Immobilization Osteoporosis

  • B. Jenny Kiratli


Bone loss occurs with inactivity and immobilization. Just as bone mass increases during growth and development and with exercise attributable to increases in mechanical loading, bone mass decreases with reduced mechanical use. This response has been recognized for more than 50 years and has been evaluated in many clinical conditions. However, much remains unknown about underlying mechanisms, and there have been few successful demonstrations of countermeasures for prevention or treatment. Clinical immobilization includes a variety of situations, ranging from temporary recumbency during recovery from surgery, to permanent paralysis resulting from a traumatic spinal cord injury, and site-specific bone loss occurs relative to the magnitude of immobilization. Although osteopenia has been reported in diseases and conditions that cause temporary or partial immobilization, few detailed studies have been conducted and available information is fairly general. A larger body of literature concerns bone loss with complete paralysis due to spinal cord injury [1]. The concepts discussed here related to bone response to paralysis are expected to apply to other, less extensive immobilizing conditions, but with reduced magnitude.


Bone Mineral Density Bone Loss Spinal Cord Injury Bone Mass Fracture Risk 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Kiratli BJ: Bone loss and osteoporosis following spinal cord injury. In Spinal Cord Medicine: Principles and Practice. Edited by Lin V, et al.: New York: Demos Medical Publishing; 2002.Google Scholar
  2. 2.
    Cowin SC (ed): Bone Mechanics Handbook, edn 2. Boca Raton: CRC Press, 2001.Google Scholar
  3. 3.
    Currey JD. The Mechanical Adaptations of Bone. Princeton: Princeton University Press; 1984.Google Scholar
  4. 4.
    van der Meulen MCH, Ashford MW, Kiratli BJ, Bachrach LK, et al.: Determinants of femoral geometry and structure during adolescent growth. J Ortho Res 1996, 14:22–29.CrossRefGoogle Scholar
  5. 5.
    Snow CM, Matkin CC, Shaw JM: Physical activity and risk for osteoporosis. In: Osteoporosis. Edited by Marcus R, Feldman D, Kelsey J. San Diego: Academic Press; 1996:511–528.Google Scholar
  6. 6.
    Turner CH:Three rules for bone adaptation to mechanical stimuli. Bone 1998, 23:399–407.PubMedCrossRefGoogle Scholar
  7. 7.
    Martin RB, Burr DB: Structure, Function, and Adaptation of Compact Bone. New York: Raven Press; 1989.Google Scholar
  8. 8.
    Hangartner TN: Osteoporosis due to disuse. Phys Med Rehab Clin North Am 1995, 6:579–594.Google Scholar
  9. 9.
    Roberts D, Lee W, Cuneo RC, et al.: Longitudinal study of bone turnover after acute spinal cord injury. J Clin Endocrinol Metab 1998, 83:415–422.PubMedCrossRefGoogle Scholar
  10. 10.
    Szollar SM, Martin EM, Sartoris DJ, et al.: Bone mineral density and indexes of bone metabolism in spinal cord injury. Arch Phys Med Rehab 1998, 77:28–35.CrossRefGoogle Scholar
  11. 11.
    Uebelhart D, Hartmann D, Vuagnat H, et al.: Early modifications of biochemical markers of bone metabolism in spinal cord injury patients. A preliminary study. Scand J Rehabil Med 1994, 26:197–202.PubMedGoogle Scholar
  12. 12.
    Bauman WA, Zhong YG, Schwartz E: Vitamin D deficiency in veterans with chronic spinal cord injury. Metabolism 1995, 44:1612–1616.PubMedCrossRefGoogle Scholar
  13. 13.
    Mechanick JI, Pomerantz F, Flanagan S, et al.: Parathyroid hormone suppression in spinal cord injury patients is associated with the degree of neurologic impairment and not the level of injury. Arch Phys Med Rehabil 1997, 78:692–696.PubMedCrossRefGoogle Scholar
  14. 14.
    Vaziri ND, Pandian MR, Segal JL, et al.: Vitamin D, parathyroid, and calcitonin profiles in persons with long-standing spinal cord injury. Arch Phys Med Rehabil 1994, 75:766–769.PubMedGoogle Scholar
  15. 15.
    Bauman WA, Spungen AM: Metabolic changes in persons after spinal cord injury. Phys Med Rehabil Clin North Am 2000, 11:109–140.Google Scholar
  16. 16.
    Maimoun L, Couret I, Micallef JP, et al.: Use of bone biochemical markers with dual-energy x-ray absorptiometry for early determination of bone loss in persons with spinal cord injury. Metabolism 2002, 51:958–963.PubMedCrossRefGoogle Scholar
  17. 17.
    Biering-Sørensen F, Bohr H, Schaadt OP: Longitudinal study of bone mineral content in the lumbar spine, the forearm and the lower extremities after spinal cord injury. Eur J Clin Invest 1990, 20:330–335.PubMedCrossRefGoogle Scholar
  18. 18.
    Biering-Sørensen R, Bohr H: Bone mineral content of the lumbar spine and lower extremities years after spinal cord lesion. Paraplegia 1988, 26:293–301.PubMedCrossRefGoogle Scholar
  19. 19.
    Demirel G, Yilmaz H, Paker N, et al.: Osteoporosis after spinal cord injury. Spinal Cord 1998, 36:822–825.PubMedCrossRefGoogle Scholar
  20. 20.
    Finsen V, Indredavik B, Fougner K: Bone mineral and hormone status in paraplegics. Paraplegia 1992, 30:343–347.PubMedCrossRefGoogle Scholar
  21. 21.
    Garland D, Stewart C, Adkins R, et al.: Osteoporosis after spinal cord injury. J Orthop Res 1992, 10:371–378.PubMedCrossRefGoogle Scholar
  22. 22.
    Hancock DA, Reed GW, Atkinson PJ, et al.: Bone and soft tissue changes in paraplegic patients. Paraplegia 1980, 17:267–271.CrossRefGoogle Scholar
  23. 23.
    Hangartner T, Rodgers M, Glaser R, et al.: Tibial bone density loss in spinal cord injured patients: effects of FES exercise. J Rehabil Res Develop 1994, 31:50–61.Google Scholar
  24. 24.
    Kiratli BJ: Skeletal adaptation to disuse: longitudinal and cross-sectional study of the response of the femur and spine to immobilization (paralysis). PhD Thesis. Madison: University of Wisconsin-Madison; 1989.Google Scholar
  25. 25.
    Leslie W, Nance P: Dissociated hip and spine demineralization: a specific finding in spinal cord injury. Arch Phys Med Rehabil 1993, 74:960–964.PubMedGoogle Scholar
  26. 26.
    Lussier L, Knight J, Bell G, et al.: Body composition comparison in two elite female wheelchair athletes. Paraplegia 1983, 21:16–22.PubMedCrossRefGoogle Scholar
  27. 27.
    Saltzstein R, Hardin S, Hastings J: Osteoporosis in spinal cord injury: using an index of mobility and its relationship to bone density. J Am Paraplegia Soc 1992, 15:232–234.PubMedGoogle Scholar
  28. 28.
    Vose G, Keele DK: Hypokinesia of bedfastness and its relationship to x-ray determined skeletal density. Texas Rep Biol Med 1970, 28:123–131.Google Scholar
  29. 29.
    Chow Y, Inman C, Pollintine P, et al.: Ultrasound bone densitometry and dual-energy x-ray absorptiometry in patients with spinal cord injury: a cross-sectional study. Spinal Cord 1996, 34:736–741.PubMedCrossRefGoogle Scholar
  30. 30.
    Jones L, Goulding A, Gerrard D: DEXA: a practical and accurate tool to demonstrate total and regional bone loss, lean tissue loss and fat mass gain in paraplegia. Spinal Cord 1998, 36:637–640.PubMedCrossRefGoogle Scholar
  31. 31.
    Liu C, Theodorou D, Andre M, et al.: Quantitative computed tomography in the evaluation of spinal osteoporosis following spinal cord injury. Osteoporos Int 2000, 1:889–896.CrossRefGoogle Scholar
  32. 32.
    Kiratli B, Smith A, Nauenberg T, et al.: Bone mineral and geometric changes through the femur with immobilization due to spinal cord injury. J Rehabil Res Dev 2000, 37:225–233.PubMedGoogle Scholar
  33. 33.
    Frey-Rindova P, deBruin E, Stussi E, et al.: Bone mineral density in upper and lower extremities during 12 months after spinal cord injury measured by peripheral quantitative computed tomography. Spinal Cord 2000, 38:26–32.PubMedCrossRefGoogle Scholar
  34. 34.
    Garland D, Adkins R: Bone loss at the knee in spinal cord injury. Top Spinal Cord Injury Rehabil 2001, 6:37–46.CrossRefGoogle Scholar
  35. 35.
    Garland D, Adkins RH, Stewart C, et al.: Regional osteoporosis in women who have complete spinal cord injury. J Bone Joint Surg 2001, 83-A:1195–1200.PubMedCrossRefGoogle Scholar
  36. 36.
    Bauman W, Spungen A, Wang J, et al.: Continuous loss of bone during chronic immobilization: a monzygotic twin study. Osteoporos Int 1999, 10:123–127.PubMedCrossRefGoogle Scholar
  37. 37.
    Bloomfield SA, Mysiw WJ, Jackson RD: Bone mass and endocrine adaptations to training in spinal cord injured individuals. Bone 1996, 19:61–68.PubMedCrossRefGoogle Scholar
  38. 38.
    Chappard D, Minaire P, Privat C, et al.: Effects of tiludronate on bone loss in paraplegic patients. J Bone Miner Res 1995, 10:112–118.PubMedCrossRefGoogle Scholar
  39. 39.
    Meythaler JM, Tuel SM, Cross LL: Successful treatment of immobilization hypercalcemia using calcitonin and etidronate. Arch Phys Med Rehabil 1993, 74:316–319.PubMedGoogle Scholar
  40. 40.
    Minaire P, Depassio J, Berard E, et al.: Effects of clodronate on immobilization bone loss. Bone 1987, 8:S63–S68.Google Scholar
  41. 41.
    Pearson EG, Nance PW, Leslie WD, et al.: Cyclical etidronate: its effect on bone density in patients with acute spinal cord injury. Arch Phys Med Rehab 1997, 78:269–272.CrossRefGoogle Scholar
  42. 42.
    Nance P, Schryvers O, Leslie W, et al.: Intravenous Pamidronate attenuates bone density loss after acute spinal cord injury. Arch Phys Med Rehabil 1999, 80:243–251.PubMedCrossRefGoogle Scholar
  43. 43.
    Banovac K, Gonzalez F: Evaluation and management of heterotopic ossification in patients with spinal cord injury. Spinal Cord 1997, 35:158–162.PubMedCrossRefGoogle Scholar
  44. 44.
    Luethi M, Zehnder Y, Michel D, et al.: Alendronate in the treatment of bone loss after spinal cord injury (SCI): preliminary data of a 2-year randomised controlled trial in 60 paraplegic men.J Bone Miner Res 2001, 16(suppl I):S219.Google Scholar
  45. 45.
    Sato Y, Asoh T, Kondo I, Satoh K: Vitamin D deficiency and risk of hip fractures among disabled elderly stroke patients. Stroke 2001, 32:1673–1677.PubMedCrossRefGoogle Scholar
  46. 46.
    Sato Y, Kuno H, Asoh T, et al.: Effect of immobilization on vitamin D status and bone mass in chronically hospitalized disabled stroke patients. Age Ageing 1999, 28:265–269.PubMedCrossRefGoogle Scholar
  47. 47.
    Panin N, Gorday WJ, Paul BJ: Osteoporosis in hemiplegia. Stroke 1971, 2:41–47.PubMedCrossRefGoogle Scholar
  48. 48.
    Prince RL, Price Rl, Ho S: Forearm bone loss in hemiplegia: a model for the study of immobilization osteoporosis. J Bone Miner Res 1988, 3:305–310.PubMedCrossRefGoogle Scholar
  49. 49.
    Iversen E, Hassager C, Christiansen C: The effect of hemiplegia on bone mass and soft tissue body composition. Acta Neurol Scand 1989, 79:155–159.PubMedCrossRefGoogle Scholar
  50. 50.
    Hamdy RC, Krishnaswamy G, Cancellaro V, et al.: Changes in bone mineral content and density after stroke. Am J Phys Med Rehabil 1993, 72:188–191.PubMedCrossRefGoogle Scholar
  51. 51.
    Yavuzer G, Ataman S, Suldur N, Atay M: Bone mineral density in patients with stroke. Int J Rehabil Res 2002, 25:235–239.PubMedCrossRefGoogle Scholar
  52. 52.
    Kanis J, Oden A, Johnell O: Acute and long-term increase in fracture risk after hospitalization for stroke. Stroke 2001, 32:702–706.PubMedCrossRefGoogle Scholar
  53. 53.
    Melton LJ, Brown RD Jr, Achenbach SJ, et al.: Long-term fracture risk following ischemic stroke: a population-based study. Osteoporos Int 2001, 12:980–986.PubMedCrossRefGoogle Scholar
  54. 54.
    Dennis MS, Lo KM, McDowall M, West T: Fractures after stroke: frequency, types, and associations. Stroke 2002, 33:728–734.PubMedCrossRefGoogle Scholar
  55. 55.
    Jorgensen L, Jacobsen BK, Wilsgaard T, Magnus JH: Walking after stroke: does it matter? Changes in bone mineral density within the first 12 months after stroke. A longitudinal study. Osteoporos Int 2000, 11:381–387.PubMedCrossRefGoogle Scholar
  56. 56.
    Comarr AE, Hutchinson RH: Extremity fractures of patients with spinal cord injuries. Am J Surg 1962, 103:732–739.PubMedCrossRefGoogle Scholar
  57. 57.
    Freehafer A, Mast W: Lower extremity fractures in patients with spinal cord injury. J Bone Joint Surg 1965, 47A:683–694.PubMedGoogle Scholar
  58. 58.
    Freehafer A, Coletta M, Becker C: Lower extremity fractures in patients with spinal cord injury. Paraplegia 1981, 19:367–372.PubMedCrossRefGoogle Scholar
  59. 59.
    Ingram R, Suman R, Freeman P: Lower limb fractures in the chronic spinal cord injured patient. Paraplegia 1989, 27:133–139.PubMedCrossRefGoogle Scholar
  60. 60.
    Ragnarsson K, Sell G: Lower extremity fractures after spinal cord injury: a retrospective study. Arch Phys Med Rehabil 1981, 62:418–423.PubMedGoogle Scholar
  61. 61.
    Vestergaard P, Krogh K, Rejnmark L, Mosekilde L: Fracture rates and risk factors for fractures in patients with spinal cord injury. Spinal Cord 1998, 36:790–796.PubMedCrossRefGoogle Scholar
  62. 62.
    Lazo MG, Shirazi P, Sam M, et al.: Osteoporosis and risk of fracture in men with spinal cord injury. Spinal Cord 2001, 39:208–214.PubMedCrossRefGoogle Scholar
  63. 63.
    de Bruin ED, Dietz V, Dambacher MA, Stussi E: Longitudinal changes in bone in men with spinal cord injury. Clin Rehabil 2000, 14:145–152.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2003

Authors and Affiliations

  • B. Jenny Kiratli

There are no affiliations available

Personalised recommendations