Physical activity benefits bone density and bone-related hormones in adult men with cervical spinal cord injury

Bioelectrical impedance vector analysis and body composition in cervical spinal cord injury: A pilot study

Introduction

Body composition assessment in cervical spinal cord injury (c-SCI) individuals is important to monitor the fat free-mass (FFM) loss, due to immobilization, or gain, due to exercise practice. Single frequency bioelectrical impedance analysis (SF-BIA) is low in cost, simple and easy.

Objectives

The aims of this study are: to evaluate the concordance between the FFM values obtained using dual X-ray absorptiometry (DXA) and the three SF-BIA previous predictive equations; and to test the applicability of the bioelectrical impedance vector analysis (BIVA).

Methods

Twenty-three c-SCI males were divided into two groups: Physically active (PA; n = 13; at least 150 min/week) and non-active individuals (NPA) and were assessed by DXA and SF-BIA simultaneously.

Results

FFM values were similar between groups PA and NPA. Considering all participants, FFM values obtained by Kocina and Heyward (>11%) and Sun (<15.4%) predictive equations were different when compared to DXA (p < 0.01). However, Buchholz's et al. predictive equation showed FFM values similar to DXA, but presented poor concordance (<7%, p = 0.99; concordance coefficient = 0.85). BIVA showed consistency in ellipse distribution using FFM obtained using Buchholz et al. predictive equation.

Conclusions

The use of non-specific BIA equations can lead to misinterpretation in FFM values in male c-SCI individuals. Predictive equations for this group need to be developed.

Forearm bone mineral density in adult men after spinal cord injuries: impact of physical activity level, smoking status, body composition, and muscle strength

Background

In the present cross-sectional study, we analyzed the relationships of physical activity level, muscle strength, body composition, injury parameters, and smoking status with bone health in the non-paralyzed upper limb in adult men after spinal cord injuries (SCI).

Methods

The study covered 50 men after spinal cord injuries aged 35.6 ± 4.9 years (25 wheelchair rugby players and 25 non-athletes). Forearm bone mineral density (BMD), bone mineral content (BMC) in distal (dis) and proximal (prox) part was measured by densitometry. Body mass index (BMI) and body fat percentage (BF) were calculated. Fat mass (FM) and fat-free mass (FFM) were estimated from somatic data. An interview was conducted based on the Global Adult Tobacco Survey questionnaire. Muscle strength (maximal hand grip strength) was measured using a Jamar dynamometer.

Results

Active male smokers after SCI had significantly lower BMD dis, BMC dis and prox, T-score dis, and prox (large effect > 0.8) than male non-smokers after SCI. Physical activity was a significant predictor (positive direction) for BMC prox (adjusted R2 = 0.56; p < 0.001). The predictor of interactions of physical activity and fat mass was significant for BMC dis (positive direction, adjusted R2 = 0.58; p < 0.001). It was also found that the predictor of interactions of four variables: physical activity, fat mass, hand grip strength (positive direction), and years of active smoking (negative direction) was significant for BMD dis (adjusted R2 = 0.58; p < 0.001). The predictor of interactions of age at injury (additive direction) and the number of cigarettes smoked per day (negative direction) was significant for T-score prox (adjusted R2 = 0.43; p < 0.001). Non-smoking physically active men after SCI had the most advantageous values of mean forearm BMD.

Conclusion

Rugby can be considered a sport that has a beneficial effect on forearm BMD. The physically active men after SCI had significantly higher bone parameters. Physical activity itself and in interactions with fat mass, hand grip strength (positive direction), and years of active smoking (negative direction) had a significant effect on bone health in non-paralyzed upper limbs. Active smoking may reduce the protective role of physical activity for bone health.

Factors influencing providers' decisions on management of bone health in people with spinal cord injury

STUDY DESIGN

Survey.

OBJECTIVES

Managing osteoporosis in persons with chronic spinal cord injury (SCI) is difficult as little evidence exists regarding effective strategies. We examined the effect of key factors on providers' bone health management decisions in persons with SCI.

SETTING

USA.

METHODS

Providers reviewed blocks of 9 hypothetical cases that varied on four factors: osteoporosis, osteopenia, or normal bone mineral density using dual-energy X-ray absorptiometry (DXA); DXA region of interest (lumbar spine, hip, knee), prior lower extremity fracture; and no or limited ambulation. They indicated how likely they would recommend pharmacological management, what treatment(s) they would recommend, and whether they would request another DXA before treatment.

RESULTS

Eighty-two healthcare providers completed the survey. Treatment recommendations for bisphosphonates and Vitamin D/calcium supplements, respectively, were more likely if there was a prior fracture (OR: 2.65, 95%CI: 1.76-3.99, p < 0.0001; OR: 2.96, 95%CI: 1.40-6.26, p = 0.004) and if a DXA scan found osteopenia (OR: 2.23, 95%CI: 1.41-3.54, p = 0.001; OR: 6.56, 95%CI: 2.71-15.85, p < 0.0001) or osteoporosis (OR: 12.08, 95%CI: 7.09-20.57, p < 0.0001; OR: 4.54, 95%CI: 2.08-9.90, p < 0.0001). Another DXA scan was more likely to be requested if there was a prior fracture (OR: 1.75, 95%CI: 1.10-2.78, p = 0.02) but less likely if the person was nonambulatory (OR: 0.41, 95%: 0.19-0.90, p = 0.03).

CONCLUSIONS

Prior fracture and DXA findings influenced treatment recommendations for bone health management in SCI. Reliance on lumbar spine scans to determine bone loss and treatment identifies a knowledge gap for which future education is required.

Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review

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.

Bone Mineral Density Testing in Spinal Cord Injury: 2019 ISCD Official Position

Spinal cord injury (SCI) causes rapid osteoporosis that is most severe below the level of injury. More than half of those with motor complete SCI will experience an osteoporotic fracture at some point following their injury, with most fractures occurring at the distal femur and proximal tibia. These fractures have devastating consequences, including delayed union or nonunion, cellulitis, skin breakdown, lower extremity amputation, and premature death. Maintaining skeletal integrity and preventing fractures is imperative following SCI to fully benefit from future advances in paralysis cure research and robotic-exoskeletons, brain computer interfaces and other evolving technologies. Clinical care has been previously limited by the lack of consensus derived guidelines or standards regarding dual-energy X-ray absorptiometry-based diagnosis of osteoporosis, fracture risk prediction, or monitoring response to therapies. The International Society of Clinical Densitometry convened a task force to establish Official Positions for bone density assessment by dual-energy X-ray absorptiometry in individuals with SCI of traumatic or nontraumatic etiology. This task force conducted a series of systematic reviews to guide the development of evidence-based position statements that were reviewed by an expert panel at the 2019 Position Development Conference in Kuala Lumpur, Malaysia. The resulting the International Society of Clinical Densitometry Official Positions are intended to inform clinical care and guide the diagnosis of osteoporosis as well as fracture risk management of osteoporosis following SCI.

Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review

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.

Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury

Traumatic spinal cord injury (SCI) may result in tetraplegia (motor and/or sensory nervous system impairment of the arms, trunk and legs) or paraplegia (motor and/or sensory impairment of the trunk and/or legs only). The adverse effects of SCI on health, fitness and functioning are frequently compounded by profoundly sedentary behaviour. People with paraplegia (PP) and tetraplegia (TP) have reduced exercise capacity due to paralysis/paresis and reduced exercising stroke volume. TP often further reduces exercise capacity due to lower maximum heart-rate and respiratory function. There is strong, consistent evidence that exercise can improve cardiorespiratory fitness and muscular strength in people with SCI. There is emerging evidence for a range of other exercise benefits, including reduced risk of cardio-metabolic disease, depression and shoulder pain, as well as improved respiratory function, quality-of-life and functional independence. Exercise recommendations for people with SCI are: ≥30min of moderate aerobic exercise on ≥5d/week or ≥20min of vigorous aerobic ≥3d/week; strength training on ≥2d/week, including scapula stabilisers and posterior shoulder girdle; and ≥2d/week flexibility training, including shoulder internal and external rotators. These recommendations may be aspirational for profoundly inactive clients and stratification into "beginning", "intermediate" and "advanced" will assist application of the recommendations in clinical practice. Flexibility exercise is recommended to preserve upper limb function but may not prevent contracture. For people with TP, Rating of Perceived Exertion may provide a more valid indication of exercise intensity than heart rate. The safety and effectiveness of exercise interventions can be enhanced by initial screening for autonomic dysreflexia, orthostatic hypotension, exercise-induced hypotension, thermoregulatory dysfunction, pressure sores, spasticity and pain.

Impact of Wheelchair Rugby on Body Composition of Subjects With Tetraplegia: A Pilot Study

OBJECTIVE

To investigate the longitudinal effects of wheelchair rugby (WR) training on body composition of subjects with tetraplegia.

DESIGN

Subjects were evaluated at baseline and after WR training.

SETTING

Faculty of physical education settings.

PARTICIPANTS

Individuals with tetraplegia (N=13; age, 26.6±6.0y).

INTERVENTIONS

Four sessions per week of WR training composed by aerobic and anaerobic activities and technical and tactical aspects of WR. The average time of intervention was 8.1±2.5 months.

MAIN OUTCOME MEASURES

Body composition assessed by dual-energy x-ray absorptiometry.

RESULTS

After training, fat mass was significantly reduced in the whole body (15,191±4603 vs 13,212±3318 g, P=.016), trunk (7058±2639 vs 5693±1498 g, P=.012), and legs (2847±817 vs 2534±742 g, P=.003). Conversely, increased bone mineral content (183±35 vs 195±32 g, P=.01) and fat-free mass (2991±549 vs 3332±602 g, P=.016) in the arms and reduced bone mineral content in the trunk (553±82 vs 521±86 g, P=.034) were observed after training. Furthermore, no significant correlation between the duration of training and changes in body composition was detected.

CONCLUSIONS

Regular WR training increased lean mass and bone mineral content in the arms and decreased total body fat mass. Conversely, WR training was associated with decreased bone mineral content in the trunk. These results suggest that regular WR training improves body composition in subjects with tetraplegia.

Chronic activity-based therapy does not improve body composition, insulin-like growth factor-I, adiponectin, or myostatin in persons with spinal cord injury

Spinal cord injury (SCI) induces dramatic changes in body composition including reductions in fat-free mass (FFM) and increases in fat mass (FM).

OBJECTIVE

To examine changes in body composition in response to chronic activity-based therapy (ABT) in persons with SCI.

DESIGN

Longitudinal exercise intervention.

METHODS

Seventeen men and women with SCI (mean age=36.1±11.5 years) completed 6 months of supervised ABT consisting of load bearing, resistance training, locomotor training, and functional electrical stimulation. At baseline and after 3 and 6 months of ABT, body weight, body fat, and FFM were assessed using dual-energy X-ray absorptiometry, and fasting blood samples were obtained to assess changes in insulin-like growth factor-I (IGF-I), adiponectin, and myostatin.

RESULTS

Across all subjects, there was no change (P>0.05) in body weight, percent body fat, or FFM of the leg, arm, or trunk, whereas whole-body FFM declined (P=0.02, 50.4±8.4 to 49.2±7.4 kg). No changes (P=0.21-0.41) were demonstrated in IGF-I, adiponectin, or myostatin during the study.

CONCLUSIONS

Chronic ABT focusing on the lower extremity does not slow muscle atrophy or alter body fat, body mass, or regional depots of FFM in persons with SCI. Further, it does not induce beneficial changes in adiponectin, myostatin, or IGF-I. Alternative exercise-based therapies are needed in SCI to reverse muscle atrophy and minimize the onset of related health risks.

Effect of chronic activity-based therapy on bone mineral density and bone turnover in persons with spinal cord injury

PURPOSE

Osteoporosis is a severe complication of spinal cord injury (SCI). Many exercise modalities are used to slow bone loss, yet their efficacy is equivocal. This study examined the effect of activity-based therapy (ABT) targeting the lower extremities on bone health in individuals with SCI.

METHODS

Thirteen men and women with SCI (age and injury duration = 29.7 ± 7.8 and 1.9 ± 2.7 years) underwent 6 months of ABT. At baseline and after 3 and 6 months of training, blood samples were obtained to assess bone formation (serum procollagen type 1 N propeptide (PINP) and bone resorption (serum C-terminal telopeptide of type I collagen (CTX), and participants underwent dual-energy X-ray absorptiometry scans to obtain total body and regional estimates of bone mineral density (BMD).

RESULTS

Results demonstrated significant increases (p < 0.05) in spine BMD (+4.8 %; 1.27 ± 0.22-1.33 ± 0.24 g/cm(2)) and decreases (p < 0.01) in total hip BMD (-6.1 %; 0.98 ± 0.18-0.91 ± 0.16 g/cm(2)) from 0 to 6 months of training. BMD at the bilateral distal femur (-7.5 to -11.0 %) and proximal tibia (- 8.0 to -11.2 %) declined but was not different (p > 0.05) versus baseline. Neither PINP nor CTX was altered (p > 0.05) with training.

CONCLUSIONS

Chronic activity-based therapy did not reverse bone loss typically observed soon after injury, yet reductions in BMD were less than the expected magnitude of decline in lower extremity BMD in persons with recent SCI.

Systematic framework to classify the status of research on spinal cord injury and physical activity

OBJECTIVES

To systematically classify the physical activity research for individuals with a spinal cord injury by using the behavioral epidemiologic framework; and to identify where the physical activity research for individuals with a spinal cord injury has focused between 2000 and 2012.

DESIGN

Relevant research was identified and then categorized into 1 of 5 phases by following the coding rules of the behavioral epidemiology framework. Phase 1 studies link physical activity and health outcomes, phase 2 studies validate or develop measures of physical activity, phase 3 studies identify factors that influence behavior or examine explanatory theories of behavior, phase 4 studies evaluate interventions, and phase 5 studies disseminate health promotion programs or policies and translate research into practice.

SETTING

Specific keywords were identified and then searched through EBSCOhost, PubMed, and Google Scholar.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

One hundred and thirteen articles met the criteria. Of the articles, 55% were categorized as phase 1, 12% as phase 2, 24% as phase 3, 5% as phase 4, and 4% as phase 5.

CONCLUSIONS

Most studies were categorized as phase 1, 2, or 3, which implies that this field is still in the early stages of development and research should focus on intervention development and dissemination.