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Dr Young - Osteoporosis Treatment?

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    Dr Young - Osteoporosis Treatment?

    Do you sugest treatment with medications for osteoporosis in those of us who are many years post SCI? If so, with what specific treatments?


    Here is an excellent article on the subject.

    Many of the treatments for osteoporosis in spinal cord injury is based on the pharmaceutical research into drugs to reverse osteoporosis in aging women. This is considered a very large market. Relatively few studies have been carried out, testing specific drugs and their ability to reverse osteoporosis in people with spinal cord injury. Despite the lack of data, there are many review articles that describe therapies to reverse osteoporosis in spinal cord injury. I attach abstracts for a select number of these review articles and some recent clinical studies of osteoporosis in spinal cord injury.

    Let me discuss several controversies. Although the popular media has suggested that weight-bearing exercises will strengthen bone and reverse osteoporosis in people with spinal cord injury, the data that standing exercises does so are very limited and controversial. Likewise, functional electrical stimulation associated with bicycling has been claimed to reduced osteoporosis. Christopher Reeve, for example, has been reported to have reduced his osteoporosis because he does standing and FES biking every day (McDonald, et al., 2002). The one treatment that has been shown to have some benefit in increasing bone calcium levels in people with spinal cord injury are the bisphosphonates. However, whether the bisphosphonates actually increase bone strength and reduces the incidence of bone fractures in unclear. Jones, et al. (2002) has reported that intensive exercises can increase upper limb bone density in people with spinal cord injury.

    The cause of bone loss in people with spinal cord injury may be more than just loss of weight bearing. Hormonal changes in people may contribute to the loss, particularly in women with spinal cord injury (Ott, et al., 2001). Sniger & Garshick (2002) reported that alexandronate (a bisphosphonate) reversing osteoporosis in a one individual with spinal cord injury. Aging women with spinal cord injury have the osteoporosis of spinal cord injury superimposed upon a hormonal change that contributes to osteporosis. The causes of osteoporosis may be different for men and women.



    • McDonald JW, Becker D, Sadowsky CL, Jane JA, Sr., Conturo TE and Schultz LM (2002). Late recovery following spinal cord injury. Case report and review of the literature. J Neurosurg. 97: 252-65. Department of Neurology and Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri 63108, USA. The authors of this prospective, single-case study evaluated the potential for functional recovery from chronic spinal cord injury (SCI). The patient was motor complete with minimal and transient sensory perception in the left hemibody. His condition was classified as C-2 American Spinal Injury Association (ASIA) Grade A and he had experienced no substantial recovery in the first 5 years after traumatic SCI. Clinical experience and evidence from the scientific literature suggest that further recovery would not take place. When the study began in 1999, the patient was tetraplegic and unable to breathe without assisted ventilation; his condition classification persisted as C-2 ASIA Grade A. Magnetic resonance imaging revealed severe injury at the C-2 level that had left a central fluid-filled cyst surrounded by a narrow donutlike rim of white matter. Five years after the injury a program known as "activity-based recovery" was instituted. The hypothesis was that patterned neural activity might stimulate the central nervous system to become more functional, as it does during development. Over a 3-year period (5-8 years after injury), the patient's condition improved from ASIA Grade A to ASIA Grade C, an improvement of two ASIA grades. Motor scores improved from 0/100 to 20/100, and sensory scores rose from 5-7/112 to 58-77/112. Using electromyography, the authors documented voluntary control over important muscle groups, including the right hemidiaphragm (C3-5), extensor carpi radialis (C-6), and vastus medialis (L2-4). Reversal of osteoporosis and an increase in muscle mass was associated with this recovery. Moreover, spasticity decreased, the incidence of medical complications fell dramatically, and the incidence of infections and use of antibiotic medications was reduced by over 90%. These improvements occurred despite the fact that less than 25 mm2 of tissue (approximately 25%) of the outer cord (presumably white matter) had survived at the injury level. The primary novelty of this report is the demonstration that substantial recovery of function (two ASIA grades) is possible in a patient with severe C-2 ASIA Grade A injury, long after the initial SCI. Less severely injured (lower injury level, clinically incomplete lesions) individuals might achieve even more meaningful recovery. The role of patterned neural activity in regeneration and recovery of function after SCI therefore appears a fruitful area for future investigation.

    • Jones LM, Legge M and Goulding A (2002). Intensive exercise may preserve bone mass of the upper limbs in spinal cord injured males but does not retard demineralisation of the lower body. Spinal Cord. 40: 230-5. The School of Physical Education, University of Otago, Dunedin, New Zealand. STUDY DESIGN: Cross-sectional study comparing a group of active spinal cord injured (SCI) males carefully matched for age, height, and weight with active able-bodied male controls. OBJECTIVES: To compare bone mass of the total body, upper and lower limbs, hip, and spine regions in active SCI and able-bodied individuals. SETTING: Outpatient study undertaken in two centres in New Zealand. METHODS: Dual energy X-ray absorptiometry (DEXA) scanning was used to determine bone mass. Questionnaires were used to ascertain total time spent in weekly physical activity for each individual. The criterion for entry into the study was regular participation in physical activity of more than 60 min per week, over and above that required for rehabilitation. RESULTS: Seventeen SCI and their able-bodied controls met our required activity criterion. Bone mineral density (BMD) values of the total body and hip regions were significantly lower in the SCI group than in their controls (P=0.0001). Leg BMD and bone mineral content (BMC) were also significantly lower in the SCI group (P=0.0001). By contrast, lumbar spine BMD and arm BMD and BMC did not differ between the SCI and control groups. Arm BMD and BMC were greater (not significant) than the reference norms (LUNAR database) for both groups. CONCLUSION: Intensive exercise regimens may contribute to preservation of arm bone mass in SCI males, but does not prevent demineralisation in the lower body.

    • Ott SM (2001). Osteoporosis in women with spinal cord injuries. Phys Med Rehabil Clin N Am. 12: 111-31. Department of Medicine, University of Washington, Seattle 98195-6426, USA. Decreased bone density and increased fracture risk are seen in patients with SCI. The bone resorption rate is markedly increased. Hypercalciuria, low PTH, and low 1,25 (OH)2 vitamin D are commonly seen. Bed-rest studies show similar findings, but of lesser magnitude. Therapies to treat or prevent osteoporosis include optimal nutrition (with care to avoid exacerbating hypercalciuria). Weight-bearing or functional electrical stimulation cycle ergometry may prevent some of the bone loss, especially in acutely injured patients. Estrogen should be considered in postmenopausal or amenorrheic women, but not if they are at high risk of thromboembolism. More research on effects of estrogen is needed in this population. Bisphosphonates may also help prevent the acute bone loss; oral routes must not be used in recumbent patients. Thiazides could be useful as adjunct therapy.

    • Sniger W and Garshick E (2002). Alendronate increases bone density in chronic spinal cord injury: a case report. Arch Phys Med Rehabil. 83: 139-40. Spinal Cord Injury Medicine Service, VA Boston Healthcare System, West Roxbury, MA, USA. Over the first 6 to 16 months after spinal cord injury (SCI), up to a third of bone mass may be lost because of demineralization, resulting in an increased risk for fractures. Studies in postmenopausal women have shown the efficacy of oral alendronate, an aminobisphosphonate, in increasing bone mass. However, the efficacy of alendronate in reversing bone density loss has not been shown in patients with chronic SCI. This article reports on the efficacy of alendronate in increasing bone mass in a patient with neurologically incomplete American Spinal Injury Association class D SCI and Brown-Sequard's syndrome. Bone mass change over 2 years while taking alendronate is compared for a weak extremity (majority of muscles grade 2/5) and strong extremity (majority of muscles grade 4/5) and spine. There was a greater increase in bone mineral density in the weaker lower extremity compared with the stronger one; the spine had the greatest increase overall.

    • Garland DE, Adkins RH, Stewart CA, Ashford R and Vigil D (2001). Regional osteoporosis in women who have a complete spinal cord injury. J Bone Joint Surg Am. 83-A: 1195-200. Neurotrauma Division, Rehabilitation Research and Training Center on Aging with Spinal Cord Injury, CA, USA. BACKGROUND: Regional bone loss in patients who have a spinal cord injury has been evaluated in males. In addition, there have been reports on groups of patients of both genders who had an acute or chronic complete or incomplete spinal cord injury. Regional bone loss in females who have a complete spinal cord injury has not been reported, to our knowledge. METHODS: In a study of thirty-one women who had a chronic, complete spinal cord injury, we assessed bone mineral density in relation to age, weight, and time since the injury. The results were compared with the bone mineral density in seventeen healthy, able-bodied women who had been age-matched by group (thirty years old and less, thirty-one to fifty years old, and more than fifty years old). Dual-energy x-ray absorptiometry was used to measure the bone mineral density of the lumbar spine, hip, and knee; Z-scores for the hip and spine were calculated. RESULTS: The mean bone mineral density in the spine in the youngest, middle, and oldest spinal-cord-injury groups was 98%, 108%, and 115% of the densities in the respective age-matched control groups (p < 0.0001), and the mean bone mineral density in the oldest spinal-cord-injury group was equal to that in the youngest control group. This gain in bone mineral density in the spine was reflected by the spine Z-scores, as the mean score in the oldest injured group averaged more than one standard deviation above both the norm and the mean score in the control group. The mean loss of bone mineral density in the knee in the youngest, middle, and oldest spinal-cord-injury groups was 38%, 41%, and 47% compared with the densities in the corresponding control age-groups [p < 0.0001). Furthermore, the oldest injured group had a mean reduction of knee bone mineral density of 54% compared with the youngest control group. The mean loss of bone mineral density in the hips of the injured patients was 18%, 25%, and 25% compared with the densities in the control subjects in the respective age-groups [p < 0.0001). CONCLUSIONS: The bone mineral density in the spine either was maintained or was increased in relation to the time since the injury. This finding is unlike that seen in healthy women, in whom bone mineral density decreases with age. The bone mineral density in the hips of the injured patients initially decreased approximately 25%; thereafter, the rate of loss was similar to that in the control group. The bone mineral density in the knees of the injured patients rapidly decreased 40% to 45% and then further decreased only minimally.
    • Lazo MG, Shirazi P, Sam M, Giobbie-Hurder A, Blacconiere MJ and Muppidi M (2001). Osteoporosis and risk of fracture in men with spinal cord injury. Spinal Cord. 39: 208-14. Spinal Cord Injury Service (128), Hines VA Hospital, Hines, Illinois 60141, USA. STUDY DESIGN: Cross-sectional study to evaluate bone mineral density (BMD) and fracture history after spinal cord injury (SCI). OBJECTIVES: To determine frequency of osteoporosis and fractures after SCI, correlate extent of bone loss with frequency of fractures after SCI, and determine fracture risk in SCI patients. SETTING: The Hines Veterans Affairs Hospital in Hines, Illinois, USA. METHODS: Femoral neck BMD was measured in 41 individuals with a history of traumatic or ischemic SCI using dual-energy X-ray absorptiometry (DEXA Lunar Whole Body Densitometer Model). RESULTS: Twenty-five patients (61%) met the World Health Organization (WHO) criteria for osteoporosis, eight (19.5%) were osteopenic, and eight (19.5%) were normal. Fracture after SCI had occurred in 14 patients (34%). There were significant differences between the femoral neck BMD and SCI duration in patients with a fracture history compared to those without. For patients in the same age group, each 0.1 gm/cm(2) and each unit of standard deviation (SD) (t-value) decrement of BMD at the femoral neck increased the risk of fracture 2.2 and 2.8 times, respectively. Considered simultaneously with age, duration of SCI, and level of SCI, BMD was the only significant predictor of the number of fractures. CONCLUSION: Osteoporosis and an increased frequency of fractures occur after SCI. Measurement of femoral neck BMD can be used to quantify fracture risk in SCI patients.
    • Sabo D, Blaich S, Wenz W, Hohmann M, Loew M and Gerner HJ (2001). Osteoporosis in patients with paralysis after spinal cord injury. A cross sectional study in 46 male patients with dual-energy X-ray absorptiometry. Arch Orthop Trauma Surg. 121: 75-8. Stiftung Orthopadische Universitatsklinik Heidelberg, Abteilung Orthopadie I, Germany. In a cross-sectional study, 46 male patients with paralysis after spinal cord injury (average age 32 years; injuries sustained from 1 to 26 years ago; 33 Frankel A, 13 Frankel B, C, D) were examined clinically and by dual-energy X-ray absorptiometry (DEXA). Their bone mineral density (BMD) values were compared with age-related controls and correlated to clinical parameters. BMD was reduced in the proximal femur (p < 0.05) and the distal forearm [p < 0.05), but not in the lumbar spine. Demineralisation was influenced in the proximal femur [Z-score -2.95) by immobilisation after surgical treatment. Patients suffering from complete lesions had significantly lower BMD in the lumbar spine [-1.47) compared with patients with incomplete lesions [+0.02). BMD was not significantly influenced by the level of the lesion and the ambulatory status. Long-term monitoring showed significant demineralisation in the proximal femur [r = -0.36) and the distal forearm [r = -0.4), but not in the lumbar spine [r = -0.21). By correlating BMD with clinical parameters, it can be deduced that, firstly, immobilisation after surgical treatment should be reduced to a minimum; secondly, that every effort must be expended to prevent turning an incomplete into a complete lesion; and finally, that rehabilitation treatment should be lifelong.


      Dr. Young (and anyone one with info),
      What about taking estrogen (such as the patch Orto Evra) for those who are younger than menopausal age and are not amenorrheic? I know that this increases the risk of DVT, but it seems to be only a slight increase that might be worth the risk if the combination of estrogen and a bisphosphonate would prevent osteoperosis or even increase bone mass.

      Also, estrogen or any of the medications out there help bones in the legs, or only hips and spine?