B, Rossi M, Paoletti R, Crosignani PG (2003) Plasma low-density lipoprotein cholesterol and bone mass densitometry in postmenopausal women. Obstet Gynecol 102:922–926

    Article  PubMed  CAS  Google Scholar 

  16. Makovey J, Chen JS, Hayward C, Williams FM, Sambrook PN (2009) Association between serum cholesterol and bone mineral density. Bone 44:208–213

    Article  PubMed  CAS  Google Scholar 

  17. Gowland C, Stratford P, Ward M, Moreland J, Torresin W, Van Hullenaar S, Sanford J, Barreca S, Vanspall B, Plews N (1993) Measuring physical impairment and disability with the Chedoke–McMaster stroke assessment. Stroke 24:58–63

    Article  PubMed  CAS  Google Scholar 

  18. Shinar D, Gross CR, Price T, Banko M, Bolduc P, Robinson R (1986) Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale. Stroke 17:241–245

  19. Tilson JK, Wu SS, Cen SY, Feng Q, Rose DR, Behrman AL, Azen SP, Duncan PW (2012) Characterizing and identifying risk for falls in the LEAPS study: a randomized clinical trial of interventions to improve walking poststroke. Stroke 43:446–452

    Article  PubMed  PubMed Central  Google Scholar 

  20. Nasreddine ZS, Philips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I (2005) The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53:695–699

    Article  PubMed  Google Scholar 

  21. Mazess RB, Barden H, Bisek J (1990) Dual-energy x-ray absorptiometry for total-body and regional bone-mineral and soft-tissue composition. Am J Clin Nutr 51:1106–1112

    PubMed  CAS  Google Scholar 

  22. Nevitt M (1994) Bone mineral density predicts non-spine fracture in very elderly women. Osteoporos Int 4:235–241

    Article  Google Scholar 

  23. Schott AM, Cormier C, Hans D, Favier F, Hausherr E, DargentMolina P, Delmas PD, Ribot C, Sebert JL, Breart G, Meunier PJ, for the EPIDOS group (1998) How hip and whole body bone mineral density predict hip fracture in elderly women: the EPIDOS prospective study. Osteoporos Int 8:247–254

    Article  PubMed  CAS  Google Scholar 

  24. Kanis JA, Gluer CC (2000) An update on the diagnosis and assessment of osteoporosis with densitometry. Osteoporos Int 11:192–202

    Article  PubMed  CAS  Google Scholar 

  25. De Laet CEDH, van der Klift M, Hofman A, Pols HAP (2002) Osteoporosis in men and women: a story about bone mineral density thresholds and hip fracture risk. J Bone Miner Res 17:2231–2236

    Article  PubMed  Google Scholar 

  26. Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrance of osteoporotic fractures. BMJ 312:1254–1259

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  27. Bilney B, Morris M, Webster K (2003) Concurrent related validity of the GAITRite walkway system for quantification of the spatial and temporal parameters of gait. Gait Posture 17:68–74

    Article  PubMed  Google Scholar 

  28. Bohannon RW (1990) Knee extension torque in stroke patients: comparison of measurements obtained with a hand-held and a Cybex dynamometer. Physiother Can 42:284–287

    Google Scholar 

  29. Mickey J, Greenland S (1989) A study of the impact of confounder selection criteria on effect estimation. Am J Epidemiol 129:125–137

    PubMed  CAS  Google Scholar 

  30. Pang MY, Ashe MC, Eng JJ (2010) Compromised bone strength index in the hemiparetic distal tibia epiphysis among chronic stroke patients: the association with cardiovascular function, muscle atrophy, mobility, and spasticity. Osteoporos Int 21:997–1007

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  31. Young D, Hopper JL, Macinnis RJ, Nowson CA, Hoang NH, Wark JD (2001) Changes in body composition as determinants of longitudinal changes in bone mineral measures in 8- to 26-year-old female twins. Osteoporos Int 12:506–515

    Article  PubMed  CAS  Google Scholar 

  32. Wang MC, Bachrach LK, Van Loan M, Hudes M, Flegal KM, Crawford PB (2005) The relative contributions of lean tissue mass and fat mass to bone density in young women. Bone 37:474–481

    Article  PubMed  CAS  Google Scholar 

  33. Soot T, Jurimae T, Jurimae J, Gapeyeva H, Paasuke M (2005) Relationship between leg bone mineral values and muscle strength in women with different physical activity. J Bone Miner Metab 23:401–406

    Article  PubMed  Google Scholar 

  34. Reid IR (2002) Relationships among body mass, its components, and bone. Bone (NY) 31:547–555

    Article  CAS  Google Scholar 

  35. Di Monaco M, Vallero F, Di Monaco R, Tappero R, Cavanna A (2007) Skeletal muscle mass, fat mass, and hip bone mineral density in elderly women with hip fracture. J Bone Miner Metab 254:237–242

    Article  Google Scholar 

  36. Kohrt WM, Barry DW, Schartz RS (2009) Muscle forces or gravity: what predominates mechanical loading on bone? Med Sci Sport Exerc 41:2050–2055

    Article  Google Scholar 

  37. Ramnemark A, Nyberg L, Lorentzon R, Olsson T, Gustafson Y (1999) Hemiosteoporosis after severe stroke, independent of changes in body composition and weight. Stroke 30:755–760

    Article  PubMed  CAS  Google Scholar 

  38. Pang MY, Ashe MC, Eng JJ (2008) Tibial bone geometry in chronic stroke patients: influence of sex, cardiovascular health, and muscle mass. J Bone Miner Res 23:1023–1030

    Article  PubMed  PubMed Central  Google Scholar 

  39. Whipple RH, Wolfson LI, Amerman PM (1987) The relationship of knee and ankle weakness to falls in nursing home residents: an isokinetic study. J Am Geriatr Soc 35:13–20

    PubMed  CAS  Google Scholar 

  40. Balasubramanian CK, Bowden MG, Neptune RR, Kautz SA (2007) Relationship between step length asymmetry and walking performance in subjects with chronic hemiparesis. Arch Phys Med Rehabil 1:43–49

    Article  Google Scholar 

  41. Jorgensen L, Crabtree NJ, Reeve J, Jacobsen BK (2000) Ambulatory level and asymmetrical weight bearing after stroke affects bone loss in the upper and lower part of the femoral neck differently: bone adaptation after decreased mechanical loading. Bone 27:701–707

    Article  PubMed  CAS  Google Scholar 

  42. Jorgensen L, Jacobsen BK (2001) Changes in muscle mass, fat mass, and bone mineral content in the legs after stroke: a 1 year prospective study. Bone 28:655–659

    Article  PubMed  CAS  Google Scholar 

  43. Pang MY, Eng JJ, Dawson AS, McKay HA, Harris JE (2005) A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. J Am Geriatr Soc 53:1667–1674

    Article  PubMed  PubMed Central  Google Scholar 

  44. Worthen LC, Kim CM, Kautz SA, Lew HL, Kiratli BJ, Beaupre GS (2005) Key characteristics of walking correlate with bone density in individuals with chronic stroke. JRRD 42:761–768

    Article  Google Scholar 

  45. Kim CM, Eng JJ (2003) Symmetry in vertical ground reaction force is accompanied by symmetry in temporal but not distance variables of gait in persons with stroke. Gait Posture 18:23–28

    Article  PubMed  Google Scholar 

  46. Lau RWK, Pang MY (2009) An assessment of the osteogenic index of therapeutic exercises for stroke patients: relationship to severity of leg motor impairment. Osteoporos Int 20:979–987

    Article  PubMed  CAS  Google Scholar 

  47. Sato Y (2000) Abnormal bone and calcium metabolosim in patients after stroke. Arch Phys Med Rehabil 81:117–121

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We acknowledge the contribution of Andrea Brown, Susie Ward, Sonia Watson, Marlee Beallor, Karen Dobson, and patients and staff at Toronto Rehab. This study was supported by the Toronto Rehabilitation Institute which receives funding under the Provincial Rehabilitation Research Program from the Ministry of Health and Long-Term Care in Ontario. SM receives funding from the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery. DB is a Canada Research Chair.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. University Health Network, Toronto Rehabilitation Institute, Toronto, Canada

    S. Marzolini, W. McIlroy, B. C. Craven, P. I. Oh & D. Brooks

  2. Heart and Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, Ontario, Canada

    S. Marzolini, W. McIlroy, A. Tang, D. Corbett, P. I. Oh & D. Brooks

  3. Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada

    W. McIlroy

  4. School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada

    A. Tang

  5. Population Health Research Institute, Hamilton, Ontario, Canada

    A. Tang

  6. Faculty of Medicine, University of Ottawa, Ottawa, Canada

    D. Corbett

  7. Department of Physical Therapy, University of Toronto, Toronto, Canada

    D. Brooks

  8. 347 Rumsey Road, Toronto, Canada, M4G1R7

    S. Marzolini

Authors
  1. S. Marzolini
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. W. McIlroy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Tang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. D. Corbett
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. B. C. Craven
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. P. I. Oh
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. D. Brooks
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. Marzolini.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOCX 16 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marzolini, S., McIlroy, W., Tang, A. et al. Predictors of low bone mineral density of the stroke-affected hip among ambulatory individuals with chronic stroke. Osteoporos Int 25, 2631–2638 (2014). https://doi.org/10.1007/s00198-014-2793-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-014-2793-3

Keywords

Search

Navigation