Immobilization HypercalcemiaAndrew N. Antonio, OTSUniversity of St. Augustine

OverviewDefinitionEtiology and pathophysiologyCharacterize the condition as it

relates SCIProsed ManagementCase ReviewQuestions

Hypercalcemia

“Hypercalemia results when the accelerated bone resorption exceeds the capacity of the kidneys to filter calcium.”

Massagli & Cardenas, 1999

CalciumRegulation and processes of body

functionsRegulation

◦Parathyroid hormone (PTH)◦Vitamin D◦Calcitonin

HypercalcemiaMild (Ca+ <12 mg/dl)Moderate (Ca+ between 12 and

14 mg/dl)Severe (Ca+ >14 mg/dl)

Diagnosed via blood test

EtiologyMain cause is hyperparathyroidism

(>90%)◦Common in women over 50 y/o

Malignancies may be associated (20%)Inherited kidney or metabolic

conditionsExcessive Vitamin D & AAluminum intoxicationMilk-Alkali SyndromeImmobilization

Immobilization Hypercalcemia

Acute spinal cord injury (10-23%)Often in male adolescents/ young

adultsTetraplegia v. paraplegiaIncrease bone resorptionLoss of trabecular bone volumeDecreased osteoblastic bone

formationDepressed parathyroid hormone

Immobilization Hypercalcemia cont.Develops within days to months of

immobilization~4 - 8 weeks after

Last weeks to monthsHypercalciuria

◦Within 1st week up to 6-18 months

Signs and SymptomsFatigueConstipationAnorexiaNauseaAlteration in moodVomitingLethargyPolydipsiaPolyuria Intravascular volume depletionHypertensionArrythmias

TreatmentGoal:

◦ Decrease serum Ca+ concentration◦ Underlying disease

HydrationLoop Diuretics (i.e. furosemide)BiphosphonatesAntineoplastic DrugsAntidote, hypercalcemia agentsGlucocorticoidsMineralsCalcimimetic AgentSurgical treatment

Massagli & Cardenas, 1999

Zoledronic Acid Biphosphonate Ca+ Regulator Reduces risk for Fx Once-yearly injection 100-850 times more potent than Pamidronate Paget’s disease, osteoporosis Side effects

◦ Flu-like symptoms (within 3 days)◦ Fever◦ Headache◦ Muscle spasm◦ Severe muscle, joint or bone pain◦ Decrease urination level and frequency◦ Hypertension◦ *Jaw problems

Rehabilitation Team“Moans”, “Stones”, “Groans” &

“Bones”Early RemobilizationActive movementWeight bearingUpdate on medical statusIncrease fluid intakePatient/ family/ caregiver

education Massagli & Cardenas, 1999

Crown et al. American Journal of Clinical Medicine, 2009

46 y/o female Stopped by airport police for erratic Bx Hx of hypertension, alcohol abuse, Hep B Presenting symptoms: generalized confusion, lethargy,

hypertension Physical exam unremarkable with no focal motor or sensory

deficits, cont. altered mental status Progressed to abdominal pain, severe constipation,

bradycardia, electrolyte imbalance

Findings: Altered state & acute pancreatitis due to hypercalcemia Hypomagnesia & acute renal failure due to dehydration

Massagli et al. Arch Phys Med Rehabilitation, 1999

9 patients with immobilization

hypercalcemia◦7 men, 2 women◦Mean age 22 y/o◦Onset ranged from 3 – 16 weeks

Pamidronate DisodiumEffectiveness, duration of Tx, and ease of

administration appear promisingLess interruption of activities Excellent response, with few complicationsOf 78% of the pts., only one treatment

needed

SummaryAcute SCIDifficult to detect early More in male adolescents and

younger adultsVarying levels of severityCannot be preventedAim to restore Ca+ levels, and treat

underlying diseaseMobilization and weight bearingMedications or injection

ReferencesAgrharkar, M. (2014). Hypercalcemia Medication. Retrieved

December 5, 2014, from http://emedicine.medscape.com/

American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.

Crown et. al. (2009) Hypercalcemic crisis: a case study. American Journal of Clinical Rehabilitation. 6(1), 38-40.

Kolnick et. al (2011). Hypercalcemia in Pregnancy: A case of milk-alkali syndrome. Retrieved December 1, 2014 from http:// ncbi.nlm.nih.gov/

Massagli, T. & Cardenas, D. (1999) Immobilization hypercalcemia treatment with pamidronate disodium after spinal cord injury. Arch Phys Med Rehabilitation. 80(2), 998-1000

Shane, E. & Berenson, J. (2014). Treatment of Hypercalcemia. Retrieved December 4, 2014, from http://uptodate.com/

Zoldronic Acid (Injection). (2014). Retrieved December 16, 2014, from https://www.ncbi.nlm.nih.gov/pubmedhealth/

Questions?