The metabolic response to spinal cord injury

Expert-Reviewed Nutritional Guidance for Adults with Spinal Cord Injury: A Delphi Study

Background/Objectives: Nutritional needs for people with chronic spinal cord injury (SCI) are inadequately addressed due to the lack of comprehensive evidence and scattered research. We established a consensus-based framework for addressing the nutritional needs of community-dwelling adults with chronic SCI who can ingest food orally. Methods: A web-based Delphi design was employed to ascertain an expert consensus. The Delphi panel consisted of physicians, registered dietitians (RDs), and researchers knowledgeable in SCI and nutrition. Informed by a literature review, 18 nutrition statements were rated by 15 panelists. The survey included statements about SCI-specific dietary energy assessments and macro- and micronutrients. Results: The response rate for the panel (N = 15) was 100%. Consensus levels, scores, stability levels, and response numbers were documented for each statement. The statements received consensus scores ranging from 4.14 to 8.13 on a 9-point Likert scale. Alternative expert comments and suggestions were also provided for each statement. Conclusion: Engaging a diverse panel of experts, the real-time Delphi process yielded expert-reviewed nutrition statements based on an extensive literature review and expert opinions. The rated statements contribute to the ongoing dialogue in SCI-specific nutrition, providing a practical resource for healthcare professionals working with adults with chronic SCI.

The Relationship Between Physical Activity and Mental Health Among Individuals With Spinal Cord Injury: Protocol for a Scoping Review

BACKGROUND

Spinal cord injury (SCI) is a devastating condition that often leads to significant impairments in physical function, leading to disability and mental health disorders. Hence, understanding the prevalence of SCI and the relationship between physical activity and mental health in individuals with SCI is crucial for informing rehabilitation strategies and optimizing outcomes.

OBJECTIVE

This study aims to comprehensively analyze existing research on the link between physical activity and mental health and identify the level of physical activity and mental health status, the barriers to physical activity, and SCI's impacts on psychological well-being in individuals with SCI.

METHODS

An electronic search strategy will be used to identify prevalence studies published since 1993 in health-related databases such as PubMed, MEDLINE, COCHRANE Library, and Wiley Library using the following query: "Spinal Cord Injury" OR "Paraplegia" OR "Tetraplegia" AND "Physical Activity" OR "Exercise" AND "Mental Health" OR "Mental Illness" OR "Mental Disorder." Bibliographies of primary studies and review articles meeting the inclusion criteria will be searched manually to identify further eligible studies. The risk of bias in the included studies will be appraised using the Joanna Briggs Institute checklist for prevalence studies by 2 review authors. Any disagreement will be resolved by reaching a consensus.

RESULTS

Funding was received in October 2023, data collection will commence in July 2024, and the results are expected by 2025. We will summarize the selection of the eligible studies using a flowchart. The data from the studies will be extracted and tabulated. This scoping review will be published in a peer-reviewed journal in accordance with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

CONCLUSIONS

This scoping review underscores the complex relationship between physical activity and mental health among individuals with SCI, highlighting the level of physical activity and mental health status, barriers to physical activity engagement, and psychological implications. Understanding these dynamics is crucial in devising tailored interventions aimed at enhancing mental well-being. This synthesis of evidence emphasizes the need for personalized strategies to promote physical activity, addressing unique challenges faced by this population to foster improved mental health outcomes and overall quality of life.

TRIAL REGISTRATION

Open Science Framework osf.io/ugx7d; https://osf.io/ugx7d/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/56081.

Sex hormone supplementation improves breathing and restores respiratory neuroplasticity following C2 hemisection in rats

In addition to loss of sensory and motor function below the level of the lesion, traumatic spinal cord injury (SCI) may reduce circulating steroid hormones that are necessary for maintaining normal physiological function for extended time periods. For men, who comprise nearly 80% of new SCI cases each year, testosterone is the most abundant circulating sex steroid. SCI often results in significantly reduced testosterone production and may result in chronic low testosterone levels. Testosterone plays a role in respiratory function and the expression of respiratory neuroplasticity. When testosterone levels are low, young adult male rats are unable to express phrenic long-term facilitation (pLTF), an inducible form of respiratory neuroplasticity invoked by acute, intermittent hypoxia (AIH). However, testosterone replacement can restore this respiratory neuroplasticity. Complicating the interpretation of this finding is that testosterone may exert its influence in three possible ways: 1) directly through androgen receptor (AR) activation, 2) through conversion to dihydrotestosterone (DHT) by way of the enzyme 5α-reductase, or 3) through conversion to 17β-estradiol (E2) by way of the enzyme aromatase. DHT signals via AR activation similar to testosterone, but with higher affinity, while E2 activates local estrogen receptors. Evidence to date supports the idea that exogenous testosterone supplementation exerts its influence through estrogen receptor signaling under conditions of low circulating testosterone. Here we explored both recovery of breathing function (measured with whole body barometric plethysmography) and the expression of AIH-induced pLTF in male rats following C2-hemisection SCI. One week post injury, rats were supplemented with either E2 or DHT for 7 days. We hypothesized that E2 would enhance ventilation and reveal pLTF following AIH in SCI rats. To our surprise, though E2 did beneficially impact overall breathing recovery following C2-hemisection, both E2 supplementation and DHT restored the expression of AIH-induced pLTF 2 weeks post-SCI.

The comparison of total energy and protein intake relative to estimated requirements in chronic spinal cord injury

In chronic spinal cord injury (SCI), individuals experience dietary inadequacies complicated by an understudied research area. Our objectives were to assess (1) the agreement between methods of estimating energy requirement (EER) and estimated energy intake (EEI) and (2) whether dietary protein intake met SCI-specific protein guidelines. Persons with chronic SCI (n = 43) completed 3-day food records to assess EEI and dietary protein intake. EER was determined with the Long and Institute of Medicine (IOM) methods and the SCI-specific Farkas method. Protein requirements were calculated as 0·8-1·0 g/kg of body weight (BW)/d. Reporting accuracy and bias were calculated and correlated to body composition. Compared with IOM and Long methods (P < 0·05), the SCI-specific method did not overestimate the EEI (P = 0·200). Reporting accuracy and bias were best for SCI-specific (98·9 %, -1·12 %) compared with Long (94·8 %, -5·24 %) and IOM (64·1 %, -35·4 %) methods. BW (r = -0·403), BMI (r = -0·323) and total fat mass (r = -0·346) correlated with the IOM reporting bias (all, P < 0·05). BW correlated with the SCI-specific and Long reporting bias (r = -0·313, P = 0·041). Seven (16 %) participants met BW-specific protein guidelines. The regression of dietary protein intake on BW demonstrated no association between the variables (β = 0·067, P = 0·730). In contrast, for every 1 kg increase in BW, the delta between total and required protein intake decreased by 0·833 g (P = 0·0001). The SCI-specific method for EER had the best agreement with the EEI. Protein intake decreased with increasing BW, contrary to protein requirements for chronic SCI.

Lesion level-dependent systemic muscle wasting after spinal cord injury is mediated by glucocorticoid signaling in mice

An incomplete mechanistic understanding of skeletal muscle wasting early after spinal cord injury (SCI) precludes targeted molecular interventions. Here, we demonstrated systemic wasting that also affected innervated nonparalyzed (supralesional) muscles and emerged within 1 week after experimental SCI in mice. Systemic muscle wasting caused muscle weakness, affected fast type 2 myofibers preferentially, and became exacerbated after high (T3) compared with low (T9) thoracic paraplegia, indicating lesion level-dependent ("neurogenic") mechanisms. The wasting of nonparalyzed muscle and its rapid onset and severity beyond what can be explained by disuse implied unknown systemic drivers. Muscle transcriptome and biochemical analysis revealed a glucocorticoid-mediated catabolic signature early after T3 SCI. SCI-induced systemic muscle wasting was mitigated by (i) endogenous glucocorticoid ablation (adrenalectomy) and (ii) pharmacological glucocorticoid receptor (GR) blockade and was (iii) completely prevented after T3 relative to T9 SCI by genetic muscle-specific GR deletion. These results suggest that neurogenic hypercortisolism contributes to a rapid systemic and functionally relevant muscle wasting syndrome early after paraplegic SCI in mice.

Energy expenditure and nutrient intake after spinal cord injury: a comprehensive review and practical recommendations

Many persons with spinal cord injury (SCI) have one or more preventable chronic diseases related to excessive energetic intake and poor eating patterns. Appropriate nutrient consumption relative to need becomes a concern despite authoritative dietary recommendations from around the world. These recommendations were developed for the non-disabled population and do not account for the injury-induced changes in body composition, hypometabolic rate, hormonal dysregulation and nutrition status after SCI. Because evidence-based dietary reference intake values for SCI do not exist, ensuring appropriate consumption of macronutrient and micronutrients for their energy requirements becomes a challenge. In this compressive review, we briefly evaluate aspects of energy balance and appetite control relative to SCI. We report on the evidence regarding energy expenditure, nutrient intake and their relationship after SCI. We compare these data with several established nutritional guidelines from American Heart Association, Australian Dietary Guidelines, Dietary Guidelines for Americans, Institute of Medicine Dietary Reference Intake, Public Health England Government Dietary Recommendations, WHO Healthy Diet and the Paralyzed Veterans of America (PVA) Clinical Practice Guidelines. We also provide practical assessment and nutritional recommendations to facilitate a healthy dietary pattern after SCI. Because of a lack of strong SCI research, there are currently limited dietary recommendations outside of the PVA guidelines that capture the unique nutrient needs after SCI. Future multicentre clinical trials are needed to develop comprehensive, evidence-based dietary reference values specific for persons with SCI across the care continuum that rely on accurate, individual assessment of energy need.

Diet Quality Assessment in Wheelchair Users with Multiple Sclerosis

Background: Diet quality has not been distinctively examined in wheelchair users with multiple sclerosis (MS). Methods: This cross-sectional study examined the Diet History Questionnaire (DHQ) III and the Automated Self-Administered 24-h (ASA24) Dietary Assessment Tool in 128 wheelchair users with MS. Participants were prompted to complete the DHQ-III and 3 ASA24 recalls during a seven-day data collection period. Healthy Eating Index (HEI)-2015 scores were calculated for DHQ-III and ASA24, and scores were compared with normative values. Spearman’s correlation analyses (r_s) estimated the associations between DHQ-III and ASA24 HEI-2015 total and component scores with supportive paired sample t-tests. Results: HEI-2015 scores for DHQ-III and ASA24 were significantly higher than normative values for total score, total protein foods, and added sugar. Correlations between HEI-2015 scores generated using ASA24 and DHQ-III were all statistically significant (range r_s = 0.23–0.69); however, significant differences between ASA24 and DHQ-III values were noted for HEI-2015 total score, total fruits, whole fruit, total vegetable, greens and beans, whole grains, seafood and plant protein, refined grains, and saturated fats. Conclusion: This study provided a novel description of diet quality in wheelchair users with MS for guiding future research promoting healthy eating in this population.

Changes in body composition during and after inpatient rehabilitation in people with recent spinal cord injury

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To investigate changes in body composition parameters in people with recent spinal cord injury (SCI) during their first inpatient rehabilitation and up to 1 year after discharge and whether those potential changes over time varied between different personal and lesion characteristics groups.

SETTING

Rehabilitation center, the Netherlands.

METHODS

People with recent SCI (≥18 years; n = 53) were tested around admission (T0) and discharge (T1) of inpatient rehabilitation. A sub-group (n = 19) was measured 1 year after discharge (T2). Personal and lesion characteristics were registered at T0. Anthropometry (height, body mass, body mass index, and waist circumference) was performed at T0, T1, and T2. Bioelectrical impedance analysis (BIA) was measured at T0 and T1.

RESULTS

During inpatient rehabilitation, no significant changes in all body composition parameters were found. During the first year after discharge, body mass index (26.8 kg/m²) significantly increased compared with the level at both admission (25.4 kg/m²; p = 0.01, 95% CI: 0.32-2.52) and discharge (25.1 kg/m²; p = 0.02, 95% CI: 0.26-3.00). People with paraplegia showed an increase in absolute waist circumference (6.5%) compared with people with tetraplegia who showed a net decrease (-5.5%) in the year after discharge (p = 0.047, 95% CI: 0.27-33.62).

CONCLUSIONS

A stable body composition during inpatient rehabilitation is followed by an increased BMI in the year after discharge in people with recent SCI. People with paraplegia showed an increase in absolute waist circumference compared with people with tetraplegia who showed a net decrease in the year after discharge.

Dietetics After Spinal Cord Injury: Current Evidence and Future Perspectives

Following spinal cord injury (SCI), individuals are at high risk for obesity and several chronic cardiometabolic disorders due to a deterioration in body composition, hypometabolic rate, and endometabolic dysregulation. Countermeasures to the consequences of an SCI include adopting a healthy diet that provides adequate nutrition to maintain good body habitus and cardiometabolic health. A proper diet for individuals with SCI should distribute carbohydrates, protein, and fat to optimize a lower energy intake requirement and should stress foods with low caloric yet high nutrient density. The purpose of this article is to present available evidence on how nutritional status after SCI should advance future research to further develop SCI-specific guidelines for total energy intake, as it relates to percent carbohydrates, protein, fat, and all vitamins and minerals, that take into consideration the adaptations after SCI.

A Primary Care Provider's Guide to Diet and Nutrition After Spinal Cord Injury

Physiological changes that occur after spinal cord injury (SCI) are profound and affect almost every organ system in the human body. Energy balance is significantly altered due to motor paralysis, spasticity or flaccidity, neurogenic sarcopenia, neurogenic osteopenia, sympathetic nervous system disruption, and blunted anabolism. Energy expenditure is markedly reduced, whereas hypothalamic control of appetite and satiety is diminished, resulting in discordant energy intake. Ultimately, neurogenic obesity ensues as the result of a positive energy balance. Even though nutritional guidelines for persons with SCI have been available since 2009, the necessity for body composition assessment and total daily energy expenditure was insufficiently addressed such that most individuals with SCI continued in positive energy balance despite "adherence" to the guidelines. Macronutrients must be carefully assessed to optimize caloric intake, while micronutrient consumption may need to be supplemented in order to meet recommended daily allowances. Such a diet would emphasize foods with low caloric yet high nutrient density. This article reviews current literature regarding nutritional requirements for SCI and provides a straightforward plan for implementing more rigorous dietary interventions meant to address the obesity crisis in this especially vulnerable population.

An observational study of feeding practice in ventilated patients with spinal cord injury

BACKGROUND AND AIMS

Cervical spinal cord injuries (CSCI) are frequently complicated by respiratory failure requiring prolonged invasive mechanical ventilation in the intensive care unit (ICU). Providing adequate nutrition may be an important factor in the recovery of respiratory muscle function for ventilator weaning. The aim of this study was to examine the practical implementation of a multi-disciplinary approach to nutrition combining indirect calorimetry and the modified Harris Benedict equation to achieve target rates of nutrition for patients with CSCI.

MATERIALS AND METHODS

A retrospective observational study was performed by collecting data of normal nutrition practice in a series of adult ventilated patients with CSCI admitted between 2014 and 2017 to the ICU. Administered calories by enteral nutrition and measured total energy expenditure (TEE) by indirect calorimetry were recorded for the first 3-weeks. Calculations were performed to measure the adequacy of calorie administration relative to TEE. Average daily temperatures and minute ventilation were recorded to support evidence for hypermetabolism. TEE estimates using the modified Harris Benedict equation were compared to indirect calorimetry measures for each patient.

RESULTS

Sixteen patients were included in the study. Calorie administration rapidly increased to a plateau of 2300-2400 kcal per day over the first four days. The median measured TEE by indirect calorimetry was initially high, starting at 3472 kcal/day and decreasing to 2784 kcal/day at three weeks. However, there was wide variation in energy expenditure amongst patients. Average daily temperatures and minute ventilation were high supporting hypermetabolism. Adequacy of calorie administration to TEE ranged between 76 and 86 percent through the study period. There was relatively wide variation when comparing estimates of TEE using the modified Harris Benedict equation versus indirect calorimetry.

CONCLUSIONS

A multi-disciplinary approach to nutrition in ventilated patients with CSCI, incorporating indirect calorimetry, achieves target rates of nutrition. Our findings suggest that a hypermetabolic response may be common but variable in this population and subsequently both under and over feeding may be a risk if nutrition targets are not guided by indirect calorimetry. Further prospective research using protocoled indirect calorimetry measures would be beneficial to ascertain accurate energy requirements for this group of patients and also determine whether feeding to target influences weaning off the ventilator.

SCI-SCREEN: A More Targeted Nutrition Screening Model to Detect Spinal Cord-Injured Patients at Risk of Malnutrition

PURPOSE

To explore if SCI-SCREEN was applicable as nutritional screening model in a neurorehabilitation unit, able to detect spinal cord injury (SCI) persons at nutritional risk.

DESIGN AND METHODS

SCI-SCREEN underwent reliability test by 3 specialist nurses, using 10 consecutive SCI in-patients. Audit of 41 SCI-patients was conducted comparing SCI SCREEN with the Danish-Nutritional-Screening-Model-for-hospitalized-persons (DNSM).

FINDINGS

Inter- and intra-tester reliability (Cohen's Kappa: 0.89-0.93) was high. SCI-SCREEN estimated average energy needs 23% lower (mean difference± SD: 2516.2±1349.1kJ) and protein needs 10% lower (9.5±19.7g/day). Risk assessment differed in 61% (CI95: 42.1; 73.7%) of cases and risk-agreement was obtained in 22% (CI95: 10.6; 37.6%). SCI-SCREEN detected 66% (CI95: 44.5; 75.8%) and DNSM 39% at risk of malnutrition.

CONCLUSIONS

The SCI-SCREEN model estimates SCI-energy and protein needs more accurately than DNSM by adjusting to SCI-consequences. However, more studies are needed.

CLINICAL RELEVANCE

SCI-SCREEN is a reasonable starting-point in the screening procedure and may be a valuable instrument to identify SCI-patients at risk of malnutrition.

Baseline Dietary Intake of Individuals with Spinal Cord Injury Who Are Overweight or Obese

BACKGROUND

Individuals with spinal cord injury (SCI) experience significant secondary health conditions including excess adiposity. Dietary guidelines for individuals with chronic SCI do not exist.

OBJECTIVE

To describe baseline dietary intake and quality based on conformance with dietary recommendations in participants enrolled in GoHealthySCI, a weight loss intervention for individuals with SCI, which promotes lifestyle change.

DESIGN

Cross-sectional analyses were conducted on data collected from April through August 2017 in a randomized pilot study.

PARTICIPANTS

Thirty-seven participants enrolled in the study in Houston, TX. All participants were at least 1 year post injury with a self-reported body mass index (calculated as kg/m²) ≥23. The racially/ethnically diverse sample was predominantly male (n=23), average age was 41.8±13.5 years, and average number of years since injury was 18.1±14.9. Participants varied in terms of level of injury; 19 participants identified as having tetraplegia and 19 identified as having paraplegia.

MAIN OUTCOME MEASURES

The Automated Self-Administered 24-Hour Recall dietary assessment was used to obtain baseline dietary intake data. Participants reported food intake on 3 nonconsecutive days.

STATISTICAL ANALYSIS

Descriptive statistics were conducted for the primary research objectives. Mean macronutrient and micronutrient intake and Healthy Eating Index-2015 total and component scores are described.

RESULTS

Average daily energy intake was 1618±434 kcal. Daily intakes of whole fruits (0.6±0.7 cups), vegetables (1.6±0.9 cups), and whole grains (15%) of total grains were lower than recommendations from the 2015-2020 Dietary Guidelines for Americans. Average daily fiber (15.0g±6.0) met the Academy of Nutrition and Dietetics Evidence Analysis Library minimum target range for individuals with SCI. All percentages of calories from macronutrients were within the acceptable macronutrient distribution ranges: total fat (34.3%±6.2%), protein (16.7%±4.2%), and carbohydrate (49.3%±8.4%). Mean Healthy Eating Index-2015 score was 54.4.

CONCLUSIONS

This study provides a description of dietary intake by individuals with SCI who are overweight or obese. Although macronutrients are within the acceptable distribution range, calories from fat are at the high end and those from protein are at the low end of those ranges. In addition, on average, individuals reported inadequate intake of fruits, vegetables, whole grains, fiber, seafood and plant protein, and healthy fats and excess intake of added sugars and saturated fat. Results provide preliminary evidence of dietary inadequacies and suggest that larger studies examining dietary intake are warranted.

Effects of ursolic acid on sub-lesional muscle pathology in a contusion model of spinal cord injury

Spinal Cord Injury (SCI) results in severe sub-lesional muscle atrophy and fiber type transformation from slow oxidative to fast glycolytic, both contributing to functional deficits and maladaptive metabolic profiles. Therapeutic countermeasures have had limited success and muscle-related pathology remains a clinical priority. mTOR signaling is known to play a critical role in skeletal muscle growth and metabolism, and signal integration of anabolic and catabolic pathways. Recent studies show that the natural compound ursolic acid (UA) enhances mTOR signaling intermediates, independently inhibiting atrophy and inducing hypertrophy. Here, we examine the effects of UA treatment on sub-lesional muscle mTOR signaling, catabolic genes, and functional deficits following severe SCI in mice. We observe that UA treatment significantly attenuates SCI induced decreases in activated forms of mTOR, and signaling intermediates PI3K, AKT, and S6K, and the upregulation of catabolic genes including FOXO1, MAFbx, MURF-1, and PSMD11. In addition, UA treatment improves SCI induced deficits in body and sub-lesional muscle mass, as well as functional outcomes related to muscle function, motor coordination, and strength. These findings provide evidence that UA treatment may be a potential therapeutic strategy to improve muscle-specific pathological consequences of SCI.

Nutritional Health Considerations for Persons with Spinal Cord Injury

Chronic spinal cord injury (SCI) often results in morbidity and mortality due to all-cause cardiovascular disease (CVD) and comorbid endocrine disorders. Several component risk factors for CVD, described as the cardiometabolic syndrome (CMS), are prevalent in SCI, with the individual risks of obesity and insulin resistance known to advance the disease prognosis to a greater extent than other established risks. Notably, adiposity and insulin resistance are attributed in large part to a commonly observed maladaptive dietary/nutritional profile. Although there are no evidence-based nutritional guidelines to address the CMS risk in SCI, contemporary treatment strategies advocate more comprehensive lifestyle management that includes sustained nutritional guidance as a necessary component for overall health management. This monograph describes factors in SCI that contribute to CMS risks, the current nutritional profile and its contribution to CMS risks, and effective treatment strategies including the adaptability of the Diabetes Prevention Program (DPP) to SCI. Establishing appropriate nutritional guidelines and recommendations will play an important role in addressing the CMS risks in SCI and preserving optimal long-term health.

Feasibility and Acceptability of Implementing Indirect Calorimetry Into Routine Clinical Care of Patients With Spinal Cord Injury

Background: In the absence of reliable predictive equations, indirect calorimetry (IC) remains the gold standard for assessing energy requirements after spinal cord injury (SCI), but it is typically confined to a research setting. The purpose of this study is to assess the feasibility and acceptability of implementing IC into routine clinical care in an Australian SCI rehabilitation facility. Methods: Bedside IC (canopy hood) was performed, and patients completed an IC acceptability questionnaire (open-ended; yes/no; 5-point Likert scale). Fasted resting energy expenditure (REE) steady-state criteria were applied to assess data quality, and adherence to a test ≥20 minutes was recorded. Staff were surveyed to assess impact of IC on usual care. Results: Of 35 eligible patients, 9 declined (7 reported claustrophobia). One patient could not be tested before discharge and 25 underwent IC (84% male, injury level C2-L2, AIS A-D). Anxiety prevented one patient from completing IC, while another failed to fast. The remaining 23 patients achieved a steady-state REE (≥5 consecutive minutes with ≤10% coefficient of variation for VO₂ and VCO₂). Test-retest (n = 5) showed <10% variation in REE. Patients deemed the procedure acceptable, with 88% reporting a willingness to repeat IC. Eighty percent of patients and 90% of staff agreed it was acceptable for IC to be integrated into usual care. Conclusion: This study found that IC is a feasible and acceptable addition to the routine clinical care of patients recovering from SCI and may serve to improve accuracy of nutrition interventions for this patient population.

Update on traumatic acute spinal cord injury. Part 2

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers).

Energy Expenditure and Protein Requirements After Traumatic Injury

Traumatic injury induces hypermetabolism. The degree of hypermetabolism can be variable, depending on the type of injury, the degree of inflammation, body composition, age, and treatment regimens. To estimate metabolic rate in some types of injury, predictive equations have been published. Some of these equations have been tested in validation studies. For other types of injury, equations do not exist. Some expert panels have recommended measuring in lieu of estimating metabolic rate, though studies have not been performed to determine whether clinical outcome is affected by the method used to determine energy requirements. Traumatically injured patients are usually catabolic, but protein needs after traumatic injury continue to be debated. Some suggest that 1.5 g protein per kg body weight is adequate and that any additional protein is simply oxidized, adding to the nitrogen load to be excreted. Alternately, protein intake >2.0 g/kg body weight increases the absolute rate of body protein synthesis, and achievement of nitrogen balance has been associated with survival. Thus, provision of high-protein feeding to achieve nitrogen balance might be worthwhile, even if that balance is achieved at the cost of additional nitrogen production.

Calorie and protein intake in acute rehabilitation inpatients with traumatic spinal cord injury versus other diagnoses

BACKGROUND

Obesity and its consequences affect patients with spinal cord injury (SCI). There is a paucity of data with regard to the dietary intake patterns of patients with SCI in the acute inpatient rehabilitation setting. Our hypothesis is that acute rehabilitation inpatients with SCI consume significantly more calories and protein than other inpatient rehabilitation diagnoses.

OBJECTIVE

To compare calorie and protein intake in patients with new SCI versus other diagnoses (new traumatic brain injury [TBI], new stroke, and Parkinson's disease [PD]) in the acute inpatient rehabilitation setting.

METHODS

The intake of 78 acute rehabilitation inpatients was recorded by registered dieticians utilizing once-weekly calorie and protein intake calculations.

RESULTS

Mean ± SD calorie intake (kcal) for the SCI, TBI, stroke, and PD groups was 1,967.9 ± 611.6, 1,546.8 ± 352.3, 1,459.7 ± 443.2, and 1,459.4 ± 434.6, respectively. ANOVA revealed a significant overall group difference, F(3, 74) = 4.74, P = .004. Mean ± SD protein intake (g) for the SCI, TBI, stroke, and PD groups was 71.5 ± 25.0, 61.1 ± 12.8, 57.6 ± 16.6, and 55.1 ± 19.1, respectively. ANOVA did not reveal an overall group difference, F(3, 74) = 2.50, P = .066.

CONCLUSIONS

Given the diet-related comorbidities and energy balance abnormalities associated with SCI, combined with the intake levels demonstrated in this study, education with regard to appropriate calorie intake in patients with SCI should be given in the acute inpatient rehabilitation setting.

Mechanisms of injury and emergency care of acute spinal cord injury in dogs and cats

OBJECTIVES

To review the literature in regards to the pathophysiology of acute spinal cord injury, and to describe current concepts in regards to patient assessment, diagnostic, and therapeutic measures with a special emphasis on emergency and critical care considerations.

ETIOLOGY

Acute spinal cord injury occurs in 2 phases. The primary injury occurs at the time of initial injury and may include intervertebral disk herniation, vertebral fracture or luxation, penetrating injury, and vascular anomalies such as fibrocartilaginous embolic myelopathy. Secondary injury occurs following primary injury and is multifactorial encompassing numerous biochemical and vascular events that result in progression of injury.

DIAGNOSIS

The diagnosis is based on history and physical examination findings. A neurologic examination should be performed following initial patient assessment and stabilization. Further diagnostics to characterize acute spinal injury include radiographs and advanced imaging modalities such as myelography, computed tomography, or magnetic resonance imaging.

THERAPY

Initial treatment should focus on addressing the patient's cardiovascular and respiratory system. Supportive measures to support systemic perfusion are vital to minimizing secondary injury. Specific therapy toward minimizing secondary injury in veterinary medicine remains controversial, especially in regards to the utilization of methylprednisolone. Other therapies are either in need of additional research or have failed to document clinical difference.

PROGNOSIS

The prognosis for acute spinal injury is varied and is dependent upon the presence of concurrent trauma, location, and type of primary injury sustained, and extent of neurologic impairment at the time of initial presentation. The etiology of the underlying trauma is of great importance in determining prognosis and outcome. Loss of deep pain is generally accepted as a poor prognostic indicator; however, even these patients can recover depending on their response to treatment.

Malnutrition in spinal cord injury: more than nutritional deficiency

Denervation of the spinal cord below the level of injury leads to complications producing malnutrition. Nutritional status affects mortality and pathology of injured subjects and it has been reported that two thirds of individuals enrolled in rehabilitation units are malnourished. Therefore, the aim should be either to maintain an optimal nutritional status, or supplement these subjects in order to overcome deficiencies in nutrients or prevent obesity. This paper reviews methods of nutritional assessment and describes the physiopathological mechanisms of malnutrition based on the assumption that spinal cord injured subjects need to receive adequate nutrition to promote optimal recovery, placing nutrition as a first line treatment and not an afterthought in the rehabilitation of spinal cord injury.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with polytrauma]

Patients with polytrauma can be viewed as paradigmatic of the critically-ill patient. These previously healthy patients undergo a life-threatening aggression leading to an organic response that is no different from that in other types of patients. The profile of trauma patients has changed and currently corresponds to patients who are somewhat older, with a higher body mass index and greater comorbidity. Severe injuries lead to intense metabolic stress, posing a risk of malnutrition. Therefore, early nutritional support, preferentially through the enteral route, with appropriate protein intake and glutamine supplementation, provides advantages over other routes and types of nutritional formula. To avoid overnutrition, reduced daily calorie intake can be considered in obese patients and in those with medullary lesions. However, little information on this topic is available in patients with medullary lesions.

Continuous positive airway pressure requirements in patients with tetraplegia and obstructive sleep apnoea

STUDY DESIGN

Clinic-based retrospective case-control study.

OBJECTIVES

To compare continuous positive airway pressure (CPAP) requirements between patients with tetraplegia and able-bodied patients with obstructive sleep apnoea (OSA).

SETTING

Melbourne, Australia.

METHODS

Diagnostic and CPAP titration polysomnograms of 219 able-bodied, and 25 patients with tetraplegia and OSA were compared for apnoea hypopnoea index (AHI) and CPAP levels required to effectively treat OSA. Demographics and body mass index (BMI) were obtained for each patient. ASIA score and injury date were obtained for patients with tetraplegia.

RESULTS

There was no significant difference in AHI (P=0.102) between the two groups; however, able-bodied patients were significantly older (P=0.003), required significantly higher levels of CPAP to control their OSA (P<0.001) and had higher BMIs (P=0.009) than patients with tetraplegia. In the tetraplegia group, there was no significant correlation between AHI and effective CPAP (r=0.022, P=0.92) or between AHI and BMI (r=-0.196, P=0.35). There was a significant correlation between effective CPAP and BMI (r=0.411, P=0.041). Among able-bodied patients, over two-thirds (68.8%) required 10-16 cm H(2)0 to control their OSA and nearly one-third required over 16 cm H(2)0. In contrast, over two-thirds (68.8%) in the tetraplegia group required less than 10 cm H(2)0 of CPAP to control their OSA.

CONCLUSION

This retrospective study suggests that OSA patients with tetraplegia require significantly less CPAP to treat their OSA at any given AHI than those who are able-bodied. This suggests that additional unknown factors may contribute to the high prevalence of OSA in tetraplegia.

Comparison of nutritional intake between individuals with acute and chronic spinal cord injury

OBJECTIVE

To compare the nutritional intake of patients with acute and chronic spinal cord injury (SCI).

DESIGN

Cross-sectional, observational study.

SETTING

Spinal cord unit.

METHODS

Twelve in-house patients of a spinal cord unit with acute SCI and paralysis duration of 5.3 ± 2.5 months (acute group) were compared with 12 subjects with chronic SCI (chronic group) with lesion duration of 55.5 ± 21.0 months. All subjects recorded their nutritional intake for 7 days, which was analyzed for intake of energy, proteins, fat, carbohydrates, vitamins, mineral nutrients, fluid, and dietary fiber. Resting energy expenditure (REE) and total body fat were also determined.

RESULTS

The chronic group showed a significantly higher total body fat content compared to the acute group (19.4 ± 3.8 vs. 15.7 ± 4.3%). All other parameters were not significantly different between groups. Both groups ingested excessive fat and insufficient amounts of carbohydrates compared with common nutritional recommendations. Low intakes of vitamins C, D, E, biotin, folic acid, as well as potassium and iron were found.

CONCLUSIONS

No differences were found in the nutritional intakes of two comparable groups of subjects with acute and chronic SCI. Independent of lesion duration, subjects with SCI showed considerable deviations from the general accepted nutritional recommendations concerning macro- and micronutrients intake. Professional nutritional education for persons with SCI should start as soon as possible after injury to prevent nutrition-related secondary complications like cardiovascular diseases. Periodic determinations of body fat content and REE combined with a physical activity program might be helpful as well.

Hypocaloric considerations in patients with potentially hypometabolic disease States

The provision of nutrition has traditionally been driven by the desire to provide adequate calories. However, over the past decade it has become evident that provision of excess calories can be detrimental to patients' outcomes in both critical care and long-term care settings. This review examines patient populations for whom hypocaloric nutrition can be both appropriate and beneficial. In specific situations, critically ill patients, such as those with obesity, stroke, and spinal cord injury, may have decreased energy requirements. In patients with spinal cord injury, the level of injury significantly correlates with the extent of reduced caloric energy expenditure. Ventilator-dependent patients with amyotrophic lateral sclerosis (ALS) have decreased energy needs; energy expenditure for ALS patients is lower than the predictive equation value. Aging patients will have decreased energy needs relative to a reduction in lean body mass. Patients with cerebral palsy (CP) have significantly lower caloric requirements than anticipated using predictive equations. Patients with CP pose a particular challenge in nutrition assessment. Several studies demonstrate that patients with CP have significantly lower caloric requirements than anticipated using predictive equations; thus, patients with CP benefit from indirect calorimetry. Provision of nutrition for obese patients is briefly addressed, as this is an increasingly important consideration for nutrition support in both the critical care and long-term care settings. When indirect calorimetry is not available, clinicians should remember that most patients will have low resting energy expenditure regardless of functional status and require frequent evaluation during institution of nutrition recommendations to guard against overfeeding and obesity.

Weight matters: physical and psychosocial well being of persons with spinal cord injury in relation to body mass index

OBJECTIVE

To examine the relationship of body mass index (BMI) with multiple health indices among persons with spinal cord injury (SCI).

DESIGN

Multicenter cross-sectional study.

SETTING

A total of 16 SCI Model Systems throughout the United States.

PARTICIPANTS

A total of 1107 men and 274 women (N=1381), mean age ± SD, 43.1±14.6 years (tetraplegia, 56.9%; complete injuries, 50.2%; mean years since injury ± SD, 7.8±8.6), who received follow-up in 2006 to 2009, were classified into 1 of the 4 BMI categories-underweight, normal, overweight, and obese-based on self-reported height and measured weight.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehospitalization, pain, self-perceived health, FIM, Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire-9 (PHQ-9), and the Diener's Satisfaction With Life Scale (SWLS).

RESULTS

The prevalence of underweight, overweight, and obesity was 7.5%, 31.4%, and 22.1%, respectively, which varied by age, sex, marital status, education, and neurologic impairment. For those with tetraplegia and functional motor-complete injuries, rehospitalization occurred more frequently among obese persons, while days rehospitalized were the longest among underweight persons. Pain was more severe in those classified as obese. Community mobility was lower in the underweight, overweight, and obese groups than in those with normal weight. There was no significant association between BMI and self-perceived health, FIM, PHQ-9, and SWLS beyond the effect of neurologic impairment.

CONCLUSIONS

Prevention and intervention directed at those significantly overweight or underweight deserve consideration as priorities in the continuity of care for persons with SCI. Efforts should be targeted particularly to those at higher risk, including persons with more severe injuries, who are less educated, and who are living alone.

Acute management of nutritional demands after spinal cord injury

A systematic review of the literature was performed to address pertinent clinical questions regarding nutritional management in the setting of acute spinal cord injury (SCI). Specific metabolic challenges are present following spinal cord injury. The acute stage is characterized by a reduction in metabolic activity, as well as a negative nitrogen balance that cannot be corrected, even with aggressive nutritional support. Metabolic demands need to be accurately monitored to avoid overfeeding. Enteral feeding is the optimal route following SCI. When oral feeding is not possible, nasogastric, followed by nasojejunal, then by percutaneous endoscopic gastrostomy, if necessary, is suggested.

Cardiometabolic risk factors in experimental spinal cord injury

Cardiometabolic risk factors are sorely underreported after spinal cord injury (SCI), despite the high prevalence of metabolic disorders and cardiovascular mortality in this population. Body-composition analysis and serum-lipid profiling are two assessments that are beginning to be more widely used to document metabolic changes after clinical SCI. Individuals with SCI have been reported to carry increased visceral fat and to exhibit altered serum-lipid levels. However, little is known about the development of these cardiometabolic risk factors in animal models. Using a combination of magnetic resonance imaging (MRI) and adipose tissue dissection, we show that visceral and subcutaneous adipose tissue were both increased at 1 month, but not at 1 week, after complete T3 SCI in rats. Additionally, at 1 month post injury, T3 SCI rats exhibited nonfasting serum hypertriglyceridemia, a result obtained using both standard clinical methods and a home cholesterol monitoring device (CardioChek). Interestingly, at 1 month post injury, rats with complete T10 SCI did not show an increase in either visceral adiposity or serum triglyceride levels. The fact that complete high-thoracic SCI disrupts lipid metabolism and perturbs fat storage in the subacute period, while low-thoracic SCI does not, suggests that differences in descending sympathetic control of adipose tissue might play a role in these changes. These results provide the first evidence of cardiometabolic risk factors in experimental animals with SCI, and are a starting point for investigations of the etiology of obesity and metabolic dysfunctions that often accompany SCI.

Obesity after spinal cord injury

America is in the midst of an obesity epidemic, and individuals who have spinal cord injury (SCI) are perhaps at greater risk than any other segment of the population. Recent changes in the way obesity has been defined have lulled SCI practitioners into a false sense of security about the health of their patients regarding the dangers of obesity and its sequelae. This article defines and uses a definition of obesity that is more relevant to persons who have SCI, reviews the physiology of adipose tissue, and discusses aspects of heredity and environment that contribute to obesity in SCI. The pathophysiology of obesity is discussed relative to health risks for persons who have SCI, particularly those contributing to cardiovascular disease. Prevalence of obesity and its comorbidities are discussed and management options reviewed.

Effects of chronic spinal cord injury on body weight and body composition in rats fed a standard chow diet

The inability to maintain body weight within prescribed ranges occurs in a significant portion of the human spinal cord injury (SCI) population. Using a rodent model of long-term high thoracic (spinal level T3) spinal cord transection (TX), we aimed to identify derangements in body weight, body composition, plasma insulin, glucose tolerance, and metabolic function, as measured by uncoupling protein 1 (UCP1) expression in interscapular brown adipose tissue (IBAT). Sixteen weeks after SCI, body weights of injured female rats stabilized and were significantly lower than surgical control animals. At the same time point, SCI rats had a significantly lower whole body fat:lean tissue mass ratio than controls, as measured indirectly by NMR. Despite lower body weight and fat mass, the cumulative consumption of standard laboratory chow (4.0 kcal/g) and mean energy intake (kcal.day(-1).100 g body wt(-1)) of chronic SCI rats was significantly more than controls. Glucose tolerance tests indicated a significant enhancement in glucose handling in 16-wk SCI rats, which were coupled with lower serum insulin levels. The post mortem weight of gonadal and retroperitoneal fat pads was significantly reduced after SCI and IBAT displayed significantly lower real-time PCR expression of UCP1 mRNA. The reduced fat mass and IBAT UCP1 mRNA expression are contraindicative of the cumulative caloric intake by the SCI rats. The prolonged postinjury loss of body weight, including fat mass, is not due to hypophagia but possibly to permanent changes in gastrointestinal transit and absorption, as well as whole body homeostatic mechanisms.

Spinal cord injury medicine. 2. Acute care management of traumatic and nontraumatic injury

This self-directed learning module highlights the basic acute care management of traumatic and nontraumatic spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Acute traumatic SCI is optimally managed in a level 1 trauma center. Decompression of the neural elements, stabilization of the spine, and maintenance of tissue perfusion are fundamental to optimizing outcomes. SCI patients are at high risk of pressure ulcers, venous thromboembolism, stress ulceration, bowel impaction, dysphagia, and pulmonary complications. Physiatric interventions are needed to prevent these complications. Prognostication of neurologic outcome based on early examination is an important skill to aid in creating a rehabilitation plan and to test for efficacy of early interventions. Nontraumatic SCI is an increasing population in rehabilitation centers. Establishing a diagnosis and treatment plan is essential, in conjunction with prevention of complications and early physiatric intervention.

OVERALL ARTICLE OBJECTIVES

(a) To describe the diagnostic evaluation of traumatic and nontraumatic spinal cord injuries and (b) to summarize the medical, surgical, and physiatric interventions during acute hospitalization for these injuries.

Estimation of resting energy expenditure in children with spinal cord injuries

BACKGROUND/OBJECTIVE

Resting energy expenditure (REE) is the amount of energy needed to maintain energy balance. Prediction equations exist to estimate REE for adults. Recommended dietary allowances (RDA) can be used to estimate energy needs for children but may not be suitable for children with spinal cord injury (SCI). Limited information is available on energy expenditure of children with SCI. Research is needed to determine a method to estimate energy needs for children with SCI. This research project was designed to determine REE in children with SCI who attended an SCI clinic at a children's hospital, determine variables that are correlated to REE in children with SCI, and determine a regression equation to estimate REE in children with SCI.

METHODS

A sample of convenience was obtained from children attending the SCI clinic at Shriners Hospitals for Children-Chicago. The REE was measured after a 4-hour fast using a portable hand-held MedGem device to perform indirect calorimetry. Data including height, weight, age, months since injury, level of injury, gender, race, American Spinal Injury Association (ASIA) Motor Score, ASIA Impairment Score, and body mass index were obtained as covariates.

RESULTS

Regression equations to predict REE were developed for boys and girls. The REE varied significantly from results obtained using both RDA and the Harris-Benedict equation. Height and level of injury were the only variables that correlated with REE in this sample.

CONCLUSIONS

Measured REE was lower than the results of prediction equations. A regression equation was developed to estimate REE in children with SCI based on height and level of injury. Further validation studies are needed.

Obesity intervention in persons with spinal cord injury

STUDY DESIGN

A single group uncontrolled trial.

OBJECTIVES

Despite widespread emphasis on the obesity-related health risks in persons with spinal cord injury (SCI), limited research has been carried out to intervene in this problem. This study was conducted to assess the initial effectiveness of a weight loss program on various health outcomes in persons with SCI.

SETTING

A rehabilitation center in Birmingham, Alabama, United States.

METHODS

A total of 16 individuals with chronic SCI who were overweight or obese participated in a weight management program that consisted of 12 weekly classes, covering nutrition, exercise, and behavior modification. Various outcomes were examined over a 6-month period (baseline, week 12, and week 24), including body composition measured by dual energy X-ray absorptiometry, physiologic measures, diet behavior, and psychosocial and physical functioning. Of these, 13 participants returned for the week 24 follow-up.

RESULTS

Weight loss averaged 3.5+/-3.1 kg (3.8% of the initial weight) at week 12 and 2.9+/-3.7 kg (3.0% of the initial weight) at week 24. There was a significant reduction from baseline values at weeks 12 and 24 in body mass index, anthropometric measurements, and fat mass and improvement in diet behavior and psychosocial and physical functioning, while lean mass and blood albumin and hemoglobin levels were maintained. A correlation analysis showed that a greater weight loss was importantly (r>0.4) associated with a greater reduction in total cholesterol at weeks 12 and 24 and in systolic and diastolic blood pressure at week 24. Several factors were important (r>0.4 or r<-0.4) in determining the success in weight loss, including age, race, marital and employment status, family history of overweight/obesity, level and duration of injury, and cholesterol level at baseline.

CONCLUSIONS

This is the first demonstration that a carefully planned program with time-calorie displacement diet is effective for overweight/obese individuals with SCI to lose weight without compromising total lean mass and overall health. It provides foundation for a future large clinical trial for weight loss of persons with SCI or other spinal cord dysfunction.

Surgical infections in the traumatized spine

Patients with acute spinal injury who require operative intervention may be at increased risk for postoperative surgical-site infection when compared with patients having elective spinal surgery. Various local, systemic, and iatrogenic factors predispose this unique population of patients to post-surgical infection. Nonmodifiable risk factors for surgical-site infection in spine trauma include age, medical comorbidities, and neurologic status. Modifiable risk factors include poor postoperative nutritional status, delay from time of injury to surgical intervention, posterior surgical approach, higher number of levels stabilized, length of postoperative stay in the intensive care unit, and treatment by a single specialty team (versus treatment by successive orthopaedic and neurosurgical teams). When treating patients with spine trauma, a high index of suspicion should be maintained for patients with multiple risk factors for infection and every effort should be made to minimize the modifiable risk factors.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Nutrition Assessment of the Critically Ill Adult

Illness and injury are physiologic stressors that alter the body's metabolic and energy demands. Approximately 30 to 55% of hospitalized patients have evidence of malnutrition, which makes nutrition screening and assessment an integral part of the evaluation of the critically ill adult. Nutritional assessment relies on a complete history and physical examination, appropriate laboratory measurements, and diagnostic testing as warranted. Although a single laboratory result may be helpful for nutritional screening, there is no single parameter that is both sensitive and specific for the diagnosis of malnutrition. Instead, nutritional assessment must be ongoing and be derived from a variety of sources in order to identify nutritional trends over time. Early identification and nutritional intervention can lessen morbidity and mortality risks; however, underlying acute and/or chronic disease processes often need to be identified and corrected before the body can reverse abnormal nutrient metabolism. A comprehensive nutritional assessment, incorporated with clinical status, will provide the basis for a nutritional support plan and evaluation strategies. In order to help the advanced practice nurse determine the appropriate nutritional regimen, this article discusses the importance of the patient history, physical examination, body composition measurement techniques, and laboratory data assessment.

Early versus late enteral feeding in patients with acute cervical spinal cord injury: a pilot study

STUDY DESIGN

A prospective randomized clinical pilot study to compare early versus late enteral feeding in patients with acute cervical spinal cord injury.

OBJECTIVES

To compare the incidence of infections in patients with acute cervical spinal cord injury who received early versus late enteral feeding. Secondary objectives included assessing nutritional status, feeding tolerance, the number of ventilator hours, and acute-care hospital length of stay.

SUMMARY OF BACKGROUND DATA

Early nutritional support has been found to be beneficial in critically ill patients. However, the same benefits may not be realized in patients with acute cervical spinal cord injury because of their unique nutritional challenges.

METHODS

Eligible patients were randomized to early feeding (initiated before 72 hours after injury) and late (initiated more than 120 hours after injury). Patients were stratified on the basis of their neurologic level. Patients were assessed daily for the first 15 days. After that time, infections (according to Center for Disease Control criteria), ventilator hours, and length of acute-care hospital stay were tracked.

RESULTS

Twenty-three patients met the eligibility criteria, and 17 patients were included in the analysis. There were 7 patients in the early group and 10 in the late group. The early group had a mean of 2.4 +/- 1.5 infections compared with the late group, which had a mean of 1.7 +/- 1.1 infections. Secondary outcomes were not substantially different between the two groups.

CONCLUSIONS

This pilot study failed to detect any differences in the incidence of infection, nutritional status, feeding complications, number of ventilator hours, or length of stay between patients receiving early versus late initiation of enteral feeding. These data will assist in the determination of an adequate sample size for future studies.

Nutritional support after spinal cord injury

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Nutritional support of patients with spinal cord injuries is recommended. Energy expenditure is best determined by indirect calorimetry in these patients because equation estimates of energy expenditure and subsequent caloric need tend to be inaccurate.

Nonoperative management of acute spinal cord injury

Advances in transport, imaging, and stabilization of the injured patient have made the topic of acute management more important than ever in patients with spinal cord injury. Optimal treatment requires prompt delivery of care for life-threatening respiratory and hemodynamic events in a manner that will not further damage the unstable spinal elements. The application of these treatment principles broadly to injured patients is necessitated by our inability to determine, on an acute basis, those patients who might eventually recover meaningful neurologic function from those who will not. Therefore, nonoperative management of acute spinal cord injury requires consideration of two goals: 1) the preservation of the patient's life and 2) optimizing the potential for recovery of neurologic function. The first consideration requires not only an understanding of the novel systemic consequences of spinal cord injury but also of treatments directed at combating them. The second includes the application of resuscitative measures without further damaging the spinal cord and, in some cases, the use of traction and immobilization. In the past these efforts were aimed primarily at increasing the survival rate of patients with spinal cord injury, whereas current care may also play an important role in the eventual recovery of neurologic function. Despite many advances in our understanding of the basic mechanisms of paralysis, clinical management of spinal cord injury remains a significant challenge and one that requires continuing efforts at improving acute and postacute therapies.

Total body water and percentage fat mass measurements using bioelectrical impedance analysis and anthropometry in spinal cord-injured patients

BACKGROUND AND AIMS

Spinal cord injured patients may be adversely affected by disturbances of nutritional status, particularly malnutrition and fat mass overload. Malnutrition increases the risk for development of pressure sores, and fat mass excess increases the cardiovascular and respiratory risks of these patients, as well as predisposing to the development of diabetes mellitus, pressures sores and bony fractures. Body impedance analysis and anthopometry are easy bedside methods for body composition assessment. The aims of the study were to validate, in 20 spinal cord injured patients, body impedance analysis as a means to estimate total body water, and to validate a skinfold measurement of percentage fat independent of hydration of fat-free mass in the same population.

METHODS

Total body water was measured by (18)O dilution as a reference method. Impedance and anthropometric measurements (four different skinfolds) were obtained. The results of total body water given by impedance analysis and calculated with three formulas were compared to the reference method. The fat mass percentage obtained with each of the skinfolds using the 3-compartment Siri's formula was compared to a reference value using the sum of the skinfolds.

RESULTS AND CONCLUSION

The formula using 100 kHz resistance, height, weight and gender overestimated total body water by only 0.76 +/- 1.85 L, with an acceptable concordance with labeled water results. The formula with 50 kHz resistance was less accurate and concordant. Each skinfold may be used for assessing percentage fat mass. Based on these findings, we feel that the triceps skinfold, whose the variability is the lowest compared to the reference values, can be used alone in clinical practice.