We present the results of a 1 year longitudinal study of bone mineral measurements and soft tissue composition in supra-and infra-lesional areas of 31 patients with a spinal cord injury (level D2-L3)_ Like others, we observed a rapid decrease of BMC in the paralysed areas, of -4%/month during the first year in areas rich in trabecular bone and of -2%/month in areas containing mainly compact bone. Lean soft tissue mass (muscle mass) decreases dramatically during the first months post injury in the legs, while fat content tends to increase. Though lean mass is better maintained in patients who develop spasticity, the evolution of BMC does not differ significantly between the groups of flaccid and spastic patients. In patients with partial or complete neurological recovery, a deficit in BMC of -10% with regards to the initial value is still observed at 1 year in the lower limbs. The lean mass of the upper limbs increases early after the cord injury, because of intensive rehabilitation. No significant change in BMC was observed in the supra-lesional areas. These data confirm the rapid loss of bone in the paralysed areas of paraplegic patients, which occurs independently of the presence of spontaneous muscle activity or of passive verticalisation. In patients with recovery, BMC does not return to pre-injury values within 1 year. Thus, there would be an interest in preventing bone loss early in the course of the disease.
We have previously shown that subjects with traumatic tetraplegia use the clavicular portion of the pectoralis major to expire actively. To determine if we could improve the expiratory function of these subjects, we studied six patients in whom the pectoralis major was trained by repetitive, strenuous, isometric contractions for 6 wk. Six patients receiving conventional respiratory rehabilitation served as control subjects. Training of the pectoralis major produced marked increases in the maximal isometric muscle strength (mean +/- SE: 54.6 +/- 5.8%; p less than 0.005) and in expiratory reserve volume (46.6 +/- 9.9%; p less than 0.005). Functional residual capacity did not change, such that residual volume decreased by 14.1 +/- 2.9% (p less than 0.005). In contrast, the control patients did not develop any significant alterations. We conclude that unlike conventional rehabilitation, training the pectoralis major for strength improves expiratory function in tetraplegic subjects. Therefore, training of this muscle should increase the effectiveness of coughing and might reduce the prevalence of bronchopulmonary infections in such subjects.
Traumatic tetraplegia produces paralysis of all the well-recognized muscles of expiration. Yet, tetraplegic subjects usually have a small expiratory reserve volume on spirographic examination. To understand the mechanism that enables these patients to empty their lungs actively, we studied the pattern of chest-wall motion during voluntary expiration. We found negligible changes in abdominal dimension, but all subjects had a marked and reproducible decrease in the dimension of the upper rib cage. Electrical measurements established that the subjects had active use of the clavicular portion of the pectoralis major, and changing the orientation of these muscle fibers by maintaining the shoulders in abduction reduced their expiratory reserve volume by about 60 percent (P less than 0.001). We therefore conclude that the clavicular portion of the pectoralis major plays a crucial part in the mechanism of active expiration in tetraplegic subjects. Training of this muscle bundle could, by increasing its strength and endurance, improve the effectiveness of coughing in such subjects and perhaps diminish the prevalence of bronchopulmonary infections.
Abstract. A longitudinal study of bone and calcium metabolism in 28 patients with spinal chord lesion shows an enhancement of bone calcium accretion, generalized to the whole skeleton. The bone calcium turnover rate is more increased in the non-paralysed area during the first 2 months.
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