Diagnosis and treatment of osteoporosis in spinal cord injury patients: A literature review

Comparison of the prevalence of osteoporosis in people with spinal cord injury according to bone mineral density reference values for the diagnosis of osteoporosis: a retrospective, cross-sectional study

BACKGROUND

Spinal cord injury (SCI) is a complex cause of rapid low bone mass that easily predisposes the affected individuals to osteoporosis-induced fractures. Several studies have investigated osteoporosis pathophysiology in SCI; however, those associated with its diagnosis in SCI are limited. Additionally, errors in osteoporosis diagnosis and its prevalence vary based on the bone mineral density (BMD) reference values (BMDRV), and no studies have reported BMDRV application for osteoporosis diagnosis in individuals with SCI. Therefore, this study aimed to compare the prevalence of osteoporosis among Korean adults aged ≥ 50 years with SCI according to BMDRV for diagnosing osteoporosis.

METHODS

Overall, 855 patients with SCI who underwent BMD tests of the lumbar spine, femoral neck, and total hip at the National Rehabilitation Center (NRC) in Korea between 2010 and 2020 were included in this retrospective cross-sectional study. Osteoporosis was diagnosed in patients with SCI by comparing the differences in prevalence, diagnostic consistency, and risk factors according to the region-based BMDRV of the dual-energy x-ray absorptiometry (DXA) manufacturer and international BMDRV based on the Third National Health and Nutrition Examination Survey (NHANES III) data of females aged 20-29 years.

RESULTS

The prevalence of osteoporosis according to the T-score provided by a single reference population of the NHANES III (TNHA) (PONHA) (males: 26.69%; females: 69.35%) was significantly higher in females and males than that according to the T-scores provided by the DXA manufacturer (TDXA) (PODXA) (males: 15.32%; females: 43.15%). The lumbar spine and femoral neck were major osteoporosis diagnosis sites for the PODXA and PONHA, respectively. Risk factors for osteoporosis differed based on the probability of osteoporosis (also known as the OZ ratio) according to the BMD criteria; however, the risk factors were similar according to old age, female sex, low body mass index (BMI), and long SCI period. No significant relationship was noted between the different SCI-related clinical factors (p > 0.05).

CONCLUSIONS

The osteoporosis diagnostic site and prevalence in SCI differed according to the regional-based TDXA and international standards of the TNHA. Therefore, further studies on BMDRV are warranted to establish accurate diagnostic criteria for osteoporosis prevention in patients with SCI.

Characteristics Associated with Bone Loss after Spinal Cord Injury: Implications for Hip Region Vulnerability

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.

Prevalence and influencing factors of spinal cord injury-related osteoporosis and fragility fractures in Thai people with chronic spinal cord injury: A cross-sectional, observational study

OBJECTIVE

To investigate the prevalence and influencing factors of spinal cord injury (SCI)-related osteoporosis and fragility fractures in Thai people with chronic spinal cord injury.

DESIGN

A cross-sectional, observational study.

SETTING

Outpatient clinic, Department of Rehabilitation Medicine, Maharaj Nakorn Chiang Mai Hospital.

PARTICIPANTS

Thais with chronic spinal cord injury (SCI) (duration of injury at least one year).

INTERVENTION

Not applicable.

OUTCOME MEASURES

Dual-energy X-ray absorptiometry (DXA) was performed to measure bone mineral density (BMD) at the hip. Analyses were performed to identify risk factors for SCI-related osteoporosis or fragility fracture development. Thai FRAX® score was calculated with and without BMD and compared for each participant.

RESULTS

Among 64 Thais with chronic SCI, the prevalence of SCI-related osteoporosis was 43.8%. Female sex, non-ambulatory status, and at least 10 years duration of spinal cord injury increased the risk of having SCI-related osteoporosis. The prevalence of fragility fracture was 9.4%. Female sex, duration of SCI, and being diagnosed with SCI-related osteoporosis increased the risk of having a fragility fracture. Thai FRAX® score without BMD value underestimated the risk of prevalent fracture in 7.8% of participants.

CONCLUSIONS

SCI-related osteoporosis and fragility fractures are common in Thais with chronic SCI. Our findings emphasize the importance of SCI-related osteoporosis and fragility fracture surveillance in people with chronic SCI regardless of their ethnicity. FRAX® without BMD calculations could underestimate the risk of fragility fracture in people with chronic SCI. Therefore, further studies are needed to develop an SCI-specific fracture-risk assessment tool using risk factors proposed in previous studies and in this study.

The Effects of Exercise and Activity-Based Physical Therapy on Bone after Spinal Cord Injury

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.

Musculoskeletal morbidity following spinal cord injury: A longitudinal cohort study of privately-insured beneficiaries

BACKGROUND

People living with spinal cord injuries (SCIs) experience motor, sensory and autonomic impairments that cause musculoskeletal disorders following the injury and that progress throughout lifetime. The range and severity of issues are largely dependent on level and completeness of the injury and preserved function.

OBJECTIVE

High risk of developing musculoskeletal morbidities among individuals after sustaining a traumatic SCI is well known in the clinical setting, however, there is a severe lack of evidence in literature. The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal morbidities among adults with and without SCIs.

METHODS

Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for SCI (n = 9081). Adults without SCI were also included (n = 1,474,232). Incidence estimates of common musculoskeletal morbidities (e.g., osteoporosis, sarcopenia, osteoarthritis, fractures, etc.) were compared at 5-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident musculoskeletal morbidities.

RESULTS

Adults living with traumatic SCIs had a higher incidence of any musculoskeletal morbidities (82.4% vs. 47.5%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater fully-adjusted hazard for any musculoskeletal morbidity (Hazard Ratio [HR]: 2.41; 95%CI: 2.30, 2.52), and all musculoskeletal disorders, and ranged from HR: 1.26 (1.14, 1.39) for rheumatoid arthritis to HR: 7.02 (6.58, 7.49) for pathologic fracture.

CONCLUSIONS

Adults with SCIs have a significantly higher incidence of and risk for common musculoskeletal morbidities, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of musculoskeletal disease onset/progression in this higher risk population.

A Primary Care Provider's Guide to Clinical Needs of Women With Spinal Cord Injury

Women are a growing proportion of individuals with SCI and have distinctive health needs spanning the life course that demand deliberate consideration and clinical expertise. Practitioners caring for women with SCI must incorporate broad medical knowledge of SCI physiology and health promotion for women, including differences in complication rates following SCI, and work collaboratively with rehabilitation, medical, and surgical specialists to optimize function and health for women with SCI. Clinical researchers must continue to perform population-based studies to best characterize the evolving needs of women with SCI and evaluate treatment efficacy and care delivery models to best serve this population.

Management of lower limb fractures in patients with spinal cord injuries

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.

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

Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.Study Design: Scoping review.Settings/Participants: Human adult subjects with a SCI/D.Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.

Reducing waste: a guidelines-based approach to reducing inappropriate vitamin D and TSH testing in the inpatient rehabilitation setting

Background

Laboratory overutilisation increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Discipline-specific guidelines do not support routine testing for Vitamin D and thyroid-stimulating hormone (TSH) in the inpatient rehabilitation setting, yet 94% of patients had Vitamin D and TSH tests on admission to inpatient rehabilitation at our institution. Our objective was to reduce Vitamin D and TSH testing by 25% on admission to inpatient Stroke, Spinal Cord Injury, Acquired Brain Injury and Amputee Rehabilitation units.

Methods

A fishbone framework for root cause analysis revealed potential causes underlying overutilisation of Vitamin D and TSH testing. A series of Plan-Do-Study-Act (PDSA) cycles were introduced to target remediable factors, starting with an academic detailing intervention with key stakeholders that reviewed applicable clinical guidelines for each patient care discipline and the rationale for reducing admission testing. Simultaneously, computerised clinical decision support (CCDS) limited Vitamin D testing to specific criteria. Audit and feedback were used in a subsequent PDSA cycle. Frequency of Vitamin D and TSH testing on admission was the primary outcome measure. The number of electronic admission order caresets containing automatic Vitamin D and/or TSH orders before and after the interventions was the process measure. Rate of Vitamin D supplementation and changes in thyroid-related medication were the balancing measures.

Results

After implementation, 2.9% of patients had admission Vitamin D testing (97% relative reduction) and 53% of patients had admission TSH testing (43% relative reduction). Admission order caresets with prepopulated Vitamin D and TSH orders decreased from 100% (n=6) to 0%. The interventions were successful; similar to previous literature, CCDS was more effective than education and audit and feedback interventions alone. The interventions represent >$9000 annualised savings.

Management of Lower Extremity Long-bone Fractures in Spinal Cord Injury Patients

The AO classification system, used as a guide for modern fracture care and fixation, follows a basic philosophy of care that emphasizes early mobility and return to function. Lower extremity long-bone fractures in patients with spinal cord injury often are pathologic injuries that present unique challenges, to which the AO principles may not be entirely applicable. Optimal treatment achieves healing without affecting the functional level of the patient. These injuries often result from low-energy mechanisms in nonambulatory patients with osteopenic bone and a thin, insensate soft-tissue envelope. The complication rate can be high, and the outcomes can be catastrophic without proper care. Satisfactory results can be obtained through various methods of immobilization. Less frequently, internal fixation is applied. In certain cases, after discussion with the patient, amputation may be suitable. Prevention strategies aim to minimize bone loss and muscle atrophy.

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

PURPOSE

Spinal cord injury (SCI) results in accelerated bone mineral density (BMD) loss and disorganization of trabecular bone architecture. The mechanisms underlying post-SCI osteoporosis are complex and different from other types of osteoporosis. Findings of studies investigating efficacy of pharmacological or rehabilitative interventions in SCI-related osteoporosis are controversial. The aim of this study was to review the literature pertaining to prevention and evidence-based treatments of SCI-related osteoporosis.

METHODS

In this systematic review, MEDLINE, EMBASE, PubMed, and the Cochrane Library were used to identify papers from 1946 to December 31, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss.

RESULTS

Finally, 56 studies were included according to the inclusion criteria. Only 16 randomized controlled trials (involving 368 patients) were found. We found following evidences for effectiveness of bisphosphonates in prevention of BMD loss in acute SCI: very low-quality evidence for clodronate and etidronate, low-quality evidence for alendronate, and moderate-quality evidence for zoledronic acid. Low-quality evidence showed no effectiveness for tiludronate. In chronic SCI cases, we found low-quality evidence for effectiveness of vitamin D₃ analogs combined with 1-alpha vitamin D₂. However, low-quality inconsistent evidence exists for alendronate. For non-pharmacologic interventions, very low-quality evidence exists for effectiveness of standing with or without treadmill walking in acute SCI. Other low-quality evidences indicated that electrical stimulation, tilt-table standing, and ultrasound provide no significant effects. Very low-quality evidence did not show any benefit for low-intensity (3 days per week) cycling with functional electrical stimulator in chronic SCI.

CONCLUSIONS

No recommendations can be made from this review, regarding overall low quality of evidence as a result of high risk of bias, low sample size in most of the studies, and notable heterogeneity in type of intervention, outcome measurement, and duration of treatment. Therefore, future high-quality RCT studies with higher sample sizes and more homogeneity are strongly recommended to provide high-quality evidence and make applicable recommendations for prevention and treatment of SCI-related bone loss.

The effects of spinal cord injury on bone loss and dysregulation of the calcium/parathyroid hormone loop in mice

Objective

To map the progression of osteoporosis following spinal cord injury in mice in specific areas and analyze changes in parathyroid hormone (PTH) and ion levels which could be responsible for overall bone loss.

Summary of background data

Spinal cord injury rapidly induces severe bone loss compared to other conditions, yet the cause of this bone loss has not been identified. Studies suggest the bone loss after injury is not solely due to disuse.

Methods

To quantify bone loss we weighed individual bones and measured bone mineral density using dual energy X-ray absorptiometry at acute (1 week) and chronic (4 week) time points following a T9 contusion. An ELISA was used to measure blood PTH levels at 1 and 4 weeks after injury. Calcium and phosphate levels were also analyzed at 4 weeks following injury at the University of Miami pathology core.

Results

We observed a significant decrease in bone mineral density in hind limbs after an acute injury, and found this bone loss to progress over time. Furthermore, following chronic injury a decrease in bone mineral density is also observed in bones above the level of injury and in the total bone mineral density. We observed a significant decrease in parathyroid hormone levels in injured mice at the chronic time point, but not at the acute time point which suggests this could be involved in the global bone loss following injury. We also observed a significant increase in serum calcium levels following injury which could account for the imbalance of PTH levels.

Bone morphology of the femur and tibia captured by statistical shape modelling predicts rapid bone loss in acute spinal cord injury patients

After spinal cord injury (SCI), bone loss in the paralysed limbs progresses at variable rates. Decreases in bone mineral density (BMD) in the first year range from 1% (slow) to 40% (rapid). In chronic SCI, fragility fractures commonly occur around the knee, with significant associated morbidity. Osteoporosis treatments await full evaluation in SCI, but should be initiated early and targeted towards patients exhibiting rapid bone loss. The potential to predict rapid bone loss from a single bone scan within weeks of a SCI was investigated using statistical shape modelling (SSM) of bone morphology, hypothesis: baseline bone shape predicts bone loss at 12-months post-injury at fracture-prone sites. In this retrospective cohort study 25 SCI patients (median age, 33 years) were scanned at the distal femur and proximal tibia using peripheral Quantitative Computed Tomography at <5 weeks (baseline), 4, 8 and 12 months post-injury. An SSM was made for each bone. Links between the baseline shape-modes and 12-month total and trabecular BMD loss were analysed using multiple linear regression. One mode from each SSM significantly predicted bone loss (age-adjusted P<0.05 R(2)=0.37-0.61) at baseline. An elongated intercondylar femoral notch (femur mode 4, +1 SD from the mean) was associated with 8.2% additional loss of femoral trabecular BMD at 12-months. A more concave posterior tibial fossa (tibia mode 3, +1 SD) was associated with 9.4% additional 12-month tibial trabecular BMD loss. Baseline bone shape determined from a single bone scan is a valid imaging biomarker for the prediction of 12-month bone loss in SCI patients.

Bone Imaging and Fracture Risk after Spinal Cord Injury

Spinal cord injury (SCI) is characterized by marked bone loss and an increased risk of fracture with high complication rate. Recent research based on advanced imaging analysis, including quantitative computed tomography (QCT) and patient-specific finite element (FE) modeling, has provided new and important insights into the magnitude and temporal pattern of bone loss, as well as the associated changes to bone structure and strength, following SCI. This work has illustrated the importance of early therapeutic treatment to prevent bone loss after SCI and may someday serve as the basis for a clinical fracture risk assessment tool for the SCI population. This review provides an update on the epidemiology of fracture after SCI and discusses new findings and significant developments related to bone loss and fracture risk assessment in the SCI population based on QCT analysis and patient-specific FE modeling.

Longitudinal study of bone loss in chronic spinal cord injury patients

[Purpose] This prospective longitudinal study evaluated the changes in bone metabolism markers and bone mineral density of spinal cord injury patients over 3 years. We also assessed the relationships among the bone mineral density, bone metabolism, and clinical data of spinal cord injury patients. [Subjects and Methods] We assessed the clinical data (i.e., immobilization due to surgery, neurological status, neurological level, and extent of lesion) in 20 spinal cord injury patients. Bone mineral density, and hormonal and biochemical markers of the patients were measured at 0, 6, 12, and 36 months. [Results] Femoral neck T score decreased significantly at 36 months (p < 0.05). Among the hormonal markers, parathyroid hormone and vitamin D were significantly elevated, while bone turnover markers (i.e., deoxypyridinoline and osteocalcin) were significantly decreased at 12 and 36 months (p < 0.05). [Conclusion] Bone mineral density of the femoral neck decreases significantly during the long-term follow-up of patients with spinal cord injury due to osteoporosis. This could be due to changes in hormonal and bone turnover markers.

Differences in bone mineral density, markers of bone turnover and extracellular matrix and daily life muscular activity among patients with recent motor-incomplete versus motor-complete spinal cord injury

Spinal cord injury (SCI) leads to severe bone loss, but the associated mechanisms are poorly described in incomplete SCI individuals. The purpose of the study is to compare alterations in bone mineral density (BMD) and serum biomarkers of bone turnover in recent motor-incomplete to -complete SCI men, as well as to describe their physical activity and spasticity. We studied 31 men with acute SCI. Whole-body DXA scans, serum biomarkers and self-reported activity and spasticity were examined 1 and/or 3 and 12 months after the injury. We observed a decrease in proximal femur BMD (p < 0.02) in both the groups. Serum phosphate and carboxy-terminal-collagen crosslinks were significantly lower in motor-incomplete versus complete SCI men, whereas albumin-corrected Ca(2+) (p = 0.02) were lower only 3 months after injury. When data from all 31 SCI participants were pooled, we observed increased serum matrix metalloproteinase-2 (MMP-2) and tissue inhibitors of MMP-2 (TIMP-2) (p < 0.02) whereas TIMP-1 decreased (p = 0.03). BMD correlated positively with self-reported activity (r = 0.59, p = 0.04) and negatively with spasticity (r = 0.74, p = 0.02) 12 months after injury. As a summary, men with motor-incomplete SCI developed significant proximal femur bone loss 12 months after injury and exhibited increased bone resorption throughout the first year after the injury. Compared with complete SCI men, incomplete SCI men show attenuated bone resorption. Our pooled data show increased turnover of extracellular matrix after injury and that increased exercise before and after injury correlated with reduced bone loss.

Impact on bone and muscle area after spinal cord injury

Spinal cord injury (SCI) causes inactivation and consequent unloading of affected skeletal muscle and bone. This cross-sectional study investigated correlations of muscle and bone in spinal cord-injured subjects compared with able-bodied subjects. Thirty-one complete SCI paraplegics were divided according to the neurological level of injury (NLoI) into group A (n=16, above thoracic 7 NLoI, age: 33±16 years, duration of paralysis (DoP): 6±6 years) and group B (n=15, thoracic 8-12, age: 39±14 years, DoP: 5.6±6 years), compared with 33 controls (group C). All were examined with peripheral quantitative computed tomography at 66% of tibia length (bone and muscle area, bone/muscle area ratio). In able-bodied subjects, muscle area was correlated with bone area (P<0.001, r=0.88). Groups A and B differed significantly from the control group in terms of bone and muscle area (P<0.001). In paraplegics, less muscle per unit of bone area (bone/muscle area ratio) was found compared with controls (P<0.001). Bone area was negatively correlated with the DoP in the total paraplegic group (r=-0.66, P<0.001) and groups A and B (r=-0.77, P=0.001 vs r=-0.52, P=0.12, respectively). Muscle area and bone/muscle ratio area correlations in paraplegic groups with DoP were weak. Paraplegic subjects who performed standing and therapeutic walking had significantly higher bone area (P=0.02 and P=0.013, respectively). The relationship between bone and muscle was consistent in able-bodied subjects and it was predictably altered in those with SCI, a clinical disease affecting bone and muscle.

Chronic complications of spinal cord injury

Spinal cord injury (SCI) is a serious medical condition that causes functional, psychological and socioeconomic disorder. Therefore, patients with SCI experience significant impairments in various aspects of their life. The goals of rehabilitation and other treatment approaches in SCI are to improve functional level, decrease secondary morbidity and enhance health-related quality of life. Acute and long-term secondary medical complications are common in patients with SCI. However, chronic complications especially further negatively impact on patients’ functional independence and quality of life. Therefore, prevention, early diagnosis and treatment of chronic secondary complications in patients with SCI is critical for limiting these complications, improving survival, community participation and health-related quality of life. The management of secondary chronic complications of SCI is also important for SCI specialists, families and caregivers as well as patients. In this paper, we review data about common secondary long-term complications after SCI, including respiratory complications, cardiovascular complications, urinary and bowel complications, spasticity, pain syndromes, pressure ulcers, osteoporosis and bone fractures. The purpose of this review is to provide an overview of risk factors, signs, symptoms, prevention and treatment approaches for secondary long-term complications in patients with SCI.

Bone mass and hormone analysis in patients with spinal cord injury: evidence for a gonadal axis disruption

CONTEXT

Bone loss is a constant finding in patients with spinal cord injury (SCI).

OBJECTIVE

We sought to evaluate potential modifiable factors that could lead to bone loss in complete motor paraplegia by examining gonadal axis hormones, vitamin D status, and bone markers.

DESIGN

This is a cross sectional.

SETTING

It includes SCI Outpatient.

PATIENTS AND OTHER PARTICIPANTS

Twenty-nine chronic male patients with SCI were compared with 17 age-matched, able-bodied men.

MAIN OUTCOME MEASURE

The bone mineral density (BMD) of lower limbs and lumbar spine were measured using dual x-ray absorptiometry. Parathormone, 25-hydroxyvitamin D [25(OH)D], collagen type I C-terminal telopeptide (CTX), and sexual hormone were measured.

RESULTS

Patients with SCI had lower BMD at the inferior limbs sites. CTX showed an inverse relationship with the time since injury. Patients had lower free T levels (SCI, 12.00 ± 2.91 vs controls, 19.51 ± 5.72; P ≤ .001), and the majority (72%) had normal/low levels of gonadotropins. Low T, however, was not related to low bone mass in patients with SCI. In the controls, the 25(OH)D level was positively correlated with the T and with the lumbar spine BMD, but these correlations were not observed in the SCI.

CONCLUSIONS

Impairment of testicular function after SCI was indicated by the low levels of T and the loss of correlation between T and 25(OH)D levels; this correlation was present in the able-bodied controls. Inappropriate levels of gonadotropins were identified in most patients, featuring a hypogonadotropic hypogonadism and suggesting a disruption of the pituitary-gonadal axis. T concentrations might not be an effective target for bone loss therapy.

Acupuncture for treatment of secondary osteoporosis in patients with spinal cord injury: a controlled study

OBJECTIVE

We explored the effect of adjunctive acupuncture on secondary osteoporosis in patients with spinal cord injury (SCI).

METHODS

Patients with subacute SCI were recruited and divided into two groups by patient choice: group 1 patients received standard combination therapy and group 2 patients received combination therapy plus acupuncture for 3 months. The concentrations of IgG, IgM and tumour necrosis factor α (TNFα) in serum and the bone mineral density were measured before and after treatment.

RESULT

The decrease in the concentration of TNFα and IgM in patients in group 2 compared with those in group 1 was statistically significant. The IgG level showed no significant change in either group. Bone mineral density increased more after adjunctive acupuncture, but the difference was not significant.

CONCLUSIONS

Further research is needed to determine whether acupuncture as an adjunct to combination therapy can reduce osteoporosis in patients with subacute SCI.

TRIAL REGISTRATION NUMBER

P153-2008-36.

Is lipid profile associated with bone mineral density and bone formation in subjects with spinal cord injury?

Purpose. The association between serum lipids and bone mineral density (BMD) has been investigated previously but, up to now, these relationships have not yet been described in spinal cord injury (SCI). We tried to assess the correlation between serum triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) and BMD in male subjects with SCI. Methods. Dual-energy X-ray absorptiometry (DXA) was used to assess BMD in femoral neck, trochanter, intertrochanteric zone, and lumbar vertebras. Blood samples were taken to measure serums lipids and bone biomarkers including osteocalcin, cross-linked type I collagen (CTX), and bone alkaline phosphatase (BALP). Partial correlation analysis was used to evaluate the relationships between mentioned measurements after adjustment for weight and age. Results. We found a positive correlation between HDL and femoral neck BMD (P: 0.004, r = 0.33). HDL was negatively correlated with osteocalcin (P: 0.017, r = -0.31) which was not in consistency with its relationship with BMD. TC and LDL were not related to CTX, BALP and BMD. Conclusion. This study does not support a strong association between serum lipids and BMD in subjects with SCI. Moreover it seems that positive association between HDL and BMD is not mediated through increased bone formation.

Prevalence and associated factors of T-score discordance between different sites in Iranian patients with spinal cord injury

OBJECTIVES

The present study was conducted to determine the prevalence of T-score discordance and its risk factors in a group of patients with spinal cord injury in a university teaching hospital in the Iranian capital of Tehran.

METHODS

This cross-sectional study was conducted on paraplegic men undergoing bone density testing in an outpatient clinic at a hospital in the Iranian capital, Tehran, between March 2011 and 2012. A questionnaire on demographic and anthropometric characteristics, including age, height, weight, engagement in physical activity and personal smoking habits, was filled out for each subject. All the subjects underwent bone mineral density measurement and blood samples were sent for laboratory testing.

RESULTS

Major T-score discordance between two sites was noted in 54 (41.22%) patients. Multivariate logistic regression revealed that every unit increase in serum calcium levels, as the only factor influencing T-score discordance, was associated with a 2.49-fold increased risk in T-score discordance in the area. As for the spine and radius, BMI was the only influencing factor as every unit increase in BMI was associated with a 14% lower risk for T-score discordance in these regions. Body mass index was the only factor, based on the multivariate model, affecting the risk of developing T-score discordance between two sites.

CONCLUSION

Our study revealed the high prevalence of T-score discordance in patients with spinal cord injury. Physicians should therefore be encouraged to perform BMD at three sites when visiting patients with such injuries.

Effectiveness of bisphosphonate analogues and functional electrical stimulation on attenuating post-injury osteoporosis in spinal cord injury patients- a systematic review and meta-analysis

BACKGROUND

Various pharmacologic and non-pharmacologic approaches have been applied to reduce sublesional bone loss after spinal cord injury (SCI), and the results are inconsistent across the studies. The objective of this meta-analysis was to investigate whether the two most-studied interventions, bisphosphonate analogues and functional electrical stimulation (FES), could effectively decrease bone mineral density (BMD) attenuation and/or restore lost BMD in the SCI population.

METHODS

Randomized controlled trials, quasi-experimental studies, and prospective follow-up studies employing bisphosphonates or FES to treat post-SCI osteoporosis were identified in PubMed and Scopus. The primary outcome was the percentage of BMD change from baseline measured by dual-energy X-ray absorptiometry (DEXA) or computed tomography (CT). Data were extracted from four points: the 3rd, 6th, 12th, and 18th month after intervention.

RESULTS

A total of 19 studies were included in the analysis and involved 364 patients and 14 healthy individuals. Acute SCI participants treated with bisphosphonate therapy demonstrated a trend toward less bone loss than participants who received placebos or usual care. A significant difference in BMD decline was noted between both groups at the 3rd and 12th month post-medication. The subgroup analysis failed to show the superiority of intravenous bisphosphonate over oral administration. Regarding FES training, chronic SCI patients had 5.96% (95% CI, 2.08% to 9.84%), 7.21% (95%CI, 1.79% to 12.62%), and 9.56% (95% CI, 2.86% to 16.26%) increases in BMD at the 3rd, 6th, and 12th months post-treatment, respectively. The studies employing FES ≥ 5 days per week were likely to have better effectiveness than studies using FES ≤ 3 days per week.

CONCLUSIONS

Our meta-analysis indicated bisphosphonate administration early following SCI effectively attenuated sublesional bone loss. FES intervention for chronic SCI patients could significantly increase sublesional BMD near the site of maximal mechanical loading.