Table 1: Systematic Review of Bone Health

Author Year; Country
Review dates
Total Sample Size




Ashe et al. 2007;



Reviewed published articles from 1980 to 2006


N= 31




Method: Literature search for English articles exploring prevention or treatment of bone loss after SCI.11 RCTs, 5 non-randomized controlled trials, 15 pre-post trials.
Outcome measures include biochemical markers, bone imaging and histomorphometry from bone biopsies.

Databases: PUBMED/Medline, CINAHL, EMBASE, PsycINFO

Level of Evidence:

SCIRE Procedures-
Modified Downs and Black for non-RCTs
PEDRo tool for RCTs


  1. There is Level 1 evidence for the prevention and treatment of bone loss using bisphosphonates (clodronate, etidronate and alendronate) that may maintain BMD or slow the decline of BMD after SCI.  There is a lack of definitive evidence supporting nonpharmacological interventions for the treatment of bone loss after an SCI with the exception of muscular electrical stimulation.
  2. Level 1 Evidence:
  • For the first year postinjury, randomized controlled trials show that clodronate prevents a decrease in BMD of the hip and knee region with limited adverse effects on bone mineralization in men living with paraplegia
  • Oral etidronate prevents a decrease in BMD of the hip and knee region in people living with incomplete paraplegia or tetraplegia who return to walking

Chang et al.




Reviewed articles published before Jan. 2013


N = 19




Method: Literature search for English articles related to treatment of post-SCI osteoporosis using bisphosphonates or FES.
Bisphosponate treatment: 7 experimental (RCT) studies and 1 quasi-experimental studies. FES treatment: 2 quasi-experimental studies and 9 longitudinal follow-up studies.
Outcome measures included percentage BMD change from baseline using DXA or CT at 3, 6, 9, 12, and 18 mos.

Databases: PubMed, Scopus

Level of Evidence:
Jadad scale for RCTs and quasi-experimental trials; Newcastle-Ottawa scale for longitudinal follow-up studies

  1. Bisphosphonate therapy in the early post-injury period attenuated sublesional bone loss, compared to placebo or usual care.
  2. Participants with chronic SCI who were exposed to an FES intervention (cycling ergometry or knee resistance exercise) of more than 3 months duration showed a significant increase in knee-region BMD at 3, 6, and 12 mos. post-intervention.
  3. Knee-region BMD increases were not maintained after FES therapy was discontinued. In one report, knee-region BMD returned to baseline after 6 months without training.
  4. Interventions that provided FES ≥ 5 days/week were likely to be more effective than interventions that used FES ≤ 3 days/week..

Biering-Sorensen et al. 2009;



Reviewed Published articles from 1988 to 2008


N= 45



Methods: Literature search for articles exploring non-pharmacological treatments of osteoporosis after SCI.
Interventions include weight-bearing, standing, walking, exercise, electrical stimulation.
Outcome measures include bone mineral content and bone mineral density.

Database: PubMed, EMBASE and the Cochrane Controlled Trials Register, PEDro database

Level of Evidence:
SCIRE procedures- PEDro tool


  1. No conclusive indication of any effective intervention.
  2. Bone mineral should be measured around the knee
  3. Length and intensity of non-pharmacological treatment should be sufficiently long and high, and should commence early after SCI.
    – stimulation used has to be maintained if the positive effect on BMD is to remain

Bryson & Gourlay 2009;



Reviewed Published articles from 1955 to 2008


N= 7




Methods: Literature search for English articles related to bisphosphonate (BPs) therapy to optimize bone health with experimental, quasi-experimental or controlled observational design.
Interventions include bisphosphonates (alendronate, zoledronate, pamidronate, etidronate).
6 experimental (RCT) studies and 1 quasi-experimental study.
Outcome measures include bone mineral density and histomorphometry bone measures.

Databases:  PubMed/MEDLINE database (1966 through December 2008), ISI database (1955 through December 2008)
Treatment regimens of second-generation BPs administered in the acute stages of SCI attenuated bone hyper-resorption in treated patients compared with placebo during the treatment period in most studies.

  1. Data were insufficient to recommend routine use of BPs for fracture prevention in SCI patients.
  2. Fair or poor quality of evidence
  • 2 studies rated poor
  • 5 studies rated fair

    3. None of the studies included fracture outcomes.