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L - Skeletal Integrity

Much of what we know about sublesional osteoporosis comes from published data describing changes in bone mineral density, among men with motor complete SCI. Less is known about women, those with incomplete injuries, and/or non-traumatic SCI. Dual x-ray absorptiometry (DXA) testing of the spine and hip region is the gold standard for the detection of osteoporosis and individuals, with high fracture risk, in the general population. However, for individuals with SCI, assessment of knee region BMD best predicts knee region fracture risk.5, 10 BMD fracture thresholds are values below which fractures begin to occur, whereas fracture breakpoints are values at which the majority of fractures occur. aBMD (aerial BMD measured via DXA) and vBMD (volumetric BMD measured via peripheral quantitative computed tomography) knee region values for fracture threshold, and fracture breakpoint are identified in Table 2.0. Table 2.0 bmd Thresholds FOR fracture and Fracture Breakpoint. Current Practice: SLOP and Fracture Risk following SCI Individuals with SCI who require intervention, related to their Skeletal Integrity, fall into one of three categories: • Those newly injured, for whom we wish to prevent SLOP, and regional declines in lower extremity bone mass (prevention). • Those with established low BMD of the hip and knee regions, and significant risk of fragility fracture who require therapy (treatment). • Those who have sustained a lower extremity fracture and require post- fracture care (management). Canadian authors have published a proposed paradigm to guide clinical decision making, regarding the detection of SLOP and treatment of individuals with high fracture risk, based on the data contained in available systematic reviews, key references available to inform practice and expert consensus. Diagnosis of SLOP involves a combination of health screening, assessment of lifestyle and nutrition factors, in addition to BMD and fracture risk assessment (see Figure 3.0). In the absence of a formal clinical practice guideline, clinical uncertainty has led to regional disparity in practice, among SCI clinicians. Health Status Secondary causes of osteoporosis are prevalent in individuals with SCI, and can exacerbate or even mask SLOP. The health evaluation process should include a detailed medical history to identify secondary causes of low BMD, unrelated to SCI; review of current and prior medications known to adversely affect bone mass, and serum and urine screen for secondary causes of osteoporosis, amenable to medical intervention. Hypothyroidism, renal insufficiency, vitamin D deficiency (with or without secondary hyperparathyroidism), and hypogonadism are frequently identified, and have established treatments. Lifestyle Lifestyle behaviours requiring intervention can be identified through simple questions regarding daily or weekly caffeine and alcohol intake, and smoking history. Smoking cessation, reduced caffeine intake (< three servings per day) and restricted alcohol intake (< two servings per day, and no more than nine servings of alcohol per week for women, and no more than 14 per week for men) are prudent behavioural intervention targets. Many individuals with SCI participate in contact or high-risk sports, with numerous physical and psychological benefits that also pose a potential fracture risk. Counselling regarding use of protective gear, and the need to have a high index of suspicion for fracture when regional swelling is evident after a collision/fall, should be provided. Name Val ue Definition Fracture threshold ≤ 0.78 g/cm2 (aBMD) < 114 mg/cm3 (vBMD-femur) < 72 mg/cm3 (vBMD-tibia) Knee region BMD values below which fragility fractures occur Fracture breakpoint < 0.49 g/cm2 (aBMD) Knee region BMD values at which the majority of fragility fractures occur BMD = bone mineral density; aBMD = areal BMD; vBMD = volumetric BMD. Reproduced from Craven BC, Robertson LA, McGillivray CF, Adachi JD (page 7).1 © 2009 Thomas Land Publishers, Inc. www.thomasland.com. Reprinted with permission. 116 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


L - Skeletal Integrity
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