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Echevarria-Cruz E, McMillan DW, Reid KF, Valderrábano RJ. Spinal Cord Injury Associated Disease of the Skeleton, an Unresolved Problem with Need for Multimodal Interventions. Adv Biol (Weinh) 2024:e2400213. [PMID: 39074256 DOI: 10.1002/adbi.202400213] [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: 04/19/2024] [Revised: 07/11/2024] [Indexed: 07/31/2024]
Abstract
Spinal cord injury is associated with skeletal unloading, sedentary behavior, decreases in skeletal muscle mass, and exercise intolerance, which results in rapid and severe bone loss. To date, monotherapy with physical interventions such as weight-bearing in standing frames, computer-controlled electrically stimulated cycling and ambulation exercise, and low-intensity vibration are unsuccessful in maintaining bone density after SCI. Strategies to maintain bone density with commonly used osteoporosis medications also fail to provide a significant clinical benefit, potentially due to a unique pathology of bone deterioration in SCI. In this review, the available data is discussed on evaluating and monitoring bone loss, fracture, and physical and pharmacological therapeutic approaches to SCI-associated disease of the skeleton. The treatment of SCI-associated disease of the skeleton, the implications for clinical management, and areas of need are considered for future investigation.
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Affiliation(s)
- Evelyn Echevarria-Cruz
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
| | - David W McMillan
- The Miami Project to Cure Paralysis, University of Miami Leonard M. Miller School of Medicine, 1611 NW 12th ave, Office 2.141, Miami, FL, 33136, USA
- Department of Neurological Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, 33136, USA
| | - Kieran F Reid
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
- 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, 02115, USA
| | - Rodrigo J Valderrábano
- Research Program in Men's Health, Aging and Metabolism, and Boston Claude D. Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave Boston, 5th Floor, Boston, MA, 02115, USA
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2
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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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Zleik N, Weaver F, Harmon RL, Le B, Radhakrishnan R, Jirau-Rosaly WD, Craven BC, Raiford M, Hill JN, Etingen B, Guihan M, Heggeness MH, Ray C, Carbone L. Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review. J Spinal Cord Med 2019; 42:735-759. [PMID: 29745791 PMCID: PMC6830234 DOI: 10.1080/10790268.2018.1469808] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Nour Zleik
- 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 Weaver
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Robert L. Harmon
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
| | - Brian Le
- 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
| | | | - Wanda D. Jirau-Rosaly
- Department of Medicine, Division of Geriatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Mattie Raiford
- School of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Jennifer N. Hill
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
| | - Marylou Guihan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
| | - Michael H. Heggeness
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, 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
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Zoulias ID, Armengol M, Poulton A, Andrews B, Gibbons R, Harwin WS, Holderbaum W. Novel instrumented frame for standing exercising of users with complete spinal cord injuries. Sci Rep 2019; 9:13003. [PMID: 31506460 PMCID: PMC6736978 DOI: 10.1038/s41598-019-49237-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 08/15/2019] [Indexed: 11/10/2022] Open
Abstract
This paper describes a Functional Electrical Stimulation (FES) standing system for rehabilitation of bone mineral density (BMD) in people with Spinal Cord Injury (SCI). BMD recovery offers an increased quality of life for people with SCI by reducing their risk of fractures. The standing system developed comprises an instrumented frame equipped with force plates and load cells, a motion capture system, and a purpose built 16-channel FES unit. This system can simultaneously record and process a wide range of biomechanical data to produce muscle stimulation which enables users with SCI to safely stand and exercise. An exergame provides visual feedback to the user to assist with upper-body posture control during exercising. To validate the system an alternate weight-shift exercise was used; 3 participants with complete SCI exercised in the system for 1 hour twice-weekly for 6 months. We observed ground reaction forces over 70% of the full body-weight distributed to the supporting leg at each exercising cycle. Exercise performance improved for each participant by an increase of 13.88 percentage points of body-weight in the loading of the supporting leg during the six-month period. Importantly, the observed ground reaction forces are of higher magnitude than other studies which reported positive effects on BMD. This novel instrumentation aims to investigate weight bearing standing therapies aimed at determining the biomechanics of lower limb joint force actions and postural kinematics.
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Affiliation(s)
| | - Monica Armengol
- School of Biological Sciences, University of Reading, Reading, UK
| | - Adrian Poulton
- School of Computing and Communications, Open University, Milton Keynes, UK
| | - Brian Andrews
- Nuffield Department of Surgical Sciences, Oxford, UK.,School of Engineering, University of Warwick, Warwick, UK
| | - Robin Gibbons
- Aspire CREATe, University College London, London, UK
| | - William S Harwin
- School of Biological Sciences, University of Reading, Reading, UK
| | - William Holderbaum
- School of Biological Sciences, University of Reading, Reading, UK.,School of Engineering, Metropolitan University of Manchester, Manchester, UK
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Cervinka T, Giangregorio L, Sievanen H, Cheung AM, Craven BC. Peripheral Quantitative Computed Tomography: Review of Evidence and Recommendations for Image Acquisition, Analysis, and Reporting, Among Individuals With Neurological Impairment. J Clin Densitom 2018; 21:563-582. [PMID: 30196052 DOI: 10.1016/j.jocd.2018.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/07/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Abstract
In 2015, the International Society for Clinical Densitometry (ISCD) position statement regarding peripheral quantitative computed tomography (pQCT) did not recommend routine use of pQCT, in clinical settings until consistency in image acquisition and analysis protocols are reached, normative studies conducted, and treatment thresholds identified. To date, the lack of consensus-derived recommendations regarding pQCT implementation remains a barrier to implementation of pQCT technology. Thus, based on description of available evidence and literature synthesis, this review recommends the most appropriate pQCT acquisition and analysis protocols for clinical care and research purposes, and recommends specific measures for diagnosis of osteoporosis, assigning fracture risk, and monitoring osteoporosis treatment effectiveness, among patients with neurological impairment. A systematic literature search of MEDLINE, EMBASE©, CINAHL, and PubMed for available pQCT studies assessing bone health was carried out from inception to August 8th, 2017. The search was limited to individuals with neurological impairment (spinal cord injury, stroke, and multiple sclerosis) as these groups have rapid and severe regional declines in bone mass. Of 923 references, we identified 69 that met review inclusion criteria. The majority of studies (n = 60) used the Stratec XCT 2000/3000 pQCT scanners as reflected in our evaluation of acquisition and analysis protocols. Overall congruence with the ISCD Official Positions was poor. Only 11% (n = 6) studies met quality reporting criteria for image acquisition and 32% (n = 19) reported their data analysis in a format suitable for reproduction. Therefore, based on current literature synthesis, ISCD position statement standards and the authors' expertise, we propose acquisition and analysis protocols at the radius, tibia, and femur sites using Stratec XCT 2000/3000 pQCT scanners among patients with neurological impairment for clinical and research purposes in order to drive practice change, develop normative datasets and complete future meta-analysis to inform fracture risk and treatment efficacy evaluation.
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Affiliation(s)
- T Cervinka
- Neural Engineering and Therapeutics Team, Toronto Rehabilitation Research Institute-University Health Network, Toronto, Ontario, Canada.
| | - L Giangregorio
- Neural Engineering and Therapeutics Team, Toronto Rehabilitation Research Institute-University Health Network, Toronto, Ontario, Canada; Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - H Sievanen
- Bone Research Group, UKK Institute, Tampere, Finland
| | - A M Cheung
- Centre of Excellence in Skeletal Health Assessment, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B C Craven
- Neural Engineering and Therapeutics Team, Toronto Rehabilitation Research Institute-University Health Network, Toronto, Ontario, Canada; Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada; Centre of Excellence in Skeletal Health Assessment, University Health Network, Toronto, Ontario, Canada; Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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6
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Tseng SC, Shields RK. Limb Segment Load Inhibits the Recovery of Soleus H-Reflex After Segmental Vibration in Humans. J Mot Behav 2017; 50:631-642. [PMID: 29140761 DOI: 10.1080/00222895.2017.1394259] [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: 10/18/2022]
Abstract
We investigated the effects of vertical vibration and compressive load on soleus H-reflex amplitude and postactivation depression. We hypothesized that, in the presence of a compressive load, limb vibration induces a longer suppression of soleus H-reflex. Eleven healthy adults received vibratory stimulation at a fixed frequency (30 Hz) over two loading conditions (0% and 50% of individual's body weight). H-reflex amplitude was depressed ∼88% in both conditions during vibration. Cyclic application of compression after cessation of the vibration caused a persistent reduction in H-reflex excitability and postactivation depression for > 2.5 min. A combination of limb segment vibration and compression may offer a nonpharmacologic method to modulate spinal reflex excitability in people after CNS injury.
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Affiliation(s)
- Shih-Chiao Tseng
- a School of Physical Therapy , Texas Woman's University , 6700 Fannin, Houston , Texas , USA
| | - Richard K Shields
- b Department of Physical Therapy & Rehabilitation Science , University of Iowa, Carver College of Medicine , Iowa City , Iowa , USA
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7
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Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1798-1814. [PMID: 28497215 DOI: 10.1007/s00586-017-5114-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/29/2017] [Indexed: 12/23/2022]
Abstract
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.
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Coupaud S, Gislason MK, Purcell M, Sasagawa K, Tanner KE. Patient-specific bone mineral density distribution in the tibia of individuals with chronic spinal cord injury, derived from multi-slice peripheral Quantitative Computed Tomography (pQCT) - A cross-sectional study. Bone 2017; 97:29-37. [PMID: 28034635 DOI: 10.1016/j.bone.2016.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 12/12/2016] [Accepted: 12/23/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The high risk of fracture associated with chronic spinal cord injury (SCI) is attributed to extensive disuse-related bone loss in previously weight-bearing long bones. Changes in bone mineral density (BMD) after SCI have been documented extensively for the epiphyses of the tibia and femur, fracture-prone sites in this patient group. Less attention has been given to patterns of cortical bone loss in the diaphyses, but variability in BMD distributions throughout the long bones may contribute to some patients' increased susceptibility to shaft fractures in chronic SCI. AIM A cross-sectional study was carried out to determine whether BMD distributions along the tibia differ between individuals with chronic SCI and healthy able-bodied (AB) controls, in both the trabecular and cortical bone compartments. The effects of time post-injury and gender on BMD distribution were also explored. METHODS Individuals with chronic (≥6months post-injury) motor-complete SCI were recruited from the Queen Elizabeth National Spinal Injuries Unit (Glasgow, UK). AB control subjects were recruited to achieve similar age and gender profiles for the SCI and control groups. Multi-slice pQCT (XCT3000, Stratec) was performed along the length of the tibia (2mm thickness, 0.5mm voxel size), at 1% intervals in the epiphyses and 5% intervals in the diaphysis (34 slices in total). These were used to reconstruct full 3-D subject-specific models (Mimics, Materialise) of BMD distribution, by interpolating between slices. Subjects with chronic SCI were subdivided into 'early' (<4years post-injury) and 'established' SCI (≥4years post-injury). Subject-specific BMD distribution was described according to new parameters determined from the 3-D patient-specific models, quantifying descriptors of the trabecular and cortical BMD regions separately (volume, peak BMD, half-peak width, area under the curve). These were compared between sub-groups (using independent-samples t-tests or Mann-Whitney tests, significance level of 5%). RESULTS 11 men (age range 17-59years old; mean 35.7±10.6) and 3 post-menopausal women (age range 56-58years old; mean 56.7±1.2years) with motor-complete SCI (ranging from 6months to 27years post-injury) were recruited; 6 men (age range 20-56years old; 33.0±12.7years) and 1 post-menopausal woman (56years) formed the AB control group. Overall, SCI resulted in lower BMD at both trabecular and cortical regions of the tibia. In men, longer time since injury resulted in greater BMD differences when compared to AB, throughout the tibia. For the post-menopausal women, differences in BMD between SCI and AB were greater in cortical bone than in trabecular bone. From the models, individual BMD distribution curves showed healthy double-peaks in AB subjects: one trabecular peak (around 200-300mg/cm3) and the other cortical (around 1000-1100mg/cm3). In most subjects with established SCI, trabecular peaks were exaggerated whilst the cortical peaks were barely discernible, with crucially some individuals already exhibiting a diminishing cortical BMD peak even <4years post-injury. CONCLUSIONS These findings may have implications for determining the fracture susceptibility of the long bones in individual patients with SCI. Epiphyseal fractures associated with low trabecular BMD are well characterised, but our data show that some individuals with SCI may also be at higher risk of shaft fractures. The proposed BMD distribution description parameters, determined from patient-specific models, could be used to identify patients with a weakened diaphysis who may be susceptible to fractures of the tibial shaft, but this requires validation.
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Affiliation(s)
- Sylvie Coupaud
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow G4 0NW, UK; Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
| | - Magnus K Gislason
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow G4 0NW, UK; Institute for Biomedical and Neural Engineering, School of Science & Engineering, University of Reykjavik, Menntavegi 1, 101 Reykjavik, Iceland
| | - Mariel Purcell
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Keisuke Sasagawa
- Department of Engineering, Niigata Institute of Technology, 1719 Fujihashi, Kashiwazaki City, Niigata 945-1195, Japan
| | - K Elizabeth Tanner
- Biomedical Engineering Division, School of Engineering, University of Glasgow, Glasgow G12 8QQ, UK
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9
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Fate decision of mesenchymal stem cells: adipocytes or osteoblasts? Cell Death Differ 2016; 23:1128-39. [PMID: 26868907 PMCID: PMC4946886 DOI: 10.1038/cdd.2015.168] [Citation(s) in RCA: 771] [Impact Index Per Article: 96.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 11/03/2015] [Accepted: 12/01/2015] [Indexed: 12/18/2022] Open
Abstract
Mesenchymal stem cells (MSCs), a non-hematopoietic stem cell population first discovered in bone marrow, are multipotent cells capable of differentiating into mature cells of several mesenchymal tissues, such as fat and bone. As common progenitor cells of adipocytes and osteoblasts, MSCs are delicately balanced for their differentiation commitment. Numerous in vitro investigations have demonstrated that fat-induction factors inhibit osteogenesis, and, conversely, bone-induction factors hinder adipogenesis. In fact, a variety of external cues contribute to the delicate balance of adipo-osteogenic differentiation of MSCs, including chemical, physical, and biological factors. These factors trigger different signaling pathways and activate various transcription factors that guide MSCs to commit to either lineage. The dysregulation of the adipo-osteogenic balance has been linked to several pathophysiologic processes, such as aging, obesity, osteopenia, osteopetrosis, and osteoporosis. Thus, the regulation of MSC differentiation has increasingly attracted great attention in recent years. Here, we review external factors and their signaling processes dictating the reciprocal regulation between adipocytes and osteoblasts during MSC differentiation and the ultimate control of the adipo-osteogenic balance.
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10
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Koyama S, Tanabe S, Saitoh E, Hirano S, Shimizu Y, Katoh M, Uno A, Takemitsu T. Characterization of unexpected postural changes during robot-assisted gait training in paraplegic patients. Spinal Cord 2015; 54:120-5. [PMID: 26261073 DOI: 10.1038/sc.2015.138] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/03/2015] [Accepted: 06/22/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN This is a retrospective study. OBJECTIVES The objectives of this study were to categorize unexpected postural changes (UPCs) during gait training in paraplegic patients with wearable gait-assist robots, to reveal the incidence of the UPC and its time-dependent changes during initial gait training period and to investigate neurological level-specific differences. SETTING This study was conducted in Fujita Health University, Aichi, Japan. METHODS We investigated five patients (46.2±14.6 years; lesion level: T6:3, T12:2). All patients had previously achieved gait with wearable robot and walker at supervision level. The UPCs were counted for 2 years and classified according to their type. The time-course data were calculated from the incidence of UPCs for 10 days from initial gait training with the walker. The neurological level-specific differences were investigated between T6 and T12 injuries. RESULTS Eighty-five UPCs were observed and classified into three categories: anterior breakdown, posterior breakdown (PBD) and mal-timing. The average rate over the entire period was 0.96±0.62 (incidents/h/subject). PBD, which was defined as hyperflexion of both hip joints, occurred with the highest frequency (0.64±0.64 incidents/h/subject). During initial gait training, there was a gradual decrease in the occurrence of UPC. For neurological level-specific differences, UPCs were observed more frequently in T6 injuries (1.36±0.35 incidents/h/subject) compared with T12 injuries (0.36±0.31 incidents/h/subject). CONCLUSION PBDs might be the result of near collisions between the trunk of the user and the walker, which make it difficult for the users to move their trunk over an anterior stance limb. Training that is focused upon well-timed forward movements of the walker might be required to avoid the occurrence of this common UPC.
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Affiliation(s)
- S Koyama
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan.,Department of Rehabilitation, Kawamura Hospital, Gifu, Japan
| | - S Tanabe
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - E Saitoh
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - S Hirano
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Y Shimizu
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - M Katoh
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - A Uno
- Tomei Brace Company, Seto, Japan
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Abstract
Obesity and osteoporosis are two of the most common chronic disorders of the 21st century. Both are accompanied by significant morbidity. The only place in the mammalian organism where bone and fat lie adjacent to each other is in the bone marrow. Marrow adipose tissue is a dynamic depot that probably exists as both constitutive and regulated compartments. Adipocytes secrete cytokines and adipokines that either stimulate or inhibit adjacent osteoblasts. The relationship of marrow adipose tissue to other fat depots is complex and might play very distinct parts in modulation of metabolic homoeostasis, haemopoiesis, and osteogenesis. Understanding of the relationship between bone and fat cells that arise from the same progenitor within the bone marrow niche provides insight into the pathophysiology of age-related osteoporosis, diabetes, and obesity.
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Affiliation(s)
| | - Clifford J Rosen
- Maine Medical Center Research Institute, Scarborough, ME 04074, USA
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Arija-Blázquez A, Ceruelo-Abajo S, Díaz-Merino MS, Godino-Durán JA, Martínez-Dhier L, Martin JLR, Florensa-Vila J. Effects of electromyostimulation on muscle and bone in men with acute traumatic spinal cord injury: A randomized clinical trial. J Spinal Cord Med 2014; 37:299-309. [PMID: 24090427 PMCID: PMC4064579 DOI: 10.1179/2045772313y.0000000142] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To study the effect of 14 weeks of electromyostimulation (EMS) training (47 minutes/day, 5 days/week) on both muscle and bone loss prevention in persons with recent, complete spinal cord injury (SCI). DESIGN Prospective, experimental, controlled, single-blind randomized trial with external blind evaluation by third parties. METHODS Eight men with recent SCI (8 weeks from injury; ASIA Impairment Scale (AIS) "A") were randomized into the intervention or the control groups. Cross-sectional area of the quadriceps femoris (QF) muscle was quantified using magnetic resonance imaging. Bone mineral density changes were assessed with a dual-energy X-ray absorptiometry. Several bone biomarkers (i.e. total testosterone, cortisol, growth hormone, insulin-growth factor I, osteocalcin, serum type I collagen C-telopeptide), lipid, and lipoprotein profiles were quantified. A standard oral glucose tolerance test was performed before and after the 14-week training. All analyses were conducted at the beginning and after the intervention. RESULTS The intervention group showed a significant increase in QF muscle size when compared with the control group. Bone losses were similar in both groups. Basal levels of bone biomarkers did not change over time. Changes in lipid and lipoprotein were similar in both groups. Glucose and insulin peaks moved forward after the training in the intervention group. CONCLUSIONS This study indicates that skeletal muscle of patients with complete SCI retains the ability to grow in response to a longitudinal EMS training, while bone does not respond to similar external stimulus. Increases in muscle mass might have induced improvements in whole body insulin-induced glucose uptake.
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Affiliation(s)
- Alfredo Arija-Blázquez
- GENUD Toledo Research Group, University of Castilla-La Mancha, Toledo, Spain,Correspondence to: Alfredo Arija-Blázquez, GENUD Toledo Research Group, University of Castilla-La Mancha, Campus Tecnológico Fábrica de Armas, Avda. Carlos III, s/n, 45071, Toledo, Spain.
| | | | | | | | | | - José L. R. Martin
- Centro de Excelencia de Investigación en Salud y Ciencias de la Vida, Escuela de Doctorado e Investigación, Universidad Europea de Madrid, Spain
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Dudley-Javoroski S, Shields RK. Active-resisted stance modulates regional bone mineral density in humans with spinal cord injury. J Spinal Cord Med 2013; 36:191-9. [PMID: 23809588 PMCID: PMC3654444 DOI: 10.1179/2045772313y.0000000092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE In people with spinal cord injury (SCI), active-resisted stance using electrical stimulation of the quadriceps delivered a therapeutic stress to the femur (∼150% of body weight) and attenuated bone mineral density (BMD) decline. In standard densitometry protocols, BMD is averaged over the entire bone cross-section. An asymmetric adaptation to mechanical load may be masked by non-responding regions. The purpose of this study was to test a novel method to assess regional BMD of the femur in individuals with SCI. We hypothesize that there will be regional bone-sparing changes as a result of active-resisted stance. DESIGN Mixed cross-sectional and longitudinal. SETTING Research laboratory. PARTICIPANTS Twelve individuals with SCI and twelve non-SCI controls. INTERVENTION Individuals with SCI experienced active-resisted stance or passive stance for up to 3 years. OUTCOME MEASURES Peripheral quantitative computed tomography images from were partitioned so that femur anatomic quadrants could be separately analyzed. RESULTS Over 1.5 years, the slope of BMD decline over time was slower at all quadrants for the active-resisted stance limbs. At >2 years of training, BMD was significantly higher for the active-resisted stance group than for the passive stance group (P = 0.007). BMD was preferentially spared in the posterior quadrants of the femur with active-resisted stance. CONCLUSIONS A regional measurement technique revealed asymmetric femur BMD changes between passive stance and active-resisted stance. Future studies are now underway to better understand other regional changes in BMD after SCI.
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Affiliation(s)
| | - Richard K. Shields
- Correspondence to: Richard K. Shields, Carver College of Medicine, University of Iowa, Iowa City, IA 52242-1190, USA.
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Standing Frame and Electrical Stimulation Therapies Partially Preserve Bone Strength in a Rodent Model of Acute Spinal Cord Injury. Am J Phys Med Rehabil 2013; 92:402-10. [DOI: 10.1097/phm.0b013e318287697c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wirth F, Schempf G, Stein G, Wellmann K, Manthou M, Scholl C, Sidorenko M, Semler O, Eisel L, Harrach R, Angelova S, Jaminet P, Ankerne J, Ashrafi M, Ozsoy O, Ozsoy U, Schubert H, Abdulla D, Dunlop SA, Angelov DN, Irintchev A, Schönau E. Whole-Body Vibration Improves Functional Recovery in Spinal Cord Injured Rats. J Neurotrauma 2013; 30:453-68. [DOI: 10.1089/neu.2012.2653] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Felicitas Wirth
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Greta Schempf
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Gregor Stein
- Department of Orthopedics and Trauma Surgery, University of Cologne, Köln, Germany
| | | | - Marilena Manthou
- Department of Histology and Embryology, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Carolin Scholl
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Malina Sidorenko
- Department of Anatomy, Medical Faculty, University of Sofia, Sofia, Bulgaria
| | - Oliver Semler
- Department of Children's Hospital, University of Cologne, Köln, Germany
| | - Leonie Eisel
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Rachida Harrach
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Srebrina Angelova
- Jean-Uhrmacher Institute for ENT-Research, University of Cologne, Köln, Germany
| | - Patrick Jaminet
- Department of Hand, Plastic, and Reconstructive Surgery with Burn Unit, BG- Trauma Centre, University of Tuebingen, Tuebingen, Germany
| | - Janina Ankerne
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Mahak Ashrafi
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Ozlem Ozsoy
- Department of Physiology, Akdeniz University, Antalya, Turkey
| | - Umut Ozsoy
- Department of Physiology Anatomy, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | | | - Diana Abdulla
- Department of Anatomy I, University of Cologne, Köln, Germany
| | - Sarah A. Dunlop
- Experimental and Regenerative Neuroscience, School of Animal Biology, The University of Western Australia, Crawley, Western Australia, Australia
| | | | - Andrey Irintchev
- Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany
| | - Eckhard Schönau
- Department of Children's Hospital, University of Cologne, Köln, Germany
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Tseng SC, Shields RK. Limb compressive load does not inhibit post activation depression of soleus H-reflex in indiviudals with chronic spinal cord injury. Clin Neurophysiol 2012; 124:982-90. [PMID: 23168355 DOI: 10.1016/j.clinph.2012.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 10/02/2012] [Accepted: 10/27/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We investigated the effect of various doses of limb compressive load on soleus H-reflex amplitude and post activation depression in individuals with/without chronic SCI. We hypothesized that SCI reorganization changes the typical reflex response to an external load. METHODS Ten healthy adults and 10 individuals with SCI received three doses of compressive load to the top of their knee (10%, 25%, and 50% of the body weight, BW). Soleus H-reflexes were measured before (baseline) and during the loading phase. RESULTS With persistent background muscle activity across all testing sessions, segment compressive load significantly decreased post activation depression in the control group, but did not change the post activation ratio in the SCI group. Normalized H2 amplitude significantly increased according to load (50%> 25%> 10%) in the control group whereas was minimally modulated to load in those with SCI. CONCLUSIONS Segment compressive load inhibits post activation depression in humans without SCI, but minimally modulates the reflex circuitry in people with chronic SCI. These findings suggest that spinal cord reorganization mitigates the typical response to load in people with chronic SCI. SIGNIFICANCE Early limb load training may impact the reorganization of the spinal cord in humans with acute SCI.
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Dudley-Javoroski S, Saha PK, Liang G, Li C, Gao Z, Shields RK. High dose compressive loads attenuate bone mineral loss in humans with spinal cord injury. Osteoporos Int 2012; 23:2335-46. [PMID: 22187008 PMCID: PMC3374128 DOI: 10.1007/s00198-011-1879-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 11/04/2011] [Indexed: 10/14/2022]
Abstract
UNLABELLED People with spinal cord injury (SCI) lose bone and muscle integrity after their injury. Early doses of stress, applied through electrically induced muscle contractions, preserved bone density at high-risk sites. Appropriately prescribed stress early after the injury may be an important consideration to prevent bone loss after SCI. INTRODUCTION Skeletal muscle force can deliver high compressive loads to bones of people with spinal cord injury (SCI). The effective osteogenic dose of load for the distal femur, a chief site of fracture, is unknown. The purpose of this study is to compare three doses of bone compressive loads at the distal femur in individuals with complete SCI who receive a novel stand training intervention. METHODS Seven participants performed unilateral quadriceps stimulation in supported stance [150% body weight (BW) compressive load-"High Dose" while opposite leg received 40% BW-"Low Dose"]. Five participants stood passively without applying quadriceps electrical stimulation to either leg (40% BW load-"Low Dose"). Fifteen participants performed no standing (0% BW load-"Untrained") and 14 individuals without SCI provided normative data. Participants underwent bone mineral density (BMD) assessment between one and six times over a 3-year training protocol. RESULTS BMD for the High Dose group significantly exceeded BMD for both the Low Dose and the Untrained groups (p < 0.05). No significant difference existed between the Low Dose and Untrained groups (p > 0.05), indicating that BMD for participants performing passive stance did not differ from individuals who performed no standing. High-resolution CT imaging of one High Dose participant revealed 86% higher BMD and 67% higher trabecular width in the High Dose limb. CONCLUSION Over 3 years of training, 150% BW compressive load in upright stance significantly attenuated BMD decline when compared to passive standing or to no standing. High-resolution CT indicated that trabecular architecture was preserved by the 150% BW dose of load.
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Affiliation(s)
- S. Dudley-Javoroski
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, 1-252 Medical Education Building, Iowa City, IA 52242-1190, USA
| | - P. K. Saha
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, IA 52242-1190, USA
- Department of Radiology, Carver College of Medicine, The University of Iowa, Iowa City, IA 52242-1190, USA
| | - G. Liang
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, IA 52242-1190, USA
| | - C. Li
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, IA 52242-1190, USA
| | - Z. Gao
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, IA 52242-1190, USA
| | - R. K. Shields
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, 1-252 Medical Education Building, Iowa City, IA 52242-1190, USA
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Arija-Blázquez A, Ceruelo-Abajo S, Díaz-Merino MS, Godino-Durán JA, Martínez-Dhier L, Florensa-Vila J. Time-course response in serum markers of bone turnover to a single-bout of electrical stimulation in patients with recent spinal cord injury. Eur J Appl Physiol 2012; 113:89-97. [PMID: 22576416 DOI: 10.1007/s00421-012-2416-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/30/2012] [Indexed: 12/14/2022]
Abstract
The objective of the present repeat-measures study was to determine whether plasma serum levels of testosterone, cortisol, osteocalcin or type I collagen C-telopeptide (CT) are acutely affected following an electro-myostimulation (EMS) bout, and their relation to bone mineral density and muscle mass. Ten men with recent (8 weeks) thoracic spinal cord injury (SCI) (ASIA A) and 10 age-matched able-bodied (AB) men performed one EMS bout on the quadriceps femoris muscle. Blood samples were drawn at basal condition, immediately after EMS, and 15 min, 30 min, 24 h and 48 h post-EMS. Muscle cross-sectional area was measured by magnetic resonance imaging. Bone mineral density (BMD) was determined by dual-energy X-ray absorptiometry. In the SCI group, a significant decrease in testosterone, cortisol and CT together with a significant increase in testosterone/cortisol ratio and osteocalcin/CT ratio was observed after EMS. For the AB subjects, only testosterone and CT decreased significantly following EMS. Muscle size was only related to testosterone/cortisol ratio in the SCI sample (R = 0.659, p < 0.05), whereas BMD did not show any relation to any biomarker. Acute EMS in recent spinal cord injured men seems to induce positive effects on bone turnover biomarkers, and anabolic and catabolic hormones.
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McHenry CL, Shields RK. A biomechanical analysis of exercise in standing, supine, and seated positions: Implications for individuals with spinal cord injury. J Spinal Cord Med 2012; 35:140-7. [PMID: 22507023 PMCID: PMC3324830 DOI: 10.1179/2045772312y.0000000011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
CONTEXT/OBJECTIVE The distal femur is the primary fracture site in patients with osteoporosis after spinal cord injury (SCI). OBJECTIVE To mathematically compare the compression and shear forces at the distal femur during quadriceps stimulation in the standing, supine, and seated positions. A force analysis across these positions may be a consideration for people with SCI during neuromuscular electrical stimulation of the quadriceps. DESIGN A biomechanical model. SETTING Research laboratory. OUTCOME MEASURES Compression and shear forces from the standing, supine, and seated biomechanical models at the distal femur during constant loads generated by the quadriceps muscles. RESULTS The standing model estimated the highest compressive force at 240% body weight and the lowest shear force of 24% body weight at the distal femur compared with the supine and seated models. The supine model yielded a compressive force of 191% body weight with a shear force of 62% body weight at the distal femur. The seated model yielded the lowest compressive force of 139% body weight and the highest shear force of 215% body weight. CONCLUSIONS When inducing a range of forces in the quadriceps muscles, the seated position yields the highest shear forces and lowest compressive forces when compared with the supine and standing positions. Standing with isometric contractions generates the highest compressive loads and lowest shear forces. Early active resistive standing may provide the most effective means to prevent bone loss after SCI.
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Affiliation(s)
- Colleen L McHenry
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
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20
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Limb segment load inhibits post activation depression of soleus H-reflex in humans. Clin Neurophysiol 2012; 123:1836-45. [PMID: 22418592 DOI: 10.1016/j.clinph.2012.02.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 02/06/2012] [Accepted: 02/10/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We investigated the effect of various doses of limb segment load on soleus H-reflex amplitude and post activation depression in healthy individuals. We also explored the influence of limb segment load on spinal circuitry in one individual with chronic SCI. METHODS Twenty-eight healthy adults and one SCI subject received compressive loads applied to the top of their knee at varied doses of load (10%, 25%, and 50% of the body weight). Soleus H-reflexes were measured before (baseline) and during the loading phase. RESULTS There were no significant differences in H-reflex amplitudes during the 50% BW load-on phase as compared to either baseline session or the load-off phase. However, the post activation depression was decreased over 9% (p<0.05) during the load-on phase compared to the load-off phase and scaled according to load (50%>25%>10%). The post activation depression ratio also appears less responsive to varying loads after chronic SCI. CONCLUSIONS Limb segment load decreases post-activation depression in humans. These findings suggest that the mechanism associated with post activation depression is modulated by limb segment load, and may be influenced by spinal reorganization after SCI. SIGNIFICANCE Future studies will determine if various levels of spasticity modulate the response of limb segment load on post activation depression in those with acute and chronic SCI.
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21
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Devlin MJ. Why does starvation make bones fat? Am J Hum Biol 2011; 23:577-85. [PMID: 21793093 DOI: 10.1002/ajhb.21202] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 04/27/2011] [Accepted: 05/30/2011] [Indexed: 12/20/2022] Open
Abstract
Body fat, or adipose tissue, is a crucial energetic buffer against starvation in humans and other mammals, and reserves of white adipose tissue (WAT) rise and fall in parallel with food intake. Much less is known about the function of bone marrow adipose tissue (BMAT), which are fat cells found in bone marrow. BMAT mass actually increases during starvation, even as other fat depots are being mobilized for energy. This review considers several possible reasons for this poorly understood phenomenon. Is BMAT a passive filler that occupies spaces left by dying bone cells, a pathological consequence of suppressed bone formation, or potentially an adaptation for surviving starvation? These possibilities are evaluated in terms of the effects of starvation on the body, particularly the skeleton, and the mechanisms involved in storing and metabolizing BMAT during negative energy balance.
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Affiliation(s)
- Maureen J Devlin
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA.
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Chang SH, Dudley-Javoroski S, Shields RK. Gravitational force modulates muscle activity during mechanical oscillation of the tibia in humans. J Electromyogr Kinesiol 2011; 21:847-53. [PMID: 21708472 DOI: 10.1016/j.jelekin.2011.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/02/2011] [Accepted: 06/02/2011] [Indexed: 11/29/2022] Open
Abstract
Mechanical oscillation (vibration) is an osteogenic stimulus for bone in animal models and may hold promise as an anti-osteoporosis measure in humans with spinal cord injury (SCI). However, the level of reflex induced muscle contractions associated with various loads (g force) during limb segment oscillation is uncertain. The purpose of this study was to determine whether certain gravitational loads (g forces) at a fixed oscillation frequency (30 Hz) increases muscle reflex activity in individuals with and without SCI. Nine healthy subjects and two individuals with SCI sat with their hip and knee joints at 90° and the foot secured on an oscillation platform. Vertical mechanical oscillations were introduced at 0.3, 0.6, 1.2, 3 and 5 g force for 20 s at 30 Hz. Non-SCI subjects received the oscillation with and without a 5% MVC background contraction. Peak soleus and tibialis anterior (TA) EMG were normalized to M-max. Soleus and TA EMG were <2.5% of M-max in both SCI and non-SCI subjects. The greatest EMG occurred at the highest acceleration (5 g). Low magnitude mechanical oscillation, shown to enhance bone anabolism in animal models, did not elicit high levels of reflex muscle activity in individuals with and without SCI. These findings support the g force modulated background muscle activity during fixed frequency vibration. The magnitude of muscle activity was low and likely does not influence the load during fixed frequency oscillation of the tibia.
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Affiliation(s)
- Shuo-Hsiu Chang
- University of Texas Health Science Center, Houston, TX, United States
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Intensive electrical stimulation attenuates femoral bone loss in acute spinal cord injury. PM R 2011; 2:1080-7. [PMID: 21145519 DOI: 10.1016/j.pmrj.2010.08.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 07/31/2010] [Accepted: 08/08/2010] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine whether intensive electrical stimulation (ES) can reduce femoral bone mineral density (BMD) loss in acute spinal cord injury (SCI). DESIGN Randomized controlled trial. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Twenty-six subjects with C4 to T12 American Spinal Injury Association Impairment Scale A or B SCI less than 12 weeks postinjury. METHODS The control group received usual rehabilitative care and the intervention group received usual care plus 1 hour of ES over the quadriceps 5 days per week for 6 weeks. MAIN OUTCOME MEASUREMENTS Outcome measurements were collected at baseline, postintervention (interim), and 3 months postinjury (follow-up), and included dual energy x-ray absorptiometry, serum osteocalcin (OC), and urinary N-telopeptide (NTx). RESULTS In the control group, there was increasing BMD loss with distance from the spine (lumbar -1.88%, hip -12.25%, distal femur -15.15%, proximal tibia -17.40%). This trend was attenuated over the distal femur in the ES group (lumbar -1.29%, hip -14.45%, distal femur -7.40%, proximal tibia -12.31%). NTx increased over the 3 assessments in controls ([mean ± standard deviation] 115.00 ± 34.10, 154.86 ± 70.41, and 171.33 ± 75.8 nmol/mmol creatinine) compared with the ES group (160.56 ± 140.06, 216.71 ± 128.40, and 154.67 ± 69.12 nmol/mmol creatinine)-all of which were elevated compared with the reference range, and the differences between the 2 groups were not significant. Osteocalcin levels markedly decreased in the control group (12.90 ± 7.30, 24.00 ± 4.29, and 6.40 ± 7.28 μg/L) to subnormal levels, and remained stable and in the normal range in the ES group (13.80 ± 7.64, 11.86 ± 6.77, and 14.80 ± 12.91 μg/L), although differences between the groups were not significant. CONCLUSIONS Lower extremity BMD loss increases with distance from the spine. An intensive lower extremity ES program may attenuate BMD loss locally after acute motor complete SCI, although it is unknown whether these benefits are maintained in the long term.
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Dudley-Javoroski S, Littmann AE, Chang SH, McHenry CL, Shields RK. Enhancing muscle force and femur compressive loads via feedback-controlled stimulation of paralyzed quadriceps in humans. Arch Phys Med Rehabil 2011; 92:242-9. [PMID: 21272720 DOI: 10.1016/j.apmr.2010.10.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 10/18/2010] [Accepted: 10/19/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare paralyzed quadriceps force properties and femur compressive loads in an upright functional task during conventional constant-frequency stimulation and force feedback-modulated stimulation. DESIGN Crossover trial. SETTING Research laboratory. PARTICIPANTS Subjects (N=13; 12 men, 1 woman) with motor-complete spinal cord injury. INTERVENTIONS Subjects performed 2 bouts of 60 isometric quadriceps contractions while supported in a standing frame. On separate days, subjects received constant-frequency stimulation at 20Hz (CONST) or frequency-modulated stimulation triggered by a change in force (FDBCK). During FDBCK, a computer algorithm responded to each 10% reduction in force with a 20% increase in stimulation frequency. MAIN OUTCOME MEASURES A biomechanical model was used to derive compressive loads on the femur, with a target starting dose of load equal to 1.5 times body weight. RESULTS Peak quadriceps force and fatigue index were higher for FDBCK than CONST (P<.05). Within-train force decline was greater during FDBCK bouts, but mean force remained above CONST values (P<.05). As fatigue developed during repetitive stimulation, FDBCK was superior to CONST for maintenance of femur compressive loads (P<.05). CONCLUSIONS Feedback-modulated stimulation in electrically activated stance is a viable method to maximize the physiologic performance of paralyzed quadriceps muscle. Compared with CONST, FDBCK yielded compressive loads that were closer to a targeted dose of stress with known osteogenic potential. Optimization of muscle force with FDBCK may be a useful tactic for future training-based antiosteoporosis protocols.
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Affiliation(s)
- Shauna Dudley-Javoroski
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
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Dudley-Javoroski S, McMullen T, Borgwardt MR, Peranich LM, Shields RK. Reliability and responsiveness of musculoskeletal ultrasound in subjects with and without spinal cord injury. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:1594-1607. [PMID: 20800961 PMCID: PMC2948870 DOI: 10.1016/j.ultrasmedbio.2010.07.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 07/22/2010] [Accepted: 07/26/2010] [Indexed: 05/29/2023]
Abstract
Rehabilitation after spinal cord injury (SCI) aims to preserve the integrity of the paralyzed musculoskeletal system. The suitability of ultrasound (US) for delineating training-related muscle/tendon adaptations after SCI is unknown. The purpose of this study was to quantify within- and between-operator reliability for US and to determine its responsiveness to post-training muscle/tendon adaptations in SCI subjects. Two novice operators and one experienced operator obtained sonographic images of the vastus lateralis, patellar tendon, soleus, and Achilles tendon from seven SCI subjects and 16 controls. For control subjects, within-operator concordance (ICC [3,1]) ranged from 0.58 to 0.95 for novice operators and exceeded 0.86 for the experienced operator. Between-operator concordance (ICC [2,1]) ranged from 0.62 to 0.74. Ultrasound detected muscle hypertrophy (p < 0.05) following electrical stimulation training in subjects with SCI (responsiveness) but did not detect differences in tendon thickness. These error estimates support the utility of US in future post-SCI training studies.
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Affiliation(s)
- Shauna Dudley-Javoroski
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City Iowa
| | - Tara McMullen
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City Iowa
| | | | - Lauren M. Peranich
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City Iowa
| | - Richard K. Shields
- Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa, Iowa City Iowa
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Dudley-Javoroski S, Shields RK. Longitudinal changes in femur bone mineral density after spinal cord injury: effects of slice placement and peel method. Osteoporos Int 2010; 21:985-95. [PMID: 19707702 PMCID: PMC2875776 DOI: 10.1007/s00198-009-1044-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 07/27/2009] [Indexed: 02/07/2023]
Abstract
SUMMARY Surveillance of femur metaphysis bone mineral density (BMD) decline after spinal cord injury (SCI) may be subject to slice placement error of 2.5%. Adaptations to anti-osteoporosis measures should exceed this potential source of error. Image analysis parameters likewise affect BMD output and should be selected strategically in longitudinal studies. INTRODUCTION Understanding the longitudinal changes in bone mineral density (BMD) after spinal cord injury (SCI) is important when assessing new interventions. We determined the longitudinal effect of SCI on BMD of the femur metaphysis. To facilitate interpretation of longitudinal outcomes, we (1) determined the BMD difference associated with erroneous peripheral quantitative computed tomography (pQCT) slice placement, and (2) determined the effect of operator-selected pQCT peel algorithms on BMD. METHODS pQCT images were obtained from the femur metaphysis (12% of length from distal end) of adult subjects with and without SCI. Slice placement errors were simulated at 3 mm intervals and were processed in two ways (threshold-based vs. concentric peel). RESULTS BMD demonstrated a rapid decline over 2 years post-injury. BMD differences attributable to operator-selected peel methods were large (17.3% for subjects with SCI). CONCLUSIONS Femur metaphysis BMD declines after SCI in a manner similar to other anatomic sites. Concentric (percentage-based) peel methods may be most appropriate when special sensitivity is required to detect BMD adaptations. Threshold-based methods may be more appropriate when asymmetric adaptations are observed.
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Cai Z, Bai EW, Shields RK. Fatigue and non-fatigue mathematical muscle models during functional electrical stimulation of paralyzed muscle. Biomed Signal Process Control 2010; 5:87-93. [PMID: 23667385 DOI: 10.1016/j.bspc.2009.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Electrical muscle stimulation demonstrates potential for preventing muscle atrophy and for restoring functional movement after spinal cord injury (SCI). Control systems used to optimize delivery of electrical stimulation protocols depend upon the algorithms generated using computational models of paralyzed muscle force output. The Hill-Huxley-type model, while being highly accurate, is also very complex, making it difficult for real-time implementation. In this paper, we propose a Wiener-Hammerstein system to model the paralyzed skeletal muscle under electrical stimulus conditions. The proposed model has substantial advantages in identification algorithm analysis and implementation including computational complexity and convergence, which enable it to be used in real-time model implementation. Experimental data sets from the soleus muscles of fourteen subjects with SCI were collected and tested. The simulation results show that the proposed model outperforms the Hill-Huxley-type model not only in peak force prediction, but also in fitting performance for force output of each individual stimulation train.
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Affiliation(s)
- Zhijun Cai
- Dept of Elect rical and Computer Engineering, University of Iowa, Iowa City, IA 52242
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Qin YX, Lam H, Ferreri S, Rubin C. Dynamic skeletal muscle stimulation and its potential in bone adaptation. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2010; 10:12-24. [PMID: 20190376 PMCID: PMC4961074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
To identify mechanotransductive signals for combating musculoskeletal deterioration, it is essential to determine the components and mechanisms critical to the anabolic processes of musculoskeletal tissues. It is hypothesized that the interaction between bone and muscle may depend on fluid exchange in these tissues by mechanical loading. It has been shown that intramedullary pressure (ImP) and low-level bone strain induced by muscle stimulation (MS) has the potential to mitigate bone loss induced by disuse osteopenia. Optimized MS signals, i.e., low-intensity and high frequency, may be critical in maintaining bone mass and mitigating muscle atrophy. The objectives for this review are to discuss the potential for MS to induce ImP and strains on bone, to regulate bone adaptation, and to identify optimized stimulation frequency in the loading regimen. The potential for MS to regulate blood and fluid flow will also be discussed. The results suggest that oscillatory MS regulates fluid dynamics with minimal mechanical strain in bone. The response was shown to be dependent on loading frequency, serving as a critical mediator in mitigating bone loss. A specific regimen of dynamic MS may be optimized in vivo to attenuate disuse osteopenia and serve as a biomechanical intervention in the clinical setting.
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Affiliation(s)
- Y X Qin
- Orthopaedic Bioengineering Research Laboratory, Department of Biomedical Engineering, State University of New York at Stony Brook, Stony Brook, NY 11794-5281, USA.
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Biering-Sørensen F, Hansen B, Lee BSB. Non-pharmacological treatment and prevention of bone loss after spinal cord injury: a systematic review. Spinal Cord 2009; 47:508-18. [PMID: 19172152 DOI: 10.1038/sc.2008.177] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Review the literature on non-pharmacological prevention and treatment of osteoporosis after spinal cord injury (SCI). METHODS PubMed, EMBASE and the Cochrane Controlled Trials Register were searched. All identified papers were read by title, abstract and full-length article when relevant. Hand search of the articles' sources identified additional papers. For included studies, the level of evidence was determined. RESULTS No studies conclusively showed an effective intervention. However, there are few randomized controlled trials (RCTs), and those that exist assess interventions and outcome measures that could be improved. Five studies on weight-bearing early post-injury are conflicting, but standing or walking may help retain bone mineral. In the chronic phase, there was no effect of weight bearing (12 studies). One study found that an early commencement of sports after SCI improved bone mineral, and the longer the period of athletic career, the higher the (leg) bone mineral. Early after SCI, there may be some effects of electrical stimulation (ES) (five studies). Chronic-phase ES studies vary (14 studies, including mixed periods after injury), but improvement is seen with longer period of training, or higher frequency or stimulus intensity. Improvements correspond to trabecular bone in the distal femur or proximal tibia. Impact vibration and pulsed electromagnetic fields may have some positive effects, whereas pulsed ultrasound does not. Six studies on the influence of spasticity show inconsistent results. CONCLUSIONS Bone mineral should be measured around the knee; the length and intensity of the treatment should be sufficiently long and high, respectively, and should commence early after SCI. If bone mineral is to remain, the stimulation has to be possibly continued for long term. In addition, RCTs are necessary.
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Dudley-Javoroski S, Shields RK. Asymmetric bone adaptations to soleus mechanical loading after spinal cord injury. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2008; 8:227-238. [PMID: 18799855 PMCID: PMC2744484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The purpose of this report is to examine longitudinal bone mineral density (BMD) changes in individuals with spinal cord injury (SCI) who began unilateral soleus electrical stimulation early after injury. Twelve men with SCI and seven without SCI underwent peripheral quantitative computed tomography assessment of distal tibia BMD. After 4.5 to 6 years of training, average trained limb BMD was 27.5% higher than untrained limb BMD. The training effect was more pronounced in the central core of the tibia cross-section (40.5% between-limb difference). No between-limb difference emerged in the anterior half of the tibia (19.2 mg/cm(3) difference, p>0.05). A robust between-limb difference emerged in the posterior half of the tibia (76.1 mg/cm(3) difference, p=0.0439). The posterior tibia BMD of one subject remained within the range of non-SCI values for 3.8 years post-SCI. The results support that the constrained orientation of soleus mechanical loads, administered over several years, elicited bone-sparing effects in the posterior tibia. This study provides a demonstration of the bone-protective potential of a carefully controlled dose of mechanical load. The specific orientation of applied mechanical loads may strongly influence the manifestation of BMD adaptations in humans with SCI.
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Affiliation(s)
- S Dudley-Javoroski
- Graduate Program in Physical Therapy and Rehabilitation Science, The University of Iowa, Iowa City, IA 52242-1190, USA
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