Physical Medicine and Rehabilitation

PCP submission

51 yo Female with paraplegia and osteoporosis exploring modalities to increase weight bearing status.

Can aquatic therapy be used to increase weight bearing in a paraplegic patient with osteoporosis?

Specialist response

If this type of patient presented to my office. These would be my general thoughts. This is a case of a 51 year old female diagnosed with paraplegia following chronic spinal cord injury (SCI) from 1987 with concerns for osteoporosis. At the this stage of chronic SCI osteoporosis is expected and there are no clinical guideline to prevent or treat osteoporosis during the chronic SCI phase. Regarding most of the physical interventions developed and evaluated to date appear to have a limited effect on bone health and most research/literature published in this area are of limited quality to draw clear conclusions. Thus clinical if she is no longer able to weight bear due to risk of fragility fractures a tilt table would not be appropriate. The recommendation for aquatic therapy is still valid as non-mechanical load-bearing exercises such as swimming and cycling while are weaker therapies in terms of reducing bone loss have still been shown to be effective at maintaining muscle mass, which can indirectly reduce fracture risk.  A further consideration would be a referral to physical therapy (PT) for Functional electrical stimulation (FES) cycling trial. While the efficacy of FES interventions in attenuating bone loss has been shown equivocal, there are some reports of benefit and typically it is a option that is available for SCI patients when they are under the supervision of a therapist. Generally however FES cycles for muscle and bone health at home are not considered medically necessary by most health plans due to the lack of evidence. Overall there are limited evidenced based interventions however the recommendation of aquatic therapy, cycling and possible FES cycling could help.