1. Osteoporosis After a Spinal Cord Injury
Birgitte Hansen
Clinic of Spinal Cord Injury
Hornbæk - Denmark

2. Osteoporosis results from reduced bone mass
disruption of the micro-architecture of bone,
decreased bone strength
increased risk of fracture.

3. A Spinal Cord Injury Has
Increase in bone resorption
Hormonal alternations
Modification of body composition
Wide-ranging physiological and pathological effects

7. 1% - 46% incidence of lower extremity fractures in people who sustain an SCI

9. Risk Factors For Osteoporosis in SCI Individuals
Completeness
Low BMI (< 25 kg/m2)
Age
Gender (female)
Age at injury ( < 18 years)
Duration of injury

10. Bone Evaluation - DXA

11. What can we do?

12. Non pharmacological treatment
Pharmacologic Therapy

13. Non pharmacological treatment
MES (muscular electrical stimulation)
FES cycle ergometry (functional electrical stimulation)
Standing
Walking
Teach safe transferring skills

14. Passive standing do not maintain or improve BMD in the hip or knee region
Kunkel et al (Arch Phys Med Rehabil) 1993
Needham-Shropshire et al. (Arch Phys Med Rehabil) 1997

15. FES cycle ergometry
Conflicting results for bone parameters for six studies

16. MES –FES assisted training
Belanger et al (Arch Phys Med Rehabil 2000)
14 men and women with SCI and 14 controls
5 days/week, 24 weeks
Results
BMD regained almost 30 % of lost bone mass compared to controls

17. Pharmacologic Therapy
Calcium – just supplement
Vitamin D – just supplement
Calcitonin – optimal dosage and long-term effectiveness unclear
Vitamin D analog (Etalpha®) – Increase in lower-limb BMD
Bisphosphonates - reduction in bone loss

18. Vitamin D Analog Treatment

19. 19 subjects had 1-α-D2 4 μg/day for 24 months (21 placebo)
Leg BMD increased significantly from baseline in the treatment group at 12, 18 and 24 months.
Both groups received calcium (1.3 g/d) and vitamin D (800 IU/d)
Smoking prevents bone effect with 1-α-D2 - reason unclear

20. Conclusion – Vitamin D Analog
Treatment of 1-α-D2 increased lower-limb BMD
Current smokers had not this effect
Long-term effect of continued 1-α-D2 therapy in persons with chronic SCI requires further investigation
Bisphosphonates + 1-α-D2 or 1-α-D2 followed by bisphosphonates should be investigated
1-α-D2 + physical intervention may be considered

21. Bisphosphonates treatment
First-generation
Etidronate, clodronate
Second-generation
Pamidronate
Third-generation
Alendronate, ibandronate, risedronate, tiludronate and zolendronic acid

22. Treatment With Bisphosphonates
Oral bisphosphonates must be
Ingested on an empty stomach
With ml water
Followed by sitting up for 1 hour prior to taking any other food or medication
Side effects
Joint pain
Stomach upset/gastric ulcer

23. Treatment With Bisphosphonates II
Intravenous bisphosphonates
Available in daily, monthly, quarterly and yearly preparations
Assured compliance
Reduced relative risk of gastric ulcer
Side effects
Fever and muscle pain (flu-like symptoms)
Low serum calcium

24. Clodronate P. Minaire et al. (J. Clin. Invest. 1981) Results
14 had clodronate (2 different doses), 7 placebo (17 males, 4 females)
Started 17.6 days after injury. 3.5 months of treatment – total 6 months study
Results
No decrease in hip and knee region on bone mineral content in the treated groups
Etidronate and Tiludronate have positive results for treatment within the 1 year of injury

25. Alendronate Y. Zehnder et al. (JBMR, 2004) Results
33 men had Aln + Ca, 32 men had Ca in 2 years
9.8 years since SCI
Results
BMD in distal and proximal tibia, and total hip remained stable in the Aln – Ca group and decreased in the Ca group

26. Future Prospects Large prospective longitudinal studies
DXA methods to target areas
Reducing the risk of falls
Osteoprotegerin/RANKL system

27. Questions to be answered
Who
When
How – and how long to treat?

28. Osteoporosis Research Centre, Hvidovre Hospital
Ulla Pedersen
Anne-Mette Rasmussen
Solveig Petersen
Jenni Teilmann
Ole Helmer Sørensen
Jens-Erik Bech Jensen
Clinic For Spinal Cord Injury, Rigshospitalet
Lisbeth Nielsen
Fin Biering-Sørensen

29. Thank you for your attention