Factors influencing providers’ decisions on management of bone health in people with spinal cord injury

Study design: Survey. Objectives: Managing osteoporosis in persons with chronic spinal cord injury (SCI) is difficult as little evidence exists regarding effective strategies. We examined the effect of key factors on providers’ bone health management decisions in persons with SCI. Setting: USA. Methods: Providers reviewed blocks of 9 hypothetical cases that varied on four factors: osteoporosis, osteopenia, or normal bone mineral density using dual-energy X-ray absorptiometry (DXA); DXA region of interest (lumbar spine, hip, knee), prior lower extremity fracture; and no or limited ambulation. They indicated how likely they would recommend pharmacological management, what treatment(s) they would recommend, and whether they would request another DXA before treatment. Results: Eighty-two healthcare providers completed the survey. Treatment recommendations for bisphosphonates and Vitamin D/calcium supplements, respectively, were more likely if there was a prior fracture (OR: 2.65, 95%CI: 1.76–3.99, p < 0.0001; OR: 2.96, 95%CI: 1.40–6.26, p = 0.004) and if a DXA scan found osteopenia (OR: 2.23, 95%CI: 1.41–3.54, p = 0.001; OR: 6.56, 95%CI: 2.71–15.85, p < 0.0001) or osteoporosis (OR: 12.08, 95%CI: 7.09–20.57, p < 0.0001; OR: 4.54, 95%CI: 2.08–9.90, p < 0.0001). Another DXA scan was more likely to be requested if there was a prior fracture (OR: 1.75, 95%CI: 1.10–2.78, p = 0.02) but less likely if the person was nonambulatory (OR: 0.41, 95%: 0.19–0.90, p = 0.03). Conclusions: Prior fracture and DXA findings influenced treatment recommendations for bone health management in SCI. Reliance on lumbar spine scans to determine bone loss and treatment identifies a knowledge gap for which future education is required.