Effectiveness of bisphosphonate analogues and functional electrical stimulation on attenuating post-injury osteoporosis in spinal cord injury patients- a systematic review and meta-analysis

Anti-Siglec-15 Antibody Prevents Marked Bone Loss after Acute Spinal Cord Injury-Induced Immobilization in Rats

Rapid and extensive sublesional bone loss after spinal cord injury (SCI) is a difficult medical problem that has been refractory to available interventions except the antiresorptive agent denosumab (DMAB). While DMAB has shown some efficacy in inhibiting bone loss, its concurrent inhibition of bone formation limits its use. Sialic acid-binding immunoglobulin-like lectin (Siglec)-15 is expressed on the cell surface of mature osteoclasts. Anti-Siglec-15 antibody (Ab) has been shown to inhibit osteoclast maturation and bone resorption while maintaining osteoblast activity, which is distinct from current antiresorptive agents that inhibit the activity of both osteoclasts and osteoblasts. The goal of the present study is to test a Siglec-15 Ab (NP159) as a new treatment option to prevent bone loss in an acute SCI model. To this end, 4-month-old male Wistar rats underwent complete spinal cord transection and were treated with either vehicle or NP159 at 20 mg/kg once every 2 weeks for 8 weeks. SCI results in significant decreases in bone mineral density (BMD, -18.7%), trabecular bone volume (-43.1%), trabecular connectivity (-59.7%), and bone stiffness (-76.3%) at the distal femur. Treatment with NP159 almost completely prevents the aforementioned deterioration of bone after SCI. Blood and histomorphometric analyses revealed that NP159 is able to greatly inhibit bone resorption while maintaining bone formation after acute SCI. In ex vivo cultures of bone marrow cells, NP159 reduces osteoclastogenesis while increasing osteoblastogenesis. In summary, treatment with NP159 almost fully prevents sublesional loss of BMD and metaphysis trabecular bone volume and preserves bone strength in a rat model of acute SCI. Because of its unique ability to reduce osteoclastogenesis and bone resorption while promoting osteoblastogenesis to maintain bone formation, Siglec-15 Ab may hold greater promise as a therapeutic agent, compared with the exclusively antiresorptive or anabolic agents that are currently used, in mitigating the striking bone loss that occurs after SCI or other conditions associated with severe immobilization. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation

Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.

Advances in materials-based therapeutic strategies against osteoporosis

Osteoporosis is caused by the disruption in homeostasis between bone formation and bone resorption. Conventional management of osteoporosis involves systematic drug administration and hormonal therapy. These treatment strategies have limited curative efficacy and multiple adverse effects. Biomaterials-based therapeutic strategies have recently emerged as promising alternatives for the treatment of osteoporosis. The present review summarizes the current status of biomaterials designed for managing osteoporosis. The advantages of biomaterials-based strategies over conventional systematic drug treatment are presented. Different anti-osteoporotic delivery systems are concisely addressed. These materials include injectable hydrogels and nanoparticles, as well as anti-osteoporotic bone tissue engineering materials. Fabrication techniques such as 3D printing, electrostatic spinning and artificial intelligence are appraised in the context of how the use of these adjunctive techniques may improve treatment efficacy. The limitations of existing biomaterials are critically analyzed, together with deliberation of the future directions in biomaterials-based therapies. The latter include discussion on the use of combination strategies to enhance therapeutic efficacy in the osteoporosis niche.

Pharmacologic and nonpharmacologic treatment modalities for bone loss in SCI - Proposal for combined approach

Increased risk of bone fracture due to bone mineral density (BMD) loss is a serious consequence of spinal cord injury (SCI). Traditionally, pharmaceutical approaches, such as bisphosphonates, have been prescribed to prevent bone loss. However, there is controversy in the literature regarding efficacy of these medications to mitigate the drastic bone loss following SCI. Individuals with SCI are particularly at risk of osteoporosis because of the lack of ambulation and weight bearing activities. In the past two decades, functional electric stimulation (FES) has allowed for another approach to treat bone loss. FES approaches are expanding into various modalities such as cycling and rowing exercises and show promising outcomes with minimal consequences. In addition, these non-pharmacological treatments can elevate overall physical and mental health. This article provides an overview of efficacy of different treatment options for BMD loss for SCI and advocates for a combined approach be pursued in standard of care.

Electrical Stimulation for Preventing Skin Injuries in Denervated Gluteal Muscles-Promising Perspectives from a Case Series and Narrative Review

Spinal cord injury (SCI) where the lower motor neuron is compromised leads to atrophy and degenerative changes in the respective muscle. This type of lesion becomes especially critical when the gluteal muscles and/or the hamstrings are affected as they usually offer a cushioning effect to protect from skin injuries. Previous research conducted over the past 30 years has made advancements in the development of parameters for the optimal application of long pulse stimulation with the aim to restore muscle structure and trophic aspects in people with chronic SCI (<20 years post-injury). This work provides an overview of previous achievements in the field through a narrative literature review before presenting preliminary results in the form of a case series from an ongoing study investigating the acute effects of six months of long pulse stimulation on the tissue composition of the gluteal muscles in five people with chronic SCI (>20 years post-injury). Participants underwent a 33-min home-based long pulse stimulation program five times a week, and their muscle and adipose tissue thicknesses were assessed at baseline, after three and six months, respectively, using magnetic resonance imaging. The results show that the largest increase in muscle thickness occurred at the level of the height of the acetabulum (+44.37%; χ2(2) = 0.5; p = 0.779), whereas the most important decrease in adipose tissue occurred at the level of the sacroiliac joint (SIJ) reference (−11.43%; χ2(2) = 1.6; p = 0.449) within only six months of regular stimulation despite the preceding long denervation period. The underlying mechanism and physiology of muscular resuscitation from myofibrillar debris as presented in chronic denervation to functional contractile entities remain to be investigated further.

Sclerostin Concentration and Bone Biomarker Trends in Patients with Spinal Cord Injury: A Prospective Study

Patients with spinal cord injury (SCI) experience a high osteoporosis incidence, which increases fracture risk. Recently, a sclerostin antibody was introduced as a target biomarker to treat osteoporosis. We aimed to determine the serum concentration of sclerostin and factors affecting its concentration over time. This was a prospective cross-sectional study. The inclusion criteria were (1) SCI patients with a grade 3 modified functional ambulatory category score (FAC—patients requiring firm continuous support) and (2) patients whose injury occurred >1 month ago. The exclusion criterion was a history of osteoporosis medication administration within 6 months. The collected data included bone biomarkers (carboxy-terminal collagen crosslinks (CTX), procollagen type 1 intact N-terminal propeptide, and sclerostin), clinical data (FAC, lower extremity motor score), body mass index, SCI duration, and hip bone mineral density (BMD). This study recruited 62 patients with SCI. Sclerostin levels significantly correlated with age, CTX level, and hip BMD. SCI duration was negatively correlated with sclerostin levels. Lower extremity motor scores were not significantly correlated with sclerostin levels. The acute SCI state showed a higher sclerostin level than the chronic SCI state. Sclerostin showed a significant relationship with CTX. In conclusion, age and BMD affect sclerostin concentration in patients with SCI.

Advanced Equipment Development and Clinical Application in Neurorehabilitation for Spinal Cord Injury: Historical Perspectives and Future Directions

Partial to complete paralysis following spinal cord injury (SCI) causes deterioration in health and has severe effects on the ability to perform activities of daily living. Following the discovery of neural plasticity, neurorehabilitation therapies have emerged that aim to reconstruct the motor circuit of the damaged spinal cord. Functional electrical stimulation (FES) has been incorporated into devices that reconstruct purposeful motions in the upper and lower limbs, the most recent of which do not require percutaneous electrode placement surgery and thus enable early rehabilitation after injury. FES-based devices have shown promising results for improving upper limb movement, including gripping and finger function, and for lower limb function such as the ability to stand and walk. FES has also been employed in hybrid cycling and rowing to increase total body fitness. Training using rehabilitation robots is advantageous in terms of consistency of quality and quantity of movements and is particularly applicable to walking training. Initiation of motor reconstruction at the early stage following SCI is likely to advance rapidly in the future, with the combined use of technologies such as regenerative medicine, brain machine interfaces, and rehabilitation robots with FES showing great promise.

Description of Bone Health Changes in a Cohort of Children With Acute Flaccid Myelitis (AFM)

OBJECTIVES

To qualitatively describe bone health changes in children with acute flaccid myelitis (AFM) and assess relationships with muscle mass and strength and functional performance.

METHODS

Retrospective analysis of a cohort of 79 children with AFM seen consecutively in one specialized academic center between January 1, 2007, and December 31, 2019.

RESULTS

Of the 79 participants who were aged 4 months to 21 years old, 41 (52%) had bone density measured by dual energy absorptiometry (DXA) and 32 of them (78%) were diagnosed with low bone mass (LBM). We recorded 25 fractures that occurred after onset of neurologic deficit in 14 of the children in the cohort (18%). Lean muscle mass correlated with bone mass and functional performance as assessed by Physical Abilities and Mobility Scale (PAMS) but not with muscle strength as assessed by manual muscle testing (MMT). Bone density in the lower limbs was associated with ambulatory status.

CONCLUSION

Children with AFM have a high likelihood of muscle and bone loss and frequently sustain pathologic fractures. Bone health in children with AFM should be carefully monitored, and efforts should be made to preserve bone mass and maximize muscle mass.

S1 Guidelines on Bone Impairment in Spinal Cord Injury

During the acute and chronic phase of spinal cord injury (SCI) bone turnover and structure are affected. Bone mineral density of lower limbs is decreased up to 28%-50% below that of age-matched peers at 12-18 mo post injury. Coexisting secondary etiologies of osteoporosis may be present, and during ageing additional loss of bone occurs. All these compose a complex canvas of bone impairment after spinal cord injury and make the therapeutical approach challenging. The risk of fragility fractures is increased after the 2nd decade post SCI affecting the functionality and quality of life of individuals with SCI. Diagnostic flaws, lack of a ranking system to categorize the degree of bone impairment similar to the one of World Health Organization, and evidence-based clinical guidelines for management in SCI requires interdisciplinary cooperation and appropriate planning of future research and interventions. Spinal Cord Section of Hellenic Society of Physical Rehabilitation Medicine convened an expert panel working group on bone and spinal cord injury at the Pan-Hellenic Congress 2018 of PRM in Athens Greece, to establish an evidence-based position statement for bone loss in individuals with SCI of traumatic or non-traumatic etiology. This was reviewed by an International Task Force and used to create S1 Guidelines. This first version S1 guideline will work towards to provide help with prophylactic basic osteoporosis therapy diagnostic and therapeutic decisions in acute and chronic phase and rehabilitation countermeasures against osteoporosis related with spinal cord injury.

Delayed Systemic Treatment with Cannabinoid Receptor 2 Agonist Mitigates Spinal Cord Injury-Induced Osteoporosis More Than Acute Treatment Directly after Injury

Nearly all persons with spinal cord injury (SCI) will develop osteoporosis following injury, and further, up to 50% of all persons with SCI will sustain a fracture during their lives. The unique mechanisms driving osteoporosis following SCI remain unknown. The cannabinoid system modulation of bone metabolism through cannabinoid 1/2 (CB1/2) has been of increasing interest for the preservation of bone mass and density in models of osteoporosis. Using a thoracic vertebral level 8 (T8) complete transection in a mouse model, we performed daily treatment with a selective CB2 receptor agonist, HU308, compared with SCI-vehicle-treated and naïve control animals either immediately after injury for 40 days, or in a delayed paradigm, following 3 months after injury. The goal was to prevent or potentially reverse SCI-induced osteoporosis. In the acute phase, administration of the CB2 agonist was not able to preserve the rapid loss of cancellous bone. In the delayed-treatment paradigm, in cortical bone, HU308 increased cortical-area to total-area ratio and periosteal perimeter in the femur, and improved bone density in the distal femur and proximal tibia. Further, we report changes to the metaphyseal periosteum with increased presence of adipocyte and fat mass in the periosteum of SCI animals, which was not present in naïve animals. The layer of fat increased markedly in HU308-treated animals compared with SCI-vehicle-treated animals. Overall, these data show that CB2 agonism targets a number of cell types that can influence overall bone quality.

Reasons for Initiation and Discontinuation of Pharmacological Therapies for Osteoporosis in Veterans with Spinal Cord Injury and Disorders

INTRODUCTION

Medications for osteoporosis have not been reported to reduce fracture rates in patients with spinal cord injury and disorders (SCI/D), yet these medications are still prescribed. Clinical decision-making underscoring the initiation and discontinuation of osteoporosis medications in SCI/D remains poorly understood.

METHODOLOGY

Veterans with a SCI/D with at least one prescription for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, and teriparatide) who received healthcare within Veterans Affairs (VA) from 2005 to 2015 were identified using VA administrative databases. A 10% subsample of Veterans was selected for electronic health record review.

RESULTS

Two hundred and sixty-seven Veterans with 330 prescriptions underwent electronic health record review. Bisphosphonates were the most frequently prescribed medication for osteoporosis (n = 223, 67.6%). Of the 187 Veterans with prescriptions for prevention or treatment of osteoporosis, the primary reason for initiation was Dual Energy X-ray Absorptiometry (DXA) scan with osteopenia or osteoporosis (n = 119, 63.6% of Veterans), primarily at the hip (81.0% of DXAs). The majority (79.0%) of DXAs were "screening tests," with SCI/D being the sole reason for the scan. Fractures (n = 51, 27.3%) and fall risk concerns (n = 29, 15.5%) were other major reasons for initiation. On average, oral bisphosphonates were filled for <3 yr, with medication-related side effects (n = 23, 15.8% of bisphosphonates discontinued), predominately gastrointestinal (n = 17, 73.9% of reported side effects), the most common reason for discontinuation. Drug holidays occurred in 14.3% of 35 oral bisphosphonates used for ≥5 yr. No cases of osteonecrosis of the jaw were found. There was one case of an atypical femoral fracture which could not be confirmed.

CONCLUSIONS

The decision to initiate pharmacological therapies in SCI/D is primarily based on osteopenia or osteoporosis at the hip by screening DXAs. Gastrointestinal side effects are the major reason for discontinuation of oral bisphosphonates. New therapies for osteoporosis in SCI/D are needed.

Dried plum mitigates spinal cord injury-induced bone loss in mice

Spinal cord injury (SCI) is accompanied by rapid loss of bone and increased risk of low impact fractures. Current pharmacological treatment approaches have proven to be relatively ineffective in preventing or treating bone loss after SCI. Dietary supplementation with dried plum (DP) has been shown to have dramatic effects on bone in various other disease models. In this study, we tested the efficacy of DP in preventing bone loss after SCI and restoring bone that has already been lost in response to SCI. Male C57BL/6J mice (3-month-old) underwent SCI and were fed a diet containing 25% DP by weight or a control diet for up to 4 weeks to assess whether DP can prevent bone loss. To determine whether DP could restore bone already lost due to SCI, mice were put on a control diet for 2 weeks (to allow bone loss) and then shifted to a DP supplemented diet for an additional 2 weeks. The skeletal responses to SCI and dietary supplementation with DP were assessed using microCT analysis, bone histomorphometry and strength testing. Dietary supplementation with DP completely prevented the loss of bone and bone strength induced by SCI in acutely injured mice. DP also could restore a fraction of the bone lost and attenuate the loss of bone strength after SCI. These results suggest that dietary supplementation with DP or factors derived from DP may prove to be an effective treatment for the loss of bone in patients with SCI.

The Effect of Bisphosphonates on Managing Osteoporosis After Spinal Cord Injury: A Meta-Analysis

BACKGROUND

The increased bone loss after spinal cord injury (SCI) is associated with an increase in the morbidity and mortality of fragility fractures, which can constitute a substantial cost to health care systems. Bisphosphonates (BPs) are now the principal class of medications used for osteoporosis.

OBJECTIVE

To demonstrate the effect of BPs on treating osteoporosis after SCI.

METHODS

A comprehensive search in PubMed, EMBASE, Web of Science and Cochrane Central databases was undertaken for randomized controlled trials (RCTs), exploring the effect of BPs on osteoporosis after SCI. The primary outcome measures were the BMD of different locations, serum bone turnover marker levels, serum biochemistry marker levels and adverse effect (AE) risks. The final search was performed in September 2019. Reporting was carried out according to PRISMA Guidelines.

RESULTS

Six RCTs were included. A total of 147 patients met the inclusion criteria. BPs were found to statistically prevent bone loss in the total hip, femoral neck and trochanter at the 6- and 12-month follow-up points and to increase the BMD of the lumbar spine at the 12-month follow-up time point. BPs had no clear effect on serum PINP or serum calcium levels at the 12-month follow-up time point.

CONCLUSION

BP therapy may prevent bone loss in the lumbar spine and hip when administered early after SCI and has relatively high safety.

Association of Bisphosphonate Therapy With Incident of Lower Extremity Fractures in Persons With Spinal Cord Injuries or Disorders

OBJECTIVE

To investigate the association between prescriptions for bisphosphonates; calcium and vitamin D supplements; and receipt of dual-energy x-ray absorptiometry (DXA) screening, and incident fracture risk in men and women with a spinal cord injury (SCI) or disorder (SCID).

DESIGN

Propensity-matched case-control analyses.

SETTING

United States Veterans Affairs (VA) facilities.

PARTICIPANTS

A total of 7989 men and 849 women with an SCID included in VA administrative databases between October 1, 2005 and October 1, 2015 were identified (N=8838). Cases included 267 men and 59 women with a bisphosphonate prescription propensity matched with up to 4 controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incident lower extremity fractures.

RESULTS

There was no significant association between prescriptions for bisphosphonates and incident lower extremity fractures in men (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.62-1.77) or women (OR, 1.02; 95% CI, 0.28-3.75). In men, similar null associations were seen among those who were adherent to bisphosphonate therapy (OR, 1.25; 95% CI, 0.73-2.16), were concomitant users of vitamin D and calcium and a bisphosphonate (OR, 1.05; 95% CI, 0.57-1.96), had more than 1 fracture on different dates during the study period (OR, 0.13; 95% CI, 0.02-1.16) and in those who had undergone DXA testing prior to the date of the bisphosphonate prescription and incident fracture (OR, 1.26; 95% CI, 0.69-2.32).

CONCLUSIONS

In men with a traumatic SCI and women with a traumatic SCID, bisphosphonate therapies for osteoporosis do not appear to significantly affect fracture risk. Adequately powered randomized controlled trials are needed to definitively demonstrate efficacy of bisphosphonates for fracture prevention in this population. There is a compelling need to identify new medications to prevent fractures in this high-risk population.

Spinal Cord Injury as a Model of Bone-Muscle Interactions: Therapeutic Implications From in vitro and in vivo Studies

Spinal cord injuries (SCIs) represent a variety of conditions related to the damage of the spinal cord with consequent musculoskeletal repercussions. The bone and muscle tissues share several catabolic pathways that lead to variable degrees of disability in SCI patients. In this review article, we provide a comprehensive characterization of the available treatment options targeting the skeleton and the bone in the setting of SCI. Among the pharmacological intervention, bisphosphonates, anti-sclerostin monoclonal antibodies, hydrogen sulfide, parathyroid hormone, and RANKL pathway inhibitors represent valuable options for treating bone alterations. Loss phenomena at the level of the muscle can be counteracted with testosterone, anabolic-androgenic steroids, and selective androgen receptor modulators. Exercise and physical therapy are valuable strategies to increase bone and muscle mass. Nutritional interventions could enhance SCI treatment, particularly in the setting of synergistic and multidisciplinary interventions, but there are no specific guidelines available to date. The development of multidisciplinary recommendations is required for a proper clinical management of SCI patients.

Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review

Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.Study Design: Scoping review.Settings/Participants: Human adult subjects with a SCI/D.Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.

Repeating Measurement of Bone Mineral Density when Monitoring with Dual-energy X-ray Absorptiometry: 2019 ISCD Official Position

Bone mineral density (BMD) can be measured at multiple skeletal sites using various technologies to aid clinical decision-making in bone and mineral disorders. BMD by dual-energy X-ray absorptiometry (DXA) has a critical role in predicting risk of fracture, diagnosis of osteoporosis, and monitoring patients. In clinical practice, DXA remains the most available and best validated tool for monitoring patients. A quality baseline DXA scan is essential for comparison with all subsequent scans. Monitoring patients with serial measurements requires technical expertise and knowledge of the least significant change in order to determine when follow-up scans should be repeated. Prior ISCD Official Positions have clarified how and when repeat DXA is useful as well as the interpretation of results. The 2019 ISCD Official Positions considered new evidence and clarifies if and when BMD should be repeated. There is good evidence showing that repeat BMD measurement can identify people who experience bone loss, which is an independent predictor of fracture risk. There is good evidence showing that the reduction in spine and hip fractures with osteoporosis medication is proportional to the change in BMD with treatment. There is evidence that measuring BMD is useful following discontinuation of osteoporosis treatment. There is less documentation addressing the effectiveness of monitoring BMD to improve medication adherence, whether monitoring of BMD reduces the risk of fracture, or effectively discriminates patients who should and should not recommence treatment following an interruption of medication. Further research is needed in all of these areas.

Prophylactic treatment of osteoporosis after SCI: promising research, but not yet indicated

In persons with spinal cord injury (SCI), osteoporosis and associated fragility fractures are a prevalent phenomenon with clinically meaningful morbidity and mortality. Prevention of osteoporosis utilizing both physical modalities and pharmacological therapies is an area of high-clinical importance. In our perspective, the current body of research cannot provide clear guidance on prophylactic interventions to prevent osteoporosis specifically to stratify SCI subjects to their risk for fragility fractures. Without this critical research, clinicians cannot weigh the risk versus benefits of interventions, such as bisphosphonates, which is not a benign treatment. Other treatments such as physical modalities provide little risk and have other therapeutic benefit. This perspective is an argument that the current research does not indicate prophylactic pharmacological intervention to prevent osteoporosis in the SCI population.

Medical and Musculoskeletal Concerns for the Wheelchair Athlete: A Review of Preventative Strategies

Adaptive sports refers to organized sporting activities that are practiced by individuals with disabilities and are worthwhile to maintain physical and psychological health. As adaptive sports participation continues to rise, health care providers must have an enhanced understanding of injury and illness patterns specific to the adaptive athlete. Early recognition and prevention are important to ensure safe and successful participation in sport. The present review aims to provide a framework for diagnosis and prevention of common conditions specific to the wheelchair athlete. In particular, autonomic dysreflexia, impaired thermoregulation, urinary tract infection, and pressure injuries, as well as shoulder pain, upper-extremity entrapment neuropathies, and osteoporotic fractures will be discussed.

Sclerostin Antibody Reverses the Severe Sublesional Bone Loss in Rats After Chronic Spinal Cord Injury

To date, no efficacious therapy exists that will prevent or treat the severe osteoporosis in individuals with neurologically motor-complete spinal cord injury (SCI). Recent preclinical studies have demonstrated that sclerostin antibody (Scl-Ab) can prevent sublesional bone loss after acute SCI in rats. However, it remains unknown whether sclerostin inhibition reverses substantial bone loss in the vast majority of the SCI population who have been injured for several years. This preclinical study tested the efficacy of Scl-Ab to reverse the bone loss that has occurred in a rodent model after chronic motor-complete SCI. Male Wistar rats underwent either complete spinal cord transection or only laminectomy. Twelve weeks after SCI, the rats were treated with Scl-Ab at 25 mg/kg/week or vehicle for 8 weeks. In the SCI group that did not receive Scl-Ab, 20 weeks of SCI resulted in a significant reduction of bone mineral density (BMD) and estimated bone strength, and deterioration of bone structure at the distal femoral metaphysis. Treatment with Scl-Ab largely restored BMD, bone structure, and bone mechanical strength. Histomorphometric analysis showed that Scl-Ab increased bone formation in animals with chronic SCI. In ex vivo cultures of bone marrow cells, Scl-Ab inhibited osteoclastogenesis, and promoted osteoblastogenesis accompanied by increased Tcf7, ENC1, and the OPG/RANKL ratio expression, and decreased SOST expression. Our findings demonstrate for the first time that Scl-Ab reverses the sublesional bone loss when therapy is begun after relatively prolonged spinal cord transection. The study suggests that, in addition to being a treatment option to prevent bone loss after acute SCI, sclerostin antagonism may be a valid clinical approach to reverse the severe bone loss that invariably occurs in patients with chronic SCI.

Special considerations in the urological management of the older spinal cord injury patient

PURPOSE

This paper reports the key findings of Committee 8 of the Joint SIU-ICUD Consultation on Urologic Management of the Spinal Cord Injured Patient and address issues pertaining to the older person with a SCI and the time-related changes relevant to their urological, gastrointestinal and functional management.

METHODS

A literature review using the Pubmed and Ovid search engines was performed examining pertinent literature regarding SCI in the older patient.

RESULTS

There is a rising incidence of both traumatic and non-traumatic spinal cord injury (SCI) in older people and improvements in healthcare and nutrition mean patients with SCI are living longer. Outcomes after a SCI in the older person are a sum of the effects of injury and its management compounded by specific effects of ageing and the emergence of unrelated comorbidities. Changes in health, comorbidities, cognition and dexterity with ageing have an impact on function and are important considerations in the management of the older patient with SCI. Treatment decisions are thus increasingly complex due to the need to take into account these changes and accompanying polypharmacy. For the person living with a SCI, changes in circumstances (social and financial) have an impact on quality of life and influence management and support strategies.

CONCLUSIONS

Older patients with SCI face additional challenges both in the acute setting and with ageing. Clinicians should take into account comorbid conditions, mental health, physical function, cognition and social support in making management decisions. With the global ageing population, health services planning will need to allow for increase in resources required to care for older patients with SCI.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section)

INTRODUCTION

Spinal cord injury (SCI) is a devastating condition and a challenge for every health system and every society. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with SCI. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for persons with SCI in order to improve their functionality, social and community reintegration, and to overcome activity limitations and/or participation restrictions.

EVIDENCE ACQUISITION

A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section.

EVIDENCE SYNTHESIS

The systematic literature review is reported together with thirty-eight recommendations resulting from the Delphi procedure.

CONCLUSIONS

The professional role of PRM physicians who have expertise in the rehabilitation of SCI is to run rehabilitation programmes in multi-professional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI.

Association between subclinical thyroid dysfunction and change in bone mineral density in prospective cohorts

BACKGROUND

Subclinical hyperthyroidism (SHyper) has been associated with increased risk of hip and other fractures, but the linking mechanisms remain unclear.

OBJECTIVE

To investigate the association between subclinical thyroid dysfunction and bone loss.

METHODS

Individual participant data analysis was performed after a systematic literature search in MEDLINE/EMBASE (1946-2016). Two reviewers independently screened and selected prospective cohorts providing baseline thyroid status and serial bone mineral density (BMD) measurements. We classified thyroid status as euthyroidism (thyroid-stimulating hormone [TSH] 0.45-4.49 mIU/L), SHyper (TSH < 0.45 mIU/L) and subclinical hypothyroidism (SHypo, TSH ≥ 4.50-19.99 mIU/L) both with normal free thyroxine levels. Our primary outcome was annualized percentage BMD change (%ΔBMD) from serial dual X-ray absorptiometry scans of the femoral neck, total hip and lumbar spine, obtained from multivariable regression in a random-effects two-step approach.

RESULTS

Amongst 5458 individuals (median age 72 years, 49.1% women) from six prospective cohorts, 451 (8.3%) had SHypo and 284 (5.2%) had SHyper. During 36 569 person-years of follow-up, those with SHyper had a greater annual bone loss at the femoral neck versus euthyroidism: %ΔBMD = -0.18 (95% CI: -0.34, -0.02; I2 = 0%), with a nonstatistically significant pattern at the total hip: %ΔBMD = -0.14 (95% CI: -0.38, 0.10; I2 = 53%), but not at the lumbar spine: %ΔBMD = 0.03 (95% CI: -0.30, 0.36; I2 = 25%); especially participants with TSH < 0.10 mIU/L showed an increased bone loss in the femoral neck (%Δ BMD = -0.59; [95% CI: -0.99, -0.19]) and total hip region (%ΔBMD = -0.46 [95% CI: -1.05, -0.13]). In contrast, SHypo was not associated with bone loss at any site.

CONCLUSION

Amongst adults, SHyper was associated with increased femoral neck bone loss, potentially contributing to the increased fracture risk.

Effects of exercise on fitness and health of adults with spinal cord injury: A systematic review

OBJECTIVE

To synthesize and appraise research testing the effects of exercise interventions on fitness, cardiometabolic health, and bone health among adults with spinal cord injury (SCI).

METHODS

Electronic databases were searched (1980-2016). Included studies employed exercise interventions for a period ≥2 weeks, involved adults with acute or chronic SCI, and measured fitness (cardiorespiratory fitness, power output, or muscle strength), cardiometabolic health (body composition or cardiovascular risk factors), or bone health outcomes. Evidence was synthesized and appraised using Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

A total of 211 studies met the inclusion criteria (22 acute, 189 chronic). For chronic SCI, GRADE confidence ratings were moderate to high for evidence showing exercise can improve all of the reviewed outcomes except bone health. For acute SCI, GRADE ratings were very low for all outcomes. For chronic SCI, there was low to moderate confidence in the evidence showing that 2-3 sessions/week of upper body aerobic exercise at a moderate to vigorous intensity for 20-40 minutes, plus upper body strength exercise (3 sets of 10 repetitions at 50%-80% 1-repetition maximum for all large muscle groups), can improve cardiorespiratory fitness, power output, and muscle strength. For chronic SCI, there was low to moderate confidence in the evidence showing that 3-5 sessions per week of upper body aerobic exercise at a moderate to vigorous intensity for 20-44 minutes can improve cardiorespiratory fitness, muscle strength, body composition, and cardiovascular risk.

CONCLUSIONS

Exercise improves fitness and cardiometabolic health of adults with chronic SCI. The evidence on effective exercise types, frequencies, intensities, and durations should be used to formulate exercise guidelines for adults with SCI.

Treatment with hydrogen sulfide attenuates sublesional skeletal deterioration following motor complete spinal cord injury in rats

Treatment with hydrogen sulfide mitigates spinal cord injury-induced sublesional bone loss, possibly through abating oxidative stress, suppressing MMP activity, and activating Wnt/β-catenin signaling.

INTRODUCTION

Spinal cord injury (SCI)-induced sublesional bone loss represents the most severe osteoporosis and is resistant to available treatments to data. The present study was undertaken to explore the therapeutic potential of hydrogen sulfide (H₂S) against osteoporosis in a rodent model of motor complete SCI.

METHODS

SCI was generated by surgical transaction of the cord at the T3-T4 levels in rats. Treatment with NaHS was initiated through intraperitoneal injection of 0.1 ml/kg/day of 0.28 mol/l NaHS from 12 h following the surgery and over 14 subsequent days.

RESULTS

H₂S levels in plasma of SCI rats were lower, which was restored by treatment with exogenous H₂S. Treatment of SCI rats with exogenous H₂S had no significant effect on body mass but increased bone mineral density in femurs and tibiae, increased BV/TV, Tb.Th, and Tb.N and reduced Tb.Sp in proximal tibiae, and increased mineral apposition rate (MAR), bone formation rate (BFR), and osteoblast surface and reduced eroded surface and osteoclast surface in proximal tibiae. More importantly, H₂S treatment led to a significant enhancement in ultimate load, stiffness, and energy to max force of femoral diaphysis. Treatment of SCI rats with exogenous H₂S reduced malondialdehyde (MDA) levels in serum and femurs, decreased hydroxyproline levels, suppressed activities of matrix metallopeptidase 9 (MMP9), and upregulated Wnt3a, Wnt6, Wnt10, and ctnnb1 expression in femurs.

CONCLUSION

Treatment with H₂S mitigates SCI-induced sublesional bone loss, possibly through abating oxidative stress, suppressing MMP activity, and activating Wnt/β-catenin signaling.

Mice with sclerostin gene deletion are resistant to the severe sublesional bone loss induced by spinal cord injury

Bone loss after spinal cord injury (SCI) is rapid, severe, and refractory to interventions studied to date. Mice with sclerostin gene deletion are resistant to the severe sublesional bone loss induced by SCI, further indicating pharmacological inhibition of sclerostin may represent a promising novel approach to this challenging medical problem.

INTRODUCTION

The bone loss secondary to spinal cord injury (SCI) is associated with several unique pathological features, including the permanent immobilization, neurological dysfunction, and systemic hormonal alternations. It remains unclear how these complex pathophysiological changes are linked to molecular alterations that influence bone metabolism in SCI. Sclerostin is a key negative regulator of bone formation and bone mass. We hypothesized that sclerostin could function as a major mediator of bone loss following SCI.

METHODS

To test this hypothesis, 10-week-old female sclerostin knockout (SOST KO) and wild type (WT) mice underwent complete spinal cord transection or laminectomy (Sham).

RESULTS

At 8 weeks after SCI, substantial loss of bone mineral density was observed at the distal femur and proximal tibia in WT mice but not in SOST KO mice. By μCT, trabecular bone volume of the distal femur was markedly decreased by 64 % in WT mice after SCI. In striking contrast, there was no significant reduction of bone volume in SOST KO/SCI mice compared with SOST KO/sham. Histomorphometric analysis of trabecular bone revealed that the significant reduction in bone formation rate following SCI was observed in WT mice but not in SOST KO mice. Moreover, SCI did not alter osteoblastogenesis of marrow stromal cells in SOST KO mice.

CONCLUSION

Our findings demonstrate that SOST KO mice were protected from the major sublesional bone loss that invariably follows SCI. The evidence indicates that sclerostin is an important mediator of the marked sublesional bone loss after SCI, and that pharmacological inhibition of sclerostin may represent a promising novel approach to this challenging clinical problem.

Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis

BACKGROUND

Increasing evidence has supported the use of dextrose prolotherapy for patients with osteoarthritis. However, the real benefits may be affected by differences in injection protocols, comparative regimens, and evaluation scales.

METHODS

PubMed and Scopus were searched from the earliest record until February 2016. One single-arm study and five randomized controlled trials were included, comprising 326 participants. We estimated the effect sizes of pain reduction before and after serial dextrose injections and compared the values between dextrose prolotherapy, comparative regimens, and exercise 6 months after the initial injection.

RESULTS

Regarding the treatment arm using dextrose prolotherapy, the effect sizes compared with baseline were 0.65 (95% confidence interval [CI], 0.14-1.17), 0.84 (95% CI, 0.40-1.27), 0.85 (95% CI, 0.60-1.10), and 0.87 (95% CI, 0.53-1.21) after the first, second, third, and fourth or more injections, respectively. The overall effect of dextrose was better than control injections (effect size, 0.36; 95% CI, 0.10-0.63). Dextrose prolotherapy had a superior effect compared with local anesthesia (effect size, 0.38; 95% CI, 0.07-0.70) and exercise (effect size, 0.71; 95% CI, 0.30-1.11). There was an insignificant advantage of dextrose over corticosteroids (effect size, 0.31; 95% CI, -0.18 to 0.80) which was only estimated from one study.

CONCLUSION

Dextrose injections decreased pain in osteoarthritis patients but did not exhibit a positive dose-response relationship following serial injections. Dextrose prolotherapy was found to provide a better therapeutic effect than exercise, local anesthetics, and probably corticosteroids when patients were retested 6 months following the initial injection.

Revisiting the Debate: Does Exercise Build Strong Bones in the Mature and Senescent Skeleton?

Traditional exercise programs seem to be less osteogenic in the mature and post-mature skeleton compared to the young skeleton. This is likely because of the decline in sensitivity of bone to mechanical loading that occurs with advancing age. Another factor contributing to the apparently diminished benefit of exercise in older adults is failure of widely used measurement techniques (i.e., DXA) to identify changes in 3-dimensional bone structure, which are important determinants of bone strength. Moreover, although hormonal contributors to bone loss in the elderly are well-recognized, the influence of age-related increases in sympathetic nervous system activity, which impacts bone metabolism, is rarely considered. In this Perspective, we cite evidence from animal and human studies demonstrating anabolic effects of exercise on bone across the lifespan and we discuss theoretical considerations for designing exercise regimens to optimize bone health. We conclude with suggestions for future research that should help define the osteogenic potential of exercise in older individuals.

Barium titanate nanoparticles: promising multitasking vectors in nanomedicine

Ceramic materials based on perovskite-like oxides have traditionally been the object of intense interest for their applicability in electrical and electronic devices. Due to its high dielectric constant and piezoelectric features, barium titanate (BaTiO3) is probably one of the most studied compounds of this family. Recently, an increasing number of studies have been focused on the exploitation of barium titanate nanoparticles (BTNPs) in the biomedical field, owing to the high biocompatibility of BTNPs and their peculiar non-linear optical properties that have encouraged their use as nanocarriers for drug delivery and as label-free imaging probes. In this review, we summarize all the recent findings about these 'smart' nanoparticles, including the latest, most promising potential as nanotransducers for cell stimulation.

FES-rowing attenuates bone loss following spinal cord injury as assessed by HR-pQCT

Neurologically motor complete spinal cord injury (SCI) presents a unique model of bone loss whereby specific regional sites are exposed to a complete loss of voluntary muscle-induced skeletal loading against gravity. This results in a high rate of bone loss, especially in the lower limbs where trabecular bone mass decreases by ~50-60% and cortical bone mass decreases by 25-34% before the rate of bone loss slows. These SCI-induced losses that are likely superimposed on continual age-related bone losses, increase the risk of low-impact fragility fracture. The fracture incidence 20 years post SCI is reported to be 4.6% per year. An intervention that effectively prevents, attenuates, or reverses bone loss is therefore highly desirable. We present a case study of an individual with chronic complete SCI, where bone loss has been attenuated following long-term functional electrical stimulation (FES)-rowing training. In this case study, we characterize the ultradistal tibia and ultradistal radius of the FES-rower with chronic complete SCI using high-resolution-peripheral quantitative computed tomography. These data are compared with a group of FES-untrained individuals with chronic complete SCI and to a normative non-SCI cohort. The evidence suggests, albeit from a single individual, that long-term FES-rowing training can attenuate bone loss secondary to chronic complete SCI. Indeed, key FES-rower's bone metrics for the ultradistal tibia more closely resemble normative age-matched values, which may have clinical significance since the majority of fragility fractures in chronic SCI occur in the lower extremities.

Bone Imaging and Fracture Risk after Spinal Cord Injury

Spinal cord injury (SCI) is characterized by marked bone loss and an increased risk of fracture with high complication rate. Recent research based on advanced imaging analysis, including quantitative computed tomography (QCT) and patient-specific finite element (FE) modeling, has provided new and important insights into the magnitude and temporal pattern of bone loss, as well as the associated changes to bone structure and strength, following SCI. This work has illustrated the importance of early therapeutic treatment to prevent bone loss after SCI and may someday serve as the basis for a clinical fracture risk assessment tool for the SCI population. This review provides an update on the epidemiology of fracture after SCI and discusses new findings and significant developments related to bone loss and fracture risk assessment in the SCI population based on QCT analysis and patient-specific FE modeling.

Assessment of the Impact of Zoledronic Acid on Ovariectomized Osteoporosis Model Using Micro-CT Scanning

Purpose/Objective

Prompted by preliminary findings, this study was conducted to investigate the impact of zoledronic acid on the cancellous bone microstructure and its effect on the level of β-catenin in a mouse model of postmenopausal osteoporosis.

Methods and Materials

96 8-week-old specific-pathogen-free C57BL/6 mice were randomly divided into 4 groups (24 per group): a sham group, an ovariectomized osteoporosis model group, an estradiol-treated group, and a zoledronic acid-treated group. Five months after surgery, the third lumbar vertebra and left femur of the animals were dissected and scanned using micro-computed tomography (micro-CT) to acquire three-dimensional imagery of their cancellous bone microstructure. The impact of ovariectomy, the effect of estradiol, and the effect of zoledronic acid intervention on cancellous bone microstructure, as well as on the expression of β-catenin, were evaluated.

Results

The estradiol-treated and the zoledronic acid-treated group exhibited a significant increase in the bone volume fraction, trabecular number, trabecular thickness, bone surface to bone volume ratio (BS/BV), and β-catenin expression, when compared with those of the control group (P <0.01). In contrast, the structure model index, trabecular separation, and BS/BV were significantly lower compared with those of the model group (P <0.01). No differences were observed in the above parameters between animals of the zoledronic acid-treated and the estradiol-treated group.

Conclusion

These results suggest that increased β-catenin expression may be the mechanism underlying zoledronic acid-related improvement in the cancellous bone microstructure in ovariectomized mice. Our findings provide a scientific rationale for using zoledronic acid as a therapeutic intervention to prevent bone loss in post-menopausal women.

Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Postoperative shoulder stiffness complicates functional recovery after arthroscopic rotator cuff repair.

PURPOSE

To compare early passive range of motion (ROM) exercise with a delayed rehabilitation protocol with regard to the effectiveness of stiffness reduction and functional improvements and rates of improper healing in patients undergoing arthroscopic repair for torn rotator cuffs.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) comparing both rehabilitation approaches were identified in PubMed and Scopus. Between-group differences in shoulder function were transformed to effect sizes for comparisons, whereas the effectiveness against stiffness and the risk of tendon failure were reported using standardized mean differences of ROM degrees and odds ratios (ORs) of recurrent tears, respectively.

RESULTS

Six RCTs were included, consisting of 482 patients. No significant difference in shoulder function existed across both protocols. The early ROM group demonstrated more improvement in shoulder forward flexion than the delayed rehabilitation group, with a standardized mean difference of 7.45° (95% CI, 3.20°-11.70°) at 6 months and 3.51° (95% CI, 0.31°-6.71°) at 12 months. Early ROM exercise tended to cause a higher rate of recurrent tendon tears (OR, 1.43; 95% CI, 0.90-2.28), and the effect became statistically significant (OR, 1.93; 95% CI, 1.04-3.60) after excluding 2 RCTs that recruited only those patients with small to medium-sized tears.

CONCLUSION

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair but was likely to result in improper tendon healing in shoulders with large-sized tears. The choice of either protocol should be based on an accommodation of the risks of recurrent tears and postoperative shoulder stiffness.

Sclerostin inhibition prevents spinal cord injury-induced cancellous bone loss

Spinal cord injury (SCI) results in rapid and extensive sublesional bone loss. Sclerostin, an osteocyte-derived glycoprotein that negatively regulates intraskeletal Wnt signaling, is elevated after SCI and may represent a mechanism underlying this excessive bone loss. However, it remains unknown whether pharmacologic sclerostin inhibition ameliorates bone loss subsequent to SCI. Our primary purposes were to determine whether a sclerostin antibody (Scl-Ab) prevents hindlimb cancellous bone loss in a rodent SCI model and to compare the effects of a Scl-Ab to that of testosterone-enanthate (TE), an agent that we have previously shown prevents SCI-induced bone loss. Fifty-five (n = 11-19/group) skeletally mature male Sprague-Dawley rats were randomized to receive: (A) SHAM surgery (T8 laminectomy), (B) moderate-severe (250 kilodyne) SCI, (C) 250 kilodyne SCI + TE (7.0 mg/wk, im), or (D) 250 kilodyne SCI + Scl-Ab (25 mg/kg, twice weekly, sc) for 3 weeks. Twenty-one days post-injury, SCI animals exhibited reduced hindlimb cancellous bone volume at the proximal tibia (via μCT and histomorphometry) and distal femur (via μCT), characterized by reduced trabecular number and thickness. SCI also reduced trabecular connectivity and platelike trabecular structures, indicating diminished structural integrity of the remaining cancellous network, and produced deficits in cortical bone (femoral diaphysis) strength. Scl-Ab and TE both prevented SCI-induced cancellous bone loss, albeit via differing mechanisms. Specifically, Scl-Ab increased osteoblast surface and bone formation, indicating direct bone anabolic effects, whereas TE reduced osteoclast surface with minimal effect on bone formation, indicating antiresorptive effects. The deleterious microarchitectural alterations in the trabecular network were also prevented in SCI + Scl-Ab and SCI + TE animals, whereas only Scl-Ab completely prevented the reduction in cortical bone strength. Our findings provide the first evidence indicating that sclerostin inhibition represents a viable treatment to prevent SCI-induced cancellous and cortical bone deficits and provides preliminary rationale for future clinical trials focused on evaluating whether Scl-Ab prevents osteoporosis in the SCI population.

Whole-Body Electromyostimulation to Fight Osteopenia in Elderly Females: The Randomized Controlled Training and Electrostimulation Trial (TEST-III)

Whole-body electromyostimulation (WB-EMS) has been shown to be effective in increasing muscle strength and mass in elderly women. Because of the interaction of muscles and bones, these adaptions might be related to changes in bone parameters. 76 community-living osteopenic women 70 years and older were randomly assigned to either a WB-EMS group (n = 38) or a control group (CG: n = 38). The WB-EMS group performed 3 sessions every 14 days for one year while the CG performed gymnastics containing identical exercises without EMS. Primary study endpoints were bone mineral density (BMD) at lumbar spine (LS) and total hip (thip) as assessed by DXA. After 54 weeks of intervention, borderline nonsignificant intergroup differences were determined for LS-BMD (WB-EMS: 0.6 ± 2.5% versus CG -0.7 ± 2.5%, P = .051) but not for thip-BMD (WB-EMS: -1.1 ± 1.9% versus CG: -0.8 ± 2.3%, P = .771). With respect to secondary endpoints, there was a gain in lean body mass (LBM) of 1.5% (P = .006) and an increase in grip strength of 8.4% (P = .000) in the WB-EMS group compared to CG. WB-EMS effects on bone are less pronounced than previously reported effects on muscle mass. However, for subjects unable or unwilling to perform intense exercise programs, WB-EMS may be an option for maintaining BMD at the LS.

Effect of whole-body vibration on lower-limb EMG activity in subjects with and without spinal cord injury

OBJECTIVE

Traumatic spinal cord injury (SCI) results in substantial reductions in lower extremity muscle mass and bone mineral density below the level of the lesion. Whole-body vibration (WBV) has been proposed as a means of counteracting or treating musculoskeletal degradation after chronic motor complete SCI. To ascertain how WBV might be used to augment muscle and bone mass, we investigated whether WBV could evoke lower extremity electromyography (EMG) activity in able-bodied individuals and individuals with SCI, and which vibration parameters produced the largest magnitude of effect.

METHODS

Ten male subjects participated in the study, six able-bodied and four with chronic SCI. Two different manufacturers' vibration platforms (WAVE(®) and Juvent™) were evaluated. The effects of vibration amplitude (0.2, 0.6 or 1.2 mm), vibration frequency (25, 35, or 45 Hz), and subject posture (knee angle of 140°, 160°, or 180°) on lower extremity EMG activation were determined (not all combinations of parameters were possible on both platforms). A novel signal processing technique was proposed to estimate the power of the EMG waveform while minimizing interference and artifacts from the plate vibration.

RESULTS

WBV can elicit EMG activity among subjects with chronic SCI, if appropriate vibration parameters are employed. The amplitude of vibration had the greatest influence on EMG activation, while the frequency of vibration had lesser but statistically significant impact on the measured lower extremity EMG activity.

CONCLUSION

These findings suggest that WBV with appropriate parameters may constitute a promising intervention to treat musculoskeletal degradation after chronic SCI.

Comparative effectiveness of platelet-rich plasma injections for treating knee joint cartilage degenerative pathology: a systematic review and meta-analysis

OBJECTIVE

To explore the effectiveness of platelet-rich plasma (PRP) in treating cartilage degenerative pathology in knee joints.

DATA SOURCES

Electronic databases, including PubMed and Scopus, were searched from the earliest record to September 2013.

STUDY SELECTION

We included single-arm prospective studies, quasi-experimental studies, and randomized controlled trials that used PRP to treat knee chondral degenerative lesions. Eight single-arm studies, 3 quasi-experimental studies, and 5 randomized controlled trials were identified, comprising 1543 participants.

DATA EXTRACTION

We determined effect sizes for the selected studies by extracting changes in functional scales after the interventions and compared the PRP group pooled values with the pretreatment baseline and the groups receiving placebo or hyaluronic acid (HA) injections.

DATA SYNTHESIS

PRP injections in patients with knee degenerative pathology showed continual efficacy for 12 months compared with their pretreatment condition. The effectiveness of PRP was likely better and more prolonged than that of HA. Injection doses ≤2, the use of a single-spinning approach, and lack of additional activators led to an uncertainty in the treatment effects. Patients with lower degrees of cartilage degeneration achieved superior outcomes as opposed to those affected by advanced osteoarthritis.

CONCLUSIONS

PRP application improves function from basal evaluations in patients with knee joint cartilage degenerative pathology and tends to be more effective than HA administration. Discrepancy in the degenerative severity modifies the treatment responses, leading to participants with lower degrees of degeneration benefiting more from PRP injections.