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Echevarria-Cruz E, McMillan DW, Reid KF, Valderrábano RJ. Spinal Cord Injury Associated Disease of the Skeleton, an Unresolved Problem with Need for Multimodal Interventions. Adv Biol (Weinh) 2024:e2400213. [PMID: 39074256 DOI: 10.1002/adbi.202400213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/11/2024] [Indexed: 07/31/2024]
Abstract
Spinal cord injury is associated with skeletal unloading, sedentary behavior, decreases in skeletal muscle mass, and exercise intolerance, which results in rapid and severe bone loss. To date, monotherapy with physical interventions such as weight-bearing in standing frames, computer-controlled electrically stimulated cycling and ambulation exercise, and low-intensity vibration are unsuccessful in maintaining bone density after SCI. Strategies to maintain bone density with commonly used osteoporosis medications also fail to provide a significant clinical benefit, potentially due to a unique pathology of bone deterioration in SCI. In this review, the available data is discussed on evaluating and monitoring bone loss, fracture, and physical and pharmacological therapeutic approaches to SCI-associated disease of the skeleton. The treatment of SCI-associated disease of the skeleton, the implications for clinical management, and areas of need are considered for future investigation.
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Affiliation(s)
- Evelyn Echevarria-Cruz
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
| | - David W McMillan
- The Miami Project to Cure Paralysis, University of Miami Leonard M. Miller School of Medicine, 1611 NW 12th ave, Office 2.141, Miami, FL, 33136, USA
- Department of Neurological Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, 33136, USA
| | - Kieran F Reid
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
- Laboratory of Exercise Physiology and Physical Performance, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Rodrigo J Valderrábano
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
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Zhang Y, Zhao X, Ge D, Huang Y, Yao Q. The impact and mechanism of nerve injury on bone metabolism. Biochem Biophys Res Commun 2024; 704:149699. [PMID: 38412668 DOI: 10.1016/j.bbrc.2024.149699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/30/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
With an increasing understanding of the mechanisms of fracture healing, it has been found that nerve injury plays a crucial role in the process, but the specific mechanism is yet to be completely revealed. To address this issue and provide novel insights for fracture treatment, we compiled this review. This review aims to study the impact of nerve injury on fracture healing, exploring the role of neurotrophic factors in the healing process. We first revisited the effects of the central nervous system (CNS) and the peripheral nervous system (PNS) on the skeletal system, and further explained the phenomenon of significantly accelerated fracture healing under nerve injury conditions. Then, from the perspective of neurotrophic factors, we delved into the physiological functions and mechanisms of neurotrophic factors, such as nerve growth factor (NGF), Neuropeptides (NPs), and Brain-derived neurotrophic factor (BDNF), in bone metabolism. These effects include direct actions on bone cells, improvement of local blood supply, regulation of bone growth factors, control of cellular signaling pathways, promotion of callus formation and bone regeneration, and synergistic or antagonistic effects with other endocrine factors, such as Sema3A and Transforming Growth Factor β (TGF-β). Finally, we discussed the treatments of fractures with nerve injuries and the future research directions in this review, suggesting that the relationship between nerve injury and fracture healing, as well as the role of nerve injury in other skeletal diseases.
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Affiliation(s)
- Yongqiang Zhang
- Department of Orthopedic Surgery, Institute of Digital Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Key Lab of Additive Manufacturing Technology, Institute of Digital Medicine, Nanjing Medical University, Nanjing, China; Research Center of Digital Medicine and 3D Printing Technology of Jiangsu Province, Nanjing, China
| | - Xiao Zhao
- Department of Orthopedic Surgery, Institute of Digital Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Key Lab of Additive Manufacturing Technology, Institute of Digital Medicine, Nanjing Medical University, Nanjing, China; Research Center of Digital Medicine and 3D Printing Technology of Jiangsu Province, Nanjing, China
| | - Dawei Ge
- Department of Orthopedic Surgery, Institute of Digital Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Key Lab of Additive Manufacturing Technology, Institute of Digital Medicine, Nanjing Medical University, Nanjing, China; Research Center of Digital Medicine and 3D Printing Technology of Jiangsu Province, Nanjing, China
| | - Yang Huang
- International Innovation Center for Forest Chemicals & Materials and Jiangsu Co-Innovation Center of Efficient Processing & Utilization of Forest Resources, Nanjing Forestry University, Nanjing, China
| | - Qingqiang Yao
- Department of Orthopedic Surgery, Institute of Digital Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Key Lab of Additive Manufacturing Technology, Institute of Digital Medicine, Nanjing Medical University, Nanjing, China; Research Center of Digital Medicine and 3D Printing Technology of Jiangsu Province, Nanjing, China.
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Peng Y, Langermann S, Kothari P, Liu L, Zhao W, Hu Y, Chen Z, Moraes de Lima Perini M, Li J, Cao J, Guo XE, Chen L, Bauman WA, Qin W. Anti-Siglec-15 Antibody Prevents Marked Bone Loss after Acute Spinal Cord Injury-Induced Immobilization in Rats. JBMR Plus 2023; 7:e10825. [PMID: 38130761 PMCID: PMC10731123 DOI: 10.1002/jbm4.10825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/23/2023] [Accepted: 09/11/2023] [Indexed: 12/23/2023] Open
Abstract
Rapid and extensive sublesional bone loss after spinal cord injury (SCI) is a difficult medical problem that has been refractory to available interventions except the antiresorptive agent denosumab (DMAB). While DMAB has shown some efficacy in inhibiting bone loss, its concurrent inhibition of bone formation limits its use. Sialic acid-binding immunoglobulin-like lectin (Siglec)-15 is expressed on the cell surface of mature osteoclasts. Anti-Siglec-15 antibody (Ab) has been shown to inhibit osteoclast maturation and bone resorption while maintaining osteoblast activity, which is distinct from current antiresorptive agents that inhibit the activity of both osteoclasts and osteoblasts. The goal of the present study is to test a Siglec-15 Ab (NP159) as a new treatment option to prevent bone loss in an acute SCI model. To this end, 4-month-old male Wistar rats underwent complete spinal cord transection and were treated with either vehicle or NP159 at 20 mg/kg once every 2 weeks for 8 weeks. SCI results in significant decreases in bone mineral density (BMD, -18.7%), trabecular bone volume (-43.1%), trabecular connectivity (-59.7%), and bone stiffness (-76.3%) at the distal femur. Treatment with NP159 almost completely prevents the aforementioned deterioration of bone after SCI. Blood and histomorphometric analyses revealed that NP159 is able to greatly inhibit bone resorption while maintaining bone formation after acute SCI. In ex vivo cultures of bone marrow cells, NP159 reduces osteoclastogenesis while increasing osteoblastogenesis. In summary, treatment with NP159 almost fully prevents sublesional loss of BMD and metaphysis trabecular bone volume and preserves bone strength in a rat model of acute SCI. Because of its unique ability to reduce osteoclastogenesis and bone resorption while promoting osteoblastogenesis to maintain bone formation, Siglec-15 Ab may hold greater promise as a therapeutic agent, compared with the exclusively antiresorptive or anabolic agents that are currently used, in mitigating the striking bone loss that occurs after SCI or other conditions associated with severe immobilization. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Yuanzhen Peng
- Spinal Cord Damage Research Center, James J. Peters Veteran Affairs Medical CenterBronxNew YorkUSA
| | | | | | | | - Wei Zhao
- Spinal Cord Damage Research Center, James J. Peters Veteran Affairs Medical CenterBronxNew YorkUSA
| | - Yizhong Hu
- Department of Biomedical EngineeringColumbia UniversityNew YorkNew YorkUSA
| | - Zihao Chen
- Department of BiotechnologyBrown UniversityProvidenceRhode IslandUSA
| | | | - Jiliang Li
- School of Science, Indiana University Purdue UniversityIndianapolisIndianaUSA
| | - Jay Cao
- USDA‐ARS Grand Forks Human Nutrition Research CenterGrand ForksNorth DakotaUSA
| | - X. Edward Guo
- Department of Biomedical EngineeringColumbia UniversityNew YorkNew YorkUSA
| | - Lieping Chen
- NextCure, IncBeltsvilleMarylandUSA
- Cancer Research, Immunobiology and Medicine, The Yale University School of MedicineNew HavenConnecticutUSA
| | - William A. Bauman
- Spinal Cord Damage Research Center, James J. Peters Veteran Affairs Medical CenterBronxNew YorkUSA
- Departments of MedicineRehabilitation and Human Performance, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Weiping Qin
- Spinal Cord Damage Research Center, James J. Peters Veteran Affairs Medical CenterBronxNew YorkUSA
- Departments of MedicineRehabilitation and Human Performance, Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Han S, Shin S, Kim O, Hong N. Characteristics Associated with Bone Loss after Spinal Cord Injury: Implications for Hip Region Vulnerability. Endocrinol Metab (Seoul) 2023; 38:578-587. [PMID: 37816499 PMCID: PMC10613772 DOI: 10.3803/enm.2023.1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGRUOUND In individuals with spinal cord injury (SCI), bone loss progresses rapidly to the area below the level of injury, leading to an increased risk of fracture. However, there are limited data regarding SCI-relevant characteristics for bone loss and the degree of bone loss in individuals with SCI compared with that in non-SCI community-dwelling adults. METHODS Data from men with SCI who underwent dual-energy X-ray absorptiometry at the National Rehabilitation Center (2008 to 2020) between 12 and 36 months after injury were collected and analyzed. Community-dwelling men were matched 1:1 for age, height, and weight as the control group, using data from the Korea National Health and Nutrition Examination Survey (KNHANES, 2008 to 2011). RESULTS A comparison of the SCI and the matched control group revealed significantly lower hip region T-scores in the SCI group, whereas the lumbar spine T-score did not differ between groups. Among the 113 men with SCI, the paraplegia group exhibited significantly higher Z-scores of the hip region than the tetraplegia group. Participants with motor-incomplete SCI showed relatively preserved Z-scores of the hip region compared to those of the lumbar region. Moreover, in participants with SCI, the percentage of skeletal muscle displayed a moderate positive correlation with femoral neck Z-scores. CONCLUSION Men with SCI exhibited significantly lower bone mineral density of the hip region than community-dwelling men. Paraplegia rather than tetraplegia, and motor incompleteness rather than motor completeness were protective factors in the hip region. Caution for loss of skeletal muscle mass or increased adiposity is also required.
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Affiliation(s)
- Sora Han
- Department of Rehabilitation Medicine, National Rehabilitation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sungjae Shin
- Division of Endocrinology, Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Onyoo Kim
- Department of Rehabilitation Medicine, National Rehabilitation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Division of Endocrinology, Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Crack LE, Haider IT, Simonian N, Barroso J, Gabel L, Schnitzer TJ, Edwards WB. Zoledronic acid after spinal cord injury mitigates losses in proximal femoral strength independent of ambulation ability. Osteoporos Int 2023; 34:1637-1645. [PMID: 37289320 DOI: 10.1007/s00198-023-06811-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023]
Abstract
Rapid bone loss can occur after spinal cord injury (SCI) and a standard of care to prevent or treat this phenomenon is an active area of research. Using advanced analysis techniques, this study demonstrates that zoledronic acid, a possible treatment, prevented loss of bone strength at the hip following SCI. INTRODUCTION Bone loss below the level of neurological lesion is a well-known complication of spinal cord injury (SCI), and effective preventive treatment for this phenomenon is an active area of research. Zoledronic acid has demonstrated efficacy to attenuate bone loss at the hip after SCI, but previous studies relied on measurements from dual-energy X-ray absorptiometry. The purpose of this investigation was to more thoroughly characterize changes to bone mineral and strength at the proximal femur in individuals receiving zoledronic acid in the acute SCI stage; we also examined the influence of ambulatory ability on bone outcomes. METHODS Participants randomized to either zoledronic acid (n = 29) or placebo (n = 30) received computed tomography (CT) scans and ambulatory assessments at baseline and 6 and 12 months following drug infusion. CT-based finite element (FE) modeling was used to predict changes in proximal femoral strength associated with treatment. RESULTS After 12 months, FE-predicted bone strength was reduced by a mean (SD) of 9.6 (17.9)% in the zoledronic acid group versus 24.6 (24.5)% in the placebo group (p = 0.007). These differences in strength were explained by reductions in CT measurements of both trabecular (p < 0.001) and cortical (p ≤ 0.021) bone at the femoral neck and trochanteric region. Ambulation ability influenced select trabecular and cortical parameters, but we were unable to detect an impact on FE-predicted bone strength. CONCLUSION These findings demonstrate that treatment with zoledronic acid in acute SCI attenuates losses in proximal femoral strength, which may reduce the risk of hip fractures across patients with varying degrees of ambulatory abilities.
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Affiliation(s)
- Laura E Crack
- Human Performance Lab, Faculty of Kinesiology, University of Calgary, Alberta, Canada.
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - Ifaz T Haider
- Human Performance Lab, Faculty of Kinesiology, University of Calgary, Alberta, Canada
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Narina Simonian
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joana Barroso
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Leigh Gabel
- Human Performance Lab, Faculty of Kinesiology, University of Calgary, Alberta, Canada
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - W Brent Edwards
- Human Performance Lab, Faculty of Kinesiology, University of Calgary, Alberta, Canada
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Biomedical Engineering, Schulich School of Engineering, University of Calgary, Alberta, Canada
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Craven BC, Cirnigliaro CM, Carbone LD, Tsang P, Morse LR. The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury. J Pers Med 2023; 13:966. [PMID: 37373955 DOI: 10.3390/jpm13060966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The prevention of lower extremity fractures and fracture-related morbidity and mortality is a critical component of health services for adults living with chronic spinal cord injury (SCI). METHODS Established best practices and guideline recommendations are articulated in recent international consensus documents from the International Society of Clinical Densitometry, the Paralyzed Veterans of America Consortium for Spinal Cord Medicine and the Orthopedic Trauma Association. RESULTS This review is a synthesis of the aforementioned consensus documents, which highlight the pathophysiology of lower extremity bone mineral density (BMD) decline after acute SCI. The role and actions treating clinicians should take to screen, diagnose and initiate the appropriate treatment of established low bone mass/osteoporosis of the hip, distal femur or proximal tibia regions associated with moderate or high fracture risk or diagnose and manage a lower extremity fracture among adults with chronic SCI are articulated. Guidance regarding the prescription of dietary calcium, vitamin D supplements, rehabilitation interventions (passive standing, functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)) to modify bone mass and/or anti-resorptive drug therapy (Alendronate, Denosumab, or Zoledronic Acid) is provided. In the event of lower extremity fracture, the need for timely orthopedic consultation for fracture diagnosis and interprofessional care following definitive fracture management to prevent health complications (venous thromboembolism, pressure injury, and autonomic dysreflexia) and rehabilitation interventions to return the individual to his/her pre-fracture functional abilities is emphasized. CONCLUSIONS Interprofessional care teams should use recent consensus publications to drive sustained practice change to mitigate fracture incidence and fracture-related morbidity and mortality among adults with chronic SCI.
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Affiliation(s)
- Beverley Catharine Craven
- KITE Research Institute, 520 Sutherland Dr, Toronto, ON M4G 3V9, Canada
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada
| | - Christopher M Cirnigliaro
- Department of Veterans Affairs Rehabilitation, Research, and Development Service, Spinal Cord Damage Research Center, Bronx, NY 10468, USA
| | - Laura D Carbone
- Department of Medicine: Rheumatology, Medical College of Georgia, Augusta University, 1120 15th St, Augusta, GA 30912, USA
| | - Philemon Tsang
- KITE Research Institute, 520 Sutherland Dr, Toronto, ON M4G 3V9, Canada
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota, 500 Harvard St SE, Minneapolis, MN 55455, USA
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Cirnigliaro CM, La Fountaine MF, Parrott JS, Kirshblum SC, Sauer SJ, Shapses SA, McClure IA, Bauman WA. Loss of lower extremity bone mineral density 1 year after denosumab is discontinued in persons with subacute spinal cord injury. Osteoporos Int 2023; 34:741-748. [PMID: 36735054 DOI: 10.1007/s00198-023-06679-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
UNLABELLED Twelve months following discontinuation of denosumab, the percent decrease in mean bone mineral density (BMD) values at the hip and knee regions were similar between both the denosumab and placebo groups. These findings emphasize the need for additional trials to understand the effect of continued administration of denosumab after subacute spinal cord injury (SCI) to avoid this demineralization. OBJECTIVE To determine changes in BMD 1 year after denosumab was discontinued in participants with subacute SCI who had drug treatment initiated within 90 days post SCI and continued for 1 year. METHODS Fourteen participants who completed a randomized, double-blinded, placebo-controlled drug trial (parent study: denosumab 60 mg (Prolia, Amgen Inc., n = 8) or placebo (n = 6); administered at baseline, 6, and 12 months) were followed 12 months after the 18 months from baseline primary end point was completed. The BMD of skeletal regions below the SCI at higher risk of fracture was measured [total hip, distal femur epiphysis (DFE), distal femur metaphysis (DFM), and proximal tibia epiphysis (PTE)] by dual energy X-ray absorptiometry. RESULTS The percent decreases in mean BMD values at all regions of the hip and knee from 18 to 30 months were similar in both the denosumab and placebo groups. However, at 30 months, the absolute values for mean BMD remained significantly higher in the drug treatment than that of the placebo group at the DFM (p = 0.03), DFE (p = 0.04), and PTE (p = 0.05). CONCLUSIONS In persons with SCI who initiated denosumab treatment during the subacute injury phase and maintained treatment for 1 year, the discontinuation of drug resulted in percent loss of mean BMD similar to that of the placebo group, with absolute mean BMD values at the knee regions at the 12-month follow-up visit significantly higher in the drug treatment than those in the placebo group. These data underscore the need to study continued administration of denosumab after subacute SCI to avoid marked demineralization in the sublesional skeleton upon discontinuation of this agent.
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Affiliation(s)
- Christopher M Cirnigliaro
- Department of Veterans Affairs Rehabilitation Research and Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY, 10468, USA.
| | - Michael F La Fountaine
- Department of Veterans Affairs Rehabilitation Research and Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY, 10468, USA
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA
- Departments of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - J Scott Parrott
- Department of Interdisciplinary Studies, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Steven C Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
- Kessler Foundation Research Center, West Orange, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Susan J Sauer
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
| | - Sue A Shapses
- Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ, USA
- Department of Medicine, Rutgers-Robert Wood Johnson Medical School, NJ, New Brunswick, USA
| | | | - William A Bauman
- Departments of Medicine and Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Ma Z, Ma M, He Y, Sun H, Yang B, Dong H, Wang Y. Bisphosphonates Alleviate Bone Loss in People with Acute Spinal Cord Injury:A Systematic Review and Meta-Analysis. World Neurosurg 2023; 170:e584-e595. [PMID: 36410707 DOI: 10.1016/j.wneu.2022.11.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Bone loss is not to be underestimated in people with acute spinal cord injury (SCI). Bisphosphonates can inhibit the bone resorption of osteoclast. To study whether the early application of bisphosphonates can alleviate bone loss after acute SCI, we included 7 randomized controlled trials for meta-analysis. METHODS Seven randomized controlled trials were found in literature databases. The percentage change in bone mineral density (BMD) at different sites were primary outcomes and serum bone turnover markers were secondary outcomes. A random-effects model was selected for meta-analysis. RESULTS There were significant differences in the percentage change in BMD of the lumbar spine, total hip, and femoral neck between the bisphosphonates and control groups, but not in the percentage change in distal femur BMD. Besides, there were no statistically significant differences between the groups in the bone formation marker Procollagen type 1 N propeptide; bisphosphonates were effective in reducing the C-terminal telopeptide at the 6-month follow-up, but not at the 12-month follow-up. Subgroup analysis of the effects of zoledronate showed positive effects on BMD of the lumbar spine, total hip, and femoral neck at the 6-month follow-up and showed positive effects on BMD of the total hip and femoral neck at the 12-month follow-up. CONCLUSIONS Bisphosphonates can effectively alleviate the bone loss of the lumbar spine, total hip, and femoral neck in patients with acute SCI, and early application is advocated.
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Affiliation(s)
- Zijian Ma
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China; Yangzhou University Medical College, Yangzhou, China
| | - Mingling Ma
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Graduate School, Dalian Medical University, Dalian, China
| | - Yilang He
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Graduate School, Dalian Medical University, Dalian, China
| | - Hao Sun
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Bin Yang
- Yangzhou University Medical College, Yangzhou, China
| | - Hui Dong
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yongxiang Wang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Dharnipragada R, Ahiarakwe U, Gupta R, Abdilahi A, Butterfield J, Naik A, Parr A, Morse LR. Pharmacologic and nonpharmacologic treatment modalities for bone loss in SCI - Proposal for combined approach. J Clin Densitom 2023; 26:101359. [PMID: 36931948 DOI: 10.1016/j.jocd.2023.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
Increased risk of bone fracture due to bone mineral density (BMD) loss is a serious consequence of spinal cord injury (SCI). Traditionally, pharmaceutical approaches, such as bisphosphonates, have been prescribed to prevent bone loss. However, there is controversy in the literature regarding efficacy of these medications to mitigate the drastic bone loss following SCI. Individuals with SCI are particularly at risk of osteoporosis because of the lack of ambulation and weight bearing activities. In the past two decades, functional electric stimulation (FES) has allowed for another approach to treat bone loss. FES approaches are expanding into various modalities such as cycling and rowing exercises and show promising outcomes with minimal consequences. In addition, these non-pharmacological treatments can elevate overall physical and mental health. This article provides an overview of efficacy of different treatment options for BMD loss for SCI and advocates for a combined approach be pursued in standard of care.
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Affiliation(s)
- Rajiv Dharnipragada
- University of Minnesota Medical School, Twin-Cities, Minneapolis, MN 55455, USA
| | | | - Ribhav Gupta
- University of Minnesota Medical School, Twin-Cities, Minneapolis, MN 55455, USA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Abdiasis Abdilahi
- University of Minnesota Medical School, Twin-Cities, Minneapolis, MN 55455, USA
| | - Jack Butterfield
- University of Minnesota Medical School, Twin-Cities, Minneapolis, MN 55455, USA
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign IL, 61801, USA
| | - Ann Parr
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota Twin-Cities, Minneapolis, MN 55455, USA.
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Fernández Dorado MT, Díaz Merino MDS, García Marco D, Cuena Boy R, Blanco Samper B, Martínez Dhier L, Labarta Bertol C. Preventive treatment with alendronate of loss of bone mineral density in acute traumatic spinal cord injury. Randomized controlled clinical trial. Spinal Cord 2022; 60:687-693. [DOI: 10.1038/s41393-022-00755-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 11/09/2022]
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Edwards WB, Haider IT, Simonian N, Barroso J, Schnitzer TJ. Durability and delayed treatment effects of zoledronic acid on bone loss after spinal cord injury: a randomized, controlled trial. J Bone Miner Res 2021; 36:2127-2138. [PMID: 34278611 DOI: 10.1002/jbmr.4416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/07/2021] [Accepted: 07/14/2021] [Indexed: 12/28/2022]
Abstract
A single infusion of zoledronic acid (ZOL) after acute spinal cord injury (SCI) attenuates bone loss at the hip (proximal femur) and knee (distal femur and proximal tibia) for at least 6 months. The objective of this study was to examine the effects of timing and frequency of ZOL over 2 years. In this double-blind, placebo-controlled trial, we randomized 60 individuals with acute SCI (<120 days of injury) to receive either ZOL 5-mg infusion (n = 30) or placebo (n = 30). After 12 months, groups were again randomized to receive ZOL or placebo, resulting in four treatment groups for year 2: (i) ZOL both years; (ii) ZOL year 1, placebo year 2; (iii) placebo year 1, ZOL year 2; and (iv) placebo both years. Our primary outcome was bone loss at 12 months; compared to placebo, a single infusion of ZOL attenuated bone loss at the proximal femur, where median changes relative to baseline were -1.7% to -2.2% for ZOL versus -11.3% to -12.8% for placebo (p < 0.001). Similarly, the distal femur and proximal tibia showed changes of -4.7% to -9.6% for ZOL versus -8.9% to -23.0% for placebo (p ≤ 0.042). After 24 months, differences were significant at the proximal femur only (-3.2% to -6.0% for ZOL vs. -16.8% to -21.8% for placebo; p ≤ 0.018). Although not statistically significant, median bone density losses suggested some benefit from two annual infusions compared to a single baseline infusion, as well as from a single infusion 12 months after baseline compared to 2 years of placebo; therefore, further investigation in the 12-month to 24-month treatment window is warranted. No unanticipated adverse events associated with drug treatment were observed. In summary, ZOL 5-mg infusion after acute SCI was well-tolerated and may provide an effective therapeutic approach to prevent bone loss in the first few years following SCI. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ifaz T Haider
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Narina Simonian
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Northwestern University Clinical and Translational Sciences Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joana Barroso
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Bauman WA. Pharmacological approaches for bone health in persons with spinal cord injury. Curr Opin Pharmacol 2021; 60:346-359. [PMID: 34534754 DOI: 10.1016/j.coph.2021.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
Spinal cord injury (SCI) results in rapid, marked skeletal deterioration below the level of neurological lesion. Ideally, the most effective therapeutic approach would prevent loss of bone mass and architecture shortly after paralysis. Bisphosphonates preserve bone mineral density at the hip but not at the knee, which is the anatomical site most prone to fracture in the SCI population. Denosumab has recently been reported to prevent bone loss in persons with acute SCI but should be continued for an as yet indeterminate time because discontinuation will result in rapid bone loss. Several other novel approaches to preserving bone at the time of acute SCI should be tested, as well as approaches to reverse bone loss in individuals with chronic SCI.
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Affiliation(s)
- William A Bauman
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Internal Medical Service, James J. Peters VA Medical Center, Bronx, NY, USA; Departments of Medicine & Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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13
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Dionyssiotis Y, Kalke YB, Frotzler A, Moosburger J, Trovas G, Kaskani E, Erhan B, Foti C, Papathanasiou J, Ferretti JL, Imamura M, Rapidi AC. S1 Guidelines on Bone Impairment in Spinal Cord Injury. J Clin Densitom 2021; 24:490-501. [PMID: 33958259 DOI: 10.1016/j.jocd.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 02/08/2023]
Abstract
During the acute and chronic phase of spinal cord injury (SCI) bone turnover and structure are affected. Bone mineral density of lower limbs is decreased up to 28%-50% below that of age-matched peers at 12-18 mo post injury. Coexisting secondary etiologies of osteoporosis may be present, and during ageing additional loss of bone occurs. All these compose a complex canvas of bone impairment after spinal cord injury and make the therapeutical approach challenging. The risk of fragility fractures is increased after the 2nd decade post SCI affecting the functionality and quality of life of individuals with SCI. Diagnostic flaws, lack of a ranking system to categorize the degree of bone impairment similar to the one of World Health Organization, and evidence-based clinical guidelines for management in SCI requires interdisciplinary cooperation and appropriate planning of future research and interventions. Spinal Cord Section of Hellenic Society of Physical Rehabilitation Medicine convened an expert panel working group on bone and spinal cord injury at the Pan-Hellenic Congress 2018 of PRM in Athens Greece, to establish an evidence-based position statement for bone loss in individuals with SCI of traumatic or non-traumatic etiology. This was reviewed by an International Task Force and used to create S1 Guidelines. This first version S1 guideline will work towards to provide help with prophylactic basic osteoporosis therapy diagnostic and therapeutic decisions in acute and chronic phase and rehabilitation countermeasures against osteoporosis related with spinal cord injury.
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Affiliation(s)
- Yannis Dionyssiotis
- 1st Physical Medicine and Rehabilitation Department, National Rehabilitation Center EKA, Athens, Greece; Hellenic Osteoporosis Foundation, Kifissia, Greece.
| | | | - Angela Frotzler
- Clinical Trial Unit, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Jürgen Moosburger
- Medical Rehabilitation Center for Spinal Cord Injured "Heinrich-Sommer-Klinik", Bad Wildbad, Germany
| | - Georgios Trovas
- Laboratory for Research of the Musculoskeletal System, "Th. Garofalidis" Medical School, National and Kapodistrian University of Athens, Kifissia, Greece; Hellenic Osteoporosis Foundation, Kifissia, Greece
| | | | - Belgin Erhan
- Physical Medicine and Rehabilitation Department, İstanbul Medeniyet University Faculty of Medicine, Instabul, Turkey
| | - Calogero Foti
- Clinical Medicine and Translational Department Tor Vergata University, Rome, Italy
| | - Jannis Papathanasiou
- Department of Medical Imaging, Allergology and Physiotherapy, Faculty of Dental Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria; Department of Kinesitherapy, Medical University of Sofia, Sofia, Bulgaria
| | - Jose Luis Ferretti
- Center of P-Ca Metabolism Studies (CEMFoC), Natl Univ of Rosario and Arg NRC (CONICET), Rosario, Argentina
| | - Marta Imamura
- Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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14
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Tucci MA, Pride Y, Strickland S, Marocho SMS, Jackson RJ, Jefferson JR, Chade AR, Grill RJ, Grayson BE. Delayed Systemic Treatment with Cannabinoid Receptor 2 Agonist Mitigates Spinal Cord Injury-Induced Osteoporosis More Than Acute Treatment Directly after Injury. Neurotrauma Rep 2021; 2:270-284. [PMID: 34223557 PMCID: PMC8244511 DOI: 10.1089/neur.2020.0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Nearly all persons with spinal cord injury (SCI) will develop osteoporosis following injury, and further, up to 50% of all persons with SCI will sustain a fracture during their lives. The unique mechanisms driving osteoporosis following SCI remain unknown. The cannabinoid system modulation of bone metabolism through cannabinoid 1/2 (CB1/2) has been of increasing interest for the preservation of bone mass and density in models of osteoporosis. Using a thoracic vertebral level 8 (T8) complete transection in a mouse model, we performed daily treatment with a selective CB2 receptor agonist, HU308, compared with SCI-vehicle-treated and naïve control animals either immediately after injury for 40 days, or in a delayed paradigm, following 3 months after injury. The goal was to prevent or potentially reverse SCI-induced osteoporosis. In the acute phase, administration of the CB2 agonist was not able to preserve the rapid loss of cancellous bone. In the delayed-treatment paradigm, in cortical bone, HU308 increased cortical-area to total-area ratio and periosteal perimeter in the femur, and improved bone density in the distal femur and proximal tibia. Further, we report changes to the metaphyseal periosteum with increased presence of adipocyte and fat mass in the periosteum of SCI animals, which was not present in naïve animals. The layer of fat increased markedly in HU308-treated animals compared with SCI-vehicle-treated animals. Overall, these data show that CB2 agonism targets a number of cell types that can influence overall bone quality.
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Affiliation(s)
- Michelle A. Tucci
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Yilianys Pride
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Suzanne Strickland
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Susanna M. Salazar Marocho
- Department of Biomedical Materials Science, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ramon J. Jackson
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Joshua R. Jefferson
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Alejandro R. Chade
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Radiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Raymond J. Grill
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Bernadette E. Grayson
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA
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15
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Wu Y, Wang F, Zhang Z. The efficacy and safety of bisphosphonate analogs for treatment of osteoporosis after spinal cord injury: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int 2021; 32:1117-1127. [PMID: 33386876 DOI: 10.1007/s00198-020-05807-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
Abstract
UNLABELLED Bisphosphonates can inhibit osteoclast-mediated bone resorption, prevent bone loss, and reduce the risk of osteoporotic fractures. Our meta-analysis of studies shows that early bisphosphonate administration after SCI was safe and beneficial to the BMD of the total hip and lumbar spine at 12 months. INTRODUCTION Rapid bone loss in the early stages of spinal cord injury (SCI) leads to an increased risk of osteoporotic fracture. A meta-analysis was conducted to assess the efficacy and safety of bisphosphonates for the treatment of osteoporosis after SCI. METHODS A literature search of the PubMed, EMBASE, Cochrane Library, and Web of Science databases identified nine randomized controlled trials with 206 individuals. This meta-analysis was performed using a random-effects model. The primary outcome was the percent change in bone mineral density (BMD) of the total hip, distal femur, and lumbar spine from baseline to 12 months. Bone turnover markers were secondary outcomes. The incidences of adverse events were assessed in order to evaluate safety. RESULTS There were significant differences in BMD of the total hip and lumbar spine or serum C-terminal telopeptide between the bisphosphonate and control groups but no difference in adverse events. The percent change in BMD of the distal femur and serum type 1 procollagen N-terminal peptide from baseline to 12 months was not superior in the treatment groups. Osteoclast-mediated bone resorption was inhibited by bisphosphonate administration. Subgroup analyses of participants treated with zoledronate at different sites revealed a beneficial effect on BMD of the total hip and lumbar spine but not the distal femur. CONCLUSION Early bisphosphonate administration after SCI was safe and beneficial to the BMD of the total hip and lumbar spine at 12 months.
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Affiliation(s)
- Y Wu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
| | - F Wang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China.
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center, No. 10, Jiaomen North Road, Fengtai District, Beijing, China.
| | - Z Zhang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
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16
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The Pathophysiology of Osteoporosis after Spinal Cord Injury. Int J Mol Sci 2021; 22:ijms22063057. [PMID: 33802713 PMCID: PMC8002377 DOI: 10.3390/ijms22063057] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Spinal cord injury (SCI) affects approximately 300,000 people in the United States. Most individuals who sustain severe SCI also develop subsequent osteoporosis. However, beyond immobilization-related lack of long bone loading, multiple mechanisms of SCI-related bone density loss are incompletely understood. Recent findings suggest neuronal impairment and disability may lead to an upregulation of receptor activator of nuclear factor-κB ligand (RANKL), which promotes bone resorption. Disruption of Wnt signaling and dysregulation of RANKL may also contribute to the pathogenesis of SCI-related osteoporosis. Estrogenic effects may protect bones from resorption by decreasing the upregulation of RANKL. This review will discuss the current proposed physiological and cellular mechanisms explaining osteoporosis associated with SCI. In addition, we will discuss emerging pharmacological and physiological treatment strategies, including the promising effects of estrogen on cellular protection.
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17
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Fang Y, Morse LR, Nguyen N, Battaglino RA, Goldstein RF, Troy KL. Functional electrical stimulation (FES)-assisted rowing combined with zoledronic acid, but not alone, preserves distal femur strength and stiffness in people with chronic spinal cord injury. Osteoporos Int 2021; 32:549-558. [PMID: 32888047 DOI: 10.1007/s00198-020-05610-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/25/2020] [Indexed: 01/04/2023]
Abstract
UNLABELLED We investigated the effect of 12 months of functional electrical stimulation-assisted rowing with and without zoledronic acid (ZA) on computationally estimated bone strength and stiffness in individuals with spinal cord injury. We found that rowing with ZA, but not rowing alone, improved stiffness at the distal femur, but not the proximal tibia. INTRODUCTION People with spinal cord injury (SCI) have high fracture risk at the knee after the injury. Therapies that prevent bone loss or stimulate an anabolic response in bone have been proposed to reduce fractures. Zoledronic acid (ZA) is a potent bisphosphonate that inhibits osteoclastic resorption. Functional electrical stimulation (FES)-assisted rowing is a potentially osteogenic exercise involving mechanical stimulation to the lower extremities. Here, we investigated the effect of FES-assisted rowing with and without ZA on bone strength and stiffness in individuals with SCI. METHODS Twenty individuals from a cohort of adults with SCI who participated in a clinical trial were included in the study. CT scans of their knees before and after the intervention were converted to finite element models. Bone failure strength (Tult) and stiffness were calculated at the proximal tibia and distal femur. RESULTS Tult at the distal femur increased 4.6% among people who received rowing + ZA and decreased 13.9% among those with rowing only (p < 0.05 for group). Torsional and compressive stiffness at the femur metaphysis increased in people with rowing + ZA (+ 3 to +4%) and decreased in people with rowing only (- 7 to -8%; p < 0.05). Tult in the proximal tibia decreased in everyone, but the loss was attenuated in the rowing + ZA group. People with initially stronger bone tended to lose more strength. CONCLUSION Overall, we observed increases in bone strength at the distal femur but not the proximal tibia, with FES-assisted rowing combined with ZA treatment. Rowing alone did not significantly prevent bone loss at either site, which might be attributed to insufficient mechanical loading.
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Affiliation(s)
- Y Fang
- Department of Mechanical Engineering, Northern Arizona University, Flagstaff, AZ, USA
| | - L R Morse
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - N Nguyen
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - R A Battaglino
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - R F Goldstein
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Cambridge, MA, USA
| | - K L Troy
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA.
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18
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Le B, Ray C, Gonzalez B, Miskevics S, Weaver FM, Priebe M, Carbone LD. Reasons for Initiation and Discontinuation of Pharmacological Therapies for Osteoporosis in Veterans with Spinal Cord Injury and Disorders. J Clin Densitom 2021; 24:67-77. [PMID: 31262561 DOI: 10.1016/j.jocd.2019.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Medications for osteoporosis have not been reported to reduce fracture rates in patients with spinal cord injury and disorders (SCI/D), yet these medications are still prescribed. Clinical decision-making underscoring the initiation and discontinuation of osteoporosis medications in SCI/D remains poorly understood. METHODOLOGY Veterans with a SCI/D with at least one prescription for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, and teriparatide) who received healthcare within Veterans Affairs (VA) from 2005 to 2015 were identified using VA administrative databases. A 10% subsample of Veterans was selected for electronic health record review. RESULTS Two hundred and sixty-seven Veterans with 330 prescriptions underwent electronic health record review. Bisphosphonates were the most frequently prescribed medication for osteoporosis (n = 223, 67.6%). Of the 187 Veterans with prescriptions for prevention or treatment of osteoporosis, the primary reason for initiation was Dual Energy X-ray Absorptiometry (DXA) scan with osteopenia or osteoporosis (n = 119, 63.6% of Veterans), primarily at the hip (81.0% of DXAs). The majority (79.0%) of DXAs were "screening tests," with SCI/D being the sole reason for the scan. Fractures (n = 51, 27.3%) and fall risk concerns (n = 29, 15.5%) were other major reasons for initiation. On average, oral bisphosphonates were filled for <3 yr, with medication-related side effects (n = 23, 15.8% of bisphosphonates discontinued), predominately gastrointestinal (n = 17, 73.9% of reported side effects), the most common reason for discontinuation. Drug holidays occurred in 14.3% of 35 oral bisphosphonates used for ≥5 yr. No cases of osteonecrosis of the jaw were found. There was one case of an atypical femoral fracture which could not be confirmed. CONCLUSIONS The decision to initiate pharmacological therapies in SCI/D is primarily based on osteopenia or osteoporosis at the hip by screening DXAs. Gastrointestinal side effects are the major reason for discontinuation of oral bisphosphonates. New therapies for osteoporosis in SCI/D are needed.
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Affiliation(s)
- Brian Le
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA; Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Biostatistics, University of Illinois, Chicago, IL, USA; Department of Mathematics, Northeastern Illinois University, Chicago, IL, USA
| | - Scott Miskevics
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA
| | - Frances M Weaver
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA; Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | - Michael Priebe
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA
| | - Laura D Carbone
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA; Department of Medicine, Division of Rheumatology, J. Harold Harrison, MD, Distinguished University Chair in Rheumatology, Medical College of Georgia at Augusta University, Augusta, GA, USA.
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19
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Weaver FM, Etingen B, Guihan M, Ray C, Priebe M, Burns S, Carbone L. Spinal cord injury providers' perspectives on managing sublesional osteoporosis. J Spinal Cord Med 2020; 43:428-434. [PMID: 31859610 PMCID: PMC7480594 DOI: 10.1080/10790268.2019.1704552] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI. Design: Telephone interviews with SCI providers. Setting: VA SCI centers and clinics. Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed. Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures. Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.
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Affiliation(s)
- Frances M. Weaver
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines VA Hospital, Hines, Illinois, USA,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois, USA,Correspondence to: Frances M. Weaver, Edward Hines VA Hospital, Center of Innovation for Complex Chronic Healthcare, Hines, IL60304, USA.
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines VA Hospital, Hines, Illinois, USA
| | - Marylou Guihan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines VA Hospital, Hines, Illinois, USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines VA Hospital, Hines, Illinois, USA
| | - Michael Priebe
- Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia, USA
| | - Stephen Burns
- Department of Veterans Affairs-Puget Sound Health Care System, Seattle, Washington, USA,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Laura Carbone
- Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia, USA,Department of Medicine, Division of Rheumatology, J. Harold Harrison, MD, Distinguished Chair in Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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20
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Cirnigliaro CM, La Fountaine MF, Parrott JS, Kirshblum SC, McKenna C, Sauer SJ, Shapses SA, Hao L, McClure IA, Hobson JC, Spungen AM, Bauman WA. Administration of Denosumab Preserves Bone Mineral Density at the Knee in Persons With Subacute Spinal Cord Injury: Findings From a Randomized Clinical Trial. JBMR Plus 2020; 4:e10375. [PMID: 33134767 PMCID: PMC7587457 DOI: 10.1002/jbm4.10375] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/01/2020] [Accepted: 05/20/2020] [Indexed: 12/21/2022] Open
Abstract
Persons with neurologically motor-complete spinal cord injury (SCI) have a marked loss of bone mineral density (BMD) of the long bones of the lower extremities, predisposing them to fragility fractures, especially at the knee. Denosumab, a commercially available human monoclonal IgG antibody to receptor activator of nuclear factor-κB ligand (RANKL), may provide an immunopharmacological solution to the rapid progressive deterioration of sublesional bone after SCI. Twenty-six SCI participants with subacute motor-complete SCI were randomized to receive either denosumab (60 mg) or placebo at baseline (BL), 6, and 12 months. Areal bone mineral density (aBMD) by dual energy x-ray absorptiometry (DXA) at 18 months at the distal femur was the primary outcome and aBMD of the proximal tibia and hip were the secondary outcomes analyzed in 18 of the 26 participants (denosumab, n = 10 and placebo, n = 8). The metrics of peripheral QCT (pQCT) were the exploratory outcomes analyzed in a subsample of the cohort (denosumab, n = 7 and placebo n = 7). The mean aBMD (±95% CI) for the denosumab versus the placebo groups demonstrated a significant group × time interactions for the following regions of interest at BL and 18 months: distal femoral metaphysis = mean aBMD 1.187; 95% CI, 1.074 to 1.300 and mean aBMD 1.202; 95% CI, 1.074 to 1.329 versus mean aBMD 1.162; 95% CI, 0.962 to 1.362 and mean aBMD 0.961; 95% CI, 0.763 to 1.159, respectively (p < 0.001); distal femoral epiphysis = mean aBMD 1.557; 95% CI, 1.437 to 1.675 and mean aBMD 1.570; 95% CI, 1.440 to 1.700 versus mean aBMD 1.565; 95% CI, 1.434 to 1.696 and mean aBMD 1.103; 95% CI, 0.898 to 1.309, respectively (p = 0.002); and proximal tibial epiphysis = mean aBMD 1.071; 95% CI, 0.957 to 1.186 and mean aBMD 1.050; 95% CI, 0.932 to 1.168 versus mean aBMD 0.994; 95% CI, 0.879 to 1.109 and mean aBMD 0.760; 95% CI, 0.601 to 0.919, respectively (p < 0.001). Analysis of pQCT imaging revealed a continued trend toward significantly greater loss in total volumetric BMD (vBMD) and trabecular vBMD at the 4% distal tibia region, with a significant percent loss for total bone mineral content. Thus, at 18 months after acute SCI, our findings show that denosumab maintained aBMD at the knee region, the site of greatest clinical relevance in the SCI population. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Christopher M Cirnigliaro
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury James J. Peters Veterans Affairs Medical Center Bronx NY USA
| | - Michael F La Fountaine
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury James J. Peters Veterans Affairs Medical Center Bronx NY USA.,Department of Physical Therapy, School of Health and Medical Sciences Seton Hall University South Orange NJ USA.,Departments of Medical Sciences and Neurology Hackensack Meridian School of Medicine at Seton Hall University Nutley NJ USA
| | - J Scott Parrott
- Department of Interdisciplinary Studies School of Health Professions, Rutgers Biomedical and Health Sciences Newark NJ USA
| | - Steven C Kirshblum
- Kessler Institute for Rehabilitation West Orange NJ USA.,Kessler Foundation West Orange NJ USA.,Department of Physical Medicine and Rehabilitation Rutgers New Jersey Medical School Newark NJ USA
| | - Cristin McKenna
- Kessler Institute for Rehabilitation West Orange NJ USA.,Kessler Foundation West Orange NJ USA
| | - Susan J Sauer
- Kessler Institute for Rehabilitation West Orange NJ USA
| | - Sue A Shapses
- Department of Nutritional Sciences, School of Environmental and Biological Sciences Rutgers University New Brunswick NJ USA
| | - Lihong Hao
- Department of Nutritional Sciences, School of Environmental and Biological Sciences Rutgers University New Brunswick NJ USA
| | - Isa A McClure
- Kessler Institute for Rehabilitation West Orange NJ USA
| | - Joshua C Hobson
- Department of Kinesiology and Applied Physiology University of Delaware Newark DE USA
| | - Ann M Spungen
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury James J. Peters Veterans Affairs Medical Center Bronx NY USA.,Departments of Medicine and Rehabilitation and Human Performance Icahn School of Medicine at Mount Sinai New York NY USA
| | - William A Bauman
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury James J. Peters Veterans Affairs Medical Center Bronx NY USA.,Departments of Medicine and Rehabilitation and Human Performance Icahn School of Medicine at Mount Sinai New York NY USA
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Zoledronic Acid Attenuates Early Bone Loss at Forearm in Patients with Acute Spinal Cord Injury. Indian J Orthop 2020; 54:127-133. [PMID: 32952920 PMCID: PMC7474023 DOI: 10.1007/s43465-020-00158-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Randomized controlled trial. OBJECTIVES To study the magnitude of bone loss at forearm in persons with acute spinal cord injury (SCI) & the effect of early administration of Zoledronic acid on its' prevention. SETTINGS Sawai Man Singh Medical College, Jaipur, India. METHODS Sixty patients with acute SCI were randomized either to receive standard medical and nursing care or Zoledronic acid infusion in combination with standard medical and nursing care. Areal bone mineral density (aBMD) was measured at the forearm (radius + ulna) once patients were medically stable using Dual Energy X-Ray Absorptiometry (DXA) at baseline and at 3, 6 and 12 months. RESULTS Significant differences in aBMD was found between the control & Zoledronic acid group at 1/3 forearm (- 0.064; 95% CI - 0.092 to - 0.036, p = 0.001), mid forearm (- 0.059; 95% CI - 0.084 to - 0.034, p = 0.001), UD forearm (- 0.048; 95% CI - 0.097 to 0.001, p = 0.016) and total forearm (- 0.048; 95% CI - 0.088 to - 0.008, p = 0.021) at 1 year in the paraplegic patients with SCI. Similar significant difference was also observed at 1/3 forearm (- 0.046; 95% CI - 0.073 to - 0.019, p = 0.002), mid forearm (- 0.063; 95% CI - 0.088 to - 0.037, p < 0.0001), UD forearm (- 0.084; 95% CI - 0.101 to - 0.067, p < 0.0001) and total forearm (- 0.115; 95% CI - 0.132 to - 0.097, p < 0.0001) respectively at 1 year in the quadriplegic patients with SCI. Significant differences in aBMD between the groups at 6 months post infusion was also observed at these sites in quadriplegic patients. [1/3 forearm - 0.022; 95% CI - 0.039 to - 0.005; p = 0.015, Mid forearm - 0.023; 95% CI - 0.042 to - 0.004; p = 0.019, UD forearm - 0.041; 95% CI - 0.055 to - 0.027; p < 0.0001 and Total forearm - 0.049; 95%CI - 0.062 to - 0.036; p < 0.0001]. Bone loss was reduced in the Zoledronic acid treated group compared to the standard treatment group in both paraplegic and quadriplegic patients. CONCLUSION Single dose of 5mg intravenous Zoledronic acid is an effective treatment in preventing bone loss at the forearm for 12 months following acute spinal cord injury.
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Xinghua J, Junjie W, Yao G, Peng S, Jianzhong H. The Effect of Bisphosphonates on Managing Osteoporosis After Spinal Cord Injury: A Meta-Analysis. Curr Pharm Des 2020; 26:5072-5078. [PMID: 32364066 DOI: 10.2174/1381612826666200504115747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The increased bone loss after spinal cord injury (SCI) is associated with an increase in the morbidity and mortality of fragility fractures, which can constitute a substantial cost to health care systems. Bisphosphonates (BPs) are now the principal class of medications used for osteoporosis. OBJECTIVE To demonstrate the effect of BPs on treating osteoporosis after SCI. METHODS A comprehensive search in PubMed, EMBASE, Web of Science and Cochrane Central databases was undertaken for randomized controlled trials (RCTs), exploring the effect of BPs on osteoporosis after SCI. The primary outcome measures were the BMD of different locations, serum bone turnover marker levels, serum biochemistry marker levels and adverse effect (AE) risks. The final search was performed in September 2019. Reporting was carried out according to PRISMA Guidelines. RESULTS Six RCTs were included. A total of 147 patients met the inclusion criteria. BPs were found to statistically prevent bone loss in the total hip, femoral neck and trochanter at the 6- and 12-month follow-up points and to increase the BMD of the lumbar spine at the 12-month follow-up time point. BPs had no clear effect on serum PINP or serum calcium levels at the 12-month follow-up time point. CONCLUSION BP therapy may prevent bone loss in the lumbar spine and hip when administered early after SCI and has relatively high safety.
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Affiliation(s)
- Ji Xinghua
- Department of Orthopaedics, Shanxi Bethune Hospital, Taiyuan, Shanxi Province, China
| | - Wang Junjie
- Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Guo Yao
- Department of Orthopaedics, Shanxi Bethune Hospital, Taiyuan, Shanxi Province, China
| | - Shang Peng
- Department of Orthopaedics, Shanxi Bethune Hospital, Taiyuan, Shanxi Province, China
| | - Huo Jianzhong
- Department of Orthopaedics, Shanxi Bethune Hospital, Taiyuan, Shanxi Province, China
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The effect of zoledronic acid on attenuation of bone loss at the hip and knee following acute traumatic spinal cord injury: a randomized-controlled study. Spinal Cord 2020; 58:921-929. [DOI: 10.1038/s41393-020-0431-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 11/09/2022]
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Association of Bisphosphonate Therapy With Incident of Lower Extremity Fractures in Persons With Spinal Cord Injuries or Disorders. Arch Phys Med Rehabil 2020; 101:633-641. [PMID: 31958428 DOI: 10.1016/j.apmr.2019.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/25/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the association between prescriptions for bisphosphonates; calcium and vitamin D supplements; and receipt of dual-energy x-ray absorptiometry (DXA) screening, and incident fracture risk in men and women with a spinal cord injury (SCI) or disorder (SCID). DESIGN Propensity-matched case-control analyses. SETTING United States Veterans Affairs (VA) facilities. PARTICIPANTS A total of 7989 men and 849 women with an SCID included in VA administrative databases between October 1, 2005 and October 1, 2015 were identified (N=8838). Cases included 267 men and 59 women with a bisphosphonate prescription propensity matched with up to 4 controls. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Incident lower extremity fractures. RESULTS There was no significant association between prescriptions for bisphosphonates and incident lower extremity fractures in men (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.62-1.77) or women (OR, 1.02; 95% CI, 0.28-3.75). In men, similar null associations were seen among those who were adherent to bisphosphonate therapy (OR, 1.25; 95% CI, 0.73-2.16), were concomitant users of vitamin D and calcium and a bisphosphonate (OR, 1.05; 95% CI, 0.57-1.96), had more than 1 fracture on different dates during the study period (OR, 0.13; 95% CI, 0.02-1.16) and in those who had undergone DXA testing prior to the date of the bisphosphonate prescription and incident fracture (OR, 1.26; 95% CI, 0.69-2.32). CONCLUSIONS In men with a traumatic SCI and women with a traumatic SCID, bisphosphonate therapies for osteoporosis do not appear to significantly affect fracture risk. Adequately powered randomized controlled trials are needed to definitively demonstrate efficacy of bisphosphonates for fracture prevention in this population. There is a compelling need to identify new medications to prevent fractures in this high-risk population.
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Zleik N, Weaver F, Harmon RL, Le B, Radhakrishnan R, Jirau-Rosaly WD, Craven BC, Raiford M, Hill JN, Etingen B, Guihan M, Heggeness MH, Ray C, Carbone L. Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review. J Spinal Cord Med 2019; 42:735-759. [PMID: 29745791 PMCID: PMC6830234 DOI: 10.1080/10790268.2018.1469808] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Nour Zleik
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Frances Weaver
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Robert L. Harmon
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
| | - Brian Le
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | | | - Wanda D. Jirau-Rosaly
- Department of Medicine, Division of Geriatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Mattie Raiford
- School of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Jennifer N. Hill
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
| | - Marylou Guihan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
| | - Michael H. Heggeness
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Laura Carbone
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Osteoporosis in Veterans with Spinal Cord Injury: an Overview of Pathophysiology, Diagnosis, and Treatments. Clin Rev Bone Miner Metab 2019. [DOI: 10.1007/s12018-019-09265-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Osteoporosis is a serious complication of spinal cord injury that is associated with increased fracture rates. Diagnosis and management of osteoporosis is limited by the lack of rigorous, well powered clinical trials with fracture as a primary outcome. Due to a lack of evidence-based guidelines, clinical practice varies greatly. This Point-counterpoint series address prophylaxis of osteoporosis in acute SCI.
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Affiliation(s)
- Leslie Morse
- Department of Rehabilitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN USA
- Rocky Mountain Regional Spinal Injury System, Craig Rehabilitation Hospital, Englewood, CO USA
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Dionyssiotis Y. Is prophylaxis for osteoporosis indicated after acute spinal cord injury? Spinal Cord Ser Cases 2019; 5:24. [PMID: 31240120 DOI: 10.1038/s41394-019-0167-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/25/2018] [Accepted: 12/28/2018] [Indexed: 01/15/2023] Open
Abstract
Spinal cord injury (SCI)-related osteoporosis is common complication in people with tetraplegia or paraplegia. Studies have shown that sublesional regions are severely demineralized. Loss of bone and sequential fractures are major problems in people with SCI that lead to further immobilization and decreasing quality of life. Despite extensive research mechanisms of this bone impairment are inadequately understood. This article discusses basics of bone metabolism physiopathology along with pharmaceutical prevention and treatment approaches to manage acute SCI-related bone loss.
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Affiliation(s)
- Yannis Dionyssiotis
- Physical Medicine and Rehabilitation Clinic, General University Hospital of Ioannina, Ioannina, Greece.
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Morse LR, Troy KL, Fang Y, Nguyen N, Battaglino R, Goldstein RF, Gupta R, Taylor JA. Combination Therapy With Zoledronic Acid and FES-Row Training Mitigates Bone Loss in Paralyzed Legs: Results of a Randomized Comparative Clinical Trial. JBMR Plus 2019; 3:e10167. [PMID: 31131346 PMCID: PMC6524678 DOI: 10.1002/jbm4.10167] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/02/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Spinal cord injury (SCI) results in rapid, severe osteoporosis and an increased risk of lower extremity fractures. Despite the medical complications associated with these fractures, there is no standard of care to prevent osteoporotic fractures following SCI. Functional electrical stimulation- (FES-) assisted rowing is a promising intervention to improve bone health in SCI because of its ability to generate a muscular contraction in conjunction with mechanical loading of the lower extremity long bones. Combination therapy consisting of FES-rowing plus zoledronic acid (ZA) may be a superior treatment via inhibition of bone resorption and stimulation of new bone formation. We studied participants enrolled in a randomized clinical trial comparing FES-rowing alone with FES-rowing plus ZA to improve bone health in SCI. Volumetric CT scans at the distal femur and proximal tibial metaphyses were performed. Bone geometric properties (cortical thickness index [CTI], cortical compressive strength index [CSI], buckling ratio [BR], bending strength index) and mineral (cortical bone volume [CBV], cortical bone mineral density, cortical bone mineral content) indices were determined. In models adjusting for baseline values, we found that the CBV (p = 0.05 to 0.006), the CTI (p = 0.009), and the BR (p = 0.001) at both the distal femoral and proximal tibial metaphyses were greater in the ZA plus rowing group compared with the rowing-only group. Similarly, there was a significant positive association between the total rowing work completed and the BR at the proximal tibia (p = 0.05). A subgroup analysis of the rowing-only arm showed that gains in the CSI at the tibial metaphysis varied in a dose-dependent fashion based on the total amount of exercise performed (p = 0.009). These findings demonstrate that the osteogenic response to FES-rowing is dose-dependent. Combination therapy with ZA and FES-row training has therapeutic potential to improve bone quality, and perhaps reduce fracture risk at the most common fracture site following SCI. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- L R Morse
- Rocky Mountain Regional Spinal Injury System Craig Rehabilitation Hospital Englewood CO USA.,Department of PMR University of Colorado School of Medicine Aurora CO USA
| | - K L Troy
- Department of Biomedical Engineering Worcester Polytechnic Institute Worcester MA USA
| | - Y Fang
- Department of Biomedical Engineering Worcester Polytechnic Institute Worcester MA USA
| | - N Nguyen
- Rocky Mountain Regional Spinal Injury System Craig Rehabilitation Hospital Englewood CO USA
| | - R Battaglino
- Department of PMR University of Colorado School of Medicine Aurora CO USA
| | - R F Goldstein
- Rocky Mountain Regional Spinal Injury System Craig Rehabilitation Hospital Englewood CO USA
| | - R Gupta
- Department of Radiology Massachusetts General Hospital Boston MA USA
| | - J A Taylor
- Spaulding Rehabilitation Hospital Boston MA USA.,Department of Physical Medicine and Rehabilitation Harvard Medical School Boston MA USA
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Goenka S, Sethi S, Pandey N, Joshi M, Jindal R. Effect of early treatment with zoledronic acid on prevention of bone loss in patients with acute spinal cord injury: a randomized controlled trial. Spinal Cord 2018; 56:1207-1211. [DOI: 10.1038/s41393-018-0195-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 08/02/2018] [Accepted: 08/13/2018] [Indexed: 01/28/2023]
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Gifre L, Humbert L, Muxi A, Del Rio L, Vidal J, Portell E, Monegal A, Guañabens N, Peris P. Analysis of the evolution of cortical and trabecular bone compartments in the proximal femur after spinal cord injury by 3D-DXA. Osteoporos Int 2018; 29:201-209. [PMID: 29043391 DOI: 10.1007/s00198-017-4268-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 10/11/2017] [Indexed: 01/18/2023]
Abstract
UNLABELLED Marked trabecular and cortical bone loss was observed at the proximal femur short-term after spinal cord injury (SCI). 3D-DXA provided measurement of vBMD evolution at both femoral compartments and cortical thinning, thereby suggesting that this technique could be useful for bone analysis in these patients. INTRODUCTION SCI is associated with a marked increase in bone loss and risk of osteoporosis development short-term after injury. 3D-DXA is a new imaging analysis technique providing 3D analysis of the cortical and trabecular bone from DXA scans. The aim of this study was to assess the evolution of trabecular macrostructure and cortical bone using 3D-DXA in patients with recent SCI followed over 12 months. METHODS Sixteen males with recent SCI (< 3 months since injury) and without antiosteoporotic treatment were included. Clinical assessment, bone mineral density (BMD) measurements by DXA, and 3D-DXA evaluation at proximal femur (analyzing the integral, trabecular and cortical volumetric BMD [vBMD] and cortical thickness) were performed at baseline and at 6 and 12 months of follow-up. RESULTS vBMD significantly decreased at integral, trabecular, and cortical compartments at 6 months (- 8.8, - 11.6, and - 2.4%), with a further decrease at 12 months, resulting in an overall decrease of - 16.6, - 21.9, and - 5.0%, respectively. Cortical thickness also decreased at 6 and 12 months (- 8.0 and - 11.4%), with the maximal decrease being observed during the first 6 months. The mean BMD losses by DXA at femoral neck and total femur were - 17.7 and - 21.1%, at 12 months, respectively. CONCLUSIONS Marked trabecular and cortical bone loss was observed at the proximal femur short-term after SCI. 3D-DXA measured vBMD evolution at both femoral compartments and cortical thinning, providing better knowledge of their differential contributory role to bone strength and probably of the effect of therapy in these patients.
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Affiliation(s)
- L Gifre
- Rheumatology Department, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Metabolic Bone Diseases Unit, Service of Rheumatology, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Rheumatology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - A Muxi
- Nuclear Medicine Department, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - J Vidal
- Guttmann Neurorehabilitation Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - E Portell
- Guttmann Neurorehabilitation Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - A Monegal
- Rheumatology Department, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Metabolic Bone Diseases Unit, Service of Rheumatology, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - N Guañabens
- Rheumatology Department, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Metabolic Bone Diseases Unit, Service of Rheumatology, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Peris
- Rheumatology Department, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Metabolic Bone Diseases Unit, Service of Rheumatology, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1798-1814. [PMID: 28497215 DOI: 10.1007/s00586-017-5114-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/29/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Spinal cord injury (SCI) results in accelerated bone mineral density (BMD) loss and disorganization of trabecular bone architecture. The mechanisms underlying post-SCI osteoporosis are complex and different from other types of osteoporosis. Findings of studies investigating efficacy of pharmacological or rehabilitative interventions in SCI-related osteoporosis are controversial. The aim of this study was to review the literature pertaining to prevention and evidence-based treatments of SCI-related osteoporosis. METHODS In this systematic review, MEDLINE, EMBASE, PubMed, and the Cochrane Library were used to identify papers from 1946 to December 31, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss. RESULTS Finally, 56 studies were included according to the inclusion criteria. Only 16 randomized controlled trials (involving 368 patients) were found. We found following evidences for effectiveness of bisphosphonates in prevention of BMD loss in acute SCI: very low-quality evidence for clodronate and etidronate, low-quality evidence for alendronate, and moderate-quality evidence for zoledronic acid. Low-quality evidence showed no effectiveness for tiludronate. In chronic SCI cases, we found low-quality evidence for effectiveness of vitamin D3 analogs combined with 1-alpha vitamin D2. However, low-quality inconsistent evidence exists for alendronate. For non-pharmacologic interventions, very low-quality evidence exists for effectiveness of standing with or without treadmill walking in acute SCI. Other low-quality evidences indicated that electrical stimulation, tilt-table standing, and ultrasound provide no significant effects. Very low-quality evidence did not show any benefit for low-intensity (3 days per week) cycling with functional electrical stimulator in chronic SCI. CONCLUSIONS No recommendations can be made from this review, regarding overall low quality of evidence as a result of high risk of bias, low sample size in most of the studies, and notable heterogeneity in type of intervention, outcome measurement, and duration of treatment. Therefore, future high-quality RCT studies with higher sample sizes and more homogeneity are strongly recommended to provide high-quality evidence and make applicable recommendations for prevention and treatment of SCI-related bone loss.
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Abderhalden L, Weaver FM, Bethel M, Demirtas H, Burns S, Svircev J, Hoenig H, Lyles K, Miskevics S, Carbone LD. Dual-energy X-ray absorptiometry and fracture prediction in patients with spinal cord injuries and disorders. Osteoporos Int 2017; 28:925-934. [PMID: 27924381 DOI: 10.1007/s00198-016-3841-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 11/11/2016] [Indexed: 01/09/2023]
Abstract
UNLABELLED Low T-scores at the hip predict incident fractures in persons with a SCI. INTRODUCTION Persons with a spinal cord injury (SCI) have substantial morbidity and mortality following osteoporotic fractures. The objective of this study was to determine whether dual-energy X-ray absorptiometry (DXA) measurements predict osteoporotic fractures in this population. METHODS A retrospective historical analysis that includes patients (n = 552) with a SCI of at least 2 years duration who had a DXA performed and were in the VA Spinal Cord Disorders Registry from fiscal year (FY) 2002-2012 was performed. RESULTS The majority of persons (n = 455, 82%) had a diagnosis of osteoporosis or osteopenia, with almost half having osteoporosis. BMD and T-scores at the lumbar spine were not significantly associated with osteoporotic fractures (p > 0.48) for both. In multivariable analyses, osteopenia (OR = 4.75 95% CI 1.23-17.64) or osteoporosis (OR = 4.31, 95% CI 1.15-16.23) compared with normal BMD was significantly associated with fractures and higher T-scores at the hip were inversely associated with fractures (OR 0.73 (95% CI 0.57-0.92)). There was no significant association of T-scores or World Health Organization (WHO) classification with incident fractures in those with complete SCI (p > 0.15 for both). CONCLUSION The majority (over 80%) of individuals with a SCI have osteopenia or osteoporosis. DXA-derived measurements at the hip, but not the lumbar spine, predict fracture risk in persons with a SCI. WHO-derived bone density categories may be useful in classifying fracture risk in persons with a SCI.
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Affiliation(s)
- L Abderhalden
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, 5000 S. 5th Ave, P.O. Box 1033, Hines, IL, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - F M Weaver
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, 5000 S. 5th Ave, P.O. Box 1033, Hines, IL, USA
- Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | - M Bethel
- Charlie Norwood Veterans Affairs Medical Center, 950 15th St, 6D-155, Augusta, GA, 30912, USA
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - H Demirtas
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - S Burns
- VA Puget Sound Health Care System-Seattle Division, 1660 S. Columbian Way, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - J Svircev
- VA Puget Sound Health Care System-Seattle Division, 1660 S. Columbian Way, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - H Hoenig
- Durham VA Medical Center, 508 Fulton St, Durham, NC, USA
| | - K Lyles
- Duke University and VA Medical Centers, Durham, NC, USA
- The Carolinas Center for Medical Excellence, Cary, NC, USA
| | - S Miskevics
- Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | - L D Carbone
- Charlie Norwood Veterans Affairs Medical Center, 950 15th St, 6D-155, Augusta, GA, 30912, USA.
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA.
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Cirnigliaro CM, Myslinski MJ, La Fountaine MF, Kirshblum SC, Forrest GF, Bauman WA. Bone loss at the distal femur and proximal tibia in persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options. Osteoporos Int 2017; 28:747-765. [PMID: 27921146 DOI: 10.1007/s00198-016-3798-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/27/2016] [Indexed: 12/15/2022]
Abstract
Persons with spinal cord injury (SCI) undergo immediate unloading of the skeleton and, as a result, have severe bone loss below the level of lesion associated with increased risk of long-bone fractures. The pattern of bone loss in individuals with SCI differs from other forms of secondary osteoporosis because the skeleton above the level of lesion remains unaffected, while marked bone loss occurs in the regions of neurological impairment. Striking demineralization of the trabecular epiphyses of the distal femur (supracondylar) and proximal tibia occurs, with the knee region being highly vulnerable to fracture because many accidents occur while sitting in a wheelchair, making the knee region the first point of contact to any applied force. To quantify bone mineral density (BMD) at the knee, dual energy x-ray absorptiometry (DXA) and/or computed tomography (CT) bone densitometry are routinely employed in the clinical and research settings. A detailed review of imaging methods to acquire and quantify BMD at the distal femur and proximal tibia has not been performed to date but, if available, would serve as a reference for clinicians and researchers. This article will discuss the risk of fracture at the knee in persons with SCI, imaging methods to acquire and quantify BMD at the distal femur and proximal tibia, and treatment options available for prophylaxis against or reversal of osteoporosis in individuals with SCI.
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Affiliation(s)
- C M Cirnigliaro
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - M J Myslinski
- Department of Physical Therapy, School of Health Related Professions, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - M F La Fountaine
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA
- The Institute for Advanced Study of Rehabilitation and Sports Science, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA
| | - S C Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - G F Forrest
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
- Kessler Foundation, West Orange, NJ, USA
| | - W A Bauman
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA.
- Departments of Medicine and Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Bethel M, Weaver FM, Bailey L, Miskevics S, Svircev JN, Burns SP, Hoenig H, Lyles K, Carbone LD. Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders. Osteoporos Int 2016; 27:3011-21. [PMID: 27230522 DOI: 10.1007/s00198-016-3627-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/02/2016] [Indexed: 01/15/2023]
Abstract
UNLABELLED Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture. INTRODUCTION Few studies to date have comprehensively addressed clinical risk factors for fracture in persons with spinal cord injury (SCI). The purpose of this study was to identify risk factors for incident osteoporotic fractures in persons with a SCI that can be easily determined at the point of care. METHODS The Veteran's Affairs Spinal Cord Dysfunction Registry, a national database of persons with a SCI, was used to examine clinical and SCI-related risk factors for fracture. Incident fractures were identified in a cohort of persons with chronic SCI, defined as SCI present for at least 2 years. Cox regression models were used to estimate the risk of incident fractures. RESULTS There were 22,516 persons with chronic SCI included in the cohort with 3365 incident fractures. The mean observational follow-up time for the overall sample was 6.2 years (median 6.0, IQR 2.9-11.0). The mean observational follow-up time for the fracture group was 3.9 years (median 3.3, IQR 1.4-6.1) and 6.7 years (median 6.7, IQR 3.1-11.0) for the nonfracture group. By the end of the study, which included predominantly older Veterans with a SCI observed for a relatively short period of time, the absolute (i.e., cumulative hazard) for incident fractures was 0.17 (95%CI 0.14-0.21). In multivariable analysis, factors associated with an increased risk of fracture included White race, traumatic etiology of SCI, paraplegia, complete extent of SCI, longer duration of SCI, use of anticonvulsants and opioids, prevalent fractures, and higher Charlson Comorbidity Indices. Women aged 50 and older were also at higher risk of sustaining an incident fracture at any time during the 11-year follow-up period. CONCLUSIONS There are multiple clinical and SCI-related risk factors which can be used to predict fracture in persons with a SCI. Clinicians should be particularly concerned about incident fracture risk in persons with a SCI who have had a previous fracture.
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Affiliation(s)
- M Bethel
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA.
- Department of Medicine, Medical College of Georgia, Augusta University, 1120 15th St, Augusta, GA, USA.
| | - F M Weaver
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA
- Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | - L Bailey
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - S Miskevics
- Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA
| | - J N Svircev
- VA Puget Sound Health Care System-Seattle Division, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - S P Burns
- VA Puget Sound Health Care System-Seattle Division, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - H Hoenig
- Durham VA Medical Center, Durham, NC, USA
| | - K Lyles
- Department of Medicine, Duke University, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, VAMC, Durham, NC, USA
| | - L D Carbone
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA
- Department of Medicine, Medical College of Georgia, Augusta University, 1120 15th St, Augusta, GA, USA
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Schnitzer TJ, Kim K, Marks J, Yeasted R, Simonian N, Chen D. Zoledronic Acid Treatment After Acute Spinal Cord Injury: Results of a Randomized, Placebo-Controlled Pilot Trial. PM R 2016; 8:833-43. [PMID: 26828618 DOI: 10.1016/j.pmrj.2016.01.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/28/2015] [Accepted: 01/23/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the effect of intravenous zoledronic acid 5 mg on the extent and course of bone loss after spinal cord injury (SCI). DESIGN Double-blind, randomized, placebo-controlled parallel-group trial. SETTING Acute in-patient, tertiary-care rehabilitation hospital. PARTICIPANTS Convenience sample of 17 in-patients with SCI <12 weeks before randomization; American Spinal Injury Association Impairment scale A, B, or C and medically stable. Twelve patients were evaluated at the primary endpoint at 6 months. METHODS Patients meeting study criteria were randomly assigned to zoledronic acid 5 mg or matching placebo. Dual x-ray absorptiometry scan and serum for bone markers (type 1 procollagen amino-terminal propeptide, bone-specific alkaline phosphatase, collagen type 1 cross-linked C-telopeptide) were obtained at baseline and after 3 months, 6 months, and the every 6 months for up to 2 years. MAIN OUTCOME MEASURES The primary endpoint was change in bone mineral density (BMD) at the total hip after 6 months; secondary endpoints were changes in BMD at other skeletal sites and changes in levels of serum bone markers. RESULTS The group treated with zoledronic acid had a smaller decrease in BMD at 6 months at the total hip than the placebo group (right: -2.2 ± 3.4% versus -8.6 ± 3.5%, respectively, P = .03; left: -3.7 ± 1.0% versus -12.3 ± 6.9%, P = .03). Differences in BMD at the femoral neck were similar (right: -5.1 ± 6.5% versus -20.0 ± 6.4%, P = .01; left: -1.1 ± 3.5% versus -11.1 ± 7.4%, P = .02) with larger bone loss and smaller between group differences at the knee. Zoledronic acid resulted in a decrease in serum levels of both formation and resorption markers. CONCLUSIONS Zoledronic acid is effective at mitigating bone loss after SCI. Duration of efficacy and activity at different skeletal sites may differ from that observed in able-bodied individuals and needs further study.
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Affiliation(s)
- Thomas J Schnitzer
- Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Chicago, IL 60611(∗).
| | - Ki Kim
- Northwestern University Feinberg School of Medicine, Chicago, IL; Rehabilitation Institute of Chicago, Chicago, IL(†)
| | - Julia Marks
- Northwestern University Feinberg School of Medicine, Chicago, IL(‡)
| | - Renita Yeasted
- Northwestern University Feinberg School of Medicine, Chicago, IL(§)
| | - Narina Simonian
- Northwestern University Feinberg School of Medicine, Chicago, IL(¶)
| | - David Chen
- Northwestern University Feinberg School of Medicine, Chicago, IL; Rehabilitation Institute of Chicago, Chicago, IL(#)
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Varzi D, Coupaud SAF, Purcell M, Allan DB, Gregory JS, Barr RJ. Bone morphology of the femur and tibia captured by statistical shape modelling predicts rapid bone loss in acute spinal cord injury patients. Bone 2015; 81:495-501. [PMID: 26341577 DOI: 10.1016/j.bone.2015.08.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/18/2015] [Accepted: 08/30/2015] [Indexed: 01/13/2023]
Abstract
After spinal cord injury (SCI), bone loss in the paralysed limbs progresses at variable rates. Decreases in bone mineral density (BMD) in the first year range from 1% (slow) to 40% (rapid). In chronic SCI, fragility fractures commonly occur around the knee, with significant associated morbidity. Osteoporosis treatments await full evaluation in SCI, but should be initiated early and targeted towards patients exhibiting rapid bone loss. The potential to predict rapid bone loss from a single bone scan within weeks of a SCI was investigated using statistical shape modelling (SSM) of bone morphology, hypothesis: baseline bone shape predicts bone loss at 12-months post-injury at fracture-prone sites. In this retrospective cohort study 25 SCI patients (median age, 33 years) were scanned at the distal femur and proximal tibia using peripheral Quantitative Computed Tomography at <5 weeks (baseline), 4, 8 and 12 months post-injury. An SSM was made for each bone. Links between the baseline shape-modes and 12-month total and trabecular BMD loss were analysed using multiple linear regression. One mode from each SSM significantly predicted bone loss (age-adjusted P<0.05 R(2)=0.37-0.61) at baseline. An elongated intercondylar femoral notch (femur mode 4, +1 SD from the mean) was associated with 8.2% additional loss of femoral trabecular BMD at 12-months. A more concave posterior tibial fossa (tibia mode 3, +1 SD) was associated with 9.4% additional 12-month tibial trabecular BMD loss. Baseline bone shape determined from a single bone scan is a valid imaging biomarker for the prediction of 12-month bone loss in SCI patients.
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Affiliation(s)
- Delaram Varzi
- Musculoskeletal Research Programme, University of Aberdeen, Aberdeen, UK
| | - Sylvie A F Coupaud
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK; Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow, UK
| | - Mariel Purcell
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow, UK
| | - David B Allan
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow, UK
| | - Jennifer S Gregory
- Musculoskeletal Research Programme, University of Aberdeen, Aberdeen, UK
| | - Rebecca J Barr
- Musculoskeletal Research Programme, University of Aberdeen, Aberdeen, UK.
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Gifre L, Vidal J, Carrasco JL, Muxi A, Portell E, Monegal A, Guañabens N, Peris P. Risk factors for the development of osteoporosis after spinal cord injury. A 12-month follow-up study. Osteoporos Int 2015; 26:2273-80. [PMID: 25939310 DOI: 10.1007/s00198-015-3150-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/22/2015] [Indexed: 12/14/2022]
Abstract
UNLABELLED Spinal cord injury (SCI) has been associated with a marked bone loss after injury and a consequent increased risk of osteoporosis. The evaluation of bone mineral density shortly after SCI is a simple and effective method for predicting the development of osteoporosis during the first year after SCI. INTRODUCTION Spinal cord injury (SCI) has been associated with a marked bone loss after injury and a consequent increased risk of osteoporosis and fractures. The aim of this study was to analyze the factors associated with osteoporosis development short-term after SCI. METHODS We included patients with complete recent SCI (<6 months) evaluating bone turnover markers (P1NP, bone ALP, and sCTx), 25-OH-vitamin D (25OHD) levels, and lumbar and femoral BMD (Lunar, Prodigy) at baseline, 6 and 12 months after SCI. The risk factors for osteoporosis analyzed included the following: age, gender, BMI, toxic habits, bone turnover markers, 25OHD levels, lumbar and femoral BMD, level, severity and type of SCI, and days-since-injury. Osteoporosis was defined according to WHO criteria. RESULTS Thirty-five patients aged 35 ± 16 years were included, and 52 % developed osteoporosis during the 12-month follow-up. These latter patients had lower BMD values at femur and lumbar spine and higher bone turnover markers at baseline. On multivariate analysis, the principal factors related to osteoporosis development were as follows: total femur BMD <1 g/cm(2) (RR, 3.61; 95 % CI 1.30-10.06, p = 0.002) and lumbar BMD <1.2 g/cm(2) at baseline (0.97 probability of osteoporosis with both parameters under these values). Increased risk for osteoporosis was also associated with increased baseline values of bone ALP (>14 ng/mL) (RR 2.40; 95 % CI 1.10-5.23, p = 0.041) and P1NP (>140 ng/mL) (RR 3.08; 95 % CI 1.10-8.57, p = 0.017). CONCLUSIONS The evaluation of BMD at the lumbar spine and femur short-term after SCI is a simple, effective method for predicting the development of osteoporosis during the first year after SCI. Our results also indicate the need to evaluate and treat these patients shortly after injury.
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Affiliation(s)
- L Gifre
- Metabolic Bone Diseases Unit, Service of Rheumatology, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain,
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Bauman WA, Cirnigliaro CM, La Fountaine MF, Martinez L, Kirshblum SC, Spungen AM. Zoledronic acid administration failed to prevent bone loss at the knee in persons with acute spinal cord injury: an observational cohort study. J Bone Miner Metab 2015; 33:410-21. [PMID: 25158630 DOI: 10.1007/s00774-014-0602-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 05/08/2014] [Indexed: 01/23/2023]
Abstract
After acute spinal cord injury (SCI), rapid depletion of the sublesional skeleton occurs, particularly at the distal femur and proximal tibia. Subsequently, fragility fractures of the knee may occur. We determined the efficacy of zoledronic acid to prevent sublesional bone mineral density (BMD) loss at 6 and 12 months after acute SCI. Thirteen subjects with acute motor-complete SCI were prospectively studied: 6 patients received zoledronic acid (5 mg) and 7 subjects did not receive the drug (controls). Zoledronic acid was administered intravenously within 16 weeks of acute injury. Areal BMD was performed by dual energy X-ray absorptiometry at baseline, 6, and 12 months after administration of drug. The treatment group demonstrated sparing of BMD at the total hip at month 6 (p < 0.0006) and at month 12 (p < 0.01). In contrast to the findings at the hip, the treatment group had a greater loss of BMD compared to the control group at the distal femur and proximal tibia at month 6 (-7.9% ± 3.4 vs.-2.7% ± 5.0, respectively, p = 0.054; and -10.5% ± 6.4 vs. -4.8% ± 6.8, respectively, p = NS) and at month 12 (-18.5% ± 3.9 vs. -8.4% ± 7.2, respectively, p = 0.01; and -20.4% ± 8.8 vs.-7.9% ± 12.3, respectively, p = 0.06). A single dose of zoledronic acid administered soon after acute SCI reduced the %BMD loss at the hip, but appeared to have no effect to prevent %BMD loss at the knee, the site where fracture risk is greatest in persons with SCI.
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Affiliation(s)
- William A Bauman
- VA RR&D National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY, 10468, USA,
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Wuermser LA, Beck LA, Lamb JL, Atkinson EJ, Amin S. The effect of low-magnitude whole body vibration on bone density and microstructure in men and women with chronic motor complete paraplegia. J Spinal Cord Med 2015; 38:178-86. [PMID: 24621040 PMCID: PMC4397199 DOI: 10.1179/2045772313y.0000000191] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To examine the effect of low-magnitude whole body vibration on bone density and microstructure in women and men with chronic motor complete paraplegia. METHODS We studied nine subjects (four women and five men) with motor complete paraplegia of 2 years duration or more, age 20-50 years. Subjects were instructed to stand on a low-magnitude vibration plate within a standing frame for 20 minutes per day, 5 days a week, and for 6 months. Bone density at the proximal femur by dual-energy X-ray absorptiometry and bone microstructure at the distal tibia by high-resolution peripheral quantitative computed tomography were assessed at four timepoints over 12 months (baseline, at 3 months and 6 months while on intervention, and after 6 months off intervention). RESULTS Standing on the low-magnitude vibration plate with a standing frame was well tolerated by participants. However, most subjects did not show an improvement in bone density or microstructure after 6 months of intervention, or any relevant changes 6 months following the discontinuation of the low-magnitude vibration. CONCLUSION We were unable to identify an improvement in either bone density or microstructure following 6 months use of a low-magnitude vibration plate in women or men with chronic motor complete paraplegia. Longer duration of use may be necessary, or it is possible that this intervention is of limited benefit following chronic spinal cord injury.
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Affiliation(s)
- Lisa-Ann Wuermser
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Lisa A. Beck
- Department of Physical Medicine and Rehabilitation, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffry L. Lamb
- Department of Physical Medicine and Rehabilitation, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J. Atkinson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shreyasee Amin
- Correspondence to: Shreyasee Amin, Division of Rheumatology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Sezer N, Akkuş S, Uğurlu FG. Chronic complications of spinal cord injury. World J Orthop 2015; 6:24-33. [PMID: 25621208 PMCID: PMC4303787 DOI: 10.5312/wjo.v6.i1.24] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Spinal cord injury (SCI) is a serious medical condition that causes functional, psychological and socioeconomic disorder. Therefore, patients with SCI experience significant impairments in various aspects of their life. The goals of rehabilitation and other treatment approaches in SCI are to improve functional level, decrease secondary morbidity and enhance health-related quality of life. Acute and long-term secondary medical complications are common in patients with SCI. However, chronic complications especially further negatively impact on patients’ functional independence and quality of life. Therefore, prevention, early diagnosis and treatment of chronic secondary complications in patients with SCI is critical for limiting these complications, improving survival, community participation and health-related quality of life. The management of secondary chronic complications of SCI is also important for SCI specialists, families and caregivers as well as patients. In this paper, we review data about common secondary long-term complications after SCI, including respiratory complications, cardiovascular complications, urinary and bowel complications, spasticity, pain syndromes, pressure ulcers, osteoporosis and bone fractures. The purpose of this review is to provide an overview of risk factors, signs, symptoms, prevention and treatment approaches for secondary long-term complications in patients with SCI.
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Vegger JB, Nielsen ES, Brüel A, Thomsen JS. Additive effect of PTH (1-34) and zoledronate in the prevention of disuse osteopenia in rats. Bone 2014; 66:287-95. [PMID: 24970039 DOI: 10.1016/j.bone.2014.06.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/23/2014] [Accepted: 06/16/2014] [Indexed: 11/29/2022]
Abstract
Immobilization is known to cause a rapid bone loss due to increased osteoclastic bone resorption and decreased osteoblastic bone formation. Zoledronate (Zln) is a potent anti-resorptive pharmaceutical, while intermittent PTH is a potent bone anabolic agent. The aim of the present study was to investigate whether PTH or Zln alone or in combination could prevent immobilization-induced osteopenia. Immobilization was achieved by injecting 4IU Botox (BTX) into the right hind limb musculature. Seventy-two 16-week-old female Wistar rats were randomized into 6 groups; baseline (Base), control (Ctrl), BTX, BTX+PTH, BTX+Zln, and BTX+PTH+Zln. PTH (1-34) (80μg/kg) was given 5days/week and Zln (100μg/kg) was given once at study start. The animals were killed after 4weeks of treatment. The bone properties were evaluated using DEXA, μCT, dynamic bone histomorphometry, and mechanical testing. BTX resulted in lower femoral trabecular bone volume fraction (BV/TV) (-25%, p<0.05), lower tibial trabecular bone formation rate (BFR/BS) (-29%, p<0.05), and lower bone strength (Fmax) at the distal femur (-19%, p<0.001) compared with Ctrl. BTX+PTH resulted in higher femoral BV/TV (+31%, p<0.05), higher tibial trabecular BFR/BS (+297%, p<0.05), and higher Fmax at the distal femur (+11%, p<0.05) compared with BTX. BTX+Zln resulted in higher femoral BV/TV (+36%, p<0.05), lower tibial trabecular BFR/BS (-93%, p<0.05), and higher Fmax at the distal femur (+10%, p<0.05) compared with BTX. BTX+PTH+Zln resulted in higher femoral BV/TV (+70%, p<0.001), higher tibial trabecular BFR/BS (+59%, p<0.05), and higher Fmax at the distal femur (+32%, p<0.001) compared with BTX. In conclusion, BTX-induced immobilization led to lower BV/TV, BFR/BS, and Fmax. In general, PTH or Zln alone prevented the BTX-induced osteopenia, whereas PTH and Zln given in combination not only prevented, but also increased BV/TV and BFR/BS, and maintained Fmax at the distal femoral metaphysis compared with Ctrl.
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MESH Headings
- Absorptiometry, Photon
- Animals
- Biomechanical Phenomena
- Bone Diseases, Metabolic/diagnostic imaging
- Bone Diseases, Metabolic/drug therapy
- Bone Diseases, Metabolic/physiopathology
- Bone Diseases, Metabolic/prevention & control
- Bone and Bones/diagnostic imaging
- Bone and Bones/drug effects
- Bone and Bones/pathology
- Bone and Bones/physiopathology
- Diphosphonates/pharmacology
- Diphosphonates/therapeutic use
- Drug Synergism
- Female
- Imaging, Three-Dimensional
- Imidazoles/pharmacology
- Imidazoles/therapeutic use
- Muscular Disorders, Atrophic/diagnostic imaging
- Muscular Disorders, Atrophic/drug therapy
- Muscular Disorders, Atrophic/physiopathology
- Muscular Disorders, Atrophic/prevention & control
- Parathyroid Hormone/pharmacology
- Parathyroid Hormone/therapeutic use
- Rats, Wistar
- X-Ray Microtomography
- Zoledronic Acid
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Affiliation(s)
- Jens Bay Vegger
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark.
| | | | - Annemarie Brüel
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark.
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43
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Bauman WA, Cardozo CP. Osteoporosis in individuals with spinal cord injury. PM R 2014; 7:188-201; quiz 201. [PMID: 25171878 DOI: 10.1016/j.pmrj.2014.08.948] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 02/07/2023]
Abstract
The pathophysiology, clinical considerations, and relevant experimental findings with regard to osteoporosis in individuals with spinal cord injury (SCI) will be discussed. The bone loss that occurs acutely after more neurologically motor complete SCI is unique for its sublesional skeletal distribution and rate, at certain skeletal sites approaching 1% of bone mineral density per week, and its resistance to currently available treatments. The areas of high bone loss include the distal femur, proximal tibia, and more distal boney sites. Evidence from a study performed in monozygotic twins discordant for SCI indicates that sublesional bone loss in the twin with SCI increases for several decades, strongly suggesting that the heightened net bone loss after SCI may persist for an extended period of time. The increased frequency of fragility fracture after paralysis will be discussed, and a few risk factors for such fractures after SCI will be examined. Because vitamin D deficiency, regardless of disability, is a relevant consideration for bone health, as well as an easily reversible condition, the increased prevalence of and treatment target values for vitamin D in this deficiency state in the SCI population will be reviewed. Pharmacological and mechanical approaches to preserving bone integrity in persons with acute and chronic SCI will be reviewed, with emphasis placed on efficacy and practicality. Emerging osteoanabolic agents that improve functioning of WNT/β-catenin signaling after paralysis will be introduced as therapeutic interventions that may hold promise.
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Affiliation(s)
- William A Bauman
- Department of Veterans Affairs Rehabilitation Research & Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468; Medical Service, James J. Peters VA Medical Center, Bronx, NY; Departments of Medicine and Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY∗.
| | - Christopher P Cardozo
- Department of Veterans Affairs Rehabilitation Research & Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY; Medical Service, James J. Peters VA Medical Center, Bronx, NY; Departments of Medicine and Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY(†)
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44
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Sabour H, Norouzi Javidan A, Latifi S, Larijani B, Shidfar F, Vafa MR, Heshmat R, Emami Razavi H. Bone biomarkers in patients with chronic traumatic spinal cord injury. Spine J 2014; 14:1132-8. [PMID: 24139865 DOI: 10.1016/j.spinee.2013.07.475] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 06/27/2013] [Accepted: 07/25/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Bone loss after spinal cord injury (SCI) occurs because of pathologic changes in osteoblastic and osteoclastic activities due to mechanical unloading. Some biochemical changes in bone metabolism after SCI are described before that were related to bone mineral loss. PURPOSE Our purpose was to determine bone markers' changes and related effective factors in patients with chronic traumatic SCI. STUDY DESIGN This investigation was designed as an observational cross-sectional study. PATIENT SAMPLE All patients with chronic SCI who were referred to Brain and Spinal Injury Research Center and did not meet our exclusion criteria entered the study. OUTCOME MEASURES Self-reporting measures including patient's demographic features and date of accident were obtained using a questionnaire and physiologic measures including spinal magnetic resonance imaging to determine the level of injury accompanied with physical examination along with dual-energy X-ray absorptiometry were performed. Blood samples were analyzed in the laboratory. METHODS Dual-energy X-ray was used to determine bone mineral density in femoral and spinal vertebrae bone sites. Serum level of C-telopeptide cross-linked Type 1 collagen (CTX), parathyroid hormone, calcitonin, osteocalcin, and bone alkaline phosphatase (BALP) were measured. RESULTS We detected a negative association between CTX level and bone mineral density in femoral and spinal bone sites that confirms that CTX is a bone resorption marker. C-telopeptide cross-linked Type 1 collagen and BALP levels did not show any significant correlation with postduration injury. Patients with spinal injury at lumbar level had the highest calcitonin level (p<.04). C-telopeptide cross-linked Type 1 collagen was positively related with osteocalcin and BALP (p<.0001, r=0.51), and osteocalcin was positively related with BALP (p<.0001, r=0.44). Osteocalcin was related negatively only to femoral intertrochanteric zone bone mineral density. CONCLUSIONS Some bone biomarkers undergo noticeable changes after SCI. C-telopeptide cross-linked Type 1 collagen was positively correlated with BALP and osteocalcin that shows the coincidental occurrence of osteoblastic and osteoclastic activities. Our data also support this fact that although bone reduction after 2 years is slower than acute phase after SCI, bone resorption rate is higher than bone formation. These bone markers also revealed different site of action as osteocalcin level only affected femoral intertrochanteric bone mineral density. Generally, it seems that the coincidental consideration of these factors that influence bone mineral density can lead to a better understanding of bone changes after SCI.
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Affiliation(s)
- Hadis Sabour
- Brain and Spinal Injury (BASIR) Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Keshavarz Avenu, Tehran, Iran
| | - Abbas Norouzi Javidan
- Brain and Spinal Injury (BASIR) Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Keshavarz Avenu, Tehran, Iran.
| | - Sahar Latifi
- Brain and Spinal Injury (BASIR) Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Keshavarz Avenu, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Institute (EMRI), Endocrinology Department, Tehran University of Medical Sciences, North Kargar St, Tehran, Iran
| | - Farzad Shidfar
- Department of Nutrition, Iran University of Medical Sciences, Hemat Highway, Tehran, Iran
| | - Mohammad Reza Vafa
- Department of Nutrition, Iran University of Medical Sciences, Hemat Highway, Tehran, Iran
| | - Ramin Heshmat
- Endocrinology and Metabolism Research Institute (EMRI), Endocrinology Department, Tehran University of Medical Sciences, North Kargar St, Tehran, Iran
| | - Hassan Emami Razavi
- Brain and Spinal Injury (BASIR) Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Keshavarz Avenu, Tehran, Iran
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Abstract
Bisphosphonates are medications known to decrease bone resorption by inhibiting osteoclastic activity. They are the first-line therapy for the treatment of osteoporosis because a significant body of literature has proved their efficacy in reducing the risk of fracture in the hip, spine and other nonvertebral osseous sites. In addition, the use of bisphosphonates has significantly decreased morbidity and increased survival, and they have also proved to be cost-effective. Unexpected adverse effects have been reported recently, but the benefit of bisphosphonates use outweighs the risks. This article reviews the current use of bisphosphonates in orthopedic surgery.
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Thiazide Use Is Associated With Reduced Risk for Incident Lower Extremity Fractures in Men With Spinal Cord Injury. Arch Phys Med Rehabil 2014; 95:1015-20. [DOI: 10.1016/j.apmr.2013.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 01/01/2023]
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Carbone LD, Chin AS, Burns SP, Svircev JN, Hoenig H, Heggeness M, Bailey L, Weaver F. Mortality after lower extremity fractures in men with spinal cord injury. J Bone Miner Res 2014; 29:432-9. [PMID: 23873733 DOI: 10.1002/jbmr.2050] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 06/28/2013] [Accepted: 07/11/2013] [Indexed: 01/22/2023]
Abstract
In the United States, there are over 200,000 men with spinal cord injuries (SCIs) who are at risk for lower limb fractures. The risk of mortality after fractures in SCI is unknown. This was a population-based, cohort study of all male veterans (mean age 54.1; range, 20.3-100.5 years) with a traumatic SCI of at least 2 years' duration enrolled in the Veterans Affairs (VA) Spinal Cord Dysfunction Registry from FY2002 to FY2010 to determine the association between lower extremity fractures and mortality. Mortality for up to 5 years was determined. The lower extremity fracture rate was 2.14 per 100 patient-years at risk for at least one fracture. In unadjusted models and in models adjusted for demographic, SCI-related factors, healthcare use, and comorbidities, there was a significant association between incident lower extremity fracture and increased mortality (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.17-1.63; HR, 1.36; 95% CI, 1.15-1.61, respectively). In complete SCI, the hazard of death after lower extremity fracture was also increased (unadjusted model: HR, 1.46; 95% CI, 1.13-1.89; adjusted model: HR, 1.32; 95% CI, 1.02-1.71). In fully-adjusted models, the association of incident lower extremity fracture with increased mortality was substantially greater in older men (age ≥50 years) for the entire cohort (HR, 3.42; 95% CI, 2.75-4.25) and for those with complete SCI (HR, 3.13; 95% CI, 2.19-4.45), compared to younger men (age <50 years) (entire cohort: HR, 1.42; 95% CI, 0.94-2.14; complete SCI: HR, 1.71; 95% CI, 0.98-3.01). Every additional point in the Charlson comorbidity index was associated with a 10% increase in the hazard of death in models involving the entire cohort (HR, 1.11; 95% CI, 1.09-1.13) and also in models limited to men with complete SCI (HR, 1.10; 95% CI, 1.06-1.15). These data support the concept that both the fracture itself and underlying comorbidities are drivers of death in men with SCI.
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Affiliation(s)
- Laura D Carbone
- Veterans Affairs Medical Center, Memphis, TN, USA; Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Chang KV, Hung CY, Chen WS, Lai MS, Chien KL, Han DS. Effectiveness of bisphosphonate analogues and functional electrical stimulation on attenuating post-injury osteoporosis in spinal cord injury patients- a systematic review and meta-analysis. PLoS One 2013; 8:e81124. [PMID: 24278386 PMCID: PMC3838359 DOI: 10.1371/journal.pone.0081124] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 10/10/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Various pharmacologic and non-pharmacologic approaches have been applied to reduce sublesional bone loss after spinal cord injury (SCI), and the results are inconsistent across the studies. The objective of this meta-analysis was to investigate whether the two most-studied interventions, bisphosphonate analogues and functional electrical stimulation (FES), could effectively decrease bone mineral density (BMD) attenuation and/or restore lost BMD in the SCI population. METHODS Randomized controlled trials, quasi-experimental studies, and prospective follow-up studies employing bisphosphonates or FES to treat post-SCI osteoporosis were identified in PubMed and Scopus. The primary outcome was the percentage of BMD change from baseline measured by dual-energy X-ray absorptiometry (DEXA) or computed tomography (CT). Data were extracted from four points: the 3rd, 6th, 12th, and 18th month after intervention. RESULTS A total of 19 studies were included in the analysis and involved 364 patients and 14 healthy individuals. Acute SCI participants treated with bisphosphonate therapy demonstrated a trend toward less bone loss than participants who received placebos or usual care. A significant difference in BMD decline was noted between both groups at the 3rd and 12th month post-medication. The subgroup analysis failed to show the superiority of intravenous bisphosphonate over oral administration. Regarding FES training, chronic SCI patients had 5.96% (95% CI, 2.08% to 9.84%), 7.21% (95%CI, 1.79% to 12.62%), and 9.56% (95% CI, 2.86% to 16.26%) increases in BMD at the 3rd, 6th, and 12th months post-treatment, respectively. The studies employing FES ≥ 5 days per week were likely to have better effectiveness than studies using FES ≤ 3 days per week. CONCLUSIONS Our meta-analysis indicated bisphosphonate administration early following SCI effectively attenuated sublesional bone loss. FES intervention for chronic SCI patients could significantly increase sublesional BMD near the site of maximal mechanical loading.
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Affiliation(s)
- Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, BeiHu Branch and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Chen-Yu Hung
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mei-Shu Lai
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail: (KLC); (DSH)
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, BeiHu Branch and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail: (KLC); (DSH)
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Abstract
Bisphosphonates are synthetic analogues of pyrophosphate that inhibit bone resorption by their action on osteoclasts. In recent years, bisphosphonates have been used in children for treatment of a growing number of disorders associated primarily with generalized or localized osteoporosis, genetic and acquired metabolic bone diseases, heterotopic calcifications in soft tissues, and for hypercalcemia. In this review, the authors address the role of and experience with bisphosphonate therapy in disorders of childhood.
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Zhang J, Wang R, Zhao YL, Sun XH, Zhao HX, Tan L, Chen DC, Hai-Bin X. Efficacy of intravenous zoledronic acid in the prevention and treatment of osteoporosis: a meta-analysis. ASIAN PAC J TROP MED 2012; 5:743-8. [PMID: 22805729 DOI: 10.1016/s1995-7645(12)60118-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 05/15/2012] [Accepted: 07/15/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the effect of zoledronic acid in treatment and prevention of osteoporosis with placebo. METHODS Random control trials regarding zoledronic acid in treatment of osteoporosis were retrieved by selecting Medline, EMbase and Pubmed databases till April 2012. The RevMan software was used for all of the statistical analysis. RESULTS A total of 9 trials were included in this meta-analysis. The pooled effect showed that zoledronic acid could increase the bone mineral density by 2.98 times compared with placebo, and reduce the rate of fracture in patients by 32%. The results should the zoledronic acid intervention had significantly less serious adverse events than controls, and the odds ratio was 0.81 (0.76-0.87). The longer term intervention, more than 12 months intervention, could gain a better prevention effect for osteoporosis (OR, 95%CI for BMD was 3.35, 2.77-3.92; for fracture was 0.67, 0.54-0.82). CONCLUSIONS This present study shows that zoledronic acid could be effective approach in the prevention of osteoporosis, and could increase the bone mineral density and reduce the risk of fracture.
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Affiliation(s)
- Jun Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Xinxiang Medical University, Weihui, PR China
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