Key Points

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Bone Health & Fracture

  • Fragility fractures, of the distal femur and proximal tibia, are common in people with SCI.
  • Bone health management should begin early following SCI, given the significant declines in hip and knee region bone mass in the first year and the associated lifetime increased fracture risk. The efficacy of drug interventions appear greater when medications are administered early after SCI onset
  • Individuals with chronic SCI and increased risk for lower extremity fragility fractures can be readily identified based on completion of a clinical history and risk factor profile.
  • Measurement and monitoring of hip and knee region BMD after SCI are essential to identify low bone mass and quantify lower extremity fracture risk.
  • Biomarkers provide clinical insight into the metabolic activity of bone, while imaging techniques provide insight into bone density, quality and architecture.

Pharmacologic Therapy for Prevention of Sublesional Osteoporosis (SLOP)

  • Oral tiludronate and clodronate prevent a decrease in BMD of the hip and knee region with no adverse effects on bone mineralization in men with paraplegia.
  • Oral etidronate prevents a decrease in BMD of the hip and knee region in people with incomplete paraplegia or tetraplegia who return to walking.
  • Oral alendronate once weekly maintains BMD at the hip.
  • Once yearly IV infusion zoledronate may reduce bone loss at the hip during the 12 months following administration.
  • Pamidronate 30 mg IV or 60 mg IV 4x/year is not effective for the prevention of BMD loss at the hip and knee region early after SCI people with motor complete paraplegia or tetraplegia.
  • In summary, there is limited evidence that bisphosphonates prevent declines in hip and knee region bone mass after SCI. However, bisphosphonates are moderately effective at ameliorating the rate of hip and knee region bone mass resorption.

Pharmacologic Therapy for Treatment of SLOP

  • Alendronate 10 mg daily and calcium 500 mg orally 3x/day is effective for the maintenance of BMD of the total body, hip and knee region for men with paraplegia.
  • Vitamin D analog is effective for maintenance of BMD in the leg.

Non-pharmacologic Therapy for Prevention and/or Treatment

  • Short term (6 weeks) therapeutic ultrasound is not effective for preventing
  • bone loss after SCI.
  • FES-cycling does not improve or maintain bone at the tibial midshaft in the acute phase.
  • Activity-based training (6 months) is effective for increasing spine BMD.
  • Electrical stimulation can maintain or increase BMD over the stimulated areas.
  • FES cycle ergometry may increase lower extremity BMD over areas stimulated.
  • There is inconclusive evidence for Reciprocating Gait Orthosis, long leg braces, passive standing or self-reported physical activity as a treatment for low bone mass.
  • There is a lack of definitive evidence supporting non-pharmacological interventions for either prevention or treatment of bone loss after a SCI.