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Pataraia A, Mayr W, Vargas Luna JL, Sternik J, Crevenna R. Feasibility of complex exercise therapy with Standing Ovation and peripheral neuromodulation for gait rehabilitation after incomplete spinal cord injury-a case report. Wien Med Wochenschr 2024:10.1007/s10354-024-01046-8. [PMID: 38836949 DOI: 10.1007/s10354-024-01046-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/02/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Spinal cord injuries (SCIs) are a global concern, annually affecting hundreds of thousands of individuals. Among these cases, incomplete SCIs, allowing some muscle activity below the injury, pose unique challenges. This case study focuses on a 55-year-old male with a moderate incomplete SCI (AIS-D). CASE PRESENTATION After initial treatments and pharmaceutical antispastic therapy, a novel intervention was introduced featuring the Standing Ovation gait exercise system (Standing Ovation GmbH, Hallwang, Austria). This individually tailored system, equipped with a rail system and seat-lifting unit, provided a secure environment for balance training. Over 14 training sessions spanning from October 13, 2021, to March 23, 2022, improvements in functional walking were observed. DISCUSSION AND CONCLUSION Locomotor improvement in SCI rehabilitation is important; the potential of task-specific gait exercises with the Standing Ovation system in incomplete spinal cord injury seems to be a promising approach. Although promising, these findings call for further systematic studies with larger patient cohorts to strengthen their reliability. Ongoing research endeavors are essential to fully understand the benefits and limitations of this intervention in spinal cord injury rehabilitation.
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Affiliation(s)
- Anna Pataraia
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria.
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Winfried Mayr
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Jose Luis Vargas Luna
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Julia Sternik
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Richard Crevenna
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
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Metzger CE, Moore RC, Pirkle AS, Tak LY, Rau J, Bryan JA, Stefanov A, Allen MR, Hook MA. A moderate spinal contusion injury in rats alters bone turnover both below and above the level of injury with sex-based differences apparent in long-term recovery. Bone Rep 2024; 21:101761. [PMID: 38646090 PMCID: PMC11033081 DOI: 10.1016/j.bonr.2024.101761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/07/2024] [Indexed: 04/23/2024] Open
Abstract
Spinal cord injury (SCI) leads to significant sublesional bone loss and high fracture rates. While loss of mechanical loading plays a significant role in SCI-induced bone loss, animal studies have demonstrated mechanical loading alone does not fully account for loss of bone following SCI. Indeed, we have shown that bone loss occurs below the level of an incomplete moderate contusion SCI, despite the resumption of weight-bearing and stepping. As systemic factors could also impact bone after SCI, bone alterations may also be present in bone sites above the level of injury. To examine this, we assessed bone microarchitecture and bone turnover in the supralesional humerus in male and female rats at two different ages following a moderate contusion injury in both sub-chronic (30 days) and chronic (180 days) time points after injury. At the 30-day timepoint, we found that both young and adult male SCI rats had decrements in trabecular bone volume at the supralesional proximal humerus (PH), while female SCI rats were not different from age-matched shams. At the 180-day timepoint, there were no statistical differences between SCI and sham groups, irrespective of age or sex, at the supralesional proximal humerus. At the 30-day timepoint, all SCI rats had lower BFR and higher osteoclast-covered trabecular surfaces in the proximal humerus compared to age-matched sham groups generally matching the pattern of SCI-induced changes in bone turnover seen in the sublesional proximal tibia. However, at the 180-day timepoint, only male SCI rats had lower BFR at the supralesional proximal humerus while female SCI rats had higher or no different BFR than their age-matched counterparts. Overall, this preclinical study demonstrates that a moderate contusion SCI leads to alterations in bone turnover above the level of injury within 30-days of injury; however male SCI rats maintained lower BFR in the supralesional humerus into long-term recovery. These data further highlight that bone loss after SCI is not driven solely by disuse. Additionally, these data allude to potential systemic factors exerting influence on bone following SCI and highlight the need to consider treatments for SCI-induced bone loss that impact both sublesional and systemic factors.
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Affiliation(s)
- Corinne E. Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Robert C. Moore
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Alexander S. Pirkle
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Landon Y. Tak
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Josephina Rau
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, United States of America
| | - Jessica A. Bryan
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, United States of America
| | - Alexander Stefanov
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, United States of America
| | - Matthew R. Allen
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Michelle A. Hook
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, United States of America
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Kim S, Kim B, Han KD, Park J, Yoo JE, Choi HL, Chang WH, Cho IY, Shin DW. Risk of fracture among patients with spinal cord injury: A nationwide cohort study in South Korea. Bone 2024; 183:117093. [PMID: 38579925 DOI: 10.1016/j.bone.2024.117093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Clinical concerns about preventing and managing fractures after spinal cord injury (SCI) have been growing. OBJECTIVE This study investigates the risk of fractures among SCI patients according to the presence of disability, disease severity, and level of injury. METHODS We performed a retrospective cohort study using the Korean National Health Insurance Service (KNHIS 2010-2018) database. We included 5190 SCI patients and 1:3 age- and sex-matched control participants. The primary outcome was fracture, and the cohort was followed until December 31, 2019. RESULTS SCI patients had a higher fracture risk than the matched controls (adjusted hazard ratio [aHR] 1.33, 95 % CI 1.16-1.54). The risk of fracture was higher in the presence of disability (aHR 1.57, 95 % CI 1.19-2.07), especially among patients with severe disability (aHR 1.65, 95 % CI 1.05-2.60). Higher fracture risks were observed among SCI patients regardless of injury level, but statistical significance was found only with cervical-level injury. When we considered site-specific fractures, vertebral (aHR 1.31, 95 % CI 1.04-1.64) and hip fracture risks (aHR 2.04, 95 % CI 1.39-2.98) were both higher among SCI patients than the controls. SCI patients with disability and cervical-level injury showed the highest hip fracture risk (aHR 3.67, 95 % CI 1.90-7.07). CONCLUSIONS Compared with the controls, SCI patients were at higher risk of any fracture, particularly hip fracture, especially those with disability and cervical-level injury. Clinicians should be aware of the fracture risk among SCI patients to provide proper management.
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Affiliation(s)
- Seonghye Kim
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Junhee Park
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Yoo
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hea Lim Choi
- Department of Family Medicine, Executive Healthcare Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Science and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - In Young Cho
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Science and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
| | - Dong Wook Shin
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Science and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea; Department of Digital Health, Samsung Advanced Institute for Health Science and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
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Valderrábano RJ, Pencina K, Shang YV, Echevarria E, Dixon R, Ghattas C, Wilson L, Reid KF, Storer T, Garrahan M, Tedtsen T, Zafonte R, Bouxsein M, Bhasin S. Bone microarchitectural alterations associated with spinal cord injury: Relation to sex hormones, metabolic factors, and loading. Bone 2024; 181:117039. [PMID: 38325649 DOI: 10.1016/j.bone.2024.117039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/04/2024] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
CONTEXT People living with spinal cord injury (SCI) are at high risk for bone fractures. Neural, hormonal and metabolic contributors to bone microarchitectural alterations are incompletely understood. OBJECTIVE To determine the relationship of physical, metabolic and endocrine characteristics with bone microarchitecture, characterized using high-resolution peripheral quantitative computed tomography (HRpQCT) in SCI. DESIGN Cross-sectional analyses of bone properties in people with SCI. PARTICIPANTS Twenty adults with SCI and paraplegia (12) or motor incomplete quadriplegia (8). OUTCOME MEASURES Distal tibia and radius HRpQCT parameters, including density, microstructure and strength by microfinite element anaysis (μFEA); sex hormones; metabolic and inflammatory markers. RESULTS The mean age of the participants with SCI was 41.5 ± 10.3 years, BMI 25.7 ± 6.2 kg/m2, time since injury 10.4 ± 9.0 years. Participants with SCI had significantly lower median total (Z score - 3.3), trabecular (-2.93), and cortical vBMD (-1.87), and Failure Load by μFEA (-2.48) at the tibia than controls. However, radius vBMD, aBMD and microarchitecture were similar in participants with SCI and un-injured controls. Unexpectedly, C-Reactive Protein (CRP) was positively associated with tibial trabecular vBMD (β = 0.77, p = 0.02), thickness (β = 0.52, p = 0.04) and number (β = 0.92, p = 0.02). At the radius, estradiol level was positively associated with total vBMD (β = 0.59, p = 0.01), trabecular thickness (β = 0.43, p = 0.04), cortical thickness (β = 0.63, p = 0.01) and cortical porosity (β = 0.74 p = 0.04). CONCLUSIONS Radius vBMD and microarchitecture is preserved but tibial total, cortical and trabecular vBMD, and estimated bone strength are markedly lower and bone microarchitectural parameters substantially degraded in people with SCI. The alterations in bone microarchitecture in people with SCI are likely multifactorial, however marked degradation of bone microarchitecture in tibia but not radius suggests that unloading is an important contributor of site-specific alterations of bone microarchitecture after SCI. Fracture prevention in SCI should focus on strategies to safely increase bone loading. CLINICALTRIALS gov registration #: (NCT03576001).
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Affiliation(s)
- Rodrigo J Valderrábano
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Karol Pencina
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Yili-Valentine Shang
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Evelyn Echevarria
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Robert Dixon
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Laboratory of Exercise Physiology and Physical Performance, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Catherine Ghattas
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Lauren Wilson
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Kieran F Reid
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Laboratory of Exercise Physiology and Physical Performance, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Thomas Storer
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Margaret Garrahan
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Trinity Tedtsen
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Mary Bouxsein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Shalender Bhasin
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
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Forrest A, Eaddy SG, Fulton ZW, Boothby B. Bilateral Intertrochanteric Femur Fractures in a Paraplegic Patient: A Case Report. Cureus 2024; 16:e54883. [PMID: 38533172 PMCID: PMC10964221 DOI: 10.7759/cureus.54883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2024] [Indexed: 03/28/2024] Open
Abstract
Bilateral intertrochanteric (IT) femur fractures are rare, and appropriate evaluation and treatment can vary depending on concurrent patient comorbidities. Even less has been described for patients with bilateral IT fractures with pre-existing paraplegia. This case report describes the unique case of a 72-year-old paraplegic female who presented with bilateral IT femur fractures due to a wheelchair accident. The patient was treated with single-stage bilateral cephalomedullary nail fixation so she could effectively transfer to and from the wheelchair with less pain and a greater chance of fracture union. At the last follow-up, the patient's pain had resolved and she was able to transfer as effectively and safely as her pre-injury baseline. Single-stage cephalomedullary fixation of bilateral IT femur fractures is indicated in the paraplegic population to relieve pain and improve effective safe transfers for daily activities.
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Affiliation(s)
- Anthony Forrest
- Orthopedic Surgery, Mercy Health St. Vincent Medical Center, Toledo, USA
| | - Samuel G Eaddy
- Orthopedic Surgery, Mercy Health St. Vincent Medical Center, Toledo, USA
| | - Zachary W Fulton
- Orthopedic Surgery, Mercy Health St. Vincent Medical Center, Toledo, USA
| | - Benjamin Boothby
- Orthopedic Surgery, Mercy Health St. Vincent Medical Center, Toledo, USA
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Bass A, Morin SN, Guidea M, Lam JTAT, Karelis AD, Aubertin-Leheudre M, Gagnon DH. Potential Effects of an Exoskeleton-Assisted Overground Walking Program for Individuals With Spinal Cord Injury Who Uses a Wheelchair on Imaging and Serum Markers of Bone Strength: Pre-Post Study. JMIR Rehabil Assist Technol 2024; 11:e53084. [PMID: 38163294 PMCID: PMC10790203 DOI: 10.2196/53084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND As many as 60% of individuals use a wheelchair long term after a spinal cord injury (SCI). This mode of locomotion leads to chronic decline in lower-extremity weight-bearing activities and contributes to the development of severe sublesional osteoporosis and high rates of fragility fracture. Overground exoskeleton-assisted walking programs provide a novel opportunity to increase lower-extremity weight bearing, with the potential to improve bone health. OBJECTIVE The aim of the study is to measure the potential effects of an exoskeleton-assisted walking program on lower-extremity bone strength and bone remodeling biomarkers in individuals with chronic (≥18 months) SCI who use a wheelchair. METHODS In total, 10 participants completed a 16-week exoskeleton-assisted walking program (34 individualized 1-hour sessions, progressing from 1 to 3 per week). Bone mineral density and bone strength markers (dual-energy x-ray absorptiometry: total body, left arm, leg, total hip, and femoral neck and peripheral quantitative computed tomography: 25% of left femur and 66% of left tibia) as well as bone remodeling biomarkers (formation=osteocalcin and resorption=C-telopeptide) were measured before and after intervention and compared using nonparametric tests. Changes were considered significant and meaningful if the following criteria were met: P<0.1, effect size ≥0.5, and relative variation >5%. RESULTS Significant and meaningful increases were observed at the femur (femoral neck bone mineral content, bone strength index, and stress-strain index) and tibia (cortical cross-sectional area and polar moment of inertia) after the intervention (all P<.10). We also noted a decrease in estimated femoral cortical thickness. However, no changes in bone remodeling biomarkers were found. CONCLUSIONS These initial results suggest promising improvements in bone strength markers after a 16-week exoskeleton-assisted walking program in individuals with chronic SCI. Additional research with larger sample sizes, longer interventions (possibly of greater loading intensity), and combined modalities (eg, pharmacotherapy or functional electrical stimulation) are warranted to strengthen current evidence. TRIAL REGISTRATION ClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/19251.
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Affiliation(s)
- Alec Bass
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montréal, QC, Canada
| | - Michael Guidea
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Jacqueline T A T Lam
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Antony D Karelis
- Department of Exercise Science, Faculty of Sciences, Université du Québec à Montréal, Montréal, QC, Canada
| | - Mylène Aubertin-Leheudre
- Department of Exercise Science, Faculty of Sciences, Université du Québec à Montréal, Montréal, QC, Canada
- Centre de Recherche de l'Institut Universitaire de Gériatrie de Montréal (CRIUGM), Montréal, QC, Canada
| | - Dany H Gagnon
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, Canada
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Pelletier C. Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines. Appl Physiol Nutr Metab 2023; 48:882-895. [PMID: 37816259 DOI: 10.1139/apnm-2023-0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Persons with spinal cord injury (SCI) experience gains in fitness, physical and mental health from regular participation in exercise and physical activity. Due to changes in physiological function of the cardiovascular, nervous, and muscular systems, general population physical activity guidelines and traditional exercise prescription methods are not appropriate for the SCI population. Exercise guidelines specific to persons with SCI recommend progressive training beginning at 20 min of moderate to vigorous intensity aerobic exercise twice per week transitioning to 30 min three times per week, with strength training of the major muscle groups two times per week. These population-specific guidelines were designed considering the substantial barriers to physical activity for persons with SCI and can be used to frame an individual exercise prescription. Rating of perceived exertion (i.e., perceptually regulated exercise) is a practical way to indicate moderate to vigorous intensity exercise in community settings. Adapted exercise modes include arm cycle ergometry, hybrid arm-leg cycling, and recumbent elliptical equipment. Body weight-supported treadmill training and other rehabilitation modalities may improve some aspects of health and fitness for people with SCI if completed at sufficient intensity. Disability-specific community programs offer beneficial opportunities for persons with SCI to experience quality exercise opportunities but are not universally available.
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Affiliation(s)
- Chelsea Pelletier
- School of Health Sciences, Faculty of Human and Health Sciences, University of Northern British Columbia, Prince George, BC, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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8
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Han S, Shin S, Kim O, Hong N. Characteristics Associated with Bone Loss after Spinal Cord Injury: Implications for Hip Region Vulnerability. Endocrinol Metab (Seoul) 2023; 38:578-587. [PMID: 37816499 PMCID: PMC10613772 DOI: 10.3803/enm.2023.1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGRUOUND In individuals with spinal cord injury (SCI), bone loss progresses rapidly to the area below the level of injury, leading to an increased risk of fracture. However, there are limited data regarding SCI-relevant characteristics for bone loss and the degree of bone loss in individuals with SCI compared with that in non-SCI community-dwelling adults. METHODS Data from men with SCI who underwent dual-energy X-ray absorptiometry at the National Rehabilitation Center (2008 to 2020) between 12 and 36 months after injury were collected and analyzed. Community-dwelling men were matched 1:1 for age, height, and weight as the control group, using data from the Korea National Health and Nutrition Examination Survey (KNHANES, 2008 to 2011). RESULTS A comparison of the SCI and the matched control group revealed significantly lower hip region T-scores in the SCI group, whereas the lumbar spine T-score did not differ between groups. Among the 113 men with SCI, the paraplegia group exhibited significantly higher Z-scores of the hip region than the tetraplegia group. Participants with motor-incomplete SCI showed relatively preserved Z-scores of the hip region compared to those of the lumbar region. Moreover, in participants with SCI, the percentage of skeletal muscle displayed a moderate positive correlation with femoral neck Z-scores. CONCLUSION Men with SCI exhibited significantly lower bone mineral density of the hip region than community-dwelling men. Paraplegia rather than tetraplegia, and motor incompleteness rather than motor completeness were protective factors in the hip region. Caution for loss of skeletal muscle mass or increased adiposity is also required.
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Affiliation(s)
- Sora Han
- Department of Rehabilitation Medicine, National Rehabilitation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sungjae Shin
- Division of Endocrinology, Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Onyoo Kim
- Department of Rehabilitation Medicine, National Rehabilitation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Division of Endocrinology, Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Maïmoun L, Gelis A, Serrand C, Mura T, Humbert L, Boudousq V, de Santa-Barbara P, Laux D, Fattal C, Mariano-Goulart D. Alteration of Volumetric Bone Mineral Density Parameters in Men with Spinal Cord Injury. Calcif Tissue Int 2023; 113:304-316. [PMID: 37353625 DOI: 10.1007/s00223-023-01110-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/15/2023] [Indexed: 06/25/2023]
Abstract
Spinal cord injury (SCI) induces severe losses of trabecular and cortical volumetric bone mineral density (vBMD), which cannot be discriminated with conventional dual-energy X-ray absorptiometry (DXA) analysis. The objectives were to: (i) determine the effects of SCI on areal BMD (aBMD) and vBMD determined by advanced 3D-DXA-based methods at various femoral regions and (ii) model the profiles of 3D-DXA-derived parameters with the time since injury. Eighty adult males with SCI and 25 age-matched able-bodied (AB) controls were enrolled in this study. Trabecular and cortical vBMD, cortical thickness and derived strength parameters were assessed by 3D-SHAPER® software at various femoral subregions. Individuals with SCI had significantly lower integral vBMD, trabecular vBMD, cortical vBMD, cortical thickness and derived bone strength parameters (p < 0.001 for all) in total proximal femur compared with AB controls. These alterations were approximately to the same degree for all three femoral subregions, and the difference between the two groups tended to be greater for cortical vBMD than trabecular vBMD. There were minor differences according to the lesion level (paraplegics vs tetraplegics) for all 3D-DXA-derived parameters. For total proximal femur, the decreasing bone parameters tended to reach a new steady state after 5.1 years for integral vBMD, 7.4 years for trabecular vBMD and 9.2 years for cortical vBMD following SCI. At proximal femur, lower vBMD (integral, cortical and trabecular) and cortical thickness resulted in low estimated bone strength in individuals with SCI. It remains to be demonstrated whether these new parameters are more closely associated with fragility fracture than aBMD.
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Affiliation(s)
- Laurent Maïmoun
- Département de Médecine Nucléaire, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France.
- Département de Biophysique, Service de Médecine Nucléaire, PhyMedExp, INSERM, CNRS, Université de Montpellier, Hôpital Lapeyronie, 371, Avenue du Doyen Gaston Giraud, 34295, cedex 5, Montpellier, France.
| | | | - Chris Serrand
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, Nimes University Hospital, University of Montpellier, Nîmes, France
| | - Thibault Mura
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, Nimes University Hospital, University of Montpellier, Nîmes, France
| | | | - Vincent Boudousq
- Département de Médecine Nucléaire, Hôpital Carémeau, CHRU Nîmes, Nîmes, France
| | - Pascal de Santa-Barbara
- Département de Biophysique, Service de Médecine Nucléaire, PhyMedExp, INSERM, CNRS, Université de Montpellier, Hôpital Lapeyronie, 371, Avenue du Doyen Gaston Giraud, 34295, cedex 5, Montpellier, France
| | - Didier Laux
- Institut d'Electronique Et Des Système, UMR CNRS 5214, Université de Montpellier, Montpellier, France
| | | | - Denis Mariano-Goulart
- Département de Médecine Nucléaire, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
- Département de Biophysique, Service de Médecine Nucléaire, PhyMedExp, INSERM, CNRS, Université de Montpellier, Hôpital Lapeyronie, 371, Avenue du Doyen Gaston Giraud, 34295, cedex 5, Montpellier, France
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10
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Mazur CM, Edwards WB, Haider IT, Fang Y, Morse LR, Schnitzer TJ, Simonian N, Troy KL. Bone Mineral Loss at the Distal Femur and Proximal Tibia Following Spinal Cord Injury in Men and Women. J Clin Densitom 2023; 26:101380. [PMID: 37201436 DOI: 10.1016/j.jocd.2023.101380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Spinal cord injury (SCI) causes rapid bone loss and increases risk of fragility fractures in the lower extremities. The majority of individuals with SCI are men, and few studies have investigated sex as a biological variable in SCI-induced osteoporosis. This cross-sectional study aimed to quantify sex-specific differences in bone mineral following SCI. METHODS Quantitative computed tomography (QCT) scans of the distal femur and proximal tibia were obtained at baseline of one of four clinical trials enrolling people who sustained SCI 1 month to 50 years prior to recruitment. Bone volume (BV), bone mineral content (BMC), bone mineral density (BMD), and bending strength index (BSI) were quantified in the integral, trabecular, and cortical bone in the epiphysis, metaphysis and diaphysis. Scans from 106 men and 31 women were analyzed to measure sex-specific effects on bone loss over time post-SCI. RESULTS BMC and BSI declined exponentially as a function of time post-SCI and were best described by separate decay curves for men and women. Women had BV, BMC, and BSI at 58-77% that of men in the acute and plateau phases, with both sexes showing similar rates of loss as a function of time post-SCI. Trabecular BMD was best described as an exponential decay versus time post-SCI, with no sex-specific differences. CONCLUSIONS Due to consistently lower BV, BMC, and BSI, women may be more susceptible to fractures after SCI than men.
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Affiliation(s)
- Courtney M Mazur
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ifaz T Haider
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ying Fang
- Department of Physical Therapy, Rosalind Franklin University, North Chicago, IL, United States
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Narina Simonian
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Karen L Troy
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA United States.
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11
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Craven BC, Cirnigliaro CM, Carbone LD, Tsang P, Morse LR. The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury. J Pers Med 2023; 13:966. [PMID: 37373955 DOI: 10.3390/jpm13060966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The prevention of lower extremity fractures and fracture-related morbidity and mortality is a critical component of health services for adults living with chronic spinal cord injury (SCI). METHODS Established best practices and guideline recommendations are articulated in recent international consensus documents from the International Society of Clinical Densitometry, the Paralyzed Veterans of America Consortium for Spinal Cord Medicine and the Orthopedic Trauma Association. RESULTS This review is a synthesis of the aforementioned consensus documents, which highlight the pathophysiology of lower extremity bone mineral density (BMD) decline after acute SCI. The role and actions treating clinicians should take to screen, diagnose and initiate the appropriate treatment of established low bone mass/osteoporosis of the hip, distal femur or proximal tibia regions associated with moderate or high fracture risk or diagnose and manage a lower extremity fracture among adults with chronic SCI are articulated. Guidance regarding the prescription of dietary calcium, vitamin D supplements, rehabilitation interventions (passive standing, functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)) to modify bone mass and/or anti-resorptive drug therapy (Alendronate, Denosumab, or Zoledronic Acid) is provided. In the event of lower extremity fracture, the need for timely orthopedic consultation for fracture diagnosis and interprofessional care following definitive fracture management to prevent health complications (venous thromboembolism, pressure injury, and autonomic dysreflexia) and rehabilitation interventions to return the individual to his/her pre-fracture functional abilities is emphasized. CONCLUSIONS Interprofessional care teams should use recent consensus publications to drive sustained practice change to mitigate fracture incidence and fracture-related morbidity and mortality among adults with chronic SCI.
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Affiliation(s)
- Beverley Catharine Craven
- KITE Research Institute, 520 Sutherland Dr, Toronto, ON M4G 3V9, Canada
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada
| | - Christopher M Cirnigliaro
- Department of Veterans Affairs Rehabilitation, Research, and Development Service, Spinal Cord Damage Research Center, Bronx, NY 10468, USA
| | - Laura D Carbone
- Department of Medicine: Rheumatology, Medical College of Georgia, Augusta University, 1120 15th St, Augusta, GA 30912, USA
| | - Philemon Tsang
- KITE Research Institute, 520 Sutherland Dr, Toronto, ON M4G 3V9, Canada
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota, 500 Harvard St SE, Minneapolis, MN 55455, USA
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12
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Abdelrahman S, Purcell M, Rantalainen T, Coupaud S, Ireland A. Regional and temporal variation in bone loss during the first year following spinal cord injury. Bone 2023; 171:116726. [PMID: 36871898 DOI: 10.1016/j.bone.2023.116726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
Osteoporosis is a consequence of spinal cord injury (SCI) that leads to fragility fractures. Visual assessment of bone scans suggests regional variation in bone loss, but this has not been objectively characterised. In addition, substantial inter-individual variation in bone loss following SCI has been reported but it is unclear how to identify fast bone losers. Therefore, to examine regional bone loss, tibial bone parameters were assessed in 13 individuals with SCI (aged 16-76 years). Peripheral quantitative computed tomography scans at 4 % and 66 % tibia length were acquired within 5 weeks, 4 months and 12 months postinjury. Changes in total bone mineral content (BMC), and bone mineral density (BMD) were assessed in ten concentric sectors at the 4 % site. Regional changes in BMC and cortical BMD were analysed in thirty-six polar sectors at the 66 % site using linear mixed effects models. Relationships between regional and total loss at 4 months and 12 months timepoints were assessed using Pearson correlation. At the 4 % site, total BMC (P = 0.001) decreased with time. Relative losses were equal across the sectors (all P > 0.1). At the 66 % site, BMC and cortical BMD absolute losses were similar (all P > 0.3 and P > 0.05, respectively) across polar sectors, but relative loss was greatest in the posterior region (all P < 0.01). At both sites, total BMC loss at 4 months was strongly positively associated with the total loss at 12 months (r = 0.84 and r = 0.82 respectively, both P < 0.001). This correlation was stronger than those observed with 4-month BMD loss in several radial and polar sectors (r = 0.56-0.77, P < 0.05). These results confirm that SCI-induced bone loss varies regionally in the tibial diaphysis. Moreover, bone loss at 4 months is a strong predictor of total loss 12 months postinjury. More studies on larger populations are required to confirm these findings.
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Affiliation(s)
- Shima Abdelrahman
- Department of Biomedical Engineering, Wolfson Building, University of Strathclyde, Glasgow, United Kingdom; Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom; Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Manchester Metropolitan University, Manchester, United Kingdom.
| | - Mariel Purcell
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Timo Rantalainen
- Neuromuscular Research Center, Department of Biology of Physical Activity, University of Jyväskylä, Finland
| | - Sylvie Coupaud
- Department of Biomedical Engineering, Wolfson Building, University of Strathclyde, Glasgow, United Kingdom; Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alex Ireland
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Manchester Metropolitan University, Manchester, United Kingdom
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13
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Alazzam AM, Goldsmith JA, Khalil RE, Khan MR, Gorgey AS. Denervation impacts muscle quality and knee bone mineral density after spinal cord injury. Spinal Cord 2023; 61:276-284. [PMID: 36899099 DOI: 10.1038/s41393-023-00885-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/12/2023]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVES To compare muscle size, body composition, bone mineral density (BMD), and metabolic profiles in denervated versus innervated individuals with spinal cord injury (SCI). SETTING Hunter Holmes McGuire Veterans Affairs (VA) Medical Center. METHODS Body composition, bone mineral density (BMD), muscle size, and metabolic parameters were collected in 16 persons with chronic SCI (n = 8 denervated, n = 8 innervated) using dual-energy x-ray absorptiometry (DXA), magnetic resonance imaging (MRI), and fasting blood samples. BMR was measured by indirect calorimetry. RESULTS Percent differences of the whole thigh muscle cross-sectional area (CSA; 38%), knee extensor CSA (49%), vasti CSA (49%), and rectus femoris CSA (61%) were smaller in the denervated group (p < 0.05). Leg lean mass was also lower (28%) in the denervated group (p < 0.05). Whole muscle intramuscular fat (IMF%; 15.5%), knee extensor IMF% (22%), and % fat mass (10.9%) were significantly greater in the denervated group (p < 0.05). Knee distal femur and proximal tibia BMD were lower in the denervated group, 18-22% and 17-23%; p < 0.05. Certain indices of metabolic profile were more favorable in the denervated group though were not significant. CONCLUSIONS SCI results in skeletal muscle atrophy and dramatic changes in body composition. Lower motor neuron (LMN) injury results in denervation of the lower extremity muscles which exacerbates atrophy. Denervated participants exhibited lower leg lean mass and muscle CSA, greater muscle IMF, and reduced knee BMD compared to innervated participants. Future research is needed to explore therapeutic treatments for the denervated muscles after SCI.
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Affiliation(s)
- Ahmad M Alazzam
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Jacob A Goldsmith
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Refka E Khalil
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - M Rehan Khan
- Radiology Services, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ashraf S Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA. .,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA.
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14
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A Scoping Review of the Recent Clinical Practice Regarding the Evaluation of Bone Mineral Density in Children and Adolescents with Neuromuscular Diseases. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020312. [PMID: 36837513 PMCID: PMC9967238 DOI: 10.3390/medicina59020312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/22/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
Introduction: Neuromuscular Diseases (NMD) are associated with decreased bone strength due to altered muscle-bone interaction. However, the evaluation of bone quality remains a certain challenge in these patients. The purpose of this scoping review is to investigate the recent literature regarding the assessment of Bone Mineral Density (BMD) in this population. Methods: An electronic search of the PubMed and Scopus database was performed considering studies published in the English literature after 2007 that evaluated BMD in pediatric and adolescent patients with NMD. We excluded studies that evaluated patients > 20 years, studies not involving humans, and studies investigating bone mineral density in various pediatric conditions, but without specific data on NMD. Results: Overall, 19 studies were included that evaluated BMD in 1983 patients with NMD. Duchenne Muscular Dystrophy was the most widely studied disease (n = 11 studies). Dual energy X-ray absorptiometry (DEXA) was the most common diagnostic modality for BMD evaluation, while the most frequent site for BMD measurement was the lumbar spine (89.4%, n = 17 studies), followed by total body BMD (68.4%, n = 13 studies). Low BMD in children with NMD was demonstrated in all studies, especially after loss of ambulation. Moreover, a positive correlation between lower BMD and older age was shown. Conclusions: BMD evaluation in NMD remains a clinical challenge, as indicated by the high heterogeneity regarding the optimal site and technique for the evaluation of bone quality in these patients. Although DXA is currently the diagnostic modality of choice, a consensus regarding the optimal site for BMD measurement, and the adjustment method for its obtained measurements for parameters such as age and height is needed.
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15
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Lippi L, Folli A, Turco A, Moalli S, Curci C, Ammendolia A, de Sire A, Invernizzi M. The impact of rehabilitation in bone loss management of patients with spinal cord injury: A systematic review. J Back Musculoskelet Rehabil 2023; 36:1219-1235. [PMID: 37482985 DOI: 10.3233/bmr-230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND Spinal cord injury (SCI) is a disabling condition characterized by multilevel skeletal muscle impairment and rapid cortical and trabecular bone loss. Rehabilitation is a cornerstone of the long-term management of patients with SCI; however, the optimal rehabilitation strategy for improving bone health has not been fully characterized. OBJECTIVE To characterize the current evidence supporting different rehabilitation interventions improving bone health in patients with SCI. METHODS On November 17th, 2022, five databases (PubMed, Scopus, Web of Science, Cochrane, and PEDro) were systematically searched for randomized controlled trials (RCTs) assessing SCI patients undergoing rehabilitation interventions. The primary outcomes were bone macroscopical effects. Secondary outcomes were changes in bone metabolisms and functional outcomes. RESULTS Out of 499 records, 11 RCTs met the eligibility criteria and were included. Electrical stimulation combined with physical exercise was assessed by 5 studies, standing intervention was assessed by 3 studies, vibration was assessed by 1 study, ultrasound therapy was assessed by 1 study, and electroacupuncture combined with a pulsed magnetic field was assessed by 1 study. The rehabilitation intervention was administered combined with pharmacological treatment (3 studies) or alone (8 studies). Positive effects in terms of BMD were reported by 3 studies. The quality assessment revealed some concerns in 9 out of 11 studies, in accordance with the Cochrane Risk of Bias assessment - version 2. CONCLUSION Our data suggest that multicomponent interventions including rehabilitation might be considered a suitable option to improve bone health management in SCI patients. Further studies are mandatory to characterize the optimal combination of non-pharmacological interventions reducing bone loss and improving the risk of fractures in patients with SCI.
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Affiliation(s)
- Lorenzo Lippi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Arianna Folli
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Alessio Turco
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Stefano Moalli
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Claudio Curci
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, ASST Carlo Poma, Mantova, Italy
| | - Antonio Ammendolia
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro Magna Graecia, Catanzaro, Italy
| | - Alessandro de Sire
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro Magna Graecia, Catanzaro, Italy
| | - Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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16
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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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17
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Metzger C, Rau J, Stefanov A, Joseph RM, Allaway HC, Allen MR, Hook MA. Inflammaging and bone loss in a rat model of spinal cord injury. J Neurotrauma 2022; 40:901-917. [PMID: 36226413 DOI: 10.1089/neu.2022.0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Spinal cord injury (SCI) results in significant loss of sublesional bone, adding to the comorbidity of SCI with an increased risk of fracture and post-fracture complications. Unfortunately, the effect of SCI on skeletal health is also likely to rise as the average age of SCI has increased and there are well-known negative effects of age on bone. To date, however, the impact of age and age-associated inflammation (inflammaging) on skeletal health after SCI remains largely unknown. To address this, we compared bone parameters in young (3 month) and middle-aged (9 month) male and female rats with a moderate thoracic contusion injury, to age and sex matched sham-operated controls. Skeletal parameters, locomotor function and serum cytokine levels were assessed at both subchronic (30 days) and chronic (180 days) time points post injury. We hypothesized that SCI would lead to a dramatic loss of bone immediately after injury in all SCI-groups, with inflammaging leading to greater loss in middle-aged SCI rats. We also predicted that while younger rats may re-establish bone properties in more chronic phases of SCI, middle-aged rats would not. Supporting these hypothesis, trabecular bone volume was significantly lower in male and young female SCI rats early after injury. Contrary to our hypothesis, however, there was greater loss of trabecular bone volume, relative to age-matched shams, in young compared to middle-aged SCI rats with no effects of SCI on trabecular bone volume in middle-aged female rats. Moreover, despite recovery of weight-supported locomotor activity, bone loss persisted into the chronic phase of injury for the young rats. Bone formation rates were lower in young male SCI rats, regardless of the time since injury, while both young and middle-aged female SCI rats had lower bone formation in the subchronic but not chronic phase of SCI. In middle-aged rats, SCI-induced higher osteoclast surfaces, which also persisted into the chronic phase of SCI in middle-aged females. Neither age nor SCI-induced increases in inflammation seemed to be associated with bone loss. In fact, SCI had more dramatic and persistent effects on bone in male rats, while aging and SCI elevated serum cytokines only in female rats. Overall, this study demonstrates SCI-induced loss of bone and altered bone turnover in male and female rats that persists into the chronic phase post-injury. The sex and age dependent variations in bone turnover and serum cytokines, however, underscore the need to further explore both mechanisms and potential therapeutics in multiple demographics.
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Affiliation(s)
- Corinne Metzger
- Indiana University School of Medicine, 12250, Anatomy Cell Biology Physiology, Indianapolis, Indiana, United States;
| | - Josephina Rau
- Texas A&M University Health Science Center Department of Neuroscience and Experimental Therapeutics, 205278, 8447 Riverside Parkway, Bryan, Texas, United States, 77807-3260;
| | - Alexander Stefanov
- Texas A&M University Health Science Center Department of Neuroscience and Experimental Therapeutics, 205278, 8447 Riverside Pkwy, Bryan, Texas, United States, 77807.,Texas A&M Institute for Neuroscience, 464968, College Station, Texas, United States;
| | - Rose M Joseph
- Texas A&M School of Medicine, Department of Neuroscience and Experimental Therapeutics, Bryan, Texas, United States;
| | - Heather C Allaway
- Louisiana State University, 5779, School of Kinesiology, Baton Rouge, Louisiana, United States;
| | - Matthew R Allen
- Indiana University School of Medicine, 12250, Anatomy Cell Biology Physiology, Indianapolis, Indiana, United States;
| | - Michelle A Hook
- Texas A&M School of Medicine, Department of Neuroscience and Experimental Therapeutics, Bryan, Texas, United States;
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Abstract
Disuse osteoporosis describes a state of bone loss due to local skeletal unloading or systemic immobilization. This review will discuss advances in the field that have shed light on clinical observations, mechanistic insights and options for the treatment of disuse osteoporosis. Clinical settings of disuse osteoporosis include spinal cord injury, other neurological and neuromuscular disorders, immobilization after fractures and bed rest (real or modeled). Furthermore, spaceflight-induced bone loss represents a well-known adaptive process to microgravity. Clinical studies have outlined that immobilization leads to immediate bone loss in both the trabecular and cortical compartments accompanied by relatively increased bone resorption and decreased bone formation. The fact that the low bone formation state has been linked to high levels of the osteocyte-secreted protein sclerostin is one of the many findings that has brought matrix-embedded, mechanosensitive osteocytes into focus in the search for mechanistic principles. Previous basic research has primarily involved rodent models based on tail suspension, spaceflight and other immobilization methods, which have underlined the importance of osteocytes in the pathogenesis of disuse osteoporosis. Furthermore, molecular-based in vitro and in vivo approaches have revealed that osteocytes sense mechanical loading through mechanosensors that translate extracellular mechanical signals to intracellular biochemical signals and regulate gene expression. Osteocytic mechanosensors include the osteocyte cytoskeleton and dendritic processes within the lacuno-canalicular system (LCS), ion channels (e.g., Piezo1), extracellular matrix, primary cilia, focal adhesions (integrin-based) and hemichannels and gap junctions (connexin-based). Overall, disuse represents one of the major factors contributing to immediate bone loss and osteoporosis, and alterations in osteocytic pathways appear crucial to the bone loss associated with unloading.
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Affiliation(s)
- Tim Rolvien
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany.
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19
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Williams JA, Huesa C, Windmill JF, Purcell M, Reid S, Coupaud S, Riddell JS. Spatiotemporal responses of trabecular and cortical bone to complete spinal cord injury in skeletally mature rats. Bone Rep 2022; 16:101592. [PMID: 35637974 PMCID: PMC9142855 DOI: 10.1016/j.bonr.2022.101592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 11/02/2022] Open
Abstract
Objective Methods Results Conclusions Skeletally mature spinal cord transected rats display biphasic bone loss The osteoporosis manifests over slower time scales than in skeletally immature rats. Relevancy for testing efficacy of interventions against SCI-induced osteoporosis.
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20
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Ghatas MP, Sutor TW, Gorgey AS. Prediction of Distal Femur and Proximal Tibia Bone Mineral Density From Total Body Dual Energy X-Ray Absorptiometry Scans in Persons with Spinal Cord Injury. J Clin Densitom 2022; 25:252-260. [PMID: 34920939 DOI: 10.1016/j.jocd.2021.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/01/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Abstract
Bone density decreases rapidly after spinal cord injury (SCI), increasing fracture risk. The most common fracture sites are at the knee (i.e., distal femur or proximal tibia). Despite this high fracture incidence, knee-specific scans for bone density using dual x-ray absorptiometry (DXA) were not available until 2014 and are still not routinely used in clinical practice today. This has made it difficult to determine the rehabilitation efficacy and hindered understanding of the long-term changes in knee areal bone density. The purpose of this investigation was to compare areal bone mineral density values for the knee from both total-body and knee-specific DXA scans in persons with SCI. A total of 20 participants (16 males) >1 yr-post spinal cord injury received two DXA scans; a total-body scan and a knee-specific scan. Standardized methods were used to create regions of interest to determine bone density of four regions - the epiphysis and metaphysis of the distal femur and proximal tibia - from the total-body scan. Linear regressions and Bland-Altman analyses were conducted to determine the correlation (r2) and agreement (mean bias ± 95% level of agreement) respectively between the two scan types for each region. Linear regression analyses showed strong significant (p < 0.001) relationships between the two scan types for the distal femur epiphysis (r2 = 0.88) and metaphysis (r2 = 0.98) and the proximal tibia epiphysis (r2 = 0.88) and metaphysis (r2 = 0.99). The mean bias ± 95% level of agreement were distal femur epiphysis (0.05 ± 0.1 g/cm2) and metaphysis (0.02 ± 0.04 g/cm2); proximal tibia epiphysis (-0.02 ± 0.1 g/cm2) and metaphysis (0.02 ± 0.03 g/cm2). Results suggest knee-specific bone density can be assessed using a total-body DXA scan. This may allow for more comprehensive use of DXA scans which would reduce the burden of multiple site-specific scans for persons with SCI and enable more widespread adoption of knee bone density assessment in this population.
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Affiliation(s)
- Mina P Ghatas
- Spinal Cord Injury and Disorders Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Tommy W Sutor
- Spinal Cord Injury and Disorders Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ashraf S Gorgey
- Spinal Cord Injury and Disorders Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA; Physical Medicine and Rehabilitation Virginia Commonwealth University, Richmond, VA, USA.
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21
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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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22
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Fernández Dorado MT, Díaz Merino MDS, García Marco D, Cuena Boy R, Blanco Samper B, Martínez Dhier L, Labarta Bertol C. Preventive treatment with alendronate of loss of bone mineral density in acute traumatic spinal cord injury. Randomized controlled clinical trial. Spinal Cord 2022; 60:687-693. [DOI: 10.1038/s41393-022-00755-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 11/09/2022]
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23
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Hook MA, Falck A, Dundumulla R, Terminel M, Cunningham R, Sefiani A, Callaway K, Gaddy D, Geoffroy CG. Osteopenia in a Mouse Model of Spinal Cord Injury: Effects of Age, Sex and Motor Function. BIOLOGY 2022; 11:biology11020189. [PMID: 35205056 PMCID: PMC8869334 DOI: 10.3390/biology11020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/16/2022]
Abstract
Simple Summary In the first two years following spinal cord injury, people lose up to 50% of bone below the injury. This injury-induced bone loss significantly affects rehabilitation and leaves people vulnerable to fractures and post-fracture complications, including lung and urinary tract infections, blood clots in the veins, and depression. Unfortunately, little is known about the factors driving this bone loss. In fact, even though we know that injury, age, and sex independently increase bone loss, there have been no studies looking at the cumulative effects of these variables. People with spinal injury are aging, and the age at which injuries occur is increasing. It is essential to know whether these factors together will further compromise bone. To examine this, we assessed bone loss in young and old, male and female mice after spinal injury. As expected, we found that aging alone decreased motor activity and bone volume. Spinal injury also reduced bone volume, but it did not worsen the effects of age. Instead, injury effects appeared related to reduced rearing activity. The data suggest that although partial weight-bearing does not reduce bone loss after spinal cord injury, therapies that put full weight on the legs may be clinically effective. Abstract After spinal cord injury (SCI), 80% of individuals are diagnosed with osteopenia or osteoporosis. The dramatic loss of bone after SCI increases the potential for fractures 100-fold, with post-fracture complications occurring in 54% of cases. With the age of new SCI injuries increasing, we hypothesized that a SCI-induced reduction in weight bearing could further exacerbate age-induced bone loss. To test this, young (2–3 months) and old (20–30 months) male and female mice were given a moderate spinal contusion injury (T9–T10), and recovery was assessed for 28 days (BMS, rearing counts, distance traveled). Tibial trabecular bone volume was measured after 28 days with ex vivo microCT. While BMS scores did not differ across groups, older subjects travelled less in the open field and there was a decrease in rearing with age and SCI. As expected, aging decreased trabecular bone volume and cortical thickness in both old male and female mice. SCI alone also reduced trabecular bone volume in young mice, but did not have an additional effect beyond the age-dependent decrease in trabecular and cortical bone volume seen in both sexes. Interestingly, both rearing and total activity correlated with decreased bone volume. These data underscore the importance of load and use on bone mass. While partial weight-bearing does not stabilize/reverse bone loss in humans, our data suggest that therapies that simulate complete loading may be effective after SCI.
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Affiliation(s)
- Michelle A. Hook
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
- Correspondence: ; Tel.: +1-979-436-0568
| | - Alyssa Falck
- Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, College Station, TX 77843, USA; (A.F.); (D.G.)
| | - Ravali Dundumulla
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
| | - Mabel Terminel
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
| | - Rachel Cunningham
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
| | - Arthur Sefiani
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
| | - Kayla Callaway
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
| | - Dana Gaddy
- Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, College Station, TX 77843, USA; (A.F.); (D.G.)
| | - Cédric G. Geoffroy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M Health Science Center, Bryan, TX 77807, USA; (R.D.); (M.T.); (R.C.); (A.S.); (K.C.); (C.G.G.)
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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:ijms23020608. [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] [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
- Correspondence: ; Tel.: +1-352-376-1611 (ext. 10-5234)
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25
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Ye G, Theventhiran P, Masani K. Effect of Spatially Distributed Sequential Stimulation on Fatigue in Functional Electrical Stimulation Rowing. IEEE Trans Neural Syst Rehabil Eng 2022; 30:999-1008. [DOI: 10.1109/tnsre.2022.3166710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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26
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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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Mancuso ME, Wilzman AR, Murdock KE, Troy KL. Effect of External Mechanical Stimuli on Human Bone: a narrative review. PROGRESS IN BIOMEDICAL ENGINEERING (BRISTOL, ENGLAND) 2022; 4:012006. [PMID: 36310606 PMCID: PMC9616042 DOI: 10.1088/2516-1091/ac41bc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Bone is a living composite material that has the capacity to adapt and respond to both internal and external stimuli. This capacity allows bone to adapt its structure to habitual loads and repair microdamage. Although human bone evolved to adapt to normal physiologic loading (for example from gravitational and muscle forces), these same biological pathways can potentially be activated through other types of external stimuli such as pulsed electromagnetic fields, mechanical vibration, and others. This review summarizes what is currently known about how human bone adapts to various types of external stimuli. We highlight how studies on sports-specific athletes and other exercise interventions have clarified the role of mechanical loading on bone structure. We also discuss clinical scenarios, such as spinal cord injury, where mechanical loading is drastically reduced, leading to rapid bone loss and permanent alterations to bone structure. Finally, we highlight areas of emerging research and unmet clinical need.
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28
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Edwards WB, Haider IT, Simonian N, Barroso J, Schnitzer TJ. Durability and delayed treatment effects of zoledronic acid on bone loss after spinal cord injury: a randomized, controlled trial. J Bone Miner Res 2021; 36:2127-2138. [PMID: 34278611 DOI: 10.1002/jbmr.4416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/07/2021] [Accepted: 07/14/2021] [Indexed: 12/28/2022]
Abstract
A single infusion of zoledronic acid (ZOL) after acute spinal cord injury (SCI) attenuates bone loss at the hip (proximal femur) and knee (distal femur and proximal tibia) for at least 6 months. The objective of this study was to examine the effects of timing and frequency of ZOL over 2 years. In this double-blind, placebo-controlled trial, we randomized 60 individuals with acute SCI (<120 days of injury) to receive either ZOL 5-mg infusion (n = 30) or placebo (n = 30). After 12 months, groups were again randomized to receive ZOL or placebo, resulting in four treatment groups for year 2: (i) ZOL both years; (ii) ZOL year 1, placebo year 2; (iii) placebo year 1, ZOL year 2; and (iv) placebo both years. Our primary outcome was bone loss at 12 months; compared to placebo, a single infusion of ZOL attenuated bone loss at the proximal femur, where median changes relative to baseline were -1.7% to -2.2% for ZOL versus -11.3% to -12.8% for placebo (p < 0.001). Similarly, the distal femur and proximal tibia showed changes of -4.7% to -9.6% for ZOL versus -8.9% to -23.0% for placebo (p ≤ 0.042). After 24 months, differences were significant at the proximal femur only (-3.2% to -6.0% for ZOL vs. -16.8% to -21.8% for placebo; p ≤ 0.018). Although not statistically significant, median bone density losses suggested some benefit from two annual infusions compared to a single baseline infusion, as well as from a single infusion 12 months after baseline compared to 2 years of placebo; therefore, further investigation in the 12-month to 24-month treatment window is warranted. No unanticipated adverse events associated with drug treatment were observed. In summary, ZOL 5-mg infusion after acute SCI was well-tolerated and may provide an effective therapeutic approach to prevent bone loss in the first few years following SCI. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ifaz T Haider
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Narina Simonian
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Northwestern University Clinical and Translational Sciences Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joana Barroso
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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29
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Yarrow JF, Wnek RD, Conover CF, Reynolds MC, Buckley KH, Kura JR, Sutor TW, Otzel DM, Mattingly AJ, Croft S, Aguirre JI, Borst SE, Beck DT, McCullough DJ. Bone loss after severe spinal cord injury coincides with reduced bone formation and precedes bone blood flow deficits. J Appl Physiol (1985) 2021; 131:1288-1299. [PMID: 34473574 DOI: 10.1152/japplphysiol.00444.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Diminished bone perfusion develops in response to disuse and has been proposed as a mechanism underlying bone loss. Bone blood flow (BF) has not been investigated within the unique context of severe contusion spinal cord injury (SCI), a condition that produces neurogenic bone loss that is precipitated by disuse and other physiological consequences of central nervous system injury. Herein, 4-mo-old male Sprague-Dawley rats received T9 laminectomy (SHAM) or laminectomy with severe contusion SCI (n = 20/group). Time course assessments of hindlimb bone microstructure and bone perfusion were performed in vivo at 1- and 2-wk postsurgery via microcomputed tomography (microCT) and intracardiac microsphere infusion, respectively, and bone turnover indices were determined via histomorphometry. Both groups exhibited cancellous bone loss beginning in the initial postsurgical week, with cancellous and cortical bone deficits progressing only in SCI thereafter. Trabecular bone deterioration coincided with uncoupled bone turnover after SCI, as indicated by signs of ongoing osteoclast-mediated bone resorption and a near-complete absence of osteoblasts and cancellous bone formation. Bone BF was not different between groups at 1 wk, when both groups displayed bone loss. In comparison, femur and tibia perfusion was 30%-40% lower in SCI versus SHAM at 2 wk, with the most pronounced regional BF deficits occurring at the distal femur. Significant associations existed between distal femur BF and cancellous and cortical bone loss indices. Our data provide the first direct evidence indicating that bone BF deficits develop in response to SCI and temporally coincide with suppressed bone formation and with cancellous and cortical bone deterioration.NEW & NOTEWORTHY We provide the first direct evidence indicating femur and tibia blood flow (BF) deficits exist in conscious (awake) rats after severe contusion spinal cord injury (SCI), with the distal femur displaying the largest BF deficits. Reduced bone perfusion temporally coincided with unopposed bone resorption, as indicated by ongoing osteoclast-mediated bone resorption and a near absence of surface-level bone formation indices, which resulted in severe cancellous and cortical microstructural deterioration after SCI.
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Affiliation(s)
- Joshua F Yarrow
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida.,Brain Rehabilitation Research Center, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida.,Division of Endocrinology, Diabetes, and Metabolism, University of Florida College of Medicine, Gainesville, Florida
| | - Russell D Wnek
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Christine F Conover
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Michael C Reynolds
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Kinley H Buckley
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Jayachandra R Kura
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Tommy W Sutor
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Dana M Otzel
- Brain Rehabilitation Research Center, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Alex J Mattingly
- Geriatrics Research, Education, and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Summer Croft
- Department of Physiological Sciences, University of Florida College of Veterinary Medicine, Gainesville, Florida
| | - J Ignacio Aguirre
- Department of Physiological Sciences, University of Florida College of Veterinary Medicine, Gainesville, Florida
| | - Stephen E Borst
- Research Service, Malcom Randall Department of Veterans Affairs Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Darren T Beck
- Department of Cell Biology and Physiology, Edward Via College of Osteopathic Medicine-Auburn Campus, Auburn, Alabama
| | - Danielle J McCullough
- Department of Cell Biology and Physiology, Edward Via College of Osteopathic Medicine-Auburn Campus, Auburn, Alabama
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30
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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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Yin R, Zhang J, Xu S, Kong Y, Wang H, Gao Y. Resistance to disuse-induced iron overload in Daurian ground squirrels (Spermophilus dauricus) during extended hibernation inactivity. Comp Biochem Physiol B Biochem Mol Biol 2021; 257:110650. [PMID: 34298179 DOI: 10.1016/j.cbpb.2021.110650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 11/30/2022]
Abstract
Iron overload occurs in disuse-induced osteoporosis. Hibernators are a natural animal model of resistance to disuse osteoporosis. We hypothesized that hibernators avoid iron overload to resist disuse-induced osteoporosis. Here, the role of iron metabolism in resistance to disuse osteoporosis was investigated by studying differences in iron content and iron metabolism in the femurs and livers of Daurian ground squirrels (Spermophilus dauricus) between the summer active and torpid states. Results showed that the femurs were generally well-maintained during torpor, with no significant differences observed in most bone microstructural parameters, except for a significantly lower (by 40%) trabecular bone connection density. Femur and liver iron concentrations were significantly lower during torpor (by 59% and 49%, respectively). Based on histological staining, livers were iron-negative and femurs showed a reduction in iron-positive area (by 83%) during torpor; The number of osteoblasts and osteoclasts showed no significant differences between the two groups. Most iron metabolism/homeostasis proteins expression levels in the femur and liver showed no significant differences between the two groups, with their stable expression likely preventing iron overload during inactivity. Higher femoral transferrin receptor 1 (TfR1) expression (by 108%) and lower liver ferritin expression (by 45%) were found in torpid squirrels. Lower liver ferritin may be related to the lower iron content, with the elevation in femoral TfR1 potentially related to restoration of bone iron levels. In conclusion, despite long periods of inactivity, iron levels in the femur and liver of squirrels were lower, bone formation and resorption were balanced and no iron overload was observed, as is found under disuse conditions in non-hibernators. Therefore, avoiding iron overload may be a potential mechanism for hibernators to avoid disuse-induced bone loss.
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Affiliation(s)
- Rongrong Yin
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi'an 710069, China; Key Laboratory of Resource Biology and Biotechnology in Western China (Northwest University), Ministry of Education, Xi'an 710069, China
| | - Jie Zhang
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi'an 710069, China; Key Laboratory of Resource Biology and Biotechnology in Western China (Northwest University), Ministry of Education, Xi'an 710069, China
| | - Shenhui Xu
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi'an 710069, China; Key Laboratory of Resource Biology and Biotechnology in Western China (Northwest University), Ministry of Education, Xi'an 710069, China
| | - Yong Kong
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi'an 710069, China; Key Laboratory of Resource Biology and Biotechnology in Western China (Northwest University), Ministry of Education, Xi'an 710069, China
| | - Huiping Wang
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi'an 710069, China; Key Laboratory of Resource Biology and Biotechnology in Western China (Northwest University), Ministry of Education, Xi'an 710069, China.
| | - Yunfang Gao
- Shaanxi Key Laboratory for Animal Conservation, College of Life Sciences, Northwest University, Xi'an 710069, China; Key Laboratory of Resource Biology and Biotechnology in Western China (Northwest University), Ministry of Education, Xi'an 710069, China.
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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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Holman ME, Chang G, Ghatas MP, Saha PK, Zhang X, Khan MR, Sima AP, Adler RA, Gorgey AS. Bone and non-contractile soft tissue changes following open kinetic chain resistance training and testosterone treatment in spinal cord injury: an exploratory study. Osteoporos Int 2021; 32:1321-1332. [PMID: 33443609 DOI: 10.1007/s00198-020-05778-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 12/04/2020] [Indexed: 01/30/2023]
Abstract
UNLABELLED Twenty men with spinal cord injury (SCI) were randomized into two 16-week intervention groups receiving testosterone treatment (TT) or TT combined with resistance training (TT + RT). TT + RT appears to hold the potential to reverse or slow down bone loss following SCI if provided over a longer period. INTRODUCTION Persons with SCI experience bone loss below the level of injury. The combined effects of resistance training and TT on bone quality following SCI remain unknown. METHODS Men with SCI were randomized into 16-week treatments receiving TT or TT + RT. Magnetic resonance imaging (MRI) of the right lower extremity before participation and post-intervention was used to visualize the proximal, middle, and distal femoral shaft, the quadriceps tendon, and the intermuscular fascia of the quadriceps. For the TT + RT group, MRI microarchitecture techniques were utilized to elucidate trabecular changes around the knee. Individual mixed models were used to estimate effect sizes. RESULTS Twenty participants completed the pilot trial. A small effect for yellow marrow in the distal femur was indicated as increases following TT and decreases following TT + RT were observed. Another small effect was observed as the TT + RT group displayed greater increases in intermuscular fascia length than the TT arm. Distal femur trabecular changes for the TT + RT group were generally small in effect (decreased trabecular thickness variability, spacing, and spacing variability; increased network area). Medium effects were generally observed in the proximal tibia (increased plate width, trabecular thickness, and network area; decreased trabecular spacing and spacing variability). CONCLUSIONS This pilot suggests longer TT + RT interventions may be a viable rehabilitation technique to combat bone loss following SCI. CLINICAL TRIAL REGISTRATION Registered with clinicaltrials.gov : NCT01652040 (07/27/2012).
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Affiliation(s)
- M E Holman
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - G Chang
- Department of Radiology, NYU School of Medicine, New York, NY, 10016, USA
| | - M P Ghatas
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - P K Saha
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, 52242, USA
- Department of Radiology, University of Iowa, Iowa City, IA, 52242, USA
| | - X Zhang
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, 52242, USA
| | - M R Khan
- Department of Radiology, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - A P Sima
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - R A Adler
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA
| | - A S Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VAMC, Richmond, VA, 23249, USA.
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA, 23284, USA.
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Wu Y, Wang F, Zhang Z. The efficacy and safety of bisphosphonate analogs for treatment of osteoporosis after spinal cord injury: a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int 2021; 32:1117-1127. [PMID: 33386876 DOI: 10.1007/s00198-020-05807-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
Abstract
UNLABELLED Bisphosphonates can inhibit osteoclast-mediated bone resorption, prevent bone loss, and reduce the risk of osteoporotic fractures. Our meta-analysis of studies shows that early bisphosphonate administration after SCI was safe and beneficial to the BMD of the total hip and lumbar spine at 12 months. INTRODUCTION Rapid bone loss in the early stages of spinal cord injury (SCI) leads to an increased risk of osteoporotic fracture. A meta-analysis was conducted to assess the efficacy and safety of bisphosphonates for the treatment of osteoporosis after SCI. METHODS A literature search of the PubMed, EMBASE, Cochrane Library, and Web of Science databases identified nine randomized controlled trials with 206 individuals. This meta-analysis was performed using a random-effects model. The primary outcome was the percent change in bone mineral density (BMD) of the total hip, distal femur, and lumbar spine from baseline to 12 months. Bone turnover markers were secondary outcomes. The incidences of adverse events were assessed in order to evaluate safety. RESULTS There were significant differences in BMD of the total hip and lumbar spine or serum C-terminal telopeptide between the bisphosphonate and control groups but no difference in adverse events. The percent change in BMD of the distal femur and serum type 1 procollagen N-terminal peptide from baseline to 12 months was not superior in the treatment groups. Osteoclast-mediated bone resorption was inhibited by bisphosphonate administration. Subgroup analyses of participants treated with zoledronate at different sites revealed a beneficial effect on BMD of the total hip and lumbar spine but not the distal femur. CONCLUSION Early bisphosphonate administration after SCI was safe and beneficial to the BMD of the total hip and lumbar spine at 12 months.
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Affiliation(s)
- Y Wu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
| | - F Wang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China.
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center, No. 10, Jiaomen North Road, Fengtai District, Beijing, China.
| | - Z Zhang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
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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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Fang Y, Morse LR, Nguyen N, Battaglino RA, Goldstein RF, Troy KL. Functional electrical stimulation (FES)-assisted rowing combined with zoledronic acid, but not alone, preserves distal femur strength and stiffness in people with chronic spinal cord injury. Osteoporos Int 2021; 32:549-558. [PMID: 32888047 DOI: 10.1007/s00198-020-05610-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/25/2020] [Indexed: 01/04/2023]
Abstract
UNLABELLED We investigated the effect of 12 months of functional electrical stimulation-assisted rowing with and without zoledronic acid (ZA) on computationally estimated bone strength and stiffness in individuals with spinal cord injury. We found that rowing with ZA, but not rowing alone, improved stiffness at the distal femur, but not the proximal tibia. INTRODUCTION People with spinal cord injury (SCI) have high fracture risk at the knee after the injury. Therapies that prevent bone loss or stimulate an anabolic response in bone have been proposed to reduce fractures. Zoledronic acid (ZA) is a potent bisphosphonate that inhibits osteoclastic resorption. Functional electrical stimulation (FES)-assisted rowing is a potentially osteogenic exercise involving mechanical stimulation to the lower extremities. Here, we investigated the effect of FES-assisted rowing with and without ZA on bone strength and stiffness in individuals with SCI. METHODS Twenty individuals from a cohort of adults with SCI who participated in a clinical trial were included in the study. CT scans of their knees before and after the intervention were converted to finite element models. Bone failure strength (Tult) and stiffness were calculated at the proximal tibia and distal femur. RESULTS Tult at the distal femur increased 4.6% among people who received rowing + ZA and decreased 13.9% among those with rowing only (p < 0.05 for group). Torsional and compressive stiffness at the femur metaphysis increased in people with rowing + ZA (+ 3 to +4%) and decreased in people with rowing only (- 7 to -8%; p < 0.05). Tult in the proximal tibia decreased in everyone, but the loss was attenuated in the rowing + ZA group. People with initially stronger bone tended to lose more strength. CONCLUSION Overall, we observed increases in bone strength at the distal femur but not the proximal tibia, with FES-assisted rowing combined with ZA treatment. Rowing alone did not significantly prevent bone loss at either site, which might be attributed to insufficient mechanical loading.
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Affiliation(s)
- Y Fang
- Department of Mechanical Engineering, Northern Arizona University, Flagstaff, AZ, USA
| | - L R Morse
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - N Nguyen
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - R A Battaglino
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - R F Goldstein
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Cambridge, MA, USA
| | - K L Troy
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA.
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Zhao W, Peng Y, Hu Y, Guo XE, Li J, Cao J, Pan J, Feng JQ, Cardozo C, Jarvis J, Bauman WA, Qin W. Electrical stimulation of hindlimb skeletal muscle has beneficial effects on sublesional bone in a rat model of spinal cord injury. Bone 2021; 144:115825. [PMID: 33348128 PMCID: PMC7868091 DOI: 10.1016/j.bone.2020.115825] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/16/2022]
Abstract
Spinal cord injury (SCI) results in marked atrophy of sublesional skeletal muscle and substantial loss of bone. In this study, the effects of prolonged electrical stimulation (ES) and/or testosterone enanthate (TE) on muscle mass and bone formation in a rat model of SCI were tested. Compared to sham-transected animals, a significant reduction of the mass of soleus, plantaris and extensor digitorum longus (EDL) muscles was observed in animals 6 weeks post-SCI. Notably, ES or ES + TE resulted in the increased mass of the EDL muscles. ES or ES + TE significantly decreased mRNA levels of muscle atrophy markers (e.g., MAFbx and MurF1) in the EDL. Significant decreases in bone mineral density (BMD) (-27%) and trabecular bone volume (-49.3%) at the distal femur were observed in animals 6 weeks post injury. TE, ES and ES + TE treatment significantly increased BMD by +6.4%, +5.4%, +8.5% and bone volume by +22.2%, and +56.2% and+ 60.2%, respectively. Notably, ES alone or ES + TE resulted in almost complete restoration of cortical stiffness estimated by finite element analysis in SCI animals. Osteoblastogenesis was evaluated by colony-forming unit-fibroblastic (CFU-F) staining using bone marrow mesenchymal stem cells obtained from the femur. SCI decreased the CFU-F+ cells by -56.8% compared to sham animals. TE or ES + TE treatment after SCI increased osteoblastogenesis by +74.6% and +67.2%, respectively. An osteoclastogenesis assay revealed significantly increased TRAP+ multinucleated cells (+34.8%) in SCI animals compared to sham animals. TE, ES and TE + ES treatment following SCI markedly decreased TRAP+ cells by -51.3%, -40.3% and -46.9%, respectively. Each intervention greatly reduced the ratio of RANKL to OPG mRNA of sublesional long bone. Collectively, our findings demonstrate that after neurologically complete paralysis, dynamic muscle resistance exercise by ES reduced muscle atrophy, downregulated genes involved in muscle wasting, and restored mechanical loading to sublesional bone to a degree that allowed for the preservation of bone by inhibition of bone resorption and/or by facilitating bone formation.
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Affiliation(s)
- Wei Zhao
- National Center for the Medical Consequences of SCI, James J. Peters VA Medical Center, Bronx, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yuanzhen Peng
- National Center for the Medical Consequences of SCI, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Yizhong Hu
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - X Edward Guo
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Jiliang Li
- Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Jay Cao
- United States Department of Agriculture Agricultural Research Service Human Nutrition Research Center, Grand Forks, ND, USA
| | - Jiangping Pan
- National Center for the Medical Consequences of SCI, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Jian Q Feng
- Baylor College of Dentistry, TX A&M, Dallas, TX, USA
| | - Christopher Cardozo
- National Center for the Medical Consequences of SCI, James J. Peters VA Medical Center, Bronx, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Jarvis
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 3AF, United Kingdom
| | - William A Bauman
- National Center for the Medical Consequences of SCI, James J. Peters VA Medical Center, Bronx, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Weiping Qin
- National Center for the Medical Consequences of SCI, James J. Peters VA Medical Center, Bronx, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Clinical Benefits and System Design of FES-Rowing Exercise for Rehabilitation of Individuals with Spinal Cord Injury: A Systematic Review. Arch Phys Med Rehabil 2021; 102:1595-1605. [PMID: 33556345 DOI: 10.1016/j.apmr.2021.01.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To comprehensively and critically appraise the clinical benefits and engineering designs of functional electrical stimulation (FES)-rowing for management of individuals with spinal cord injury (SCI). DATA SOURCES Electronic database searches were conducted in Cumulative Index to Nursing & Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Excerpta Medica database, Emcare, Medline, PubMed, Scopus, and Web of Science databases from inception to May 12, 2020. STUDY SELECTION Search terms used were synonyms of "spinal cord injury" for Population and "Electric Stimulation (Therapy)/ and rowing" for Intervention. Two reviewers independently assessed articles based on the following inclusion criteria: recruited individuals with SCI; had aerobic FES-rowing exercise as study intervention; reported cardiovascular, muscular, bone mineral density, or metabolic outcomes; and examined engineering design of FES-rowing systems. Of the 256 titles that were retrieved in the primary search, 24 were included in this study. DATA EXTRACTION Study characteristics, quality, participants' characteristics, test descriptions, and results were independently extracted by 2 reviewers. The quality of studies was assessed with the Downs and Black checklist. DATA SYNTHESIS Comparison of peak oxygen consumption (V̇o2peak) rates showed that V̇o2peak during FES-rowing was significantly higher than arm-only exercise; FES-rowing training improved V̇o2peak by 11.2% on average (95% confidence interval, 7.25-15.1), with a 4.1% (95% confidence interval, 2.23-5.97) increase in V̇o2peak per month of training. FES-rowing training reduced bone density loss with increased time postinjury. The rowing ergometer used in 2 studies provided motor assistance during rowing. Studies preferred manual stimulation control (n=20) over automatic (n=4). CONCLUSIONS Our results suggest FES-rowing is a viable exercise for individuals with SCI that can improve cardiovascular performance and reduce bone density loss. Further randomized controlled trials are needed to better understand the optimal set-up for FES-rowing that maximizes the rehabilitation outcomes.
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Ghasem-Zadeh A, Galea MP, Nunn A, Panisset M, Wang XF, Iuliano S, Boyd SK, Forwood MR, Seeman E. Heterogeneity in microstructural deterioration following spinal cord injury. Bone 2021; 142:115778. [PMID: 33253932 DOI: 10.1016/j.bone.2020.115778] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Modelling and remodelling adapt bone morphology to accommodate strains commonly encountered during loading. If strains exceed a threshold threatening fracture, modelling-based bone formation increases bone volume reducing these strains. If unloading reduces strains below a threshold that inhibits resorption, increased remodelling-based bone resorption reduces bone volume restoring strains, but at the price of compromised bone volume and microstructure. As weight-bearing regions are adapted to greater strains, we hypothesized that microstructural deterioration will be more severe than at regions commonly adapted to low strains following spinal cord injury. METHODS We quantified distal tibial, fibula and radius volumetric bone mineral density (vBMD) using high-resolution peripheral quantitative computed tomography in 31 men, mean age 43.5 years (range 23.5-75.0), 12 with tetraplegia and 19 with paraplegia of 0.7 to 18.6 years duration, and 102 healthy age- and sex-matched controls. Differences in morphology relative to controls were expressed as standardized deviation (SD) scores (mean ± SD). Standardized between-region differences in vBMD were expressed as SDs (95% confidence intervals, CI). RESULTS Relative to controls, men with tetraplegia had deficits in total vBMD of -1.72 ± 1.38 SD at the distal tibia (p < 0.001) and - 0.68 ± 0.69 SD at distal fibula (p = 0.041), but not at the distal radius, despite paralysis. Deficits in men with paraplegia were -2.14 ± 1.50 SD (p < 0.001) at the distal tibia and -0.83 ± 0.98 SD (p = 0.005) at the distal fibula while distal radial total vBMD was 0.23 ± 1.02 (p = 0.371), not significantly increased, despite upper limb mobility. Comparing regions, in men with tetraplegia, distal tibial total vBMD was 1.04 SD (95%CI 0.07, 2.01) lower than at the distal fibula (p = 0.037) and 1.51 SD (95%CI 0.45, 2.57) lower than at the distal radius (p = 0.007); the latter two sites did not differ from each other. Results were similar in men with paraplegia, but total vBMD at the distal fibula was 1.06 SD (95%CI 0.35, 1.77) lower than at the distal radius (p = 0.004). CONCLUSION Microarchitectural deterioration following spinal cord injury is heterogeneous, perhaps partly because strain thresholds regulating the cellular activity of mechano-transduction are region specific.
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Affiliation(s)
- Ali Ghasem-Zadeh
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Dept of Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia.
| | - Mary P Galea
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Depts of Medicine and Victorian Spinal Cord Service, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Andrew Nunn
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Depts of Medicine and Victorian Spinal Cord Service, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Maya Panisset
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Depts of Medicine and Victorian Spinal Cord Service, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Xiao-Fang Wang
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Dept of Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Sandra Iuliano
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Dept of Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Steven K Boyd
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Mark R Forwood
- School of Medical Science and Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Ego Seeman
- Depts of Medicine and Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia; Dept of Endocrinology, Austin Health, The University of Melbourne, Melbourne, Australia
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Miszkiewicz JJ, Rider C, Kealy S, Vrahnas C, Sims NA, Vongsvivut J, Tobin MJ, Bolunia MJLA, De Leon AS, Peñalosa AL, Pagulayan PS, Soriano AV, Page R, Oxenham MF. Asymmetric midshaft femur remodeling in an adult male with left sided hip joint ankylosis, Metal Period Nagsabaran, Philippines. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2020; 31:14-22. [PMID: 32877865 DOI: 10.1016/j.ijpp.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This study investigated microstructural changes of the right and left midshaft femur in an archaeological individual afflicted with left-sided hip joint ankylosis to assess whether increased cortical porosity was present as a result of leg disuse. MATERIALS The individual is a middle-aged adult male excavated from the Metal Period (∼2000 BP) Nagsabaran, Luzon Island, Philippines. METHODS Following standard examination of femur gross anatomy and differential diagnosis of the hip joint fusion, ∼1 cm thick posterior midshaft femur samples were removed for microstructural examination. Using static histomorphometry, bone multi-cellular unit activity from Haversian canal (vascular pore) density, area, and circularity was reconstructed. Spatial positioning of Haversian canals was mapped using Geographic Information Systems software. Phosphate, carbonate, and carbonate:phosphate ratios were obtained using synchrotron-sourced Fourier transform infrared microspectroscopy. RESULTS The left femur had greater cortical pore density, with smaller and rounder vascular canals, in addition to lower matrix levels of phosphate and carbonate, when compared to the right femur. CONCLUSIONS Our data indicate compromised bone tissue in the left femur, and conform to expected bone functional adaptation paradigms of remodeling responses to pathological and biomechanical changes. SIGNIFICANCE The preservation of this individual's hip abnormality created a unique opportunity to evaluate intra-skeletal bone health asymmetry, which may help other researchers evaluate the presence of limb disuse in archaeological samples. LIMITATIONS A lack of lower limb data limits our interpretations to femur remodeling only. SUGGESTIONS FOR FURTHER RESEARCH Future research efforts should aim to examine the presence of remodeling changes in all bones of the lower limb. LAYUNIN Gamit ang buto ng magkabilang pemur ng isang taong natagpuan sa isang archaeological site na may sakit na ankylosis sa kaliwang balakang, pinag-aralan ang iba't-ibang microstructures galing sa gitnang bahagi o midshaft ng pemur upang malaman kung may makikitang mataas na cortical porosity ang buto dahil hindi ito malimit gamitin. GAMIT Ang pinag-aaralang buto ay galing sa isang indibidwal na tinatayang middle-age na lalaki na namuhay noong Panahon ng Metal (∼2000 BP) sa Nagsabaran, Cagayan, Republika ng Pilipinas. PAMAMARAAN Matapos ang unang pagkilatis sa femur at ang pagkilala ng sakit sa balakang, kumuha ng ∼1 sentimetro ng buto galing sa midshaft ng pemur upang lalong mapag-aralan ang kanyang microstructure. Gamit ang static histomorphometry, napag-aralan ang mga naiwang bakas ng multi-cellular unit activity ayon sa kapal, laki at pagkakabilog ng Haversian canal (vascular pore). Gumamit din ng Geographic Information Systems (GIS) software upang mapag-aralan ang kaugnayan ng posisyon ng Haversian canal. Panghuli, gumamit din ng synchroton-sourced Fourier transform infrared (sFTIR) microspectroscopy upang makuha ang bilang ng phosphate, carbonate, at carbonate:phosphate ratio. RESULTA Napag-alaman na ang kaliwang pemur ay mayroong higit na maraming cortical pores, maliit at mabilog na vascular canals, at mababang bilang ng phosphate, carbonate kung ihahambing sa kanang pemur. KONKLUSYON Ayon sa aming datos, ang kaliwang pemur ay umaayon sa mga katangian ng isang butong may sakit. Sumunod din ito sa inaasahang bone functional adaptation paradigms of remodeling ng buto dahil may sakit at hindi nagamit. KAHALAGAHAN Dahil maganda ang pagkakalibing ng buto ng balakang, nagkaroon ng pagkakataong makilatis ang kalusugan ng sinaunang-tao sa pamamagitan ng pag-aaral ng kalusugan ng buto. Dagdag pa, makakatulong din ito upang malaman kung ibang mananaliksik ang pag-aaral ng ibang butong hindi nagagamit mula sa archaeological site. LIMITASYON Dahil walang nakuhang ibang buto mula sa binti at paa, ang pemur lang ang naimbestigahan. MUNGKAHI PARA SA MGA SUSUNOD NA PAG-AARAL Kung magkakaroon ng pagkakataon sa susunod, dapat maimbistigahan ang lahat ng buto ng binti (lower limb).
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Affiliation(s)
- Justyna J Miszkiewicz
- School of Archaeology and Anthropology, Australian National University, 44 Linnaeus Way, Canberra, ACT, 2601 Australia.
| | - Claire Rider
- School of Archaeology and Anthropology, Australian National University, 44 Linnaeus Way, Canberra, ACT, 2601 Australia
| | - Shimona Kealy
- School of Culture, History, and Language, Archaeology and Natural History, College of Asia and the Pacific, Australian National University, Canberra, ACT, 0200, Australia; ARC Centre of Excellence for Australian Biodiversity and Heritage, Australian National University, Canberra, ACT, 0200, Australia
| | - Christina Vrahnas
- Bone Biology and Disease Unit, St. Vincent's Institute of Medical Research, 9 Princes Street, Fitzroy, Melbourne, VIC, 3065, Australia; Department of Medicine, The University of Melbourne, St. Vincent's Hospital, Melbourne, VIC, 3065, Australia; MRC Protein Phosphorylation and Ubiquitylation Unit, James Black Centre, University of Dundee, Dundee, DD1 4HN, United Kingdom
| | - Natalie A Sims
- Bone Biology and Disease Unit, St. Vincent's Institute of Medical Research, 9 Princes Street, Fitzroy, Melbourne, VIC, 3065, Australia; Department of Medicine, The University of Melbourne, St. Vincent's Hospital, Melbourne, VIC, 3065, Australia
| | - Jitraporn Vongsvivut
- Infrared Microspectroscopy (IRM) Beamline, ANSTO - Australian Synchrotron, 800 Blackburn Road, Clayton, VIC 3168, Australia
| | - Mark J Tobin
- Infrared Microspectroscopy (IRM) Beamline, ANSTO - Australian Synchrotron, 800 Blackburn Road, Clayton, VIC 3168, Australia
| | | | - Alexandra S De Leon
- Archaeology Division, National Museum of the Philippines, P. Burgos St., Manila, 1000, Philippines
| | - Antonio L Peñalosa
- Archaeology Division, National Museum of the Philippines, P. Burgos St., Manila, 1000, Philippines
| | - Pablo S Pagulayan
- Archaeology Division, National Museum of the Philippines, P. Burgos St., Manila, 1000, Philippines
| | - Adan V Soriano
- Archaeology Division, National Museum of the Philippines, P. Burgos St., Manila, 1000, Philippines
| | - Ruth Page
- School of Archaeology and Anthropology, Australian National University, 44 Linnaeus Way, Canberra, ACT, 2601 Australia
| | - Marc F Oxenham
- School of Archaeology and Anthropology, Australian National University, 44 Linnaeus Way, Canberra, ACT, 2601 Australia; Department of Archaeology, University of Aberdeen, St. Mary's, Elphinstone Road, Aberdeen, AB24 3UF, Scotland, United Kingdom
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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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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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Osteocyte-Related Cytokines Regulate Osteoclast Formation and Bone Resorption. Int J Mol Sci 2020; 21:ijms21145169. [PMID: 32708317 PMCID: PMC7404053 DOI: 10.3390/ijms21145169] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 01/18/2023] Open
Abstract
The process of bone remodeling is the result of the regulated balance between bone cell populations, namely bone-forming osteoblasts, bone-resorbing osteoclasts, and the osteocyte, the mechanosensory cell type. Osteoclasts derived from the hematopoietic stem cell lineage are the principal cells involved in bone resorption. In osteolytic diseases such as rheumatoid arthritis, periodontitis, and osteoporosis, the balance is lost and changes in favor of bone resorption. Therefore, it is vital to elucidate the mechanisms of osteoclast formation and bone resorption. It has been reported that osteocytes express Receptor activator of nuclear factor κΒ ligand (RANKL), an essential factor for osteoclast formation. RANKL secreted by osteocytes is the most important factor for physiologically supported osteoclast formation in the developing skeleton and in pathological bone resorption such as experimental periodontal bone loss. TNF-α directly enhances RANKL expression in osteocytes and promotes osteoclast formation. Moreover, TNF-α enhances sclerostin expression in osteocytes, which also increases osteoclast formation. These findings suggest that osteocyte-related cytokines act directly to enhance osteoclast formation and bone resorption. In this review, we outline the most recent knowledge concerning bone resorption-related cytokines and discuss the osteocyte as the master regulator of bone resorption and effector in osteoclast formation.
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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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Bone Loss and the Current Diagnosis of Osteoporosis and Risk of Fragility Fracture in Persons with Spinal Cord Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00268-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Koong DP, Symes MJ, Sefton AK, Sivakumar BS, Ellis A. Management of lower limb fractures in patients with spinal cord injuries. ANZ J Surg 2020; 90:1743-1749. [PMID: 32356588 DOI: 10.1111/ans.15924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Low-energy fractures of the lower limb in patients post spinal cord injury (SCI) present significant management challenges. This is the first Australian study to review the experience from a tertiary referral SCI centre and aims to identify trends and suggest therapeutic options. METHODS Retrospective review over a 5-year period in patients with SCI treated for a lower limb fragility fracture. Patient demographics, spinal injury severity scores, fracture characteristics and treatment were assessed. Time to union, length of stay and treatment-related complications were also examined. RESULTS A total of 38 SCI patients with 42 lower extremity fractures met inclusion criteria. Mean age was 55.7 years and mean duration post-SCI at fracture was 22.5 ± 12.7 years. The femur (73.8%) was more commonly fractured than the lower leg (26.2%), with extra-articular distal femoral fractures most prevalent (35.7%). A total of 25 (60%) fractures were managed operatively, and 17 (40%) non-operatively. The majority of femoral fractures were managed with intramedullary nailing. Tibial fractures were more commonly managed non-operatively. Eight cases (19.1%) experienced complications, with a significant difference between frequency of complications in non-operative (35.3%) and operative (8.0%) groups; P = 0.045. All fractures united except one; time to union was shorter in patients treated surgically (13.6 ± 6.4 weeks) compared to those managed non-operatively (19.1 ± 8.1 weeks). CONCLUSIONS Lower limb fragility fractures in patients with SCI can be managed successfully via either operative or non-operative measures. In this series, fewer complications and shorter time to union were found in patients managed operatively.
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Affiliation(s)
- Denis P Koong
- Department of Orthopaedics and Trauma, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Michael J Symes
- The Orthopaedic Research Institute and Department of Orthopaedic Surgery, St George and Sutherland Clinical School, University of New South Wales Medicine, Sydney, New South Wales, Australia
| | - Andrew K Sefton
- Department of Orthopaedics and Trauma, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia
| | - Andrew Ellis
- Department of Orthopaedics and Trauma, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Chandrasekaran S, Davis J, Bersch I, Goldberg G, Gorgey AS. Electrical stimulation and denervated muscles after spinal cord injury. Neural Regen Res 2020; 15:1397-1407. [PMID: 31997798 PMCID: PMC7059583 DOI: 10.4103/1673-5374.274326] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Spinal cord injury (SCI) population with injury below T10 or injury to the cauda equina region is characterized by denervated muscles, extensive muscle atrophy, infiltration of intramuscular fat and formation of fibrous tissue. These morphological changes may put individuals with SCI at higher risk for developing other diseases such as various cardiovascular diseases, diabetes, obesity and osteoporosis. Currently, there is no available rehabilitation intervention to rescue the muscles or restore muscle size in SCI individuals with lower motor neuron denervation. We, hereby, performed a review of the available evidence that supports the use of electrical stimulation in restoration of denervated muscle following SCI. Long pulse width stimulation (LPWS) technique is an upcoming method of stimulating denervated muscles. Our primary objective is to explore the best stimulation paradigms (stimulation parameters, stimulation technique and stimulation wave) to achieve restoration of the denervated muscle. Stimulation parameters, such as the pulse duration, need to be 100–1000 times longer than in innervated muscles to achieve desirable excitability and contraction. The use of electrical stimulation in animal and human models induces muscle hypertrophy. Findings in animal models indicate that electrical stimulation, with a combination of exercise and pharmacological interventions, have proven to be effective in improving various aspects like relative muscle weight, muscle cross sectional area, number of myelinated regenerated fibers, and restoring some level of muscle function. Human studies have shown similar outcomes, identifying the use of LPWS as an effective strategy in increasing muscle cross sectional area, the size of muscle fibers, and improving muscle function. Therefore, displaying promise is an effective future stimulation intervention. In summary, LPWS is a novel stimulation technique for denervated muscles in humans with SCI. Successful studies on LPWS of denervated muscles will help in translating this stimulation technique to the clinical level as a rehabilitation intervention after SCI.
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Affiliation(s)
| | - John Davis
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ines Bersch
- Swiss Paraplegic Centre, Nottwil, Switzerland; Institute of Clinical Sciences, Department of Orthopedics at the University of Gothenburg, Gothenburg, Sweden
| | - Gary Goldberg
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University; Electrodiagnostic Center, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ashraf S Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center; Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
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Global and site-specific analysis of bone in a rat model of spinal cord injury-induced osteoporosis. Bone Rep 2019; 12:100233. [PMID: 31886322 PMCID: PMC6920718 DOI: 10.1016/j.bonr.2019.100233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/22/2019] [Accepted: 11/27/2019] [Indexed: 11/23/2022] Open
Abstract
Micro-Computed Tomography bone analysis is the gold standard method for assessing trabecular and cortical bone microarchitecture in small animal bones. This technique reports morphometric parameters as averages over selected volumes of interest (VOIs). This study proposes the introduction of an additional global 2D morphometric step into the analysis process, that provides a survey of the underlying morphometric variation present throughout both trabecular and cortical bone. The visualisation of these morphometric distributions provides a systematic approach to VOI selection that provides rationale and adds confidence to subsequent 3D morphometric analysis. To test the applicability and value of this methodological addition it was applied to the distal femur of a rat model of spinal cord injury (SCI)-induced osteoporosis. The 2D morphometric variation of both trabecular and cortical bone was quantified as a function of bone length. SCI-induced osteoporosis was localised in i) trabecular bone, where metaphyseal bone was more severely affected than epiphyseal bone, and there was a significant reduction in Distal Femoral Trabecular Extent, a new parameter defined here that quantifies how far trabecular bone penetrates in to the marrow cavity, ii) cortical bone, where diaphyseal bone underwent significant lowering of both cortical area and thickness, while distal-metaphyseal bone did not. Theses site-specific changes were validated, further elucidated and compared with follow-up conventional 3D analysis. The techniques applied here are equally applicable to other long bones (tibia, humerus, radius, ulna), other types of imaging modality and other types of experimental design including the effects of rehabilitation, aging, loading, gene knockout and pharmacological intervention. 2D morphological surveying identifies regions warranting further 3D investigation. Trabecular microarchitecture site-specifically varies in the distal femur. SCI-induced osteoporosis changes metaphyseal more than epiphyseal trabecular bone. SCI-induced osteoporosis reduced the extent of metaphyseal trabecular bone.
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Frotzler A, Krebs J, Göhring A, Hartmann K, Tesini S, Lippuner K. Osteoporosis in the lower extremities in chronic spinal cord injury. Spinal Cord 2019; 58:441-448. [DOI: 10.1038/s41393-019-0383-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 12/27/2022]
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Rinaldin CDP, Cabral LPA, Krueger E, Nogueira-Neto GN, Nohama P, Scheeren EM. Fatigue in complete spinal cord injury and implications on total delay. Artif Organs 2019; 44:305-313. [PMID: 31553061 DOI: 10.1111/aor.13573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022]
Abstract
The use of neuromuscular electrical stimulation (NMES) to artificially restore movement in people with complete spinal cord injury (SCI) induces an accelerated process of muscle fatigue. Fatigue increases the time between the beginning of NMES and the onset of muscle force (DelayTOT ). Understanding how much muscle fatigue affects the DelayTOT in people with SCI could help in the design of closed-loop neuroprostheses that compensate for this delay, thus making the control system more stable. The aim of this study was to evaluate the impact of the extent of fatigue on DelayTOT and peak force of the lower limbs in people with complete SCI. Fifteen men-young adults with complete SCI (paraplegia and tetraplegia) and stable health-participated in the experiment. DelayTOT was defined as the time interval between the beginning of NMES application until the onset of muscle force. The electrical intensity of NMES applied was adjusted individually and consisted of the amplitude required to obtain a full extension of the knee (0°), considering the maximum electrically stimulated extension (MESE). Subsequently, 70% of the MESE was applied during the fatigue induction protocol. Significant differences were identified between the moments before and after the fatigue protocol, both for peak force (P ≤ .026) and DelayTOT (P ≤ .001). The medians and interquartile range of the DelayTOT were higher in postfatigue (199.0 ms) when compared to the moment before fatigue (146.5 ms). The medians and interquartile range of the peak force were higher in unfatigued lower limbs (0.43 kgf) when compared to the moment postfatigue (0.27 kgf). The results support the hypothesis that muscle fatigue influences the increase in DelayTOT and decrease in force production in people with SCI. For future applications, the combined evaluation of the delay and force in SCI patients provides valuable feedback for NMES paradigms. The study will provide potentially critical muscle mechanical evidence for the investigation of the evolution of atrophy.
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Affiliation(s)
| | - Luciane Patrícia Adreani Cabral
- Human Motricity Laboratory/PPGTS, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil.,Regional University Hospital of Campos Gerais, Campus of Ponta Grossa State University, Ponta Grossa, Brazil
| | - Eddy Krueger
- Neural Engineering and Rehabilitation Laboratory, Master and Doctoral Program in Rehabilitation Sciences UEL-UNOPAR, Anatomy Department, State University of Londrina, Londrina, Brazil.,Rehabilitation Engineering Laboratory/CPGEI/PPGEB, Federal Technological University of Paraná (UTFPR), Curitiba, Brazil
| | - Guilherme N Nogueira-Neto
- Rehabilitation Engineering Laboratory/PPGTS, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Percy Nohama
- Rehabilitation Engineering Laboratory/CPGEI/PPGEB, Federal Technological University of Paraná (UTFPR), Curitiba, Brazil.,Rehabilitation Engineering Laboratory/PPGTS, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | - Eduardo M Scheeren
- Human Motricity Laboratory/PPGTS, Pontifical Catholic University of Paraná (PUCPR), Curitiba, Brazil
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