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L - Skeletal Integrity

Individuals aging with SCI frequently develop functional declines, in their mobility, resulting in changes in gait, use of mobility aids, and deteriorating transfers. Careful review of functional abilities and transfer techniques is essential to prevent future fragility fractures. Discussion of strategies to reduce the risk of falls, in the home, has a particularly high yield for those with AIS C and D impairment. Nutrition A 30% prevalence of vitamin D deficiency is reported among individuals with SCI, and dietary intakes of calcium are often insufficient, below 660 mg per day. Serum screening and assessment of dietary adequacy is necessary to ensure optimal, but not excessive, calcium and vitamin D intakes, through diet or supplements. Dietary sources of calcium are preferred over supplements, due to the reported cardiovascular risks associated with supplementation. A dietary calcium intake of 1,000 mg per day, in divided doses, is recommended for individuals with SCI and SLOP, without a prior history of renal or bladder stones. Serum screening is important for identifying individuals with deficiency, and facilitates titration to an appropriate serum level. While a serum vitamin D level of 75nmol/L is desirable for fracture prevention, in the general population, a serum level ≥ 100nmol/L is optimal for bone health, as well as cancer and cardiovascular disease prevention, among individuals with SCI. Once optimal calcium and vitamin D intakes are achieved, additional rehabilitation or pharmacologic intervention may be considered, in those with an elevated fracture risk. Bone Density Testing Despite established methods for assessing health status, lifestyle, nutrition and BMD via DXA following SCI, there is variation in access to services, and considerable variation in their utilization. Figure 4.0 illustrates access to skeletal integrity services, across Canada. While most sites have access to bone density testing (onsite or offsite), the majority (n = 8 sites) do not assess knee region BMD, and indicate no established treatment protocol or standard of care. Four sites report use of a common knee region DXA protocol developed at Toronto Rehab. Despite the availability of multidisciplinary staff in most centres, few sites provide interdisciplinary care, skeletal integrity services are almost exclusively provided by physiatrists throughout the country (Figure 5.0). Figure 4.0 Overview of national Acces to Skeletal Integrity-Related Services. 0 2 4 6 8 10 12 Bone Density Serum and Urine Testing Nutrition Assessment Number of Sites Figure ? Overview of Access to Healthcare Professionals with Expertise Related to Skeletal Integrity Figure 5.0 Overview of Acces to Healthcare Profesionals with Skeletal Integrity Expertise. 0 2 4 6 8 10 12 Dietitian/Nutritionist DXA Technologist Endocrinologist Engineer Family Physician Nurse (RN) Occupational Therapist Pharmacist Physiatrist Physiotherapist Radiologist Number of Sites Evaluating Treatment Effectiveness Have the Service Service Onsite Service Offsite - Internal Service Offsite - External To be valid, changes in BMD, from serial scans, must be equivalent to or exceed the least significant change (LSC) of the densitometer. The International Society of Clinical Densitometry (ISCD) recommends monitoring the treatment response, among osteoporotic patients, with DXA measures of BMD, every one to two years, at the same facility, with the same densitometer, using the same acquisition and analysis protocols.11 LSC is the least amount of BMD change considered statistically significant, and is calculated by multiplying the precision error by 2.77. In clinical practice, an increase in BMD, above the LSC, is considered effective therapy; while a decrease, below the LSC, is considered non-response to therapy.12 Non-response to therapy should prompt a review of treatment adherence, followed by consideration of therapy cessation or alternate therapy. 118 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


L - Skeletal Integrity
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