An effective oral vitamin D replacement therapy in persons with spinal cord injury

The Role of Vitamins in Spinal Cord Injury: Mechanisms and Benefits

Spinal cord injury (SCI) is a common neurological disease worldwide, often resulting in a substantial decrease in quality of life, disability, and in severe cases, even death. Unfortunately, there is currently no effective treatment for this disease. Nevertheless, current basic and clinical evidence suggests that vitamins, with their antioxidant properties and biological functions, may play a valuable role in improving the quality of life for individuals with SCI. They can promote overall health and facilitate the healing process. In this review, we discuss the mechanisms and therapeutic potential of vitamins in the treatment of SCI.

Bioactive role of vitamins as a key modulator of oxidative stress, cellular damage and comorbidities associated with spinal cord injury (SCI)

Introduction: Spinal cord injury (SCI) cause significant disability and impact the quality of life of those affected by it. The nutritional status and diet are fundamental to diminish the progression of complications; vitamins modulate the inflammatory response and oxidative stress, promote blood-spinal cord barrier preservation and the prompt recovery of homeostasis. A deep knowledge of the benefits achieved from vitamins in patients with SCI are summarized. Information of dosage, time, and effects of vitamins in these patients are also displayed. Vitamins have been extensively investigated; however, more clinical trials are needed to clarify the scope of vitamin supplementation.Objective: The objective of this review was to offer relevant therapeutic information based on vitamins supplementation for SCI patients.Methods: Basic and clinical studies that have implemented the use of vitamins in SCI were considered. They were selected from the year 2000-2022 from three databases: PubMed, Science Direct and Google Scholar.Results: Consistent benefits in clinical trials were shown in those who were supplemented with vitamin D (prevents osteoporosis and improves physical performance variables), B3 (improves lipid profile) and B12 (neurological prophylaxis of chronic SCI damage) mainly. On the other hand, improvement related to neuroprotection, damage modulation (vitamin A) and its prophylaxis were associated to B complex vitamins supplementation; the studies who reported positive results are displayed in this review.Discussion: Physicians should become familiar with relevant information that can support conventional treatment in patients with SCI, such as the use of vitamins, a viable option that can improve outcomes in patients with this condition.

Rehabilitation: Neurogenic Bone Loss after Spinal Cord Injury

Osteoporosis is a common skeletal disorder which can severely limit one's ability to complete daily tasks due to the increased risk of bone fractures, reducing quality of life. Spinal cord injury (SCI) can also result in osteoporosis and sarcopenia. Most individuals experience sarcopenia and osteoporosis due to advancing age; however, individuals with SCI experience more rapid and debilitating levels of muscle and bone loss due to neurogenic factors, musculoskeletal disuse, and cellular/molecular events. Thus, preserving and maintaining bone mass after SCI is crucial to decreasing the risk of fragility and fracture in vulnerable SCI populations. Recent studies have provided an improved understanding of the pathophysiology and risk factors related to musculoskeletal loss after SCI. Pharmacological and non-pharmacological therapies have also provided for the reduction in or elimination of neurogenic bone loss after SCI. This review article will discuss the pathophysiology and risk factors of muscle and bone loss after SCI, including the mechanisms that may lead to muscle and bone loss after SCI. This review will also focus on current and future pharmacological and non-pharmacological therapies for reducing or eliminating neurogenic bone loss following SCI.

The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury

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.

The use of alkaline phosphatase as a bone turnover marker after spinal cord injury: A scoping review of human and animal studies

BACKGROUND

Serum alkaline phosphatase (ALP) is measured as an indicator of bone or liver disease. Bone-specific alkaline phosphatase (B-ALP) is an isoform of ALP found in the bone tissue which can predict fractures and heterotopic ossification.

OBJECTIVE

The aim of this scoping review was to explore the current use of ALP and B-ALP in studies using humans or animal models of SCI, and to identify ways to advance future research using ALP and B-ALP as a bone marker after SCI.

RESULTS

HUMAN STUDIES: 42 studies were included. The evidence regarding changes or differences in ALP levels in individuals with SCI compared to controls is conflicting. For example, a negative correlation between B-ALP and total femur BMD was observed in only one of three studies examining the association. B-ALP seemed to increase after administration of teriparatide, and to decrease after treatment with denosumab. The effects of exercise on ALP and B-ALP levels are heterogeneous and depend on the type of exercise performed. ANIMAL STUDIES: 11 studies were included. There is uncertainty regarding the response of ALP or B-ALP levels after SCI; levels increased after some interventions, including vibration protocols, curcumin supplementation, cycles in electromagnetic field or hyperbaric chamber. Calcitonin or bisphosphonate administration did not affect ALP levels.

CONCLUSION

Researchers are encouraged to measure the bone-specific isoform of ALP rather than total ALP in future studies in humans of animal models of SCI.

Primary Care in the Spinal Cord Injury Population: Things to Consider in the Ongoing Discussion

Purpose of Review

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population.

Findings

Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population.

Summary

Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

Impact of vitamin D on the prognosis after spinal cord injury: A systematic review

Vitamin D (VitD) insufficiency is a worldwide health problem and affects billions of people. Spinal cord injury (SCI) patients seem more susceptible to developing suboptimal levels of VitD. However, the literature regarding its impact on the prognosis of SCI is limited. Thus, in this review, we systematically investigated the published studies via a combination of keywords associated with SCI and VitD in four medical databases (Medline, Embase, Scopus, and Web of Science). All included studies were analyzed, and selected clinical data on the prevalence of VitD insufficiency (serum 25-hydroxyvitamin D < 30 ng/ml) and deficiency (serum 25-hydroxyvitamin D < 20 ng/ml) were collected for further meta-analysis via random effects. Through literature review, a total of 35 studies were eligible and included. The meta-analysis of VitD status (13 studies, 1,962 patients) indicated high prevalence of insufficiency (81.6% [75.7, 87.5]) and deficiency (52.5% [38.1, 66.9]) after SCI. Besides, low levels of VitD were reported to be associated with a higher risk of skeletal diseases, venous thromboembolism, psychoneurological syndromes, and chest illness after injury. Existing literature suggested that supplemental therapy might act as an adjuvant treatment to facilitate post-injury rehabilitation. Non-human experimental studies highlighted the neuroprotective effect of VitD, which was associated with enhancing axonal and neuronal survival, suppressing neuroinflammation, and modulating autophagy. Therefore, the current evidence suggests that the prevalence of VitD insufficiency is high in the SCI population, and low-level VitD may impair functional restoration after SCI. VitD supplemental treatment may have potential benefits to accelerate rehabilitation in mechanistically related processes after SCI. However, due to the limitation of the available evidence, more well-designed randomized controlled trials and mechanism experimental research are still needed to validate its therapeutic effect, elucidate its neuroprotective mechanism, and develop novel treatments.

Vitamin D supplementation in chronic spinal cord injury (VitD-SCI): study protocol for a randomised controlled trial

INTRODUCTION

Vitamin D insufficiency, a vitamin D status or serum 25(OH)D concentration of ≤75 nmol/L, is highly prevalent in individuals with a spinal cord injury (SCI). Vitamin D is important for the functioning of the musculoskeletal, immune and respiratory systems, which are relevant determinants of secondary health conditions in SCI. An insufficiency should be treated with vitamin D supplementation. However, there is a lack of evidence regarding the optimal dosage and duration of vitamin D supplementation for individualised and long-term management of the vitamin D status in the context of SCI. This paper presents the protocol for the vitamin D supplementation in chronic spinal cord injury (VitD-SCI) trial that aims to investigate the effect of a 12-month intake of vitamin D supplementation on vitamin D status as well as on several secondary parameters among individuals with a chronic SCI.

METHODS AND ANALYSES

The VitD-SCI trial is a randomised, placebo-controlled, double-blinded, parallel-group, superiority trial, conducted at the Swiss Paraplegic Centre. A total of 45 participants living with an SCI for at least 3 years (chronic SCI) and a vitamin D insufficiency at the first study visit, will be randomly assigned to one of three intervention groups. Participants receive either a monthly dosage of 24 000 IU or 48 000 IU vitamin D or a placebo for 12 months. Measurements taking place every 3 months include the assessment of vitamin D status (primary outcome) as well as bone mineral density, handgrip strength, fatigue, mood, pain and pressure injuries (secondary outcomes). Safety and tolerance of vitamin D supplementation will also be evaluated.

ETHICS AND DISSEMINATION

The Swiss Ethics Committee for Northwest/Central Switzerland (EKNZ, 2020-01493) and the Swiss Agency for Therapeutic Products (Swissmedic, 2020DR3150) approved this study. Findings will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBERS

NCT04652544 and SNCTP000004032.

Pharmacological approaches for bone health in persons with spinal cord injury

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.

Bone and non-contractile soft tissue changes following open kinetic chain resistance training and testosterone treatment in spinal cord injury: an exploratory study

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).

Effect of vitamin D supplementation on lower extremity motor function and ambulation in stroke patients

Background/aim

The aim of this study was to investigate the effect of vitamin D supplementation on ambulation and mobility in hospitalized patients undergoing stroke rehabilitation.

Materials and methods

This study was conducted retrospectively between September 2020 and October 2020 at Gazi University Faculty of Medicine Physical Medicine and Rehabilitation Department. Seventy-six patients who received inpatient stroke rehabilitation treatment between May 2018 and February 2020 were included in the study. The patients were divided into two groups as those who did and did not take vitamin D supplements. Lower extremity motor function and ambulation status were compared using Brunnstrom recovery stage (lower extremity) and functional ambulation classification (FAC) scores before and after rehabilitation.

Results

Thirty-nine patients received vitamin D treatment during the rehabilitation process and 37 patients did not. The two groups were similar in terms of age, sex, time since stroke, stroke type, comorbid diseases, nutritional status, rehabilitation duration, and FAC and Brunnstrom scores before rehabilitation (p > 0.05). At the end of rehabilitation, the changes in FAC and Brunnstrom scores were higher in patients receiving vitamin D supplementation (p = 0.005 and p = 0.018). The change in FAC and Brunnstrom scores in patients who were undergoing rehabilitation for the first time and/or in the first 3 months after stroke was higher in the group receiving vitamin D supplementation compared with the group not receiving vitamin D (p < 0.05). In patients who were not within the first 3 months after stroke, vitamin D treatment did not affect FAC and Brunnstrom scores.

Conclusion

Vitamin D supplementation may increase the success of rehabilitation therapy in patients during the first 3 months poststroke.

Bone Mineral Density at the Distal Femur and Proximal Tibia and Related Factors During the First Year of Spinal Cord Injury

Background

Spinal cord injury (SCI) can lead to disuse osteoporosis. The most vulnerable sites for fragility-induced fractures are the distal femur (DF) and proximal tibia (PT). The aim of this study was to evaluate changes in bone mineral density (BMD) at the DF and PT, as well as related factors, during the first year of SCI.

Patients and Methods

Thirty-six SCI patients within 12 months of their injury were selected, as were 36 healthy controls. The dual-energy X-ray absorptiometry was used to measure BMDs at the DF, PT, and hip of all subjects. According to the duration of SCI when receiving DXA scan, 36 SCI patients were divided into three subgroups. The BMDs of overall patients and subgroups were compared to those of controls. Biochemical markers of bone metabolism were detected in SCI patients.

Results

The BMDs at the DF, PT, and hips of overall SCI patients were significantly lower than those of controls. The percentage difference of BMD between SCI patients and controls at the DF and PT was higher than at the hip. The BMD at the PT of SCI within 6 weeks post-injury was lower than that of controls. The BMDs at the DF and PT of SCI during 6 weeks-3 months post-injury were lower than those of controls. Whereas there was no difference in the BMD at the hip during the first 3 months of SCI. Age and 25OHD were the influencing factors of DF BMD. Age and gender were found to influence PT BMD.

Conclusion

The rapid loss of BMD at the PT and DF during the first year of SCI occurred significantly earlier than that of the hip. It is recommended to monitor the BMD of DF and PT in early-stage SCI patients, combined with detection of biochemical markers of bone metabolism.

Dried plum mitigates spinal cord injury-induced bone loss in mice

Spinal cord injury (SCI) is accompanied by rapid loss of bone and increased risk of low impact fractures. Current pharmacological treatment approaches have proven to be relatively ineffective in preventing or treating bone loss after SCI. Dietary supplementation with dried plum (DP) has been shown to have dramatic effects on bone in various other disease models. In this study, we tested the efficacy of DP in preventing bone loss after SCI and restoring bone that has already been lost in response to SCI. Male C57BL/6J mice (3-month-old) underwent SCI and were fed a diet containing 25% DP by weight or a control diet for up to 4 weeks to assess whether DP can prevent bone loss. To determine whether DP could restore bone already lost due to SCI, mice were put on a control diet for 2 weeks (to allow bone loss) and then shifted to a DP supplemented diet for an additional 2 weeks. The skeletal responses to SCI and dietary supplementation with DP were assessed using microCT analysis, bone histomorphometry and strength testing. Dietary supplementation with DP completely prevented the loss of bone and bone strength induced by SCI in acutely injured mice. DP also could restore a fraction of the bone lost and attenuate the loss of bone strength after SCI. These results suggest that dietary supplementation with DP or factors derived from DP may prove to be an effective treatment for the loss of bone in patients with SCI.

Spinal cord injury providers' perspectives on managing sublesional osteoporosis

Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI. Design: Telephone interviews with SCI providers. Setting: VA SCI centers and clinics. Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed. Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures. Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.

Exploring nutrition knowledge and dietary intake of adults with spinal cord injury in specialist rehabilitation

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To explore nutrition knowledge and dietary intake in adults with spinal cord injury (SCI).

SETTING

SCI centre, Australia.

METHODS

A validated General Nutrition Knowledge Questionnaire-R (GNKQ-R) evaluated nutrition knowledge to explore correlations with dietary intake. Dietary intake (current and pre-hospitalisation) was compared with national dietary modelling tools and Nutrient Reference Values (NRV) for assessing nutritional adequacy.

RESULTS

Fifty participants, predominantly male (70%), with a median age of 50 years took part in the study. The mean GNKQ-R score was 59 (13.1)/85 (69%). Participants with a higher level of education scored higher (82%; p < 0.01). The GNKQ-R score was also positively associated with the level of education (r = 0.45; p = < 0.01) with a large effect size (>0.80 Cohen's d). Non-conformance with Australian Dietary Guidelines (ADG) and failure to meet NRV were also noted. Low calcium intakes were found in 69% (n = 34) and saturated fatty acid (SFA) consumption exceeded both the acceptable macronutrient distribution range (AMDR) of 10% for adults (n = 32, 65%) and the lower target of 7% recommended for at-risk groups (n = 49, 100%). Lower nutrition knowledge scores were negatively correlated with SFA intake (r = -0.28; p = 0.05, two-tailed) with a large Cohen's d effect size (>0.80).

CONCLUSIONS

Discordance with the ADG for most food groups was exemplified by high intake of SFA. Individuals with SCI have elevated cardiovascular disease (CVD) risk. Poor nutrition knowledge correlated with high SFA intake, indicates a need for timely, targeted interventions for CVD prevention in this patient group.

Evaluating Bone Loss with Bone Turnover Markers Following Acute Spinal Cord Injury

STUDY DESIGN

Prospective observational study.

PURPOSE

To evaluate bone turnover markers (BTMs) in individuals with acute spinal cord injury (SCI) and to compare the results with those of healthy controls and postmenopausal females.

OVERVIEW OF LITERATURE

SCI significantly impacts bone health. Change in bone mineral density appears 6 months after SCI and rapid bone loss during the acute phase is often underestimated, resulting in osteoporosis and a high risk of sublesional fractures. However, few studies have evaluated BTMs in the Indian SCI population. Despite a high risk of fracture, there are no guidelines for the diagnosis, monitoring, and management of SCI-induced osteoporosis.

METHODS

Twenty patients within 1 month of traumatic SCI who had been admitted to a tertiary care rehabilitation center were included in this study. Serum BTMs, C telopeptide (CTX) as a bone resorption marker, and osteocalcin as a bone formation marker, were serially measured at baseline, and 3 and 6 months after SCI. BTMs of SCI patients were compared with those of a control group of age-matched healthy males, premenopausal females, and a vulnerable group of postmenopausal females.

RESULTS

BTMs were significantly elevated in patients with SCI, with maximum levels observed at the 3rd month of injury. At baseline, the bone resorption marker CTX was approximately 3 times higher in SCI patients than in the control male population and premenopausal females, and about double that of postmenopausal females. The rise in the bone formation marker was marginal in comparison to that of the bone resorption marker. BTMs were persistently elevated and did not reach the normative range until the 6th month of SCI.

CONCLUSIONS

Raised bone resorption markers in comparison to bone formation markers indicate hyper-resorption-related bone loss following acute SCI. Markedly elevated bone resorption markers in the SCI population, compared with those in control and vulnerable groups, emphasize the need for early bone health monitoring and management.

Evaluating Bone Loss with Bone Turnover Markers Following Acute Spinal Cord Injury

STUDY DESIGN

Prospective observational study.

PURPOSE

To evaluate bone turnover markers (BTMs) in individuals with acute spinal cord injury (SCI) and to compare the results with those of healthy controls and postmenopausal females.

OVERVIEW OF LITERATURE

SCI significantly impacts bone health. Change in bone mineral density appears 6 months after SCI and rapid bone loss during the acute phase is often underestimated, resulting in osteoporosis and a high risk of sublesional fractures. However, few studies have evaluated BTMs in the Indian SCI population. Despite a high risk of fracture, there are no guidelines for the diagnosis, monitoring, and management of SCI-induced osteoporosis.

METHODS

Twenty patients within 1 month of traumatic SCI who had been admitted to a tertiary care rehabilitation center were included in this study. Serum BTMs, C telopeptide (CTX) as a bone resorption marker, and osteocalcin as a bone formation marker, were serially measured at baseline, and 3 and 6 months after SCI. BTMs of SCI patients were compared with those of a control group of age-matched healthy males, premenopausal females, and a vulnerable group of postmenopausal females.

RESULTS

BTMs were significantly elevated in patients with SCI, with maximum levels observed at the 3rd month of injury. At baseline, the bone resorption marker CTX was approximately 3 times higher in SCI patients than in the control male population and premenopausal females, and about double that of postmenopausal females. The rise in the bone formation marker was marginal in comparison to that of the bone resorption marker. BTMs were persistently elevated and did not reach the normative range until the 6th month of SCI.

CONCLUSIONS

Raised bone resorption markers in comparison to bone formation markers indicate hyper-resorption-related bone loss following acute SCI. Markedly elevated bone resorption markers in the SCI population, compared with those in control and vulnerable groups, emphasize the need for early bone health monitoring and management.

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.

Weight-Bearing Physical Activity Influences the Effect of Vitamin D on Bone Turnover Markers in Patients with Intellectual Disability

OBJECTIVES

Individuals with intellectual disabilities (IDs) are at increased risk for low bone mass and fragility fractures, and those who are nonambulatory may be at even higher risk. Patients with IDs often are vitamin D deficient, but there is little information concerning how vitamin D treatment of patients with IDs affects markers of bone formation and resorption.

METHODS

We performed a retrospective analysis of 23 institutionalized individuals with IDs who were the subject of a performance improvement continuing medical education project designed to reduce risk for fracture by optimizing serum vitamin D levels. Patients were divided into those with normal weight-bearing (NWB) physical activity (15 patients: 14 men, 1 woman) and those with low weight-bearing (LWB) physical activity (8 patients: 7 men, 1 woman). All of the subjects received 50,000 IU of vitamin D₃ weekly for 4 to 8 weeks, followed by a maintenance dose of 50,000 IU monthly for 3 to 6 months. Bone turnover markers (type 1 cross-linked C-telopeptide [CTX], type 1 N-terminal propeptide [P1NP], and parathyroid hormone [PTH]) and 25(OH)-vitamin D levels were measured before and after vitamin D supplementation.

RESULTS

At baseline, there were no significant differences in the serum levels of 25OH-D, PTH, P1NP, or CTX between the two groups (NWB and LWB). Vitamin D levels were increased to a higher value in LWB subjects than in NWB subjects (61 ± 4.1 vs 48.4 ± 2.2 ng/mL, P < 0.001). Vitamin D treatment suppressed PTH (20.5% ± 14.3% vs 31.4% ± 7.7%, P = not significant) and P1NP (33.0% ± 6.2% vs 29.4% ± 6.9%, P = not significant) similarly in both groups. Although CTX levels declined by 26.4% ± 5.3% (P = 0.0002) in NWB individuals (as anticipated), vitamin D supplementation resulted in an unexpected 25.8% ± 8% increase (P = 0.01) in CTX in LWB individuals, suggesting osteoclast activation.

CONCLUSIONS

Although high-dose vitamin D appeared to suppress osteoclast activity in NWB adults with IDs, the increase in serum CTX levels in those with LWB activity implies activation of osteoclasts that could exacerbate their unique low bone mass and increase fracture risk. The results support the use of a lower-dose vitamin D regimen in this patient group with LWB.

Effectiveness of two vitamin D3 repletion protocols on the vitamin D status of adults with a recent spinal cord injury undergoing inpatient rehabilitation: a prospective case series

Study design

Prospective case series.

Objectives

To assess the effectiveness and safety of two vitamin D₃ repletion protocols given to individuals with spinal cord injury (SCI).

Setting

Publicly-funded intensive inpatient rehabilitation center, Montreal, Canada.

Methods

Thirty adults with recent SCI complete or incomplete sensorimotor impairments were recruited upon admission from designated regional SCI trauma centers. Participants with serum 25OHD ≤ 30 nmol/L were given 10,000 IU of weekly and 1000 IU of daily vitamin D₃ for 36.8 ± 11.9 days (higher dose: HD). Subjects with serum 25OHD > 30 nmol/L received 1000 IU of daily vitamin D₃ for 38.2 ± 11.6 days (lower dose: LD). Outcomes were changes in 25OHD levels from baseline to the end of the study period and safety outcomes. Thresholds for vitamin D deficiency, insufficiency and sufficiency were: 25OHD levels ≤30 nmol/L, 30-74 nmol/L, and ≥75 nmol/L.

Results

At baseline, 34 and 66% of participants had serum 25OHD < 30 and >30 nmol/L. Both protocols induced a rise in serum 25OHD with a greater increase in the HD vs. LD regimen (31.4 [95% CI: 16.7, 46.0] vs. 11.7 nmol/L [95% CI: 2.2, 21.2]). None of the participants given the HD remained vitamin D deficient, but only one achieved vitamin D sufficiency. Nearly all individuals on the LD regimen remained vitamin D insufficient with only two reaching vitamin D sufficiency. No adverse effects were observed over the course of the supplementation.

Conclusions

Although 1000 IU of daily vitamin D₃ alone or in combination with weekly 10,000 IU for an average of 37.6 days increased serum 25OHD, they were unsuccessful in improving the impaired vitamin D status during inpatient rehabilitation of individuals with a recent SCI.

Creatine or vitamin D supplementation in individuals with a spinal cord injury undergoing resistance training: A double-blinded, randomized pilot trial

PURPOSE

Determine whether creatine or vitamin D supplementation improves muscle strength in individuals with spinal cord injury undergoing resistance training.

METHODS

Thirteen male and one female with spinal cord injury, from two Portuguese rehabilitation centers, were randomized to creatine (3g daily), vitamin D (25000 IU each two weeks) or placebo group in a double-blind design. All participants performed progressive resistance training during eight weeks. The outcome measures, obtained at baseline and after intervention, included: Sum of four skinfolds; Corrected arm muscle area; Seated medicine ball throw; Handgrip strength with dynamometer; Manual wheelchair slalom test and one repetition maximum for Chest press, Triceps, Pec deck and Lat pulldown. Vitamin D levels were obtained in all participants before and after intervention.

RESULTS

71.4% of participants had deficit values of vitamin D. The corrected arm muscle area improved significantly (p<0.05) in creatine group relatively to the control group. There was a significant correlation (p<0.05) between the one repetition maximum Pec deck and levels of vitamin D.

CONCLUSIONS

Supplementation with creatine may improve muscle strength parameters in individuals with spinal cord injury. Vitamin D deficiency is highly prevalent in this population. It is recommended an initial screening of vitamin D levels at the beginning of the physical rehabilitation process.

Effect of 12-Week Vitamin D Supplementation on 25[OH]D Status and Performance in Athletes with a Spinal Cord Injury

(1) BACKGROUND: studies with able-bodied athletes showed that performance might possibly be influenced by vitamin D status. Vitamin D seems to have a direct impact on neuromuscular function by docking on vitamin D receptors in the muscle tissue. Additionally, a high prevalence of vitamin D deficiency was shown not only in infants and in the elderly but also in healthy adults and spinal cord injured individuals. Therefore, the aim of our study was to investigate whether a vitamin D dose of 6000 IU daily over 12 weeks would be sufficient to increase vitamin D status in indoor wheelchair athletes to a normal or optimal vitamin D level and whether vitamin D deficiency is associated with an impairment in muscle performance in these individuals; (2) METHODS: vitamin D status was assessed in indoor elite wheelchair athletes in order to have a baseline measurement. If vitamin D status was below 75 nmol/L, athletes were supplemented with 6000 IU of vitamin D daily over 12 weeks. A vitamin D status over 75 nmol/L was supplemented with a placebo supplement. Vitamin D status, as well as a Wingate test and an isokinetic dynamometer test, were performed at baseline and after six and 12 weeks; (3) RESULTS: 20 indoor elite wheelchair athletes participated in this double-blind study. All of these athletes showed an insufficient vitamin D status at baseline and were, therefore, supplemented with vitamin D. All athletes increased vitamin D status significantly over 12 weeks and reached an optimal level. Wingate performance was not significantly increased. Isokinetic dynamometer strength was significantly increased but only in the non-dominant arm in isometric and concentric elbow flexion; (4) CONCLUSION: a dose of 6000 IU of vitamin D daily over a duration of 12 weeks seems to be sufficient to increase vitamin D status to an optimal level in indoor wheelchair athletes. It remains unclear, whether upper body performance or muscle strength and vitamin D status are associated with each other.

Vitamin D and spinal cord injury: should we care?

STUDY DESIGN

Narrative review.

OBJECTIVES

This review provides an overview of the etiological factors and consequences of vitamin D insufficiency in relation to spinal cord injury (SCI) as well as important considerations for vitamin D supplementation.

SETTING

Montreal, Canada.

METHODS

Literature search.

RESULTS

Vitamin D insufficiency is common in SCI individuals owing to the presence of many contributing factors including limited sun exposure and intake, use of medication and endocrine perturbations. Although there are several biological plausible mechanisms by which vitamin D may act upon musculoskeletal and cardiometabolic health, the impact of vitamin D insufficiency on such systems remains ill defined in SCI. In the absence of guidelines for the management of vitamin D insufficiency in this high-risk population and in an attempt to provide clinical guidance, considerations for vitamin D supplementation such as the type of vitamin D, dosing regimens and toxicity are discussed and tentative recommendations suggested with particular reference to issues faced by SCI patients.

CONCLUSION

Although high rates of vitamin D insufficiency are encountered in SCI individuals, its consequences and the amount of vitamin D required to prevent insufficiency are still unknown, indicating a need for more intervention studies with well-defined outcome measures. Routine screening and monitoring of vitamin D as well as treatment of suboptimal status should be instituted in both acute and chronic setting. The close interactions between vitamin D and related bone minerals should be kept in mind when supplementing SCI individuals, and practices should be individualized with clinical conditions.

Osteoporosis in individuals with spinal cord injury

The pathophysiology, clinical considerations, and relevant experimental findings with regard to osteoporosis in individuals with spinal cord injury (SCI) will be discussed. The bone loss that occurs acutely after more neurologically motor complete SCI is unique for its sublesional skeletal distribution and rate, at certain skeletal sites approaching 1% of bone mineral density per week, and its resistance to currently available treatments. The areas of high bone loss include the distal femur, proximal tibia, and more distal boney sites. Evidence from a study performed in monozygotic twins discordant for SCI indicates that sublesional bone loss in the twin with SCI increases for several decades, strongly suggesting that the heightened net bone loss after SCI may persist for an extended period of time. The increased frequency of fragility fracture after paralysis will be discussed, and a few risk factors for such fractures after SCI will be examined. Because vitamin D deficiency, regardless of disability, is a relevant consideration for bone health, as well as an easily reversible condition, the increased prevalence of and treatment target values for vitamin D in this deficiency state in the SCI population will be reviewed. Pharmacological and mechanical approaches to preserving bone integrity in persons with acute and chronic SCI will be reviewed, with emphasis placed on efficacy and practicality. Emerging osteoanabolic agents that improve functioning of WNT/β-catenin signaling after paralysis will be introduced as therapeutic interventions that may hold promise.

Possible way to reduce fracture rates in patients with traumatic spinal cord injury?

Lower extremity fractures in men with spinal cord injury (SCI) are a major problem. The use of thiazide diuretics, a simple and safe intervention, may be effective in reducing the risk of fracture in patients with traumatic SCI. Furthermore, thiazide diuretics have an added benefit of reducing kidney stone formation.

31st g. Heiner sell lectureship: secondary medical consequences of spinal cord injury

Persons with spinal cord injury (SCI) have secondary medical consequences of paralysis and/or the consequences of extreme inactivity. The metabolic changes that result from reduced activity include insulin resistance with carbohydrate disorders and dyslipidemia. A higher prevalence of coronary artery calcification was found in persons with SCI than that in matched able-bodied controls. A depression in anabolic hormones, circulating testosterone and growth hormone, has been described. Adverse soft tissue body composition changes of increased adiposity and reduced skeletal muscle are appreciated. Immobilization is the cause for sublesional disuse osteoporosis with an associated increased risk of fragility fracture. Bowel dysmotility affects all segments of the gastrointestinal tract, with an interest in better defining and addressing gastroesophageal reflux disease and difficulty with evacuation. Developing and testing more effective approaches to cleanse the bowel for elective colonoscopy are being evaluated. The extent of respiratory dysfunction depends on the level and completeness of SCI. Individuals with higher spinal lesions have both restrictive and obstructive airway disease. Pharmacological approaches and expiratory muscle training are being studied as interventions to improve pulmonary function and cough strength with the objective of reducing pulmonary complications. Persons with spinal lesions above the 6th thoracic level lack both cardiac and peripheral vascular mechanisms to maintain blood pressure, and they are frequently hypotensive, with even worse hypotension with upright posture. Persistent and/or orthostatic hypotension may predispose those with SCI to cognitive impairments. The safety and efficacy of anti-hypotensive agents to normalize blood pressure in persons with higher level cord lesions is being investigated.