title: Effects of transcranial direct current stimulation over the supplementary motor area body weight-supported treadmill gait training in hemiparetic patients after stroke Upright activity and higher motor function may preserve bone mineral density within 6 months of stroke: a longitudinal study Prevention of Secondary Osteoporosis Postmenopause in Hemiplegia Time and magnitude of torque generation is impaired in both arms following stroke. A Single Infusion of Zoledronate Prevents Bone Loss After Stroke Bone Mineral Density in Patients with Stroke Fractures After Stroke: Frequency, Types, and Associations Adding injury to insult: fracture risk after stroke in veterans. Skeletal and body composition changes in hemiplegic patients. Progressive Hemiosteoporosis on the Paretic Side and Increased Bone Mineral Density in the Nonparetic Arm the First Year after Severe Stroke
   Increased Bone Resorption in the Proximal Femur in Patients with Hemiplegia Bone mineral density alterations in upper and lower extremities 12 months after stroke measured by peripheral quantitative computed tomography and DXA. A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. Bone Mineral Density in Acute Stroke Patients: Low Bone Mineral Density May Predict First Stroke in Women The relationship between bone mineral density and immobilization duration in hemiplegic limbs 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.
abstract: Transcranial direct current stimulation ( tDCS ) is used in a variety of disorders after stroke including upper limb motor dysfunctions , hemispatial neglect , aphasia , and apraxia , and its effectiveness has been demonstrated . Although gait ability is important for daily living , there were few reports of the use of tDCS to improve balance and gait ability . The supplementary motor area ( SMA ) was reported to play a potentially important role in balance recovery after stroke . We aim ed to investigate the effect of combined therapy body weight-supported treadmill training ( BWSTT ) and tDCS on gait function recovery of stroke patients . Thirty stroke in patients participated in this study . The two BWSTT periods of 1weeks each , with real tDCS ( anode : front of Cz , cathode : inion , 1mA , 20min ) on SMA and sham stimulation , were r and omized in a double-blind crossover design . We measured the time required for the 10 m Walk Test ( 10MWT ) and Timed Up and Go ( TUG ) test before and after each period . We found that the real tDCS with BWSTT significantly improved gait speed ( 10MWT ) and applicative walking ability ( TUG ) , compared with BWSTT+sham stimulation periods ( p<0.05 ) . Our findings demonstrated the feasibility and efficacy of tDCS in gait training after stroke . The facilitative effects of tDCS on SMA possibly improved postural control during BWSTT . The results indicated the implication s for the use of tDCS in balance and gait training rehabilitation after stroke Purpose Bone fragility contributes to increased fracture risk , but little is known about the emergence of post-stroke bone loss . We investigated skeletal changes and relationships with physical activity , stroke severity , motor control and lean mass within 6 months of stroke . Methods This is a prospect i ve observational study . Participants were non-diabetic but unable to walk within 2 weeks of first stroke .  Distal tibial volumetric bone mineral density ( vBMD , primary outcome ) , bone geometry and microstructure ( high-resolution peripheral quantitative computed tomography ) were assessed at baseline and 6 months , as were secondary outcomes total body bone mineral content and lean mass ( dual energy X-ray absorptiometry ) , bone metabolism ( serum osteocalcin , N-terminal propeptide of type 1 procollagen ( P1NP ) , C-terminal telopeptide of type 1 collagen ( CTX ) ) , physical activity ( PAL2 accelerometer ) and motor control ( Chedoke McMaster )  which were also measured at 1 and 3 months . Results Thirty-seven participants ( 69.7 years ( SD 11.6 ) , 37.8 % females , NIHSS 12.6 ( SD 4.7 ) ) were included . The magnitude of difference in vBMD between paretic and non-paretic legs increased within 6 months , with a greater reduction observed in paretic legs ( mean difference = 1.5 % ( 95 % CI 0.5 , 2.6 ) , p = 0.007 ) . At 6 months , better motor control was associated with less bone loss since stroke ( r = 0.46 , p = 0.02 ) . A trend towards less bone loss was observed in people who regained independent walking compared to those who did not ( p = 0.053 ) . Higher baseline daily count of st and ing up was associated with less change in bone turnover over 6 months : osteocalcin ( r = −0.51 , p = 0.01 ) , P1NP ( r = −0.47 , p = 0.01 ) , CTX ( r = −0.53 , p = 0.01 ) . Conclusion Better motor control and walking recovery were associated with reduced bone loss . Interventions targeting these impairments from early post-stroke are warranted . Clinical trial registration URL : http://www.anzctr.org.au . Unique identifier : ACTRN12612000123842 Ikai T , Uematsu M , Eun SS , Kimura C , Hasegawa C , Miyano S : Prevention of secondary osteoporosis postmenopause in hemiplegia . Am J Phys Med Rehabil 2001;80:169–174 . Objectives To study secondary osteoporosis postmenopause in women with hemiplegia and to show the therapeutic effects of etidronate and how osteoporotic conditions relate to the activities of daily living ( ADL ) . Design Eighty-one postmenopausal women with hemiplegia were admitted within 6 mo of their first cerebrovascular accident . The bone mineral density ( BMD ) and biochemical markers of bone turnover were measured at the time of admission . Forty women ( treatment group ) received a 2-wk administration of etidronate . Forty-one women ( control group ) were not administered etidronate . Results After completing a 3-mo rehabilitation program , BMD levels were remeasured . ADL was evaluated by FIMTM . The low ADL group had a larger decrease in BMD than the high ADL group . For the control group , the BMD rate of change on the paretic side of the femoral neck was −9.6%/3 mo for the low ADL group . BMD loss was reduced significantly by the administration of etidronate for the low ADL group . Conclusions Results indicate that ADL corresponds to the progression of osteoporosis in postmenopausal women with hemiplegia and that increasing the level of ADL will reduce the progression of osteoporosis . Use of etidronate has also been proven to have a suppressive effect on the BMD decrease in women Muscle strength , usually measured as the peak torque during maximal contraction , is impaired in persons with stroke . Time-dependent properties of muscle contraction may also be altered but have not been quantified . We quantified both magnitude ( peak torque ) and time-dependent parameters ( times to develop and reduce torque ) in eight different isometric joint actions . Parameters were compared among the more and less affected arms of 20 persons with chronic stroke and the nondominant arms of 10 similarly aged healthy persons .  Torque-generation parameters were independent from one another ( i.e. , low correlations ) and highly reliable between trials and days . All parameters were impaired in the more affected arm , whereas peak torque and time to develop torque were impaired in the less affected arm . Following stroke , torque-generation impairments include both magnitude and time-dependent properties and exist not only in the more affected but also in the less affected arm . Clinicians attempting to improve upper-extremity function should employ therapeutic exercises that challenge patients to improve both their strength and speed of muscle contraction Background and Purpose — Stroke is a major risk factor for hip fracture . Patients with intermediate rather than severe or mild stroke deficits at the time of hospital discharge have the most fractures . This proof-of-concept study evaluated the efficacy of a single infusion of zoledronate , an intravenous bisphosphonate , in preserving hip bone density after stroke . Methods — In a 1-year r and omized , double-blind , placebo-controlled , clinical trial , 27 newly hemiplegic patients ( 6 females , 21 males ) with acute stroke were assigned to receive 4 mg of the intravenous zoledronate ( n=14 ) or placebo ( n=13 ) within 35 days . Strict inclusion criteria were followed-up to ensure recruited patients were likely to have residual functional impairment . Both groups received calcium and vitamin D supplementation . The primary outcome measure was the change in bone mineral density ( BMD ; Lunar Prodigy ) at the hemiplegic hip during the year of investigation . Results — The treatment was generally well tolerated . Mean total hip BMD was unchanged in the hemiplegic hip of the zoledronate group ( mean 0.0 % change ) , whereas in the placebo group the total hip BMD changed by −5.5 % , with the greatest bone loss observed in the trochanteric subregion ( mean , −8.1 % ) . On the unaffected side the mean change in total hip BMD was + 1.0 % with zoledronate versus a mean change of −2.7 % without . Repeated measures ANOVA confirmed the significance of the differences between groups at both hips ( hemiplegic , P<0.001 ; unaffected , P=0.002 ) . Conclusions — Stroke patients were protected from the deleterious effects of hemiplegia on hip bone density for at least 1 year after a single infusion of zoledronate Şahin L , Özoran K , Gündüz OH , Uçan H , Yücel M : Bone mineral density in patients with stroke . Am J Phys Med Rehabil 2001;80:592–596 . ObjectiveS troke is an acute neurologic dysfunction of vascular origin , characterized by loss of voluntary movement , sensory disturbances , and neurologic findings in the contralateral half of the body . Acute and long-term complications because of immobilization are seen in all organ systems . The aim of this study was to determine any differences between the affected and unaffected sides ’ bone mineral densities of acute and chronic stroke patients . Design In this study , we determined the bone mineral densities ( BMD ) of 30 male patients with acute ( 0 - 20 days ) and 30 male patients with chronic ( 6 months or longer ) stroke and compared the densities with the normal side . Upper and lower limb BMDs were measured by dual-energy x-ray absorptiometry . Additionally , patients were evaluated for the degree of spasticity , the phases of motor improvement , and the activities of daily living . Results In acute-phase stroke patients , BMD of the affected side was not significantly different from BMD of the normal side . BMD of both upper limbs of acute stroke patients was not different from normal side upper limb BMD of chronic stroke patients . In both acute and chronic stroke patients , affected and unaffected side lower limb BMDs ( femur total BMD scores ) were not significantly different . However , in chronic stroke patients , affected side BMD of Ward ’s region was significantly higher compared with the normal side . There is no correlation between BMD and Brunnstrom phases , Ashworth scales , and the degree of activities of daily living . Conclusions Higher BMD of the affected side Ward ’s region in chronic cerebrovascular accident patients may be related to spasticity and changes in walking pattern , which increase the mechanical stress loading of the Ward ’s region Background and Purpose — Stroke patients may have an increased risk of fractures because of weak bones or an increased risk of falling . Our goal was to estimate the frequency of fracture after stroke and to identify those at greatest risk . Methods — This study incorporated 2 complementary strategies : a prospect i ve , single-center , cohort study and an analysis of Scottish routine hospital discharge data  . Results — Eighty-eight fractures ( 30 % hip ) occurred in 2696 hospital-referred stroke patients . The proportions sustaining any fracture or hip fracture within 2 years were 4 % and 1.1 % , respectively , 1.4 ( 95 % CI , 0.92 to 2.07 ) times the rate of hip fracture in the general population ( ie , observed number divided by expected number or st and ardized morbidity ratio ) . Female sex , older age , low abbreviated mental test score , and prestroke dependence were associated with an increased hip fracture rate . Routine data identified 129 935 acute stroke patients admitted to Scottish hospitals . During 363 447 patient-years , 4528 patients had hip fractures  , 2.0 % had fractures by 1 year , and 10.6 % had fractures by 10 years . This is 1.7 times the rate of hip fracture in the general population and 2.3 times that in patients with myocardial infa rct ion . Older patients predictably had the highest rate of poststroke hip fractures but a lower st and ardized morbidity ratio than younger patients . Conclusions — Fractures after stroke are probably frequent and serious enough to justify the development of preventive strategies , but the modest event rate would mean that r and omized , controlled trials to test these strategies specifically in stroke patients would need to enroll thous and s of patients OBJECTIVES To determine fracture risk in U.S. stroke patients and identify patient characteristics that predict highest fracture risk in two complementary cohorts . DESIGN Secondary analyses of two prospect i ve cohorts . SETTING Veterans Affairs ( VA ) Medical Centers . PARTICIPANTS The VA Acute Stroke ( VASt ) cohort includes 1,073 veterans admitted to nine VA hospitals for stroke between April 1995 and March 1997 . The Integrated Stroke Outcomes Data base ( ISOD ) includes 6,578 veterans who received inpatient rehabilitation for stroke at 121 VA facilities during fiscal years 2001 and 2002 . MEASUREMENTS Fractures detected using International Classification of Diseases , 9th Revision , codes in the VA computerized patient record system ; baseline patient characteristics and stroke features ; Functional Independence Measures scores in ISOD . RESULTS Estimated 2-year fracture rates after stroke in the VASt and ISOD cohorts were 6.1 % and 4.7 % , respectively . Longer hospitalizations for stroke ( P=.06 ) and new motor or sensory impairment ( P=.09 ) showed trends toward greater risk in the VASt cohort . Female sex ( P < .001 ) , cognitive impairment ( P=.01 ) , and nonblack race ( P=.04 ) were associated with higher fracture risk in the ISOD . Intermediate functional impairment conferred higher fracture risk than mild or severe functional impairment . CONCLUSION Veterans who suffer a stroke are at high risk of subsequent fracture , which can lead to further disability . Women , nonblacks , and those with intermediate functional impairment were at particularly high risk of fracture . Future study should investigate therapies to decrease fracture risk in stroke patients Hemiplegic patients are prone to bone loss and alterations in fat and lean mass , which ultimately affect their rehabilitation status and propensity in bone fractures . The present study aim ed to evaluate body composition and bone mineral density ( BMD ) in stroke patients within 1st year post-stroke . Fifty-eight hemiplegic patients ( 36 men and 22 women ) were enrolled in this prospect i ve study . Dual-energy X-ray absorptiometry was used to assess total-body and lower-extremity BMDs ( g/cm(2 ) ) , lean mass ( g ) , and fat mass ( g ) after 3 , 6 and 12 mo of stroke that led to hemiplegia . The Modified Ashworth Scale and the functional ambulation category were used to evaluate spasticity and ambulatory category of patients , respectively . Both sexes exhibited total-body and paretic lower-limb BMD loss , fat mass gain , and lean mass waste during the 1st 12 mo poststroke , and in most cases , statistically significant differences were found between 3 and 6 mo ; however , the pattern of changes was different between males and females . Therefore , it is suggested that disability because of hemiplegia led to alterations in muscle function , which triggered skeletal and body composition changes and rendered these patients particularly prone to increased fracture risk Abstract : Fractures are a common and serious complication after stroke and the risk of hip fractures among stroke patients is 2 to 4 times greater than among other elderly people . The aim of this study was to investigate prospect ively the change in bone mineral density ( BMD ) after severe stroke and to study the association between motor impairment , disability and the development of hemiosteoporosis . The study comprised 24 stroke patients , with no persistent paresis from previous strokes or previous osteoporotic fractures , included 1 month after stroke onset .  BMD , motor function , ambulation and activities of daily living ( ADL )  were assessed at 1 , 4 , 7 and 12 months after stroke onset . At inclusion , the patients ’ BMD was normal for their age . During the study , there was a significant loss of BMD in the total body ( −2.0 % ; p<0.05 ) , but not in the head or spine . BMD differed significantly between the paretic and the non-paretic arm at inclusion ( −4.8 % ; p<0.001 ) . Decrease in BMD was most pronounced in the affected humerus ( −17.4 % ; p<0.001 ) and proximal femur ( −12.2 % ; p<0.01 ) . BMD decreased significantly in both lower extremities during follow-up , but the losses were more pronounced on the paretic side ( p<0.01 ) . In the nonaffected ultradistal radius there was a significant increase in BMD from inclusion to the end of the study ( + 5.8 % ; p<0.01 ) . There was no pattern in the bone losses correlating with presumptive risk factors for hemiosteoporosis such as motor function , ability to perform ADL or ambulation . Two patients had fractures at follow-up , both on the paretic side . Loss of bone mineral density in the paretic extremities is thus pronounced and progressive during the first year after stroke , indicating that loss of BMD is probably an important risk factor for post-stroke fractures . Surprisingly , BMD in the nonaffected arm increased significantly during the first year after stroke , most likely due to increased physical activity , and perhaps a redistribution of bone minerals from the paretic extremities Levendo&U01E7;lu F , U&U01E7;urlu H , Gürbilek M , Akkurt E , Karagözo&U01E7;lu E : Increased bone resorption in the proximal femur in patients with hemiplegia . Am J Phys Med Rehabil 2004;83:835–841 . Objectives : To investigate the relationship between the proximal femoral bone mineral density and bone resorption markers , determinants of calcium metabolism and vitamin D levels in elderly stroke patients . Design : A total of 80 patients and 20 controls were enrolled in the study .  Bone mineral density measurements were obtained at the proximal femur . In all subjects ,  25-hydroxyvitamin D , 1,25-dihydroxyvitamin D , intact parathyroid hormone , osteocalcin , deoxypyridinoline , and ionized calcium concentrations  were measured . Barthel Index and Motricity Index Leg Score were recorded all patients . Results : The serum concentrations of deoxypyridinoline , intact parathyroid hormone , and the mean serum ionized calcium levels were significantly higher in patients with stroke than that of the control subjects . The mean serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D concentrations in patients were significantly lower than those of the control group ( P < 0.05 ) . The bone mineral density of proximal femurs of paretic limbs was decreased significantly compared with those of the control group ( P < 0.05 ) . There were significant correlations between the Z score of the hemiplegic side and the patients ’ Barthel Index , Motricity Index Leg Score , 25-hydroxyvitamin D , 1,25-dihydroxyvitamin D , calcium , and deoxypyridinoline . Conclusions : This study provides clear evidence that decreased mobility , vitamin D status , and bone turnover variables in patients after stroke are important factors in the greater bone loss in the paretic leg To evaluate the loss of trabecular and cortical bone mineral density ( BMD ) and geometric parameters of bone strength expressed by stress-strain index ( SSI ) in the proximal and distal forearm and the alterations of BMD in the hip of hemiplegic patient and 12 mo after stroke . Sixty-seven hemiplegic patients ( 43 men and 24 women ) with a history of single completed strokes associated with unilateral weakness were enrolled in this prospect i ve study . All patients underwent bone densitometry measurements at 3 , 6 , and 12 mo after the initial episode of stroke . Both paretic and normal forearms were examined by peripheral quantitative computed tomography ( pQCT ) at the 4 % and 20 % sites of the forearm length and both hips were examined by dual-energy X-ray absorptiometry ( DXA ) including the area of femoral neck and greater trochanter . The diagnosis of stroke was confirmed by cranial computed tomography . Motor function was assessed by the functional ambulation category ( FAC ) and spasticity by the modified Ashworth scale ( MAS ) . We found statistically significant trabecular and cortical bone density reductions during the course of our study in the forearm , which was more profound on the paretic side . Trabecular bone loss and SSI measured at 4 % of the paretic forearm in the male group represented a 12-mo decrease of 14.01 % and 28.61 % , respectively , and in the female group 9.29 % and 19.17 % , respectively . Cortical bone and SSI measured at the 20 % site of paretic forearm in the male group corresponded to a 12-mo decrease of 4.02 % and 7.43 % , respectively , and in the female group 2.59 % and 6.97 % , respectively . Paretic femoral neck and trochanter measurements in males showed a reduction of 11.76 % and 10.38 % , respectively , and in females 13.04 % and 12.6 % , respectively . A significant loss of BMD and bone strength was found during the first year after stroke in both trabecular and cortical bone at the forearm and at the neck and great trochanter on the paretic hip . Most prominent BMD reduction was evident in men compared with perimenopausal women in the same age OBJECTIVES To examine the effects of a community-based group exercise program for older individuals with chronic stroke . DESIGN Prospect i ve , single-blind , r and omized , controlled intervention trial . SETTING Intervention was community-based . Data collection was performed in a research laboratory located in a rehabilitation hospital . PARTICIPANTS Sixty-three older individuals ( aged > or = 50 ) with chronic stroke ( poststroke duration > or = 1 year ) who were living in the community . INTERVENTION Participants were r and omized into intervention group ( n=32 ) or control group ( n=31 ) . The intervention group underwent a fitness and mobility exercise ( FAME ) program design ed to improve cardiorespiratory fitness , mobility , leg muscle strength , balance , and hip bone mineral density ( BMD ) ( 1-hour sessions , three sessions/week , for 19 weeks ) . The control group underwent a seated upper extremity program . MEASUREMENTS Cardiorespiratory fitness ( maximal oxygen consumption ) , mobility ( 6-minute walk test ) , leg muscle strength ( isometric knee extension ) , balance ( Berg Balance Scale ) , activity and participation ( Physical Activity Scale for Individuals with Physical Disabilities ) , and femoral neck BMD ( using dual-energy x-ray absorptiometry ) . RESULTS The intervention group had significantly more gains in cardiorespiratory fitness , mobility , and paretic leg muscle strength than controls . Femoral neck BMD of the paretic leg was maintained in the intervention group , whereas a significant decline of the same occurred in controls . There was no significant time-by-group interaction for balance , activity and participation , nonparetic leg muscle strength , or nonparetic femoral neck BMD . CONCLUSION The FAME program is feasible and beneficial for improving some of the secondary complications result ing from physical inactivity in older adults living with stroke . It may serve as a good model of a community-based fitness program for preventing secondary diseases in older adults living with chronic conditions Background and Purpose — Osteoporosis and stroke share several risk factors , including age , smoking , low physical activity , and hypertension . Thus , low bone mineral density ( BMD ) and high stroke risk may be related . We examined the relationship between BMD and acute stroke in noninstitutionalized men and women aged ≥60 years . Methods — Sixty-three stroke patients ( 33 women and 30 men ) and 188 control subjects from the general population were included .  BMD was measured by using dual-energy x-ray absorptiometry at both proximal femurs . The measurements of the stroke patients were performed 6 days after the onset of stroke . Results — The BMD at the femoral neck in the female stroke patients was 8 % lower than in the control subjects ( P = 0.007 ) . In men , no difference in BMD between the stroke patients and their controls was found . Women with BMD values in the lowest quartile had a higher risk of stroke than women with BMD values in the highest quartile ( OR 4.8 ) , and the probability value for linear trend over the quartiles was statistically significant ( P = 0.003 ) . The OR for stroke increased 1.9 per SD ( 0.13 g/cm2 ) reduction in BMD , and the association between low BMD and stroke in women remained significant when the analysis was adjusted for potential confounders . Conclusions — Female , but not male , stroke patients  have lower BMD than population controls . Low BMD may predict stroke in women Objective Prolonged immobilization in stroke is known to result in hypercalciuria , hypercalcemia , accelerated bone resorption , and osteoporosis . Furthermore , bone mineral loss accelerated with increasing duration of hemiplegia . Although stroke is a common disease that causes sudden immobilization , relatively few investigations of bone metabolism in stroke have been reported . The aim of this study was to investigate the changes in bone mineral density of the forearms and legs related to duration of hemiplegia-induced immobilization after stroke . Methods Forty-one hemiplegic patients with stroke were evaluated . The patients ’ age , gender and duration of hemiplegia-induced immobilization were recorded . The measurements of bone mineral density ( BMD ) in all patients were evaluated with DEXA using the Norl and apparatus . The BMD values ( g/cm2 ) were determined by measurements made in the lumbar vertebrae , both forearm and legs ( femoral neck and trochanter ) . Results We found that bone mineral density was decreased in the affected extremities relative to the intact contralateral side on measurements by dual energy x-ray absorptiometry in bones such as forearm , femoral neck and trochanter . There was a significant difference between bone mineral density of paretic and nonparetic forearms and legs . Bone mineral density of the upper limbs was lower than that of the lower limbs . There was a negative correlation between duration of hemiplegia and BMD values . Conclusions Bone mineral loss may be related to the duration of hemiplegia-induced immobilization . Bone mineral loss is accelerated when the duration of hemiplegia is prolonged The aim of this 1-year prospect i ve study of acute stroke patients was to determine the effects of walking and asymmetrical weight bearing on the loss of bone mineral in the upper and lower femoral neck . Forty patients were followed . Eight remained unable to walk , whereas 32  relearned to walk independently within 7 months ( 12 shortly after the stroke , 15 by 2 months , 5 by 7 months ) . Bone mineral density ( BMD ) was measured in the proximal femur within the first week after stroke and 1 year later ; regional BMD changes were computed for the lower and upper femoral neck . The lower part of the femoral neck is mainly influenced by compressive stresses of the hip , the upper part by tensile stresses during walking . When comparing mean BMD loss in groups of patients according to when they relearned to walk , a statistically significant trend in BMD loss was found in the lower femoral neck on both the paretic and nonparetic sides ( p < 0.01 and p = 0.01 , respectively ) , whereas , for the upper femoral neck , no significant trend was seen ( p > /= 0.1 ) . In addition , the body weight distribution during st and ing was assessed by use of a force-plate in 38 patients who could st and independently at the 7 month evaluation . The only significant correlation between changes in BMD and asymmetrical weight bearing was found in the lower femoral neck on the paretic side ( r = 0.6 , p < 0.001 ) . In conclusion , this study shows that the reduction in BMD in the femoral neck occurs mainly in the lower part of the neck and on the paretic side . The BMD loss depended on when or if the patients relearned to walk , but also on the amount of body weight born on the paretic leg . Thus , measuring the lower part of the femoral neck gives a better estimate of the impact of gait and weight bearing than measuring the total femoral neck
target: In subacute and chronic stroke studies , the skeletal sites in the paretic limbs sustained a more pronounced decline in bone quality than did their counterparts in the non-paretic limbs .
  The rate of changes showed a decelerating trend as post-stroke duration increased , but the timing of achieving the steady rate differed across skeletal sites .
  The magnitude of bone changes in the paretic upper limb was more pronounced than the paretic lower limb .
  There was a strong relationship between muscle strength/mass and bone density/strength index .
  Muscle spasticity seemed to have a negative impact on bone integrity in the paretic upper limb , but its influence on bone properties in the paretic lower limb was uncertain .
  Substantial bone changes in the paretic limbs occurred particularly in the first few months after stroke onset .
  Early intervention , muscle strength training , and long-term management strategies may be important to enhance bone health post-stroke .
background: To systematic ally review available evidence related to the characteristics of bone changes  post-stroke and the relationship between various aspects of muscle function ( e.g. , strength , spasticity ) and bone properties after stroke onset .