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Ponzano M, Wiest MJ, Coleman A, Newton E, Pakosh M, Patsakos EM, Magnuson DSK, Giangregorio LM, Craven BC. The use of alkaline phosphatase as a bone turnover marker after spinal cord injury: A scoping review of human and animal studies. J Spinal Cord Med 2023; 46:167-180. [PMID: 34935593 PMCID: PMC9987745 DOI: 10.1080/10790268.2021.1977905] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Serum alkaline phosphatase (ALP) is measured as an indicator of bone or liver disease. Bone-specific alkaline phosphatase (B-ALP) is an isoform of ALP found in the bone tissue which can predict fractures and heterotopic ossification. OBJECTIVE The aim of this scoping review was to explore the current use of ALP and B-ALP in studies using humans or animal models of SCI, and to identify ways to advance future research using ALP and B-ALP as a bone marker after SCI. RESULTS HUMAN STUDIES: 42 studies were included. The evidence regarding changes or differences in ALP levels in individuals with SCI compared to controls is conflicting. For example, a negative correlation between B-ALP and total femur BMD was observed in only one of three studies examining the association. B-ALP seemed to increase after administration of teriparatide, and to decrease after treatment with denosumab. The effects of exercise on ALP and B-ALP levels are heterogeneous and depend on the type of exercise performed. ANIMAL STUDIES: 11 studies were included. There is uncertainty regarding the response of ALP or B-ALP levels after SCI; levels increased after some interventions, including vibration protocols, curcumin supplementation, cycles in electromagnetic field or hyperbaric chamber. Calcitonin or bisphosphonate administration did not affect ALP levels. CONCLUSION Researchers are encouraged to measure the bone-specific isoform of ALP rather than total ALP in future studies in humans of animal models of SCI.
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Affiliation(s)
- Matteo Ponzano
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, Canada
| | - Matheus J Wiest
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - André Coleman
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Emily Newton
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto Rehabilitation Institute, Toronto, Canada
| | - Eleni M Patsakos
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - David S K Magnuson
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky, USA
| | - Lora M Giangregorio
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, Canada.,Schlegel-UW Research Institute for Aging, Waterloo, Canada
| | - B Catharine Craven
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, Canada.,Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
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2
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Gibbs JC, Patsakos EM, Maltais DB, Wolfe DL, Gagnon DH, Craven BC. Rehabilitation interventions to modify endocrine-metabolic disease risk in individuals with chronic spinal cord injury living in the community (RIISC): A systematic search and review of prospective cohort and case-control studies. J Spinal Cord Med 2023; 46:6-25. [PMID: 33596167 PMCID: PMC9897753 DOI: 10.1080/10790268.2020.1863898] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
CONTEXT Endocrine-metabolic disease (EMD) is associated with functional disability, social isolation, hospitalization and even death in individuals living with a chronic spinal cord injury (SCI). There is currently very low-quality evidence that rehabilitation interventions can reduce EMD risk during chronic SCI. Non-randomized trials and alternative study designs are excluded from traditional knowledge synthesis. OBJECTIVE To characterize evidence from level 3-4 studies evaluating rehabilitation interventions for their effectiveness to improve EMD risk in community-dwelling adults with chronic SCI. METHODS Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, Cochrane Database of Systematic Reviews, and PsychInfo were completed. All longitudinal trials, prospective cohort, case-control studies, and case series evaluating the effectiveness of rehabilitation/therapeutic interventions to modify/associate with EMD outcomes in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean changes from baseline were reported for EMD outcomes. The Downs and Black Checklist was used to rate evidence quality. RESULTS Of 489 articles identified, 44 articles (N = 842) were eligible for inclusion. Individual studies reported statistically significant effects of electrical stimulation-assisted training on lower-extremity bone outcomes, and the combined effects of exercise and dietary interventions to improve body composition and cardiometabolic biomarkers (lipid profiles, glucose regulation). In contrast, there were also reports of no clinically important changes in EMD outcomes, suggesting lower quality evidence (study bias, inconsistent findings). CONCLUSION Longitudinal multicentre pragmatic studies involving longer-term exercise and dietary intervention and follow-up periods are needed to fully understand the impact of these rehabilitation approaches to mitigate EMD risk. Our broad evaluation of prospective cohort and case-control studies provides new perspectives on alternative study designs, a multi-impairment paradigm approach of studying EMD outcomes, and knowledge gaps related to SCI rehabilitation.
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Affiliation(s)
- Jenna C. Gibbs
- Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, QC, Canada,Correspondence to: Jenna C. Gibbs, Department of Kinesiology and Physical Education, McGill University, Currie Gym Office A208, 475 Pine Avenue West, Montreal, Quebec, H2W 1S4, Canada; Ph: 514-398-4184 ext. 00473.
| | - Eleni M. Patsakos
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada
| | - Desiree B. Maltais
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Dalton L. Wolfe
- Parkwood Institute Research, Lawson Health Research Institute, London, ON, Canada,Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Dany H. Gagnon
- Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada,School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - B. Catharine Craven
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada,Division of Physical Therapy and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
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3
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Armengol M, Zoulias ID, Gibbons RS, McCarthy I, Andrews BJ, Harwin WS, Holderbaum W. The effect of Functional Electrical Stimulation-assisted posture-shifting in bone mineral density: case series-pilot study. Spinal Cord Ser Cases 2022; 8:60. [PMID: 35680785 PMCID: PMC9184609 DOI: 10.1038/s41394-022-00523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 11/09/2022] Open
Abstract
Study design A training intervention study using standing dynamic load-shifting Functional Electrical Stimulation (FES) in a group of individuals with complete spinal cord injury (SCI) T2 to T10. Objectives Investigate the effect of FES-assisted dynamic load-shifting exercises on bone mineral density (BMD). Setting University Lab within the Biomedical Engineering Methods Twelve participants with ASIA A SCI were recruited for this study. Three participants completed side-to-side load-shifting FES-assisted exercises for 29 ± 5 weeks, 2× per week for 1 h, and FES knee extension exercises on alternate days 3× per week for 1 h. Volumetric Bone Mineral density (vBMD) at the distal femur and tibia were assessed using peripheral quantitative computed tomography (pQCT) before and after the intervention study. Results Participants with acute and subacute SCI showed an absolute increase of f trabecular vBMD (vBMDTRAB) in the proximal (mean of 26.9%) and distal tibia (mean of 22.35%). Loss of vBMDTRAB in the distal femur was observed. Conclusion Improvements in vBMDTRAB in the distal tibia were found in acute and subacute SCI participants, and in the proximal tibia of acute participants, when subjected to anti-gravity FES-assisted load-bearing exercises for 29 ± 5 weeks. No vBMD improvement in distal femur or tibial shaft were observed in any of the participants as was expected. However, improvements of vBMD in the proximal and distal tibia were observed in two participants. This study provides evidence of an improvement of vBMDTRAB, when combining high-intensity exercises with lower intensity exercises 5× per week for 1 h.
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Fibula response to disuse: a longitudinal analysis in people with spinal cord injury. Arch Osteoporos 2022; 17:51. [PMID: 35305185 PMCID: PMC8934326 DOI: 10.1007/s11657-022-01095-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 03/09/2022] [Indexed: 02/03/2023]
Abstract
Fibular response to disuse has been described in cross-sectional but not longitudinal studies. This study assessed fibular bone changes in people with spinal cord injury. Fibular bone loss was less than in the tibia and was not correlated together. This might explain low fibular fracture incidents in these patients. PURPOSE Cross-sectional studies suggest that the fibula responds differently to loading and disuse compared to the tibia. Whilst tibial bone changes following spinal cord injury (SCI) have been established in longitudinal studies, fibular changes remain unexplored. METHODS Fibular and tibial bone parameters were assessed in 13 individuals with SCI (aged 16-76 years). Peripheral quantitative computed tomography scans were acquired at 4%, 38% and 66% distal-proximal tibia length at 5 weeks and 12 months post-injury. Changes in 4% site total bone mineral content (BMC), total cross-sectional area (CSA) and bone mineral density (BMD), and 38% and 66% sites total BMC, total CSA, cortical BMD and cortical CSA were assessed using paired T-tests. Relationships between bone loss in the two bones at equivalent sites were assessed using paired T-tests and correlation. RESULTS At the 4% site, fibular total BMC and BMD losses were less than tibial losses (- 6.9 ± 5.1% and - 6.6 ± 6.0% vs - 14.8 ± 12.4% and - 14.4 ± 12.4%, p = 0.02 and p = 0.03, respectively). Similarly, at the 66% site, fibular BMC losses were less than those in the tibia (- 2.0 ± 2.6% vs - 4.3 ± 3.6%, p = 0.03), but there was no difference at 38% (- 1.8 ± 3.5% vs - 3.8 ± 2.1%, p = 0.1). No correlation was observed for BMC changes between the two bones (all p > 0.25). CONCLUSION These results support cross-sectional evidence of smaller disuse-related bone loss in the fibula compared to the tibia. These results may in part explain lower incidence of fibula fractures in individuals with chronic SCI. The lack of association between losses in the two bones might point to different underlying mechanisms.
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Sutor TW, Kura J, Mattingly AJ, Otzel DM, Yarrow JF. The Effects of Exercise and Activity-Based Physical Therapy on Bone after Spinal Cord Injury. Int J Mol Sci 2022; 23:608. [PMID: 35054791 PMCID: PMC8775843 DOI: 10.3390/ijms23020608] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/15/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023] Open
Abstract
Spinal cord injury (SCI) produces paralysis and a unique form of neurogenic disuse osteoporosis that dramatically increases fracture risk at the distal femur and proximal tibia. This bone loss is driven by heightened bone resorption and near-absent bone formation during the acute post-SCI recovery phase and by a more traditional high-turnover osteopenia that emerges more chronically, which is likely influenced by the continual neural impairment and musculoskeletal unloading. These observations have stimulated interest in specialized exercise or activity-based physical therapy (ABPT) modalities (e.g., neuromuscular or functional electrical stimulation cycling, rowing, or resistance training, as well as other standing, walking, or partial weight-bearing interventions) that reload the paralyzed limbs and promote muscle recovery and use-dependent neuroplasticity. However, only sparse and relatively inconsistent evidence supports the ability of these physical rehabilitation regimens to influence bone metabolism or to increase bone mineral density (BMD) at the most fracture-prone sites in persons with severe SCI. This review discusses the pathophysiology and cellular/molecular mechanisms that influence bone loss after SCI, describes studies evaluating bone turnover and BMD responses to ABPTs during acute versus chronic SCI, identifies factors that may impact the bone responses to ABPT, and provides recommendations to optimize ABPTs for bone recovery.
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Affiliation(s)
- Tommy W. Sutor
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA; (T.W.S.); (J.K.)
- Brain Rehabilitation Research Center, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA;
| | - Jayachandra Kura
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA; (T.W.S.); (J.K.)
| | - Alex J. Mattingly
- Geriatrics Research, Education, and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA;
| | - Dana M. Otzel
- Brain Rehabilitation Research Center, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA;
| | - Joshua F. Yarrow
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA; (T.W.S.); (J.K.)
- Brain Rehabilitation Research Center, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA;
- Division of Endocrinology, Diabetes, and Metabolism, University of Florida College of Medicine, Gainesville, FL 32611, USA
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6
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Guihan M, Roddick K, Cervinka T, Ray C, Sutton C, Carbone L, Weaver FM. Physical and occupational therapist rehabilitation of lower extremity fractures in veterans with spinal cord injuries and disorders. J Spinal Cord Med 2022; 45:33-41. [PMID: 33705274 PMCID: PMC8890553 DOI: 10.1080/10790268.2021.1890680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
CONTEXT/OBJECTIVE The risk of lower extremity (LE) fractures in persons with spinal cord injury or disorders (SCI/D) is double that of the able-bodied population. LE fractures are the most common fracture location in SCI/D. Physical therapists (PTs) and occupational therapists (OTs) play an important role in rehabilitating LE fractures in Veterans with SCI/D. This paper describes their role in assisting persons with SCI/D and LE fractures to return to previous function and levels of participation. DESIGN Cross-sectional semi-structured interviews were conducted by telephone. Setting: VA SCI centers. PARTICIPANTS Purposive sample of therapists (PTs and OTs) experienced in LE fracture rehabilitation in SCI/D Interventions: NA. OUTCOME MEASURES Coding of responses used a data-driven thematic and deductive approach, dictated by a semi-structured interview guide addressing the entire treatment process. RESULTS Participants strongly advocated for early PT/OT involvement in post-fracture rehabilitation in order to recommend braces and devices to minimize skin breakdown, and needs for patient equipment, skills training and/or caregiver assistance resulting from post-fracture mobility changes. Seating specialists should be involved in post-fracture seating assessments in wheelchair users to address changes in alignment, deformities, limb length discrepancies and/or seating posture during and following fracture management. CONCLUSION PTs and OTs are critical in rehabilitating LE fractures in persons with SCI/D and LE fractures, bringing expertise in patient function, ambulatory status, transfer strategies, mobility equipment, spasticity, lifestyle, and home and caregiver support. Involving them early in the rehabilitation process, along with orthopedic surgeons, physiatrists and other SCI clinicians can address the multiple and often unique issues that occur in managing fractures in this population.
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Affiliation(s)
- Marylou Guihan
- Health Services Research and Development Service, Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, Illinois, USA,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA,Correspondence to: Marylou Guihan, Edward Hines, Jr. VA Hospital (151-H), 5000 S. 5th Avenue, Hines, Illinois60141-3030, USA.
| | - Kayla Roddick
- Department of Spinal Cord Injury, VA Boston Healthcare System, West Roxbury, Massachusetts, USA,Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Tomas Cervinka
- Department of Physiotherapy and Rehabilitation, Faculty of Health and Welfare, Satakunta University of Applied Sciences, Pori, Finland
| | - Cara Ray
- Health Services Research and Development Service, Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, Illinois, USA
| | - Christopher Sutton
- Department of Orthopaedics, Medical College of Georgia at Augusta University, Augusta, Georgia, 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
| | - Frances M. Weaver
- Health Services Research and Development Service, Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, Illinois, USA,Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University, Maywood, Illinois, USA
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7
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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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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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El-Kotob R, Craven BC, Thabane L, Papaioannou A, Adachi JD, Giangregorio LM. Exploring changes in bone mass in individuals with a chronic spinal cord injury. Osteoporos Int 2021; 32:759-767. [PMID: 33089353 DOI: 10.1007/s00198-020-05705-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/16/2020] [Indexed: 12/28/2022]
Abstract
UNLABELLED People experience rapid bone loss shortly after a spinal cord injury (SCI), but the long-term bone changes are yet to be confirmed. This study showed that trabecular bone may have reached a steady state, whereas cortical bone continued to decline in people with a chronic SCI (mean time post injury: 15.5 ± 10 years). INTRODUCTION (1) To explore changes in bone [primary measure: trabecular volumetric bone mineral density (vBMD); secondary measures: cortical vBMD, cortical thickness, cortical cross-sectional area (CSA), and polar moment of inertia] over 2 years in individuals with a chronic spinal cord injury (SCI). (2) To explore whether muscle density changes were potential correlates of the observed bone changes. METHODS This study is a secondary data analysis of a prospective, observational study involving 70 people with a chronic SCI (≥ 2 years post injury). The study included 4 strata of participants with diverse impairments: (1) Paraplegia (T1-T12) motor complete American Spinal Injury Association Impairment Scale (AIS) A/B (n = 23), (2) Paraplegia motor incomplete AIS C/D (n = 11), (3) Tetraplegia (C2-C8) AIS A/B (n = 22), and (4) Tetraplegia AIS C/D (n = 14). Peripheral quantitative computed tomography scans were taken at the 4% (distal tibia), 38% (diaphyseal tibia), and 66% (muscle cross-sectional area) tibia sites by measuring from the distal to proximal tibia starting at the inferior border of the medial malleolus. The tibia sites were assessed annually over a span of 2 years. Comparisons were made using a paired-samples t test and simple linear regression was used to adjust for sex, time post injury, and bisphosphonate use. RESULTS We observed no changes in trabecular vBMD at the 4% tibia site, but there was a statistically significant decline in cortical vBMD, cortical thickness, and CSA at the 38% tibia site. Changes in muscle density were not associated with the decreases observed in cortical bone. CONCLUSION Our findings suggest that individuals with chronic SCI (mean duration of injury: 15.5 ± 10 years) may have reached a plateau in bone loss with respect to trabecular bone, but cortical bone loss can continue well into the chronic stages.
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Affiliation(s)
- R El-Kotob
- Deparment of Kinesiology, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada.
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, M4G 3V9, Canada.
| | - B C Craven
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, M4G 3V9, Canada
- Department of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - L Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - A Papaioannou
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - J D Adachi
- Department of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - L M Giangregorio
- Deparment of Kinesiology, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON, N2J 0E2, Canada
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Bessler J, Prange-Lasonder GB, Schaake L, Saenz JF, Bidard C, Fassi I, Valori M, Lassen AB, Buurke JH. Safety Assessment of Rehabilitation Robots: A Review Identifying Safety Skills and Current Knowledge Gaps. Front Robot AI 2021; 8:602878. [PMID: 33937345 PMCID: PMC8080797 DOI: 10.3389/frobt.2021.602878] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
The assessment of rehabilitation robot safety is a vital aspect of the development process, which is often experienced as difficult. There are gaps in best practices and knowledge to ensure safe usage of rehabilitation robots. Currently, safety is commonly assessed by monitoring adverse events occurrence. The aim of this article is to explore how safety of rehabilitation robots can be assessed early in the development phase, before they are used with patients. We are suggesting a uniform approach for safety validation of robots closely interacting with humans, based on safety skills and validation protocols. Safety skills are an abstract representation of the ability of a robot to reduce a specific risk or deal with a specific hazard. They can be implemented in various ways, depending on the application requirements, which enables the use of a single safety skill across a wide range of applications and domains. Safety validation protocols have been developed that correspond to these skills and consider domain-specific conditions. This gives robot users and developers concise testing procedures to prove the mechanical safety of their robotic system, even when the applications are in domains with a lack of standards and best practices such as the healthcare domain. Based on knowledge about adverse events occurring in rehabilitation robot use, we identified multi-directional excessive forces on the soft tissue level and musculoskeletal level as most relevant hazards for rehabilitation robots and related them to four safety skills, providing a concrete starting point for safety assessment of rehabilitation robots. We further identified a number of gaps which need to be addressed in the future to pave the way for more comprehensive guidelines for rehabilitation robot safety assessments. Predominantly, besides new developments of safety by design features, there is a strong need for reliable measurement methods as well as acceptable limit values for human-robot interaction forces both on skin and joint level.
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Affiliation(s)
- Jule Bessler
- Roessingh Research and Development, Enschede, Netherlands.,Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Gerdienke B Prange-Lasonder
- Roessingh Research and Development, Enschede, Netherlands.,Department of Biomechanical Engineering, University of Twente, Enschede, Netherlands
| | | | - José F Saenz
- Fraunhofer Institute for Factory Operation and Automation, Magdeburg, Germany
| | | | - Irene Fassi
- National Research Council of Italy, Milan, Italy
| | | | - Aske Bach Lassen
- Department of Robot Technology, Danish Technological Institute, Odense, Denmark
| | - Jaap H Buurke
- Roessingh Research and Development, Enschede, Netherlands.,Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
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Choi H, Chang SY, Yoo J, Lim SH, Hong BY, Kim JS. Correlation Between Duration From Injury and Bone Mineral Density in Individuals With Spinal Cord Injury. Ann Rehabil Med 2021; 45:1-6. [PMID: 33557478 PMCID: PMC7960953 DOI: 10.5535/arm.20169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/03/2020] [Indexed: 11/27/2022] Open
Abstract
Objective To investigate the correlation between bone mineral density (BMD) and duration of injury in individuals with spinal cord injury (SCI). Methods Patients with SCI who visited the outpatient department between January 2009 and January 2019 were enrolled. Patients’ most recent dual energy X-ray absorptiometry images were reviewed. According to the 2007 International Society for Clinical Densitometry guidelines, vertebrae with a local structural change were excluded when deriving spine BMD. If one or no vertebra is suitable for evaluation, spine BMD was judged as “improper for assessment”. Correlation analysis was performed between duration from injury and BMD Z-scores of the hip and spine. Results Among 83 individuals with SCI, the spines of 44 were judged as improper for assessment. The correlation analysis showed a significant negative relationship between the duration from injury and femur neck BMD (r=-0.40, p<0.01) and total proximal femur BMD (r=-0.39, p<0.01). However, no significant correlation was found between the duration from injury and spine BMD Z-score. Conclusion The duration of SCI correlated with hip BMD, but not with spine BMD. Further, more than half of the individuals with SCI could not undergo spinal assessment due to local structural changes. Therefore, spine BMD measurement is not an appropriate method for predicting future fracture risk in those with SCI.
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Affiliation(s)
- Hyehoon Choi
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - So-Youn Chang
- Department of Rehabilitation Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jaewan Yoo
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Joon Sung Kim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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12
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Chandran VD, Lambach RL, Gibbons RS, Andrews BJ, Beaupre GS, Pal S. Tibiofemoral forces during FES rowing in individuals with spinal cord injury. Comput Methods Biomech Biomed Engin 2020; 24:231-244. [PMID: 32940534 DOI: 10.1080/10255842.2020.1821880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The purpose of this study is to determine the tibiofemoral forces during functional electrical stimulation (FES) rowing in individuals with spinal cord injury (SCI). We analysed the motion of five participants with SCI during FES rowing, with simultaneous measurements of (i) three-dimensional marker trajectories, (ii) foot reaction forces (FRFs), (iii) ergometer handle forces, and (iv) timestamps for electrical stimulation of the quadriceps and hamstrings muscles. We created full-body musculoskeletal models in OpenSim to determine subject-specific tibiofemoral forces during FES rowing. The peak magnitudes of tibiofemoral forces averaged over five participants with SCI were 2.43 ± 0.39 BW and 2.25 ± 0.71 BW for the left and right legs, respectively. The peak magnitudes of FRFs were 0.19 ± 0.04 BW in each leg. The peak magnitude of handle forces was 0.47 ± 0.19 BW. Peak tibiofemoral force was associated with peak FRF (magnitudes, R2 = 0.56, p = 0.013) and peak handle force (magnitudes, R2 = 0.54, p = 0.016). The ratios of peak magnitude of tibiofemoral force to peak magnitude of FRF were 12.9 ± 1.9 (left) and 11.6 ± 2.4 (right), and to peak magnitude of handle force were 5.7 ± 2.3 (left) and 4.9 ± 0.9 (right). This work lays the foundation for developing a direct exercise intensity metric for bone mechanical stimulus at the knee during rehabilitation exercises. Clinical Significance: Knowledge of tibiofemoral forces from exercises such as FES rowing may provide clinicians the ability to personalize rehabilitation protocols to ensure that an SCI patient is receiving the minimum dose of mechanical stimulus necessary to maintain bone health.
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Affiliation(s)
- Vishnu D Chandran
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, USA
| | - Rebecca L Lambach
- Musculoskeletal Research Laboratory, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Robin S Gibbons
- Centre for Rehabilitation Engineering and Assistive Technologies, University College London, Stanmore, UK
| | - Brian J Andrews
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Biomedical Engineering Group, School of Engineering, Warwick University, Coventry, UK
| | - Gary S Beaupre
- Musculoskeletal Research Laboratory, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Saikat Pal
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, USA.,Department of Electrical and Computer Engineering, New Jersey Institute of Technology, Newark, NJ, USA
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13
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Stiffness and Strength Predictions From Finite Element Models of the Knee are Associated with Lower-Limb Fractures After Spinal Cord Injury. Ann Biomed Eng 2020; 49:769-779. [PMID: 32929557 DOI: 10.1007/s10439-020-02606-w] [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: 06/01/2020] [Accepted: 09/02/2020] [Indexed: 02/07/2023]
Abstract
Spinal cord injury (SCI) is associated with bone fragility and fractures around the knee. The purpose of this investigation was to validate a computed tomography (CT) based finite element (FE) model of the proximal tibia and distal femur under biaxial loading, and to retrospectively quantify the relationship between model predictions and fracture incidence. Twenty-six cadaveric tibiae and femora (n = 13 each) were loaded to 300 N of compression, then internally rotated until failure. FE predictions of torsional stiffness (K) and strength (Tult) explained 74% (n = 26) and 93% (n = 7) of the variation in experimental measurements, respectively. Univariate analysis and logistic regression were subsequently used to determine if FE predictions and radiographic measurements from CT and dual energy X-ray absorptiometry (DXA) were associated with prevalent lower-limb fracture in 50 individuals with SCI (n = 14 fractures). FE and CT measures, but not DXA, were lower in individuals with fracture. FE predictions of Tult at the tibia demonstrated the highest odds ratio (4.98; p = 0.006) and receiver operating characteristic (0.84; p = 0.008) but did not significantly outperform other metrics. In conclusion, CT-based FE model predictions were associated with prevalent fracture risk after SCI; this technique could be a powerful tool in future clinical research.
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14
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Cirnigliaro CM, Parrott JS, Myslinski MJ, Asselin P, Lombard AT, La Fountaine MF, Kirshblum SC, Forrest GF, Dyson-Hudson T, Spungen AM, Bauman WA. Relationships between T-scores at the hip and bone mineral density at the distal femur and proximal tibia in persons with spinal cord injury. J Spinal Cord Med 2020; 43:685-695. [PMID: 31663832 PMCID: PMC7534195 DOI: 10.1080/10790268.2019.1669957] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: To identify T-score values at the total hip (TH) and femoral neck (FN) that correspond to the cutoff value of <0.60 g/cm2 for heightened risk of fracture at the distal femur (DF) and proximal tibia (PT).Design: Retrospective analysis of data in a research center's database. Setting: Community-based individuals with spinal cord injury (SCI). Participants: 105 unique individuals with SCI. Outcome Measurements: DXA derived areal BMD (aBMD) and T-score of the DF, PT, TH, and FN. Results: The aBMD at the DF and PT regions were predictors of T-scores at the TH (R2 = 0.63, P < 0.001 and R2 = 0.65, P < 0.001) and FN (R2 = 0.55, P < 0.001 and R2 = 0.58, P < 0.001). Using the DF and PT aBMD of 0.60 g/cm2 as a value below which fractures were more likely to occur, the predicted T-score was -3.1 and -3.5 at the TH and -2.6 and -2.9 at the FN, respectively. However, when the predicted and observed T-score values disagree outside the 95% limit of agreement, the predicted T-score values are lower than the measured T-score values, overestimating the measured values between -2.0 and -4.0 SD. Conclusion: The DF and PT cutoff value for aBMD of 0.60 g/cm2 was a moderate predictor of T-score values at the TH and FN, with considerable inaccuracies outside the clinically acceptable limits of agreement. As such, the direct measurement of knee aBMD in persons with SCI should be performed, whenever possible, prior to prescribing weight bearing upright activities, such as robotic exoskeletal-assisted walking.
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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, New York, USA,Correspondence to: Christopher M. Cirnigliaro, Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY10468, USA; Ph: (718) 584-9000, Ext. 5420. ;
| | - J. Scott Parrott
- Department of Interdisciplinary Studies, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
| | - Mary Jane Myslinski
- Department of Physical Therapy, School of Biomedical and Health Sciences, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Pierre Asselin
- 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, New York, USA
| | - Alexander T. Lombard
- 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, New York, 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, New York, USA,Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, South Orange, New Jersey, USA,The Institute for Advanced Study of Rehabilitation and Sports Science, School of Health and Medical Sciences, Seton Hall University, South Orange, New Jersey, USA
| | - Steven C. Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,Kessler Foundation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gail F. Forrest
- Kessler Foundation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Trevor Dyson-Hudson
- Kessler Foundation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, 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, New York, USA,Departments of Medicine and Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, 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, New York, USA,Departments of Medicine and Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Chen J, Jin Z, Yao J, Wang H, Li Y, Ouyang Z, Wang Y, Niu W. Influence of the intelligent standing mobile robot on lower extremity physiology of complete spinal cord injury patients. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2020. [DOI: 10.1016/j.medntd.2020.100045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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16
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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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17
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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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18
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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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19
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Lobos S, Cooke A, Simonett G, Ho C, Boyd SK, Edwards WB. Trabecular Bone Score at the Distal Femur and Proximal Tibia in Individuals With Spinal Cord Injury. J Clin Densitom 2019; 22:249-256. [PMID: 29776736 DOI: 10.1016/j.jocd.2018.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 04/19/2018] [Indexed: 11/16/2022]
Abstract
Rapid declines in bone mineral density (BMD) at the knee after spinal cord injury (SCI) are associated with an increased risk of fracture. Evaluation of bone quality using the trabecular bone score (TBS) may provide a complimentary measure to BMD assessment to examine bone health and fracture risk after SCI. The purpose of this study was to assess bone mineral density (BMD) and trabecular bone score (TBS) at the knee in individuals with and without SCI. Nine individuals with complete SCI (mean time since SCI 2.9 ± 3.8 yr) and 9 non-SCI controls received dual-energy X-ray absorptiometry scans of the right knee using the lumbar spine protocol. BMD and TBS were quantified at epiphyseal, metaphyseal, diaphyseal, and total bone regions of the distal femur and proximal tibia. Individuals with SCI illustrated significantly lower total BMD at the distal femur (23%; p = 0.029) and proximal tibia (19%; p = 0.02) when compared with non-SCI controls. Despite these marked differences in BMD from both locations, significant differences in total TBS were observed at the distal femur only (6%; p = 0.023). The observed differences in total BMD and TBS could be attributed to reductions in epiphyseal rather than metaphyseal or diaphysis measurements. The relationship between TBS and duration of SCI was well explained by a logarithmic trend at the distal femoral epiphysis (r2 = 0.54, p = 0.025). The logarithmic trend would predict that after 3 yr of SCI, TBS would be approximately 6% lower than the non-SCI controls. Further evaluation is needed to determine if TBS measures at the knee provide important information about bone quality that is not captured by traditional BMD.
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Affiliation(s)
- Stacey Lobos
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Anne Cooke
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Gillian Simonett
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Chester Ho
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada; Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Steven K Boyd
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada; Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada; McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada; Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
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20
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Cirnigliaro CM, Myslinski MJ, Asselin P, Hobson JC, Specht A, La Fountaine MF, Kirshblum SC, Forrest GF, Dyson-Hudson T, Spungen AM, Bauman WA. Progressive Sublesional Bone Loss Extends into the Second Decade After Spinal Cord Injury. J Clin Densitom 2019; 22:185-194. [PMID: 30503961 DOI: 10.1016/j.jocd.2018.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The rate of areal bone mineral density (aBMD) loss at the knee (distal femur (DF) and proximal tibia ) and hip (femoral neck (FN) and total hip (TH)) was determined in persons with traumatic spinal cord injury (SCI) who were stratified into subgroups based on time since injury (TSI). DESIGN Cross-sectional retrospective review. SETTING Department of Veterans Affairs Medical Center and Private Rehabilitation Hospital. PARTICIPANTS Data on 105 individuals with SCI (TSI ≤12 months, n = 19; TSI 1-5 years, n = 35; 6-10 years, n = 19; TSI 11-20 years, n = 16; TSI >20 years, n = 15) and 17 able-bodied reference (ABref) controls. INTERVENTIONS NA Main Outcome Measures: The knee and hip aBMD values were obtained by dual energy X-ray absorptiometry (GE Lunar iDXA) using standard clinical software for the proximal femur employed in conjunction with proprietary research orthopedic knee software applications. Young-normal (T-score) and age-matched (Z-scores) standardized scores for the FN and TH were obtained using the combined GE Lunar/National Health and Nutrition Examination Survey (NHANES III) combined reference database. RESULTS When groups were stratified and compared as epochs of TSI, significantly lower mean aBMD and reference scores were observed as TSI increased, despite similar mean ages of participants among the majority of TSI epoch subgroups. Loss in aBMD occurred at the distal femur (DF), proximal tibia (PT), FN, and TH with 46%, 49%, 32%, and 43% of the variance in loss, respectively, described by the exponential decay curves with a time to steady state (tss) occurring at 14.6, 11.3, 14, and 6.2 years, respectively, after SCI. CONCLUSIONS Sublesional bone loss after SCI was marked and occurred as an inverse function of TSI. For aBMD at the hip and knee, tss extended into the second decade after SCI.
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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.
| | - Mary Jane Myslinski
- Department of Physical Therapy, School of Biomedical and Health Sciences, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Pierre Asselin
- 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
| | - Joshua C Hobson
- 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
| | - Adam Specht
- 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; The Institute for Advanced Study of Rehabilitation and Sports Science, School of Health and Medical Sciences, Seton Hall University, South Orange, 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
| | - Gail F Forrest
- Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Trevor Dyson-Hudson
- Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, 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 Medicine, 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 Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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21
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Rodríguez-Gómez I, Martín-Manjarrés S, Martín-García M, Vila-Maldonado S, Gil-Agudo Á, M. Alegre L, Ara I. Cardiorespiratory fitness and arm bone mineral health in young males with spinal cord injury: the mediator role of lean mass. J Sports Sci 2018; 37:717-725. [DOI: 10.1080/02640414.2018.1522948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Irene Rodríguez-Gómez
- GENUD Toledo Research Group, Universidad de Castilla-La Mancha, Toledo, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
| | - Soraya Martín-Manjarrés
- Department of Physical Medicine and Rehabilitation, National Hospital for Paraplegics. SESCAM, Toledo, Spain
| | - María Martín-García
- GENUD Toledo Research Group, Universidad de Castilla-La Mancha, Toledo, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
| | - Sara Vila-Maldonado
- GENUD Toledo Research Group, Universidad de Castilla-La Mancha, Toledo, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
| | - Ángel Gil-Agudo
- Biomechanics and Technical Aids Unit, Department of Physical Medicine and Rehabilitation, National Hospital for Spinal Cord Injury. SESCAM, Toledo, Spain
| | - Luis M. Alegre
- GENUD Toledo Research Group, Universidad de Castilla-La Mancha, Toledo, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
| | - Ignacio Ara
- GENUD Toledo Research Group, Universidad de Castilla-La Mancha, Toledo, Spain
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
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22
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The application of finite element modelling based on clinical pQCT for classification of fracture status. Biomech Model Mechanobiol 2018; 18:245-260. [PMID: 30293203 DOI: 10.1007/s10237-018-1079-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 09/17/2018] [Indexed: 10/28/2022]
Abstract
Fracture risk assessment using dual-energy X-ray absorptiometry (DXA) frequently fails to diagnose osteoporosis amongst individuals who later experience fragility fractures. Hence, more reliable techniques that improve the prediction of fracture risk are needed. In this study, we evaluated a finite element (FE) modelling framework based on clinical peripheral quantitative computed tomography (pQCT) imaging of the tibial epiphysis and diaphysis to predict the stiffness at these locations in compression, shear, torsion and bending. The ability of these properties to identify a group of women who had recently sustained a low-trauma fracture from an age- and weight-matched control group was determined and compared to clinical pQCT and DXA properties and structural properties based on composite beam theory. The predicted stiffnesses derived from the FE models and composite beam theory were significantly different (p < 0.05) between the control and fracture groups, whereas no meaningful differences were observed using DXA and for the stress-strain indices (SSIs) derived using pQCT. The diagnostic performance of each property was assessed by the odds ratio (OR) and the area under the receiver operating curve (AUC), and both were greatest for the FE-predicted shear stiffness (OR 16.09, 95% CI 2.52-102.56, p = 0.003) (AUC: 0.80, 95% CI 0.67-0.93). The clinical pQCT variable total density (ρtot) and a number of structural and FE-predicted variables had a similar probability of correct classification between the control and fracture groups (i.e. ORs and AUCs with mean values greater than 5.00 and 0.80, respectively). In general, the diagnostic characteristics were lower for variables derived using DXA and for the SSIs (i.e. ORs and AUCs with mean values of 1.65-2.98 and 0.64-0.71, respectively). For all properties considered, the trabecular-dominant tibial epiphysis exhibited enhanced classification characteristics, as compared to the cortical-dominant tibial diaphysis. The results of this study demonstrate that bone properties may be derived using FE modelling that have the potential to enhance fracture risk assessment using conventional pQCT or DXA instruments in clinical settings.
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Cervinka T, Giangregorio L, Sievanen H, Cheung AM, Craven BC. Peripheral Quantitative Computed Tomography: Review of Evidence and Recommendations for Image Acquisition, Analysis, and Reporting, Among Individuals With Neurological Impairment. J Clin Densitom 2018; 21:563-582. [PMID: 30196052 DOI: 10.1016/j.jocd.2018.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/07/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Abstract
In 2015, the International Society for Clinical Densitometry (ISCD) position statement regarding peripheral quantitative computed tomography (pQCT) did not recommend routine use of pQCT, in clinical settings until consistency in image acquisition and analysis protocols are reached, normative studies conducted, and treatment thresholds identified. To date, the lack of consensus-derived recommendations regarding pQCT implementation remains a barrier to implementation of pQCT technology. Thus, based on description of available evidence and literature synthesis, this review recommends the most appropriate pQCT acquisition and analysis protocols for clinical care and research purposes, and recommends specific measures for diagnosis of osteoporosis, assigning fracture risk, and monitoring osteoporosis treatment effectiveness, among patients with neurological impairment. A systematic literature search of MEDLINE, EMBASE©, CINAHL, and PubMed for available pQCT studies assessing bone health was carried out from inception to August 8th, 2017. The search was limited to individuals with neurological impairment (spinal cord injury, stroke, and multiple sclerosis) as these groups have rapid and severe regional declines in bone mass. Of 923 references, we identified 69 that met review inclusion criteria. The majority of studies (n = 60) used the Stratec XCT 2000/3000 pQCT scanners as reflected in our evaluation of acquisition and analysis protocols. Overall congruence with the ISCD Official Positions was poor. Only 11% (n = 6) studies met quality reporting criteria for image acquisition and 32% (n = 19) reported their data analysis in a format suitable for reproduction. Therefore, based on current literature synthesis, ISCD position statement standards and the authors' expertise, we propose acquisition and analysis protocols at the radius, tibia, and femur sites using Stratec XCT 2000/3000 pQCT scanners among patients with neurological impairment for clinical and research purposes in order to drive practice change, develop normative datasets and complete future meta-analysis to inform fracture risk and treatment efficacy evaluation.
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Affiliation(s)
- T Cervinka
- Neural Engineering and Therapeutics Team, Toronto Rehabilitation Research Institute-University Health Network, Toronto, Ontario, Canada.
| | - L Giangregorio
- Neural Engineering and Therapeutics Team, Toronto Rehabilitation Research Institute-University Health Network, Toronto, Ontario, Canada; Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - H Sievanen
- Bone Research Group, UKK Institute, Tampere, Finland
| | - A M Cheung
- Centre of Excellence in Skeletal Health Assessment, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B C Craven
- Neural Engineering and Therapeutics Team, Toronto Rehabilitation Research Institute-University Health Network, Toronto, Ontario, Canada; Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada; Centre of Excellence in Skeletal Health Assessment, University Health Network, Toronto, Ontario, Canada; Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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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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Guimarães JA, da Fonseca LO, de Sousa AC, Paredes MEG, Brindeiro GA, Bó APL, Fachin-Martins E. FES Bike Race preparation to Cybathlon 2016 by EMA team: a short case report. Eur J Transl Myol 2017; 27:7169. [PMID: 29299225 PMCID: PMC5745387 DOI: 10.4081/ejtm.2017.7169] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 01/07/2023] Open
Abstract
FES-assisted cycling has been recommended to people struggling to emerge from a disability to more functioning life after spinal cord injury. Recommendations issued by a gowing number of scientific papershas promised toimprove body composition and physical activity levels, as well as to controlinvoluntary muscle response; favoring activity and participation which break new grounds in expanding locomotion, leisure and occupational options for people with paraplegia and tetraplegia. In this report we described our experience to select and prepare a pilot to compete in the FES Bike Race modality at Cybathlon 2016 in Kloten (Zurick). He was a man, 38 years old, with a complete spinal cord injury, level T9, three years of injury. He took part in a two preparation phases lasting respectively 18 and 12 weeks each: (1st) pre-FES-cycling and a (2nd) FES-cycling. The 1st phase aimed to explore electrical stimulation response in the quadricps, hamstrings and gluteus muscles; searching for a standard muscular recruitment enable to propel the pedals of a trike. Following, in the 2nd phase, stationary to mobile FES-cycling was performed at the same time the development of the automation and control systems were being incorporated in the trike. We adapted a commercial tadpole trycicle anda pilot controlled system. Although we had planned a three session by week protocol, for reasons of term and time to finish the trike development and be prepared to compete, in the last two weeks before the Cybatlhon an intense level of exercise was maintained. After the race, we noticedinflammatory signs on the left knee which later revealed a patella fracture. The video footage analysis confirmed ithappened during the race's first lap.
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Affiliation(s)
| | - Lucas Oliveira da Fonseca
- NTAAI, Faculdade de Ceilândia, Universidade de Brasília, Brasília, Brazil
- LARA, Faculdade de Tecnologia, Universidade de Brasília, Brasília, Brazil
| | | | | | | | - Antônio Padilha Lanari Bó
- NTAAI, Faculdade de Ceilândia, Universidade de Brasília, Brasília, Brazil
- LARA, Faculdade de Tecnologia, Universidade de Brasília, Brasília, Brazil
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Andrews B, Gibbons R, Wheeler G. Development of Functional Electrical Stimulation Rowing: The Rowstim Series. Artif Organs 2017; 41:E203-E212. [DOI: 10.1111/aor.13053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brian Andrews
- School of Engineering; University of Warwick; Coventry UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
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27
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Gibbs JC, Gagnon DH, Bergquist AJ, Arel J, Cervinka T, El-Kotob R, Maltais DB, Wolfe DL, Craven BC. Rehabilitation Interventions to modify endocrine-metabolic disease risk in Individuals with chronic Spinal cord injury living in the Community (RIISC): A systematic review and scoping perspective. J Spinal Cord Med 2017; 40:733-747. [PMID: 28703038 PMCID: PMC5778937 DOI: 10.1080/10790268.2017.1350341] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Endocrine-metabolic disease (EMD) risk following spinal cord injury (SCI) is associated with significant multi-morbidity (i.e. fracture, diabetes, heart disease), mortality, and economic burden. It is unclear to what extent rehabilitation interventions can modify EMD risk and improve health status in community-dwelling adults with chronic SCI. OBJECTIVES To characterize rehabilitation interventions and summarize evidence on their efficacy/effectiveness to modify precursors to EMD risk in community-dwelling adults with chronic SCI. METHODS Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, CDSR, and PsychInfo were completed. All randomized, quasi-experimental, and prospective controlled trials comparing rehabilitation/therapeutic interventions with control/placebo interventions in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean differences of change from baseline were reported for EMD risk outcomes. The GRADE approach was used to rate the quality of evidence. RESULTS Of 489 articles identified, 16 articles (11 studies; n=396) were eligible for inclusion. No studies assessed the effects of rehabilitation interventions on incident fragility fractures, heart disease, and/or diabetes. Individual studies reported that exercise and/or nutrition interventions could improve anthropometric indices, body composition/adiposity, and biomarkers. However, there were also reports of non-statistically significant between-group differences. CONCLUSIONS There was very low-quality evidence that rehabilitation interventions can improve precursors to EMD risk in community-dwelling adults with chronic SCI. The small number of studies, imprecise estimates, and inconsistency across studies limited our ability to make conclusions. A high-quality longitudinal intervention trial is needed to inform community-based rehabilitation strategies for EMD risk after chronic SCI.
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Affiliation(s)
- Jenna C. Gibbs
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada,University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada,Correspondence to: Dr. Jenna Gibbs, University of Waterloo, Department of Kinesiology, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | - Dany H. Gagnon
- Université de Montréal, École de Réadaptation, Montréal, QC, Canada
| | - Austin J. Bergquist
- University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada
| | - Jasmine Arel
- Université de Montréal, École de Réadaptation, Montréal, QC, Canada
| | - Tomas Cervinka
- University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada
| | - Rasha El-Kotob
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada,University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada
| | | | - Dalton L. Wolfe
- Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada,Lawson Health Research Institute, Parkwood Institute Research, London, ON, Canada
| | - B. Catharine Craven
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada,University Health Network-Toronto Rehabilitation Institute, Lyndhurst Centre, Toronto, ON, Canada,Department of Medicine, University of Toronto, Toronto, ON, Canada
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28
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Felter C. Whole Body Vibration for People with Spinal Cord Injury: a review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0155-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Cervinka T, Lynch CL, Giangregorio L, Adachi JD, Papaioannou A, Thabane L, Craven BC. Agreement between fragility fracture risk assessment algorithms as applied to adults with chronic spinal cord injury. Spinal Cord 2017; 55:985-993. [PMID: 28607522 DOI: 10.1038/sc.2017.65] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 01/22/2023]
Abstract
STUDY DESIGN Cross-sectional. OBJECTIVES The objective of the study was to determine and report agreement in fracture risk stratification of adults with spinal cord injury (SCI) using (1) Canadian Association of Radiologists and Osteoporosis Canada (CAROC) and Canadian Fracture Risk Assessment (FRAX) tools with and without areal bone mineral density (aBMD) and (2) SCI-specific fracture thresholds. SETTING Tertiary rehabilitation center, Ontario, Canada. METHODS Community-dwelling adults with chronic SCI (n=90, C2-T12, AIS A-D) consented to participation. Femoral neck aBMD values determined 10-year fracture risk (CAROC and FRAX). Knee-region aBMD and distal tibia volumetric BMD values were compared to SCI-specific fracture thresholds. Agreements between CAROC and FRAX risk stratifications, and between fracture threshold risk stratification, were assessed using prevalence- and bias-adjusted Kappa statistics (PABAK). RESULTS CAROC and FRAX assessment tools showed moderate agreement for post-menopausal women (PABAK=0.56, 95% confidence interval (CI): 0.27, 0.84) and men aged ⩾50 years (PABAK=0.51, 95% CI: 0.34, 0.67), with poor agreement for young men and pre-menopausal women (PABAK⩽0). Excellent agreement was evident between FRAX with and without aBMD in young adults and in those with motor incomplete injury (PABAK=0.86-0.92). In other subgroups, agreement ranged from moderate to substantial (PABAK=0.41-0.73). SCI-specific fracture thresholds (Eser versus Garland) showed poor agreement (PABAK⩽0). CONCLUSION Fracture risk estimates among individuals with SCI vary substantially with the risk assessment tool. Use of SCI-specific risk factors to identify patients with high fracture risk is recommended until a validated SCI-specific tool for predicting fracture risk is developed.
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Affiliation(s)
- T Cervinka
- Department of Research, Neural Engineering and Therapeutics Team, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - C L Lynch
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - L Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - J D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Papaioannou
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - L Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - B C Craven
- Department of Research, Neural Engineering and Therapeutics Team, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada.,Division of Physiatry, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Coupaud S, Gislason MK, Purcell M, Sasagawa K, Tanner KE. Patient-specific bone mineral density distribution in the tibia of individuals with chronic spinal cord injury, derived from multi-slice peripheral Quantitative Computed Tomography (pQCT) - A cross-sectional study. Bone 2017; 97:29-37. [PMID: 28034635 DOI: 10.1016/j.bone.2016.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 12/12/2016] [Accepted: 12/23/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The high risk of fracture associated with chronic spinal cord injury (SCI) is attributed to extensive disuse-related bone loss in previously weight-bearing long bones. Changes in bone mineral density (BMD) after SCI have been documented extensively for the epiphyses of the tibia and femur, fracture-prone sites in this patient group. Less attention has been given to patterns of cortical bone loss in the diaphyses, but variability in BMD distributions throughout the long bones may contribute to some patients' increased susceptibility to shaft fractures in chronic SCI. AIM A cross-sectional study was carried out to determine whether BMD distributions along the tibia differ between individuals with chronic SCI and healthy able-bodied (AB) controls, in both the trabecular and cortical bone compartments. The effects of time post-injury and gender on BMD distribution were also explored. METHODS Individuals with chronic (≥6months post-injury) motor-complete SCI were recruited from the Queen Elizabeth National Spinal Injuries Unit (Glasgow, UK). AB control subjects were recruited to achieve similar age and gender profiles for the SCI and control groups. Multi-slice pQCT (XCT3000, Stratec) was performed along the length of the tibia (2mm thickness, 0.5mm voxel size), at 1% intervals in the epiphyses and 5% intervals in the diaphysis (34 slices in total). These were used to reconstruct full 3-D subject-specific models (Mimics, Materialise) of BMD distribution, by interpolating between slices. Subjects with chronic SCI were subdivided into 'early' (<4years post-injury) and 'established' SCI (≥4years post-injury). Subject-specific BMD distribution was described according to new parameters determined from the 3-D patient-specific models, quantifying descriptors of the trabecular and cortical BMD regions separately (volume, peak BMD, half-peak width, area under the curve). These were compared between sub-groups (using independent-samples t-tests or Mann-Whitney tests, significance level of 5%). RESULTS 11 men (age range 17-59years old; mean 35.7±10.6) and 3 post-menopausal women (age range 56-58years old; mean 56.7±1.2years) with motor-complete SCI (ranging from 6months to 27years post-injury) were recruited; 6 men (age range 20-56years old; 33.0±12.7years) and 1 post-menopausal woman (56years) formed the AB control group. Overall, SCI resulted in lower BMD at both trabecular and cortical regions of the tibia. In men, longer time since injury resulted in greater BMD differences when compared to AB, throughout the tibia. For the post-menopausal women, differences in BMD between SCI and AB were greater in cortical bone than in trabecular bone. From the models, individual BMD distribution curves showed healthy double-peaks in AB subjects: one trabecular peak (around 200-300mg/cm3) and the other cortical (around 1000-1100mg/cm3). In most subjects with established SCI, trabecular peaks were exaggerated whilst the cortical peaks were barely discernible, with crucially some individuals already exhibiting a diminishing cortical BMD peak even <4years post-injury. CONCLUSIONS These findings may have implications for determining the fracture susceptibility of the long bones in individual patients with SCI. Epiphyseal fractures associated with low trabecular BMD are well characterised, but our data show that some individuals with SCI may also be at higher risk of shaft fractures. The proposed BMD distribution description parameters, determined from patient-specific models, could be used to identify patients with a weakened diaphysis who may be susceptible to fractures of the tibial shaft, but this requires validation.
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Affiliation(s)
- Sylvie Coupaud
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow G4 0NW, UK; Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
| | - Magnus K Gislason
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow G4 0NW, UK; Institute for Biomedical and Neural Engineering, School of Science & Engineering, University of Reykjavik, Menntavegi 1, 101 Reykjavik, Iceland
| | - Mariel Purcell
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Keisuke Sasagawa
- Department of Engineering, Niigata Institute of Technology, 1719 Fujihashi, Kashiwazaki City, Niigata 945-1195, Japan
| | - K Elizabeth Tanner
- Biomedical Engineering Division, School of Engineering, University of Glasgow, Glasgow G12 8QQ, UK
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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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Baker AM, Wagner DW, Kiratli BJ, Beaupre GS. Pixel-Based DXA-Derived Structural Properties Strongly Correlate with pQCT Measures at the One-Third Distal Femur Site. Ann Biomed Eng 2017; 45:1247-1254. [PMID: 28105580 DOI: 10.1007/s10439-017-1796-6] [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] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/11/2017] [Indexed: 11/26/2022]
Abstract
While bone mineral density has been traditionally used to quantify fracture risk for individuals with spinal cord injuries, recent studies are including engineering measurements such as section modulus and cross sectional moment of inertia. These are almost exclusively calculated by peripheral QCT scanners which, unlike DXA scanners, are rarely found in clinical settings. Using fifty-four fresh frozen femora, we developed and validated a pixel-by-pixel method to calculate engineering properties at the distal femur using a Hologic QDR-1000 W DXA scanner and compared them against similar parameters measured using a Stratec XCT-3000 peripheral QCT scanner. We found excellent agreement between standard DXA and pixel-by-pixel measured BMD (r 2 = 0.996). Cross-sectional moment of inertia about the anteroposterior axis measured using DXA and pQCT correlated very strongly (r 2 = 0.99). Cross-sectional moment of inertia about the anteroposterior axis measured using DXA also correlated strongly with pQCT measured bone strength index (r 2 = 0.99). These correlations indicate that DXA scans can measure equivalent pQCT parameters, and some existing DXA scans can be reprocessed with pixel-by-pixel techniques. Ultimately, these engineering parameters may help better quantify fracture-risk in fracture-prone populations such as those with spinal cord injuries.
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Affiliation(s)
- Alexander M Baker
- VA Palo Alto, Musculoskeletal Research Laboratories, Palo Alto, CA, USA.
| | - David W Wagner
- VA Palo Alto, Musculoskeletal Research Laboratories, Palo Alto, CA, USA
| | - B Jenny Kiratli
- VA Palo Alto Health Care System, Spinal Cord Injury & Disorders Center, Palo Alto, CA, USA
- Physical Medicine and Rehabilitation Division, Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Gary S Beaupre
- VA Palo Alto, Musculoskeletal Research Laboratories, Palo Alto, CA, USA
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Giangregorio LM, Gibbs JC, Craven BC. Measuring muscle and bone in individuals with neurologic impairment; lessons learned about participant selection and pQCT scan acquisition and analysis. Osteoporos Int 2016; 27:2433-46. [PMID: 27026329 DOI: 10.1007/s00198-016-3572-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/14/2016] [Indexed: 10/22/2022]
Abstract
Peripheral quantitative computed tomography (pQCT) can be used to examine bone strength outcomes and muscle size and fatty infiltration. Our research team and others have used it to examine bone loss after spinal cord injury (SCI). However, the high prevalence of restricted lower extremity range of motion, spasticity, edema, excessive muscle atrophy, or severe osteoporosis necessitates changes to standard protocols for screening, positioning during scan acquisition, and analysis methods. This manuscript outlines the challenges that we experienced using pQCT in individuals with SCI, and provides solutions, ones that may also be applicable when using pQCT in individuals with other chronic conditions or in older adults. Suggestions for participant screening, positioning individuals for scanning while in a wheelchair, scan site selection, need for attendant assistance, and considerations in the presence of secondary complications, such as contracture, spasticity, and paralysis, are presented. In the presence of very low bone mineral density or severe muscle atrophy, the default analysis modes provided by the manufacturer may not provide valid estimates of bone or muscle indices; we propose alternates. We have used watershed segmentation methods to determine muscle size and density based on lower precision error compared to threshold-based edge-detection segmentation, particularly for adults with SCI, where more fatty infiltration was present. By presenting our "lessons learned," we hope to reduce the learning curve for researchers using pQCT in the future.
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Affiliation(s)
- L M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue W-BMH 1109, Waterloo, ON, Canada.
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.
- Research Scientist, Schlegel-UW Research Institute of Aging, Waterloo, ON, Canada.
| | - J C Gibbs
- Department of Kinesiology, University of Waterloo, 200 University Avenue W-BMH 1109, Waterloo, ON, Canada
| | - B C Craven
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Asselin PK, Avedissian M, Knezevic S, Kornfeld S, Spungen AM. Training Persons with Spinal Cord Injury to Ambulate Using a Powered Exoskeleton. J Vis Exp 2016:54071. [PMID: 27340808 PMCID: PMC4927801 DOI: 10.3791/54071] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Powered exoskeletons have become available for overground ambulation in persons with paralyses due to spinal cord injury (SCI) who have intact upper extremity function and are able to maintain upright balance using forearm crutches. To ambulate in an exoskeleton, the user must acquire the ability to maintain balance while standing, sitting and appropriate weight shifting with each step. This can be a challenging task for those with deficits in sensation and proprioception in their lower extremities. This manuscript describes screening criteria and a training program developed at the James J. Peters VA Medical Center, Bronx, NY to teach users the skills needed to utilize these devices in institutional, home or community environments. Before training can begin, potential users are screened for appropriate range of motion of the hip, knee and ankle joints. Persons with SCI are at an increased risk of sustaining lower extremity fractures, even with minimal strain or trauma, therefore a bone mineral density assessment is performed to reduce the risk of fracture. Also, as part of screening, a physical examination is performed in order to identify additional health-related contraindications. Once the person has successfully passed all screening requirements, they are cleared to begin the training program. The device is properly adjusted to fit the user. A series of static and dynamic balance tasks are taught and performed by the user before learning to walk. The person is taught to ambulate in various environments ranging from indoor level surfaces to outdoors over uneven or changing surfaces. Once skilled enough to be a candidate for home use with the exoskeleton, the user is then required to designate a companion-walker who will train alongside them. Together, the pair must demonstrate the ability to perform various advanced tasks in order to be permitted to use the exoskeleton in their home/community environment.
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Affiliation(s)
- Pierre K Asselin
- Department of Veterans Affairs (VA) Rehabilitation Research and Development National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center
| | - Manuel Avedissian
- Department of Veterans Affairs (VA) Rehabilitation Research and Development National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center
| | - Steven Knezevic
- Department of Veterans Affairs (VA) Rehabilitation Research and Development National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center
| | - Stephen Kornfeld
- Department of Veterans Affairs (VA) Spinal Cord Injury Service, James J. Peters VA Medical Center
| | - Ann M Spungen
- Department of Veterans Affairs (VA) Rehabilitation Research and Development National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center;
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Johnston TE, Marino RJ, Oleson CV, Schmidt-Read M, Leiby BE, Sendecki J, Singh H, Modlesky CM. Musculoskeletal Effects of 2 Functional Electrical Stimulation Cycling Paradigms Conducted at Different Cadences for People With Spinal Cord Injury: A Pilot Study. Arch Phys Med Rehabil 2015; 97:1413-1422. [PMID: 26705884 DOI: 10.1016/j.apmr.2015.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare the musculoskeletal effects of low cadence cycling with functional electrical stimulation (FES) with high cadence FES cycling for people with spinal cord injury (SCI). DESIGN Randomized pre-post design. SETTING Outpatient rehabilitation clinic. PARTICIPANTS Participants (N=17; 14 men, 3 women; age range, 22-67y) with C4-T6 motor complete chronic SCI were randomized to low cadence cycling (n=9) or high cadence cycling (n=8). INTERVENTIONS Low cadence cycling at 20 revolutions per minute (RPM) and high cadence cycling at 50 RPM 3 times per week for 6 months. Cycling torque (resistance per pedal rotation) increased if targeted cycling cadence was maintained. MAIN OUTCOME MEASURES Dual-energy x-ray absorptiometry was used to assess distal femur areal bone mineral density, magnetic resonance imaging was used to assess to assess trabecular bone microarchitecture and cortical bone macroarchitecture and thigh muscle volume, and biochemical markers were used to assess bone turnover. It was hypothesized that subjects using low cadence cycling would cycle with greater torque and therefore show greater musculoskeletal improvements than subjects using high cadence cycling. RESULTS A total of 15 participants completed the study. Low cadence cycling obtained a maximal average torque of 2.9±2.8Nm, and high cadence cycling obtained a maximal average torque of 0.8±0.2Nm. Low cadence cycling showed greater decreases in bone-specific alkaline phosphatase, indicating less bone formation (15.5% decrease for low cadence cycling, 10.7% increase for high cadence cycling). N-telopeptide decreased 34% following low cadence cycling, indicating decreased resorption. Both groups increased muscle volume (low cadence cycling by 19%, high cadence cycling by 10%). Low cadence cycling resulted in a nonsignificant 7% increase in apparent trabecular number (P=.08) and 6% decrease in apparent trabecular separation (P=.08) in the distal femur, whereas high cadence cycling resulted in a nonsignificant (P>.3) 2% decrease and 3% increase, respectively. CONCLUSIONS This study suggests that the greater torque achieved with low cadence cycling may result in improved bone health because of decreased bone turnover and improved trabecular bone microarchitecture. Longer-term outcome studies are warranted to identify the effect on fracture risk.
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Affiliation(s)
- Therese E Johnston
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, PA.
| | - Ralph J Marino
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Christina V Oleson
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Benjamin E Leiby
- Division of Biostatics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Jocelyn Sendecki
- Division of Biostatics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Harshvardhan Singh
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
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Johnston TE, Marino RJ, Oleson CV, Schmidt-Read M, Modlesky CM. Cycling with Functional Electrical Stimulation Before and After a Distal Femur Fracture in a Man with Paraplegia. Top Spinal Cord Inj Rehabil 2015; 21:275-81. [PMID: 26689692 DOI: 10.1310/sci2104-275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
CASE PRESENTATION A man with chronic paraplegia sustained a distal femur fracture following an unrelated fall while enrolled in a study examining musculoskeletal changes after 6 months of cycling with functional electrical stimulation (FES). After healing, he restarted and completed the study. MANAGEMENT AND OUTCOME Study measures included areal bone mineral density, trabecular bone microarchitecture, cortical bone macroarchitecture, serum bone formation/resorption markers, and muscle volume. The patient made small gains in bone- and muscle-related measures. Bone markers had not returned to baseline prior to restarting cycling, which may have impacted results. DISCUSSION This case shows that cycling with FES may be safely resumed after distal femur fracture.
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Affiliation(s)
- Therese E Johnston
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ralph J Marino
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christina V Oleson
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Christopher M Modlesky
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware
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Gibbs JC, Craven BC, Moore C, Thabane L, Adachi JD, Giangregorio LM. Muscle Density and Bone Quality of the Distal Lower Extremity Among Individuals with Chronic Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2015; 21:282-93. [PMID: 26689693 DOI: 10.1310/sci2104-282] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Understanding the related fates of muscle density and bone quality after chronic spinal cord injury (SCI) is an important initial step in determining endocrine-metabolic risk. OBJECTIVE To examine the associations between muscle density and indices of bone quality at the distal lower extremity of adults with chronic SCI. METHODS A secondary data analysis was conducted in 70 adults with chronic SCI (C2-T12; American Spinal Injury Association Impairment Scale [AIS] A-D; ≥2 years post injury). Muscle density and cross-sectional area (CSA) and bone quality indices (trabecular bone mineral density [TbBMD] at the distal tibia [4% site] and cortical thickness [CtTh], cortical area [CtAr], cortical BMD [CtBMD], and polar moment of inertia [PMI] at the tibial shaft [66% site]) were measured using peripheral quantitative computed tomography. Calf lower extremity motor score (cLEMS) was used as a clinical measure of muscle function. Multivariable linear regression analyses were performed to determine the strength of the muscle-bone associations after adjusting for confounding variables (sex, impairment severity [AIS A/B vs AIS C/D], duration of injury, and wheelchair use). RESULTS Muscle density was positively associated with TbBMD (b = 0.85 [0.04, 1.66]), CtTh (b = 0.02 [0.001, 0.034]), and CtBMD (b = 1.70 [0.71, 2.69]) (P < .05). Muscle CSA was most strongly associated with CtAr (b = 2.50 [0.12, 4.88]) and PMI (b = 731.8 [161.7, 1301.9]) (P < .05), whereas cLEMS was most strongly associated with TbBMD (b = 7.69 [4.63, 10.76]) (P < .001). CONCLUSIONS Muscle density and function were most strongly associated with TbBMD at the distal tibia in adults with chronic SCI, whereas muscle size was most strongly associated with bone size and geometry at the tibial shaft.
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Affiliation(s)
- Jenna C Gibbs
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - B Catharine Craven
- Lyndhurst Centre, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Cameron Moore
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Lyndhurst Centre, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Lyndhurst Centre, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada.,Schlegel Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
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Troy KL, Morse LR. Measurement of Bone: Diagnosis of SCI-Induced Osteoporosis and Fracture Risk Prediction. Top Spinal Cord Inj Rehabil 2015; 21:267-74. [PMID: 26689691 PMCID: PMC4750811 DOI: 10.1310/sci2104-267] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Spinal cord injury (SCI) is associated with a rapid loss of bone mass, resulting in severe osteoporosis and a 5- to 23-fold increase in fracture risk. Despite the seriousness of fractures in SCI, there are multiple barriers to osteoporosis diagnosis and wide variations in treatment practices for SCI-induced osteoporosis. METHODS We review the biological and structural changes that are known to occur in bone after SCI in the context of promoting future research to prevent or reduce risk of fracture in this population. We also review the most commonly used methods for assessing bone after SCI and discuss the strengths, limitations, and clinical applications of each method. CONCLUSIONS Although dual-energy x-ray absorptiometry assessments of bone mineral density may be used clinically to detect changes in bone after SCI, 3-dimensional methods such as quantitative CT analysis are recommended for research applications and are explained in detail.
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Affiliation(s)
- Karen L. Troy
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Leslie R. Morse
- Spaulding-Harvard SCI Model System, Spaulding Rehabilitation Hospital, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
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Abstract
Spinal cord injury (SCI) is characterized by marked bone loss and an increased risk of fracture with high complication rate. Recent research based on advanced imaging analysis, including quantitative computed tomography (QCT) and patient-specific finite element (FE) modeling, has provided new and important insights into the magnitude and temporal pattern of bone loss, as well as the associated changes to bone structure and strength, following SCI. This work has illustrated the importance of early therapeutic treatment to prevent bone loss after SCI and may someday serve as the basis for a clinical fracture risk assessment tool for the SCI population. This review provides an update on the epidemiology of fracture after SCI and discusses new findings and significant developments related to bone loss and fracture risk assessment in the SCI population based on QCT analysis and patient-specific FE modeling.
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Affiliation(s)
- W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, and Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 2500 University Dr. NW, Calgary, AB, T2N 1N4, Canada,
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Panisset MG, Galea MP, El-Ansary D. Does early exercise attenuate muscle atrophy or bone loss after spinal cord injury? Spinal Cord 2015; 54:84-92. [PMID: 26345485 DOI: 10.1038/sc.2015.150] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To systematically identify and assess the evidence on the efficacy of exercise initiated early after traumatic spinal cord injury (SCI). METHODS A comprehensive search (Any-2014) of eleven databases identified studies evaluating exercise interventions initiated within 12 weeks after SCI on muscle and bone loss in paralyzed limbs and comparing with standard care or immobilization. Two reviewers assessed methodological quality. One reviewer extracted data and critiqued results according to the Spinal Cord Injury Rehabilitation Evidence body of evidence framework. RESULTS A total of 2811 titles were screened. Eleven studies were included: five randomized controlled trials, four cohort studies and two within-subject control studies. All provided level II evidence with a moderate risk of bias. Two studies found significant positive effects of high-load FES-resisted stance on physiological measures of muscle. Three reported positive effects of 3 months of Functional Electrical Stimulation (FES) on muscle size. Two studies found positive effects of 6-month body-weight supported treadmill training or FES on trabecular bone using pQCT. CONCLUSION We found consistent evidence of positive effects of early exercise on muscle, possibly related to load intensity of the protocol. However, the heterogeneity of interventions and outcomes makes this determination speculative. Evidence for the effectiveness of early exercise on bone is scant and confined to measures of trabecular bone mineral density via pQCT. Transparent reporting of methods and variability of data, combined with standardization of valid and sensitive measures of muscle atrophy and bone loss, could facilitate future meta-analysis on this topic.
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Affiliation(s)
- M G Panisset
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - M P Galea
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - D El-Ansary
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
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Tou JC. Evaluating resveratrol as a therapeutic bone agent: preclinical evidence from rat models of osteoporosis. Ann N Y Acad Sci 2015. [PMID: 26200189 DOI: 10.1111/nyas.12840] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Resveratrol (RSV) is a naturally occurring plant polyphenol that has potential to attenuate osteoporosis with distinct pathologies. This review evaluates preclinical evidence regarding the efficacy and safety of RSV as a therapeutic bone agent using different rat models. Limitations of these animal models are discussed, and suggestions for strengthening the experimental design of future studies are provided. The ovariectomized rat model of postmenopausal osteoporosis reported that RSV supplementation attenuated estrogen deficiency-induced bone loss and trabecular structural deterioration. RSV safety was indicated by the absence of stimulation of estrogen-sensitive tissue. Providing RSV to rats aged >6 months attenuated age-related bone mass loss and structural deterioration but produced inconsistent effects on bones in rats aged <6 months. The hindlimb-suspension rat model of disuse osteoporosis reported that RSV attenuated bone loss in old rats, but higher doses and longer duration supplementation before mechanical loading were required for younger rats. Limitations common to studies using rat models of osteoporosis include requirements to include animals that are skeletally mature, longer study durations, and to adjust for potential confounding effects due to altered body weight and endocrine function. Strengthening experimental design can contribute to translation of animal results to clinically relevant recommendations for humans.
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Affiliation(s)
- Janet C Tou
- Human Nutrition and Foods, Division of Animal and Nutritional Sciences, West Virginia University, Morgantown, West Virginia
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Long-bone fractures in persons with spinal cord injury. Spinal Cord 2015; 53:701-4. [PMID: 25987003 DOI: 10.1038/sc.2015.74] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/01/2015] [Accepted: 04/01/2015] [Indexed: 12/11/2022]
Abstract
STUDY DESIGN Retrospective data analysis. OBJECTIVES To document fracture characteristics, management and related complications in individuals with traumatic spinal cord injury (SCI). SETTING Rehabilitation centre for SCI individuals. METHOD Patients' records were reviewed. Patients with traumatic SCI and extremity fractures that had occurred after SCI were included. Patient characteristics, fractured bone, fracture localisation, severity and management (operative/conservative), and fracture-related complications were extracted. RESULTS A total of 156 long-bone fractures in 107 SCI patients (34 women and 73 men) were identified. The majority of patients were paraplegics (77.6%) and classified as American Spinal Injury Association Impairment Scale A (86.0%). Only the lower extremities were affected, whereby the femur (60.9% of all fractures) was fractured more frequently than the lower leg (39.1%). A total of 70 patients (65.4%) had one fracture, whereas 37 patients (34.6%) had two or more fractures. Simple or extraarticular fractures were most common (75.0%). Overall, 130 (83.3%) fractures were managed operatively. Approximately half of the femur fractures (48.2%) were treated with locking compression plates. In the lower leg, fractures were mainly managed with external fixation (48.8%). Conservative fracture management was applied in 16.7% of the cases and consisted of braces or a well-padded soft cast. Fracture-associated complications were present in 13.5% of the cases but did not differ significantly between operative (13.1%) and conservative (15.4%) fracture management. CONCLUSION SCI was associated with simple or extraarticular fractures of the distal femur and the lower leg. Fractures were mainly managed operatively with a low complication rate.
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Coupaud S, McLean AN, Purcell M, Fraser MH, Allan DB. Decreases in bone mineral density at cortical and trabecular sites in the tibia and femur during the first year of spinal cord injury. Bone 2015; 74:69-75. [PMID: 25596521 DOI: 10.1016/j.bone.2015.01.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/05/2015] [Accepted: 01/08/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Disuse osteoporosis occurs in response to long-term immobilization. Spinal cord injury (SCI) leads to a form of disuse osteoporosis that only affects the paralyzed limbs. High rates of bone resorption after injury are evident from decreases in bone mineral content (BMC), which in the past have been attributed in the main to loss of trabecular bone in the epiphyses and cortical thinning in the shaft through endocortical resorption. METHODS Patients with motor-complete SCI recruited from the Queen Elizabeth National Spinal Injuries Unit (Glasgow, UK) were scanned within 5weeks of injury (baseline) using peripheral Quantitative Computed Tomography (pQCT). Unilateral scans of the tibia, femur and radius provided separate estimates of trabecular and cortical bone parameters in the epiphyses and diaphyses, respectively. Using repeat pQCT scans at 4, 8 and 12months post-injury, changes in BMC, bone mineral density (BMD) and cross-sectional area (CSA) of the bone were quantified. RESULTS Twenty-six subjects (5 female, 21 male) with SCI (12 paraplegic, 14 tetraplegic), ranging from 16 to 76years old, were enrolled onto the study. Repeated-measures analyses showed a significant effect of time since injury on key bone parameters at the epiphyses of the tibia and femur (BMC, total BMD, trabecular BMD) and their diaphyses (BMC, cortical BMD, cortical CSA). There was no significant effect of gender or age on key outcome measures, but there was a tendency for the female subjects to experience greater decreases in cortical BMD. The decreases in cortical BMD in the tibia and femur were found to be statistically significant in both men and women. CONCLUSIONS By carrying out repeat pQCT scans at four-monthly intervals, this study provides a uniquely detailed description of the cortical bone changes that occur alongside trabecular bone changes in the first year of complete SCI. Significant decreases in BMD were recorded in both the cortical and trabecular bone compartments of the tibia and femur throughout the first year of injury. This study provides evidence for the need for targeted early intervention to preserve bone mass within this patient group.
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Affiliation(s)
- Sylvie Coupaud
- Department of Biomedical Engineering, School of Engineering, University of Glasgow, Glasgow G12 8QQ, United Kingdom; Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow G51 4TF, United Kingdom.
| | - Alan N McLean
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow G51 4TF, United Kingdom
| | - Mariel Purcell
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow G51 4TF, United Kingdom
| | - Matthew H Fraser
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow G51 4TF, United Kingdom
| | - David B Allan
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow G51 4TF, United Kingdom
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Benson I, Hart K, Tussler D, van Middendorp JJ. Lower-limb exoskeletons for individuals with chronic spinal cord injury: findings from a feasibility study. Clin Rehabil 2015; 30:73-84. [PMID: 25761635 DOI: 10.1177/0269215515575166] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/31/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the feasibility of conducting a well-powered trial evaluating the neurological and functional effects of using an exoskeleton in individuals with chronic spinal cord injury. DESIGN A longitudinal, prospective, self-controlled feasibility study. SETTING Specialist Spinal Cord Injuries Centre, UK; 8 months during 2013-2014. SUBJECTS Individuals with chronic motor complete or incomplete spinal cord injury. INTERVENTIONS Enrolled subjects were assigned to 20 exoskeleton (ReWalk™, Argo Medical Technologies Ltd, Yokneam Ilit, Israel) training sessions over a 10-week training period. MAIN MEASURES Feasibility measures, clinical and mobility outcome measures and measures appraising subjects' disability and attitude towards assistive technology were assessed before, during and after the study. Descriptive statistics were applied. RESULTS Out of 60 candidates, ten (17%) were enrolled and five (8%) completed the training programme. Primary reasons for not enrolling were ineligibility (n = 24, 40%) and limited interest to engage in a 10-week training programme (n = 16, 27%). Five out of ten enrolled subjects experienced grade I/II skin aberrations. While walking speeds were higher and walking distances were longer in all exoskeleton users when compared with non-use, the exoskeleton did generally not meet subjects' high expectations in terms of perceived benefits. CONCLUSIONS The conduct of a controlled trial evaluating the benefits of using exoskeletons that require a lengthy user-commitment to training of individuals with chronic motor complete or incomplete spinal cord injury comes with considerable feasibility challenges. Vigilance is required for preventing and detecting medical complications in spinal cord injury exoskeleton users.
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Affiliation(s)
- Ian Benson
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, UK Stoke Mandeville Spinal Research, Stoke Mandeville Hospital, Aylesbury, UK
| | - Kirsten Hart
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, UK
| | - Dot Tussler
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, UK
| | - Joost J van Middendorp
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, UK Stoke Mandeville Spinal Research, Stoke Mandeville Hospital, Aylesbury, UK
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Edwards WB, Schnitzer TJ, Troy KL. Reduction in proximal femoral strength in patients with acute spinal cord injury. J Bone Miner Res 2014; 29:2074-9. [PMID: 24677293 DOI: 10.1002/jbmr.2227] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/08/2014] [Accepted: 03/12/2014] [Indexed: 11/11/2022]
Abstract
Bone loss after spinal cord injury (SCI) is associated with an increased risk of fracture resulting from minor trauma. Proximal femoral fractures account for approximately 10% to 20% of the fractures in this population and are among the most serious of injuries. Our purpose was to quantify changes to proximal femoral strength in patients with acute SCI. Thirteen subjects received dual-energy X-ray absorptiometry (DXA) and clinical computed tomography (CT) scans at serial time points during acute SCI separated by a mean of 3.5 months (range 2.6 to 4.8 months). Areal bone mineral density (aBMD) at the proximal femur was quantified from DXA, and proximal femoral strength was predicted using CT-based finite element (FE) modeling in a sideways fall configuration. During the acute period of SCI, femoral neck and total proximal femur aBMD decreased by 2.0 ± 1.1%/month (p < 0.001) and 2.2 ± 0.7%/month (p < 0.001), respectively. The observed reductions in aBMD were associated with a 6.9 ± 2.0%/month (p < 0.001) reduction in femoral strength. Thus, changes in femoral strength were some 3 times greater than the observed changes in aBMD (p < 0.001). It was interesting to note that in just 3.5 months of acute SCI, reductions in strength for some patients were on the order of that predicted for lifetime declines owing to aging. Therefore, it is important that therapeutic interventions are implemented soon after SCI in an effort to halt bone loss and decrease fracture risk. In addition, clinicians utilizing DXA to monitor bone health after SCI should be aware of the potential discrepancy between changes in aBMD and strength.
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Affiliation(s)
- W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada
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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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Edwards WB, Schnitzer TJ, Troy KL. Bone mineral and stiffness loss at the distal femur and proximal tibia in acute spinal cord injury. Osteoporos Int 2014; 25:1005-15. [PMID: 24190426 DOI: 10.1007/s00198-013-2557-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 08/21/2013] [Indexed: 11/24/2022]
Abstract
SUMMARY Computed tomography and finite element modeling were used to assess bone mineral and stiffness loss at the knee following acute spinal cord injury (SCI). Marked bone mineral loss was observed from a combination of trabecular and endocortical resorption. Reductions in stiffness were 2-fold greater than reductions in integral bone mineral. INTRODUCTION SCI is associated with a rapid loss of bone mineral and an increased rate of fragility fracture. The large majority of these fractures occur around regions of the knee. Our purpose was to quantify changes to bone mineral, geometry, strength indices, and stiffness at the distal femur and proximal tibia in acute SCI. METHODS Quantitative computed tomography (QCT) and patient-specific finite element analysis were performed on 13 subjects with acute SCI at serial time points separated by a mean of 3.5 months (range 2.6-4.8 months). Changes in bone mineral content (BMC) and volumetric bone mineral density (vBMD) were quantified for integral, trabecular, and cortical bone at epiphyseal, metaphyseal, and diaphyseal regions of the distal femur and proximal tibia. Changes in bone volumes, cross-sectional areas, strength indices and stiffness were also determined. RESULTS Bone mineral loss was similar in magnitude at the distal femur and proximal tibia. Reductions were most pronounced at epiphyseal regions, ranging from 3.0 % to 3.6 % per month for integral BMC (p < 0.001) and from 2.8 % to 3.4 % per month (p < 0.001) for integral vBMC. Trabecular BMC decreased by 3.1-4.4 %/month (p < 0.001) and trabecular vBMD by 2.7-4.7 %/month (p < 0.001). A 3.8-5.4 %/month reduction was observed for cortical BMC (p < 0.001); the reduction in cortical vBMD was noticeably lower (0.6-0.8 %/month; p ≤ 0.01). The cortical bone loss occurred primarily through endosteal resorption, and reductions in strength indices and stiffness were some 2-fold greater than reductions in integral bone mineral. CONCLUSIONS These findings highlight the need for therapeutic interventions targeting both trabecular and endocortical bone mineral preservation in acute SCI.
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Affiliation(s)
- W B Edwards
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, 1919 W. Taylor Street, 650 AHSB, M/C 517, Chicago, IL, 60621, USA,
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Modlesky CM, Whitney DG, Carter PT, Allerton BM, Kirby JT, Miller F. The pattern of trabecular bone microarchitecture in the distal femur of typically developing children and its effect on processing of magnetic resonance images. Bone 2014; 60:1-7. [PMID: 24269277 PMCID: PMC4485561 DOI: 10.1016/j.bone.2013.11.009] [Citation(s) in RCA: 3] [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: 07/10/2013] [Revised: 11/11/2013] [Accepted: 11/12/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) is used to assess trabecular bone microarchitecture in humans; however, image processing can be labor intensive and time consuming. One aim of this study was to determine the pattern of trabecular bone microarchitecture in the distal femur of typically developing children. A second aim was to determine the proportion and location of magnetic resonance images that need to be processed to yield representative estimates of trabecular bone microarchitecture. MATERIALS AND METHODS Twenty-six high resolution magnetic resonance images were collected immediately above the growth plate in the distal femur of 6-12year-old typically developing children (n=40). Measures of trabecular bone microarchitecture [i.e., apparent trabecular bone volume to total volume (appBV/TV), trabecular number (appTb.N), trabecular thickness (appTb.Th) and trabecular separation (appTb.Sp)] in the lateral aspect of the distal femur were determined using the twenty most central images (20IM). The average values for appBV/TV, appTb.N, appTb.Th and appTb.Sp from 20IM were compared to the average values from 10 images (10IM), 5 images (5IM) and 3 images (3IM) equally dispersed throughout the total image set and one image (1IM) from the center of the total image set using linear regression analysis. The resulting mathematical models were cross-validated using the leave-one-out technique. RESULTS Distance from the growth plate was strongly and inversely related to appBV/TV (r(2)=0.68, p<0.001) and appTb.N (r(2)=0.92, p<0.001) and was strongly and positively related to appTb.Sp (r(2)=0.86, p<0.001). The relationship between distance from the growth plate and appTb.Th was not linear (r(2)=0.06, p=0.28), but instead it was quadratic and statistically significant (r(2)=0.54, p<0.001). Trabecular bone microarchitecture estimates from 10IM, 5IM, 3IM and 1IM were not different from estimates from 20IM (p>0.05). However, there was a progressive decrease in the strength of the relationships as a smaller proportion of images were used to predict estimates from 20IM (r(2)=0.98 to 0.99 using 10IM, 0.94 to 0.96 using 5IM, 0.87 to 0.90 using 3IM and 0.66 to 0.72 using 1IM; all p<0.001). Using the resulting mathematical models and the leave-one-out cross-validation analysis, measures of trabecular bone microarchitecture estimated from the 10IM and 5IM partial image sets agreed extremely well with estimates from 20IM. CONCLUSIONS The findings indicate that partial magnetic resonance image sets can be used to provide reasonable estimates of trabecular bone microarchitecture status in the distal femur of typically developing children. However, because the relative amount of trabecular bone in the distal femur decreases with distance from the growth plate due to a decrease in trabecular number, careful positioning of the region of interest and sampling from throughout the region of interest is necessary.
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Affiliation(s)
- Christopher M Modlesky
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE 19716, USA.
| | - Daniel G Whitney
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE 19716, USA.
| | - Patrick T Carter
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE 19716, USA.
| | - Brianne M Allerton
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE 19716, USA.
| | - Joshua T Kirby
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE 19716, USA.
| | - Freeman Miller
- Department of Orthopedics, Nemours AI duPont Hospital for Children, Wilmington, DE, USA.
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Gislason MK, Coupaud S, Sasagawa K, Tanabe Y, Purcell M, Allan DB, Tanner KE. Prediction of risk of fracture in the tibia due to altered bone mineral density distribution resulting from disuse: a finite element study. Proc Inst Mech Eng H 2014; 228:165-74. [PMID: 24503510 DOI: 10.1177/0954411914522438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The disuse-related bone loss that results from immobilisation following injury shares characteristics with osteoporosis in post-menopausal women and the aged, with decreases in bone mineral density leading to weakening of the bone and increased risk of fracture. The aim of this study was to use the finite element method to: (i) calculate the mechanical response of the tibia under mechanical load and (ii) estimate of the risk of fracture; comparing between two groups, an able-bodied group and spinal cord injury patients group suffering from varying degrees of bone loss. The tibiae of eight male subjects with chronic spinal cord injury and those of four able-bodied age-matched controls were scanned using multi-slice peripheral quantitative computed tomography. Images were used to develop full three-dimensional models of the tibiae in Mimics (Materialise) and exported into Abaqus (Simulia) for calculation of stress distribution and fracture risk in response to specified loading conditions - compression, bending and torsion. The percentage of elements that exceeded a calculated value of the ultimate stress provided an estimate of the risk of fracture for each subject, which differed between spinal cord injury subjects and their controls. The differences in bone mineral density distribution along the tibia in different subjects resulted in different regions of the bone being at high risk of fracture under set loading conditions, illustrating the benefit of creating individual material distribution models. A predictive tool can be developed based on these models, to enable clinicians to estimate the amount of loading that can be safely allowed onto the skeletal frame of individual patients who suffer from extensive musculoskeletal degeneration (including spinal cord injury, multiple sclerosis and the ageing population). The ultimate aim is to reduce fracture occurrence in these vulnerable groups.
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Affiliation(s)
- Magnus K Gislason
- Departments of Mechanical and Biomedical Engineering, University of Strathclyde, Glasgow, UK
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50
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Lala D, Craven BC, Thabane L, Papaioannou A, Adachi JD, Popovic MR, Giangregorio LM. Exploring the determinants of fracture risk among individuals with spinal cord injury. Osteoporos Int 2014; 25:177-85. [PMID: 23812595 PMCID: PMC5096939 DOI: 10.1007/s00198-013-2419-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 05/08/2013] [Indexed: 01/10/2023]
Abstract
UNLABELLED In this cross-sectional study, we found that areal bone mineral density (aBMD) at the knee and specific tibia bone geometry variables are associated with fragility fractures in men and women with chronic spinal cord injury (SCI). INTRODUCTION Low aBMD of the hip and knee regions have been associated with fractures among individuals with chronic motor complete SCI; however, it is unclear whether these variables can be used to identify those at risk of fracture. In this cross-sectional study, we examined whether BMD and geometry measures are associated with lower extremity fragility fractures in individuals with chronic SCI. METHODS Adults with chronic [duration of injury ≥ 2 years] traumatic SCI (C1-L1 American Spinal Cord Injury Association Impairment Scale A-D) reported post injury lower extremity fragility fractures. Dual-energy X-ray absorptiometry (DXA) was used to measure aBMD of the hip, distal femur, and proximal tibia regions, while bone geometry at the tibia was assessed using peripheral quantitative computed tomography (pQCT). Logistic regression and univariate analyses were used to identify whether clinical characteristics or bone geometry variables were associated with fractures. RESULTS Seventy individuals with SCI [mean age (standard deviation [SD]), 48.8 (11.5); 20 females] reported 19 fragility fractures. Individuals without fractures had significantly greater aBMD of the hip and knee regions and indices of bone geometry. Every SD decrease in aBMD of the distal femur and proximal tibia, trabecular volumetric bone mineral density, and polar moment of inertia was associated with fracture prevalence after adjusting for motor complete injury (odds ratio ranged from 3.2 to 6.1). CONCLUSION Low knee aBMD and suboptimal bone geometry are significantly associated with fractures. Prospective studies are necessary to confirm the bone parameters reported to predict fracture risk in individuals with low bone mass and chronic SCI.
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Affiliation(s)
- D Lala
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, Canada
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