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Bone mineral density (BMD) T-scores for regional BMD in the spinal cord injured (SCI) males and controls (mean±SD). *P=0.0001, **not significant
Source publication
Cross-sectional study comparing a group of active spinal cord injured (SCI) males carefully matched for age, height, and weight with active able-bodied male controls.
To compare bone mass of the total body, upper and lower limbs, hip, and spine regions in active SCI and able-bodied individuals.
Outpatient study undertaken in two centres in New Zeal...
Context in source publication
Context 1
... WHO criteria, the mean T-scores for the SCI group demonstrated that leg and trochanter BMD was in the osteoporotic range, with BMD of the femoral neck and Wards triangle being in the osteopenic range. The T-scores at the leg, femoral neck, Wards triangle and trochanter were all signi®cantly dierent from the able-bodied control group (Figure 2). However mean arm BMD T-scores for the SCI group fell within the normal range at 0.8+1.2, and did not dier signi®cantly from the controls, 0.7+1.0, ...
Similar publications
Bone mineral density (BMD) of the lumbar spine (L-spine) has been reported to be normal or increased in persons with chronic spinal cord injury (SCI).
To determine BMD of the L-spine by dual-energy X-ray absorptiometry (DXA) and quantitative computerized tomography (qCT) in men with chronic SCI compared with able-bodied controls.
Cross-sectional, c...
Citations
... Literature evidence suggests that lower limbs are mostly affected by paralysis as SCI victims heavily rely on upper limbs to perform their activities of daily living (ADL) [13]. Although regular and controlled exercise has generally been shown to have certain health benefits [14], its clinical significance on muscle and bone health is debatable [15]. ...
Leg exercises through standing, cycling and walking with/without FES may be used to preserve lower limb muscle and bone health in persons with physical disability due to SCI. This study sought to examine the effectiveness of leg exercises on bone mineral density and muscle cross-sectional area based on their clinical efficacy in persons with SCI. Several literature databases were searched for potential eligible studies from the earliest return date to January 2022. The primary outcome targeted was the change in muscle mass/volume and bone mineral density as measured by CT, MRI and similar devices. Relevant studies indicated that persons with SCI that undertook FES- and frame-supported leg exercise exhibited better improvement in muscle and bone health preservation in comparison to those who were confined to frame-assisted leg exercise only. However, this observation is only valid for exercise initiated early (i.e., within 3 months after injury) and for ≥30 min/day for ≥ thrice a week and for up to 24 months or as long as desired and/or tolerable. Consequently, apart from the positive psychological effects on the users, leg exercise may reduce fracture rate and its effectiveness may be improved if augmented with FES.
... One cross-sectional study (Goemaere et al. 1994) used a self-report physical activity measure to highlight the potential for standing to reduce BMD decline at the femoral shaft; patients with long leg braces had a significantly higher trochanter and total BMD compared with standing frame or standing wheelchair. In contrast, another cross-sectional investigation of bone outcomes and self-report physical activity measures found no effect of activity on lower extremity bone parameters (Jones et al. 2002). ...
Available at: https://scireproject.com/evidence/rehabilitation-evidence/bone-health/
Key Points:
Bone Health & Fracture
* Fragility fractures of the distal femur and proximal tibia are common in people with spinal cord injury (SCI).
* Bone health monitoring should begin in the subacute phase after SCI given the anticipated substantial 30-50% declines in hip and knee region bone mass in the first year, and the associated lifetime increased fracture risk (~1-4% per year post-SCI).
* Individuals with chronic SCI and increased risk for lower extremity fragility fractures can be readily identified based on the completion of clinical history and fracture risk factor profile.
* Measuring and monitoring hip and knee region bone mineral density (BMD) after SCI are essential to identify low bone mass and quantify lower extremity fracture risk.
* Biomarkers provide clinical insight into the metabolic activity of bone, while imaging techniques provide insight into bone density, quality, and architecture. To date, no published prospective study has had sufficient power (sample size and study duration) to evaluate fracture risk reduction.
Bisphosphonates for Prevention of Sublesional Osteoporosis (SLOP) – Benefits
* The efficacy of bisphosphonates for the prevention of SLOP appear greater when administered early after SCI onset.
* Oral tiludronate and clodronate prevent a decrease in hip and knee region BMD in men with paraplegia.
* Oral etidronate prevents a decrease in hip and knee region BMD among adults with incomplete paraplegia or tetraplegia who return to walking.
* Oral alendronate once weekly maintains hip region BMD.
* Once yearly intravenous infusion of zoledronate may reduce hip region BMD decline 12 months following administration.
* Pamidronate 30 mg or 60 mg intravenous 4x/year is not effective for the prevention of hip and knee region BMD loss early after SCI among adults with motor complete paraplegia or tetraplegia.
* In summary, there is limited evidence that bisphosphonates are moderately effective at preventing declines in hip and knee region BMD by mitigating excessive resorption early after SCI among adults with motor complete paraplegia.
Bisphosphonates for Prevention of SLOP – Side effect control
* Bisphosphonates should be used with caution in 1) premenopausal women due to the unknown teratogenic effects of these medications on the fetus during pregnancy; or 2) patients with a prior history of cancer and radiotherapy due to the increased risk of osteonecrosis of the jaw.
* Short-term side effects of intravenous bisphosphonates include fever and transient low white blood cell count; oral bisphosphonates may cause heartburn, upset stomach and/or joint pain. Patients taking non-steroidal anti-inflammatory medication and /or anti-coagulants concurrently may require gastrointestinal prophylaxis to reduce the risk of developing upper GI bleeding.
* All bisphosphonates (oral or intravenous) may increase the risk of atrial fibrillation, osteonecrosis of the jaw, and atypical femur fracture.
* Treating physicians must weigh the relative risk of fracture versus the adverse sequelae of therapy, prior to prescribing oral or intravenous bisphosphonate therapy.
Pharmacologic Therapy for Treatment of SLOP
* Alendronate 10 mg daily and calcium 500 mg orally 3x/day is effective for the maintenance of BMD of the total body, hip, and knee region for men with paraplegia.
* Vitamin D supplementation results in maintenance of leg region BMD.
Non-pharmacologic Therapy for Prevention and/or Treatment of SLOP * Short-term (6 weeks) therapeutic ultrasound is not effective for preventing BMD decline after SCI.
* Functional electrical stimulation cycling (FES-cycling) does not improve or maintain bone at the tibial midshaft in the acute phase.
* FES-cycling may increase lower extremity BMD over areas stimulated among adults with chronic SCI.
* Six months of activity-based training is effective for increasing spine BMD.
* Neuromuscular electrical stimulation can maintain or increase BMD over the stimulated areas.
* There is inconclusive evidence for reciprocating gait orthoses, long leg braces, passive standing, or self-reported physical activity as a treatment for low BMD.
****There is a lack of definitive evidence supporting non-pharmacological interventions for either prevention or treatment of SLOP after SCI****
... Similar results were obtained in the study conducted by Machida et al., (2013). Other studies clearly showed that the experiences people have by participating in sports activities enhance life skills and life quality by strengthening their resilience (Anderson, 2009;Anderson et al., 2008;Gould et al., 2002;Graham et al., 2008;Groff et al., 2009;Jones et al., 2002;Latimer et al., 2004). ...
The purpose of the study was to examine sources of resilience for physical disability athletes. This is a qualitative study aiming for in-depth investigation of protective mechanisms for physical disability ath-etes in their lives. The criterion sampling method, one of the purposeful sampling methods, was used to determine the participants of the current study: (I) Having an acquired physical (orthopedic) disability. (II) Being at least over the age of 18, (III) Currently, participating in a sport and, (IV) having national or international achievements in their recognized sports. The participants consisted of 12 physically disabled athletes five of whom were women and seven of whom were men. A semi-structured interview technique was employed in the present study. Content analysis was used to analyze data obtained in the study. Resulting social support, included the positive outlook one has, spirituality and belief, demonstrated significant protective factors for strengthening resilience. It was shown that participating in sporting activities, the experiences during these activities, the interpersonal relations established through them, and receiving achievements in this context provides significant strength for people.
... There are several reports regarding the association of age, race, sex, medication use and prevalent fracture with areal BMD by DXA. We found ten articles that examined the association between age and areal BMD by DXA in persons with a SCI 13,16,[40][41][42][43][44][45][46] . Studies that reported on age had mixed results. ...
... Most studies examining BMD and level of injury compared individuals with paraplegia vs. tetraplegia. Ten of eleven studies did not find a relation between level of injury and bone loss 44,45,[48][49][50][51][52][53] . These studies often did not consider ambulatory status or completeness of injury, in additional to level of injury. ...
... Generally, no change in BMD is seen in the lumbar spine after SCI either in longitudinal studies or in comparison with able-bodied individuals 7,13,31,45,66-70 , but degenerative changes within the posterior elements, heterotopic ossification, or hardware may falsely increase BMD in the spine 63,71 . No significant changes in BMD after SCI were found in the proximal and distal forearm (radius and ulna) 15 , radius 64,67 , forearm 66 , or arm 45,72,73 . However at the same time individuals with tetraplegia may have lower BMD than those with paraplegia 25,74,75 , and these sites may even have higher values than normal 31,33,76 , not least if performing upper extremity activities (e.g. ...
Spinal cord injury (SCI) causes rapid osteoporosis that is most severe below the level of injury. More than half of those with motor complete SCI will experience an osteoporotic fracture at some point following their injury, with most fractures occurring at the distal femur and proximal tibia. These fractures have devastating consequences, including delayed union or nonunion, cellulitis, skin breakdown, lower extremity amputation, and premature death. Maintaining skeletal integrity and preventing fractures is imperative following SCI to fully benefit from future advances in paralysis cure research and robotic-exoskeletons, brain computer interfaces and other evolving technologies. Clinical care has been previously limited by the lack of consensus derived guidelines or standards regarding dual-energy X-ray absorptiometry-based diagnosis of osteoporosis, fracture risk prediction, or monitoring response to therapies. The International Society of Clinical Densitometry convened a task force to establish Official Positions for bone density assessment by dual-energy X-ray absorptiometry in individuals with SCI of traumatic or nontraumatic etiology. This task force conducted a series of systematic reviews to guide the development of evidence-based position statements that were reviewed by an expert panel at the 2019 Position Development Conference in Kuala Lumpur, Malaysia. The resulting the International Society of Clinical Densitometry Official Positions are intended to inform clinical care and guide the diagnosis of osteoporosis as well as fracture risk management of osteoporosis following SCI.
... By contrast, radial shaft bone mass in subjects with paraplegia may actually be greater than in able-bodied individuals because of the increased mechanical loading associated with wheelchair use (148). Upper-extremity exercise may be a way to protect against bone loss in people with tetraplegia (149). Less empirical evidence is available for secondary consequences of upper-extremity fractures. ...
Individuals with spinal cord injury (SCI) may experience
myriad musculoskeletal consequences secondary to their
SCI. Wheelchair use can cause pain in the upper-extremity,
neck, and back, while post-injury changes in bone structure
and composition can lead to lower- and upper-extremity
osteoporotic fractures. Each can negatively impact quality
of life, yet can be managed through intervention. The following
is a brief discussion of the clinical research concerning
overuse injuries and fractures in people with SCI. The
aim of this chapter is to provide a better understanding of
the pathophysiology, risk factors, measurement techniques,
and management of both conditions.
... Cardiorespiratory fitness levels have demonstrated that physically active SCI patients had higher values in arm BMD and LM compared to active able-bodied people (Beck, Lamb, Atkinson, Wuermser, & Amin, 2014;Jones, Legge, & Goulding, 2002;Miyahara et al., 2008;Sutton, Wallace, Goosey-Tolfrey, Scott, & Reilly, 2009). Furthermore, a strong relationship was present between lean tissue and bone mass in the arms, a non-weight-bearing bone, regardless of the level or completeness of lesion (Spungen, Wang, Pierson, & Bauman, 2000). ...
Spinal cord injury (SCI) derives in loss of bone mineral content (BMC) and bone mineral density (BMD). However, physical activity is an important determinant in bone mass acquisition, which is partially mediated through the lean mass (LM). The aim was to examine the effect of cardiorespiratory fitness (CRF) on BMD and BMC arms of adult males with SCI and able-bodied controls using the arm LM as a mediator variable. Thirty able-bodied men and thirty men with SCI participated. BMC and BMD were analysed by DXA, and indirect calorimetry was used to calculate VO2peak during a progressive arm-cranking test. Dividing by the amount of LM, the subgroup with highest LM had significantly higher arm BMC compared to the lowest subgroup (p≤0.05) in both SCI and able-bodied groups. Moreover, confidence intervals were also analysed and it showed the same differences. Only in the SCI group, arm LM mediated the relationship between bone mass and CRF at 30.9%, as indicated by the Sobel test (z=2.17 and z=2.04 for BMC and BMD, respectively). In conclusion, LM mediates the indirect association between CRF and bone health, specifically in the arms. This finding highlights the importance of having an adequate CRF for the maintenance of good bone health in SCI men.
... [94][95][96][97] It is possible that while weight-bearing and increased mobility are clearly important for skeletal health in SCI, 98 they are not sufficient to maintain BMD of the lower extremity. 99,100 Further, there may be individual variations in response to activity based therapies. 101,102 Considerations for weight bearing interventions should include the timing of the intervention, length and intensity of the treatment (should be sufficiently long and high), and the need to be maintained over the long term. ...
Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.
Study Design: Scoping review.
Settings/Participants: Human adult subjects with a SCI/D.
Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.
Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.
Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.
... Although bone loss eventually may reach a steady state, the decline in BMD has been linked to debilitating comorbidities [48] from the resulting sublesional osteoporosis [49][50][51]. One consequence, pathological fractures, are between 1.5 to six times more common for people with SCI compared to their non-spinal cord injured counterparts [40,[52][53][54][55]. Currently, there is not a gold standard treatment for BMD loss in people with SCI; however, investigation into the effects of WBV on BMD is ongoing [1,8,9,35]. ...
Purpose of Review
The purposes of this review are to summarize recent findings related to use of whole body vibration for people with spinal cord injury, explain their significance for clinical practice, and outline future areas for research.
Recent Findings
Positive outcomes identified by whole body vibration research performed to date are that it appears to be safe and well tolerated, that it may improve tolerance to upright standing via increased muscle oxygenation and improved maintenance of blood pressure in the upright standing position, and that it improves the patient’s body awareness during treatment.
Summary
Clinical decision-making at this time should be guided by careful consideration of existing studies in light of the limited but emerging research in this area.
... However, in acute SCI persons, training therapy did not improve osteocalcin levels (10). Previous studies varying in exercise mode, intensity, and duration and injury level, measured BMD of the femoral neck and lumbar spine ( (27) showed that following activity-based training increased BMD and remained osteocalcin and alkaline phosphatase unchanged. They suggested that alternative treatment is needed to reverse osteoporosis of the lower extremities. ...
... The sites and rate of bone loss in SCI-induced OP are different from that in disuse OP [12,13]. Furthermore, functional exercise may contribute to the reversion of bone mass in disuse-induced bone loss, but cannot prevent demineralisation in the SCI-induced bone loss [14]. Therefore, OP after SCI is a complex process including multiple pathogenetic factors, and should not be simply considered disuse OP. ...
Spinal cord injury (SCI) causes a significant amount of bone loss, which results in osteoporosis (OP). The neuropeptide substance P (SP) and SP receptors may play important roles in the pathogenesis of OP after SCI. To identify the roles of SP in the bone marrow mesenchymal stem cell derived osteoblasts (BMSC-OB) in SCI rats, we investigated the expression of neurokinin-1 receptors (NK1R) in BMSC-OB and the effects of SP on bone formation by development of BMSC-OB cultures. Sixty young male Sprague-Dawley rats were randomized into two groups: SHAM and SCI. The expression of NK1R protein in BMSC-OB was observed using immunohistochemistry and Western blot analysis. The dose- and time-dependent effects of SP on the proliferation, differentiation and mineralization of BMSC-OB and the expression of osteoblastic markers by in vitro experiments. The expression of NK1R in BMSC-OB was observed on plasma membranes and in cytoplasm. One week after osteogenic differentiation, the expression of NK1R was significantly increased after SCI at mRNA and protein levels. However, this difference was gradually attenuated at 2 or 3 weeks later. SP have the function to enhance cell proliferation, inhibite cell differentiation and mineralization at a proper concentration and incubation time, and this effect would be inhibited by adding SP or NK1R antagonist. The expression of RANKL/OPG was significantly increased in tibiae after SCI. Similarly, the RANKL/OPG expression in SCI rats was significantly increased when treating with 10⁻⁸ M SP. SP plays a very important role in the pathogenesis of OP after SCI. The direct effect of SP may lead to increased bone resorption through the RANKL/OPG axis after SCI. In addition, high expression of SP also results in the suppression of osteogenesis in SCI rats. Then, the balance between bone resorption and bone formation was broken and finally osteoporosis occurred.
