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BACKGROUND/RATIONALE:
Spinal cord injury (SCI) results in rapid and severe osteoporosis that increases the risk of low-impact fractures (i.e., spontaneous or with little trauma). In contrast to persons without SCI, where the hip and lumbar spine are sites of greatest fracture risk, in SCI, the sites most commonly fractured are the metaphyses of the distal femur and proximal tibia, sites of greatest bone loss.
However, these sites are not included in standardized dual x-ray absorptiometry (DXA) protocols designed for screening for osteoporosis in the able-bodied. The rate of fracture in SCI is estimated to be 2% per year, double that in the general population, but is probably underestimated because adequate population-based data has not been collected. Data are also lacking on the full health consequences of low-impact fractures in SCI. Fractures reduce independence and mobility and put people with SCI at risk for severe complications associated with immobility during healing. Despite the health implications of low impact fractures, there is currently no specific set of guidelines for prevention or treatment of SCI-induced osteoporosis. Osteoporosis appears to be under-diagnosed and there are no consensus-based screening recommendations or preventative measures.
OBJECTIVE(S):
We will address uncertainties regarding the identification and treatment of osteoporosis in chronic SCI. The objectives are to (1) identify risk factors for hospitalization in VA medical centers 1996 through 2003 for low-impact fractures in veterans participating in a prospective health study at VA Boston; (2) use an internet-based survey to assess current practice patterns regarding the diagnosis and treatment of osteoporosis by physiatrists, SCI specialists, and other SCI-service personnel in the VHA nationally, and compared this to best practices suggested by the literature; (3) since DXA scanners are designed for use in the able-bodied, assess physical barriers to providing DXA scan services, and (4) assess the precision of bone mineral density (BMD) data obtained by scanning the distal femur and proximal tibia in chronic SCI.
METHODS:
(1) Fracture-related hospitalization: Since 1994, we have conducted a prospective health study at VA Boston and have collected personal health and clinical information on SCI patients. Through 12/2002, 315 veterans were recruited to complete a standardized health questionnaire. Each person also had an exam that included an assessment of weight, stature, and level and completeness of SCI. We have abstracted acute hospitalization data from the VA National Patient Care Dataset located in Austin, Texas 10/1/1996 through 12/31/2003 to allow at least one year of follow-up after study enrollment. We will assess prospectively risk factors for hospital admission for fracture of lower limbs (ICD=820-829) and upper limbs (810-819) listed as primary and secondary diagnosis. Cox Proportional hazards methods for repeated outcomes (TPHREG procedure in SAS software version 9.1 [SAS Inc, Cary, NC] will be used to assess predictors of fracture related admissions.
(2) Internet-based survey: We have designed an internet based survey that will be made available to VA SCI specialists, nurses, and nurse practitioners to describe practice patterns and attitudes regarding osteoporosis in SCI. These data will be contrasted to our review of literature based practice information.
(3) Physical Barriers: Since DXA scanners were designed for use in the able-bodied, will review the configuration of DXA scanners available for clinical use and describe physical barriers to providing these scan services to persons with SCI
(4) Reproducibility of BMD data at the distal femur and proximal tibia: We plan on scanning these areas in 20 SCI patients, and have developed a protocol for scanning.
FINDINGS/RESULTS:
(1) Fracture-related hospitalizations: There were 1,487 admissions among 315 participants, and of these hospitalizations 39 were for treatment of low impact osteoporotic fractures. In a multivariate model, persons with complete motor SCI compared to others were more likely to have a fracture related admission (hazard ratio [HR] =3.73, 95%CI=1.46-10.50), and the risk significantly increased with greater alcohol consumption after injury. Medical record review indicated that no individual with a fracture-related admission underwent an evaluation for osteoporosis.
(2) Internet-based survey: A survey has been made available to VA SCI specialists, nurses, and nurse practitioners, and of 454 iniviations to complete a survey sent twice to unique e-mail addresses, there were 124 responses (28%) .
(3) Physical Barriers: We identified several barriers including scanner design and configuration in the scanning room that limit accessibility, increase typical scanning time, and make additional staff necessary.
(4) Reproducibility of BMD data at the distal femur and proximal tibia: We have scanned 20 SCI patients, and all completed the protocol.
IMPACT:
(1) Fracture-related hospitalizations: Our results confirm that persons with neurologically complete SCI are at increased risk for being hospitalized for osteoporotic fractures, and that alcohol consuption increases this risk.
(2) Internet-based survey: The low response rate suggests that there is no uniform approach to the assessment of osteoporeosis in the VHA
(3) Physical Barriers: In order for dual energy x-ray absorptiometry to become a routine component of ongoing care in spinal cord injury medicine, we recommend the following changes: fitting the scanning room with ceiling-mounted hydraulic lifts and grab bars to facilitate transfers, increased staffing during scans, increased time allotment for scans, installation of the scanner in an adequately-sized room, and partnering with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury.
(4) Reproducibility of BMD data at the distal femur and proximal tibia: These data are under analysis, but all 20 patients completed our scanning protocol, indicating it is feasible to scan the knee in chronic SCI. .
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases
DRE:
Quality of Care
Keywords:
Spinal cord injury
MeSH Terms:
none
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