Evidence for non-pharmacological prevention of SLOP includes data from seventeen investigations (n=270 participants). This includes five RCTs (88 participants), five non-randomized controlled trials (160 participants) and three pre-post studies (22 participants) (Table 11). As with pharmacological studies, there were difficulties with interpretation because of low numbers of participants and variability with the primary outcome measures. For each of the different rehab modalities, there is limited evidence available and there was variability in the selection of the primary outcomes. The therapeutic ultrasound study by Warden and colleagues (2001) found no significant improvement in bone health after a 6-week intervention. Although prospective observational data (Frey-Rindova et al. 2000) highlight the loss of bone in the early phase (first 6-months post-SCI), there was no significant influence of self-reported physical activity level. Training adherence was: 78.4% for FES-cycling, 79.4% for NMES, 94.4 for standing/walking and 100% for ultrasound and physical activity. Overall, the evidence suggests that rehabilitation modalities did not prevent bone mass decline in the acute phase after SCI, although general training compliance was relatively high.
There is level 1 evidence (one RCT) that 6 weeks of pulsed calcaneal ultrasound has no effect on calcaneal BMD measured by DXA or QUS. (Warden et al. 2001)
There is level 1 evidence (one RCT) that NMES training of quadriceps 5 days per week for 14 weeks did not result in significant changes in lower limb or hip region BMD. (Arija-Blázquez et al. 2014)
There is level 2 evidence (from 1 non-randomized prospective controlled trial) that NMES of plantar flexors for 2-3years initiated after 2-4 months of injury reduced the decline in tibia vBMD (Shields et al. 2006a; 2006b).
There is level 2 evidence (from 1 non-randomized prospective controlled trial) that FES-cycling 30 minutes thrice weekly for 6 months did not improve or maintain cortical BMD of the right tibial diaphysis in the acute phase. (Eser et al. 2003)
There is level 1 evidence (from 1 RCT) that standing thrice weekly for 12 weeks initiated within 4-6 months of injury did not prevent proximal femur BMD decline (Ben et al. 2005).
There is level 3/4 evidence that active-assisted standing (FES) with for 2-3 years was effective in mitigating BMD decline of the trabecular BMD of the distal femur (Dudley-Javoroski & Shields 2013).
There is level 4 evidence (from 1 pre-post study) that BWSTT twice weekly for 6-8 months more than three months post-injury did not prevent declines in hip or knee region bone mineral density (DXA or QCT). (Giangregorio et al. 2005)
There is level 4 evidence (from 1 pre-post study) that activity-based training 2-3 hours/day for a minimum of 2 days a week for 6 months increased spine BMD (Astorino et al. 2013).
Interventions, beyond 6 months in duration, with an adequate sample size, are needed to determine the efficacy of rehabilitation intervention for prevention or treatment of SLOP.