Metabolic syndrome in adolescents with spinal cord dysfunction

Neurogenic Aging After Spinal Cord Injury: Highlighting the Unique Characteristics of Aging After Spinal Cord Injury

Emanating from several decades of study into the effects of the aging process after spinal cord injury (SCI), "accelerated aging" has become a common expression as the SCI accelerates the onset of age-related pathologies. However, the aging process follows a distinct trajectory, characterized by unique patterns of decline that differ from those observed in the general population without SCI. Aging brings significant changes to muscles, bones, and hormones, impacting overall physical function. Muscle mass and strength begin to decrease with a reduction in muscle fibers and impaired repair mechanisms. Bones become susceptible to fractures as bone density decreases. Hormonal changes combined with decreased physical activity accelerate the reduction of muscle mass and increase in body fat. Muscle atrophy and skeletal muscle fiber type transformation occur rapidly and in a unique pattern after SCI. Bone loss develops more rapidly and results in an increased risk of fractures in body regions unique to individuals with SCI. Other factors, such as excessive adiposity, decreased testosterone and human growth hormone, and increased systemic inflammation, contribute to a higher risk of neuropathically driven obesity, dyslipidemia, glucose intolerance, insulin resistance, and increasing cardiovascular disease risk. Cardiorespiratory changes after SCI result in lower exercise heart rates, decreased oxygenation, and mitochondrial dysfunction. While it is important to acknowledge the accelerated aging processes after SCI, it is essential to recognize the distinct differences in the aging process between individuals without physical disabilities and those with SCI. These differences, influenced by neuropathology, indicate that it may be more accurate to describe the aging process in individuals with chronic SCI as neurogenic accelerated aging (NAA). Research should continue to address conditions associated with NAA and how to ameliorate the accelerated rate of premature age-related conditions. This review focuses on the NAA processes and the differences between them and the aging process in those without SCI. Recommendations are provided to help slow the development of premature aging conditions.

Nutritional Aspects of Spina Bifida Care: Optimizing Medical Management and Surgical Healing

PURPOSE OF REVIEW

This review aims to highlight background of contributing factors for suboptimal nutrition in individuals with spina bifida and introduce strategies for amelioration.

RECENT FINDINGS

Recent studies demonstrate increased risk of metabolic syndrome by neurosegmental level, which is associated with truncal obesity and reduced mobility. From the neonatal intensive care stay, which may disrupt breast feeding and the developing microbiome of the gastrointestinal tract, to early childhood various insults may lead to suboptimal feeding practices, preferences and dietary intake. Family coping skills, financial stressors may lead to food insecurity and/or residence in an area with limited availability of fresh food. As children grow, weakness and challenging transfers may lead to more sedentary lifestyle and weight gain despite limited linear growth. Body habitus changes including atrophy of the lower extremities may lead to decreased muscle mass and reduced energy expenditure, with predisposition to truncal obesity and metabolic syndrome.

Application of Bioelectrical Impedance Analysis in Weight Management of Children with Spina Bifida

BACKGROUND

Children with spina bifida (SB) face an elevated risk of obesity, which necessitates precise methods for assessing body composition to ensure effective weight management. Conventional measures like BMI are inadequate for this population because of variations in growth patterns and skeletal structure. Bioelectrical impedance analysis (BIA) is a method that offers a clearer picture of body composition, yet its use in children with SB remains underexplored.

METHODS

Conducted on 57 children with SB and 28 healthy controls, with a median age of 11 years, this study evaluated anthropometrics, including BMI and BIA-derived metrics. The Hoffer's scale to assess physical activity was applied in SB children.

RESULTS

Results showed that while 32% of SB patients were classified as overweight or obese based on BMI, 62% exhibited high body fat percentage via BIA. Fat-free mass, muscle and fat mass, and fat-to-muscle ratio (FMR) differed significantly compared to the reference group. Non-ambulators showed a higher median body fat mass percentage (25.9% vs. 17.8%, p = 0.01) and FMR (0.92 vs. 0.44, p = 0.003) in comparison to the community walkers.

CONCLUSIONS

In SB children, BIA-measured fat mass is a better obesity indicator than BMI. Non-ambulatory, SB patients with obesity had the highest FMR values, indicating a higher risk for metabolic syndrome.

Nutrient composition influences the gut microbiota in chronic thoracic spinal cord-injured rats

Chronic spinal cord injury (SCI) results in an increased predisposition to various metabolic problems that can be exacerbated by consuming a diet rich in calories and saturated fat. In addition, gastrointestinal symptoms have been reported after SCI, including intestinal dysbiosis of the gut microbiome. The effects of both diet and SCI on the gut microbiome of adult male Long Evans rats euthanized 16 wk after injury were investigated. The rats were either thoracic spinal contused or received sham procedures. After 12 wk of either a low-fat or high-fat diet, cecal contents were analyzed, revealing significant microbial changes to every taxonomic level below the kingdom level. Shannon α diversity analyses demonstrated a significant difference in diversity between the groups based on the surgical condition of the rats. SCI produced a unique signature of changes in commensal bacteria that were significantly different than Sham. Specific changes in commensal bacteria as a result of diet manipulation had high fidelity with reports in the literature, such as Clostridia, Thiohalorhabdales, and Pseudomonadales. In addition, novel changes in commensal bacteria were identified that are unique dietary influences on SCI. Linear regression analysis on body fat and lean mass showed that a consequence of chronic SCI produces uncoupled associations between some commensal bacteria and body composition. In conclusion, despite tightly controlling the protein content and varying the carbohydrate and fat contents, Sham and SCI rats respond uniquely to diet. These data provide potential direction for therapeutic modulation of the microbiome to improve health and wellness following SCI.

Endocrinological and inflammatory markers in individuals with spinal cord injury: A systematic review and meta-analysis

Spinal cord injury (SCI) can lead to dramatic physiological changes which can be a factor in developing secondary health conditions and might be reflected in biomarker changes in this elevated risk group. We focused specifically on the endocrine and inflammation profile differences between SCI and able-bodied individuals (ABI). Our aim was to determine the differences in inflammatory markers and endocrine profiles between SCI and ABI. We systematically searched 4 electronic databases for relevant studies. Human observational (cross-sectional, cohort, case-control) studies that compared biomarkers of interest between SCI and ABI population were included. Weighted mean difference between SCI and ABI was calculated using random-effects models. Heterogeneity was computed using I² statistic and chi-squared test. Study quality was evaluated through the Newcastle-Ottawa Scale. The search strategy yielded a total of 2,603 studies from which 256 articles were selected for full-text assessment. Sixty-two studies were included in the meta-analysis. SCI individuals had higher levels of pro-inflammatory C-reactive protein and IL-6 than ABI. Creatinine and 25-hydroxyvitamin D₃ levels were lower in SCI than ABI. Total testosterone levels and IGF-1 were also found to be lower, while cortisol and leptin levels were higher in SCI when compared to ABI. Accordingly, meta-regression, subgroup analysis, and leave-one-out analysis were performed, however, they were only able to partially explain the high levels of heterogeneity. Individuals with SCI show higher levels of inflammatory markers and present significant endocrinological changes when compared to ABI. Moreover, higher incidence of obesity, diabetes, osteoporosis, and hypogonadism in SCI individuals, together with decreased creatinine levels reflect some of the readily measurable aspects of the phenotype changes in the SCI group. These findings need to be considered in anticipating medically related complications and personalizing SCI medical care.

Metabolic Syndrome in Children With Myelomeningocele and the Role of Physical Activity: A Narrative Review of the Literature

Objectives

The purpose of this review is to describe the current scientific literature on the prevalence of metabolic syndrome in children with myelomeningocele and to gain insight into the baseline levels of aerobic fitness, endurance, and strength in this population in order to identify gaps in knowledge, suggest potential primary prevention strategies, and provide recommendations for future studies.

Methods

A literature review of articles published in English and French between 1990 and April 2020 was conducted.

Results

Obese adolescents with myelomeningocele have an increased prevalence of components of the metabolic syndrome. Children and adolescents with myelomeningocele have decreased aerobic fitness and muscular strength, decreased lean mass, and increased fat mass, all of which, when combined with higher levels of physical inactivity, put them at higher risk of developing metabolic syndrome and cardiovascular diseases.

Conclusion

Until more research is conducted, addressing weight-related challenges and promoting healthy habits (such as optimal activity levels) could be easily integrated into yearly myelomeningocele clinics. An actionable suggestion might be to systematically weigh and measure children in these clinics and utilize the results and trends as a talking point with the parents and children. The follow-up appointments could also be used to develop physical activity goals and monitor progress. We recommend that the health care practitioner tasked with this intervention (physician, nurse, etc.) should be aware of locally available accessible sports platforms and have knowledge of motivational interviewing to facilitate removal of perceived barriers to physical activity.

Visceral Adiposity, Inflammation, and Testosterone Predict Skeletal Muscle Mitochondrial Mass and Activity in Chronic Spinal Cord Injury

Background

Mitochondrial health is an important predictor of several health-related comorbidities including obesity, type 2 diabetes mellitus, and cardiovascular disease. In persons with spinal cord injury (SCI), mitochondrial health has been linked to several important body composition and metabolic parameters. However, the complex interplay of how mitochondrial health is affected has yet to be determined in this population.

Objective

In this study, we examined the contribution of visceral adiposity, inflammatory biomarkers, testosterone and circulating serum growth factors as predictors of mitochondrial health in persons with chronic SCI.

Participants

Thirty-three individuals with chronic SCI (n = 27 Males, n = 6 Females, age: 40 ± 13.26 years, level of injury: C4-L1, BMI: 23 ± 5.57) participated in this cross-sectional study.

Methods

Visceral adipose tissue (VAT) was measured via magnetic resonance imaging (MRI). After an overnight fast, serum testosterone, inflammatory biomarkers [interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-α), c-reactive protein (CRP)], and anabolic growth factors [insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 3 (IGFBP-3)] were measured. Skeletal muscle biopsies were obtained from the vastus lateralis muscle to measure citrate synthase (CS) and Complex III activity. Regression analyses were used to examine predictors of mitochondrial mass and activity.

Results

CS activity was negatively associated with VAT (r² = 0.360, p < 0.001), CRP (r² = 0.168, p = 0.047), and positively associated with testosterone (r² = 0.145, p = 0.042). Complex III activity was negatively associated with VAT relative to total lean mass (VAT:TLM) (r² = 0.169, p = 0.033), trended for CRP (r² = 0.142, p = 0.069), and positively associated with testosterone (r² = 0.224, p = 0.010). Multiple regression showed CS activity was significantly associated with VAT + CRP (r² = 0.412, p = 0.008) and VAT + Testosterone (r² = 0.433, p = 0.001). Complex III activity was significantly associated with VAT relative to total trunk cross-sectional area (CSA) + CRP (VAT:total trunk CSA + CRP; r² = 0.286, p = 0.048) and VAT + Testosterone (r² = 0.277, p = 0.024).

Conclusion

Increased visceral adiposity and associated inflammatory signaling (CRP) along with reduced testosterone levels predict mitochondrial dysfunction following SCI. Specifically, lower VAT_CSA and higher testosterone levels or lower VAT_CSA and lower CRP levels positively predict mitochondrial mass and enzyme activity in persons with chronic SCI. Future research should investigate the efficacy of diet, exercise, and potentially testosterone replacement therapy on enhancing mitochondrial health in chronic SCI.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier: [NCT02660073].

A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury

Objectives

To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI).

Methods

A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures.

Results

One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported.

Conclusion

The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.

Cause of Death Trends Among Persons With Spinal Cord Injury in the United States: 1960-2017

OBJECTIVE

To identify trends in causes of death after spinal cord injury (SCI) that could enhance understanding of why life expectancy after SCI has not improved in the last 3 decades.

DESIGN

Cohort study.

SETTING

Twenty-nine SCI Model Systems and 3 Shriners Hospitals.

PARTICIPANTS

Individuals with traumatic SCI (N=49,266) enrolled in the SCI Collaborative Survival Study Database between 1973 and 2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Age-standardized cause-specific SCI mortality rates and 95% confidence intervals were calculated for 5 time intervals (1960-1979, 1980-1989, 1990-1999, 2000-2009, and 2010-2017).

RESULTS

A total of 17,249 deaths occurred in 797,226 person-years of follow-up. Since 2010, the highest mortality rate was for respiratory diseases, followed by heart disease, cancer, infective and parasitic diseases (primarily septicemia), and unintentional injuries. Mortality rates for respiratory diseases, cancer, stroke, urinary diseases, and digestive diseases, initially decreased significantly but remained relatively stable since 1980, whereas essentially no progress occurred for infective and parasitic diseases. Mortality rates for heart disease, pulmonary embolus, and suicide decreased significantly throughout the entire study period, but were offset by increases in mortality rates for endocrine (primarily diabetes), nutritional, and metabolic diseases, as well as unintentional injuries. From 2010 to 2017, the overall age-standardized mortality rate was 3 times higher for individuals with SCI than the general population, ranging from 27% higher for cancer to 9 times higher for infective and parasitic diseases.

CONCLUSION

Improving life expectancy after SCI will require: (1) reducing mortality rates from respiratory diseases and septicemia that have remained high, (2) reversing current trends in diabetes and unintentional injury deaths, and (3) continuing to reduce mortality from heart disease and other leading causes.

Health promotion and preventive health care service guidelines for the care of people with spina bifida

Individuals with Spina Bifida (SB) have unique lifelong medical and social needs. Thus, when considering how to promote health and offer preventive care, providers must adapt general healthcare screening and counseling recommendations to their patients' physical and cognitive impairments along with discerning how to monitor secondary or chronic conditions common to the population. This article provides an update on the health promotion and preventive health care guidelines developed as part of the Spina Bifida Association's fourth edition of the Guidelines for the Care of People with Spina Bifida. The guidelines highlight accommodations needed to promote general preventive health, common secondary/chronic conditions such as obesity, metabolic syndrome, hypertension, musculoskeletal pain, and considerations for preventing acute care utilization for the SB population throughout the lifespan. Further research is needed to understand the effectiveness of preventive care interventions in promoting positive health outcomes and mitigating potentially preventable acute care utilization.

The Potential Role of Inflammation in Modulating Endogenous Hippocampal Neurogenesis After Spinal Cord Injury

Currently there are approximately 291,000 people suffering from a spinal cord injury (SCI) in the United States. SCI is associated with traumatic changes in mobility and neuralgia, as well as many other long-term chronic health complications, including metabolic disorders, diabetes mellitus, non-alcoholic steatohepatitis, osteoporosis, and elevated inflammatory markers. Due to medical advances, patients with SCI survive much longer than previously. This increase in life expectancy exposes them to novel neurological complications such as memory loss, cognitive decline, depression, and Alzheimer's disease. In fact, these usually age-associated disorders are more prevalent in people living with SCI. A common factor of these disorders is the reduction in hippocampal neurogenesis. Inflammation, which is elevated after SCI, plays a major role in modulating hippocampal neurogenesis. While there is no clear consensus on the mechanism of the decline in hippocampal neurogenesis and cognition after SCI, we will examine in this review how SCI-induced inflammation could modulate hippocampal neurogenesis and provoke age-associated neurological disorders. Thereafter, we will discuss possible therapeutic options which may mitigate the influence of SCI associated complications on hippocampal neurogenesis.

Metabolic Dysfunction in Spinal Muscular Atrophy

Spinal muscular atrophy (SMA) is an autosomal recessive genetic disorder leading to paralysis, muscle atrophy, and death. Significant advances in antisense oligonucleotide treatment and gene therapy have made it possible for SMA patients to benefit from improvements in many aspects of the once devastating natural history of the disease. How the depletion of survival motor neuron (SMN) protein, the product of the gene implicated in the disease, leads to the consequent pathogenic changes remains unresolved. Over the past few years, evidence toward a potential contribution of gastrointestinal, metabolic, and endocrine defects to disease phenotype has surfaced. These findings ranged from disrupted body composition, gastrointestinal tract, fatty acid, glucose, amino acid, and hormonal regulation. Together, these changes could have a meaningful clinical impact on disease traits. However, it is currently unclear whether these findings are secondary to widespread denervation or unique to the SMA phenotype. This review provides an in-depth account of metabolism-related research available to date, with a discussion of unique features compared to other motor neuron and related disorders.

Role of exercise on visceral adiposity after spinal cord injury: a cardiometabolic risk factor

PURPOSE

Visceral adipose tissue (VAT) is associated with cardiometabolic disease risk in able-bodied (AB) populations. However, the underlying mechanisms of VAT-induced disease risk are unknown in persons with spinal cord injury (SCI). Potential mechanisms of VAT-induced cardiometabolic dysfunction in persons with SCI include systemic inflammation, liver adiposity, mitochondrial dysfunction, and anabolic deficiency. Moreover, how exercise interventions impact these mechanisms associated with VAT-induced cardiometabolic dysfunction are still being explored.

METHODS

A search for relevant scientific literature about the effects of exercise on VAT and cardiometabolic health was conducted on the PubMed database. Literature from reference lists was also included when appropriate.

RESULTS

Both aerobic and resistance exercise training beneficially impact health and VAT mass via improving mitochondrial function, glucose effectiveness, and inflammatory signaling in SCI and AB populations. Specifically, aerobic exercise appears to also modulate cellular senescence in AB populations and animal models, while resistance exercise seems to augment anabolic signaling in persons with SCI.

CONCLUSIONS

The current evidence supports regular engagement in exercise to reduce VAT mass and the adverse effects on cardiometabolic health in persons with SCI. Future research is needed to further elucidate the precise mechanisms by which VAT negatively impacts health following SCI. This will likely facilitate the development of rehabilitation protocols that target VAT reduction in persons with SCI.

Anthropometric Prediction of Visceral Adiposity in Persons With Spinal Cord Injury

Over two-thirds of persons with spinal cord injury (SCI) experience neurogenic obesity-induced cardiometabolic syndrome (CMS) and other chronic comorbidities. Obesity is likely to impede social and recreational activities, impact quality of life, and impose additional socioeconomic burdens on persons with SCI. Advances in imaging technology facilitate the mapping of adiposity and its association with the cardiometabolic profile after SCI. Central adiposity or central obesity is characterized by increased waist (WC) and abdominal circumferences (AC) as well as visceral adipose tissue (VAT). A number of studies, while relying on expensive imaging techniques, have reported direct associations of both central obesity and VAT in imposing significant health risks after SCI. The mechanistic role of central obesity on cardiometabolic heath in persons with SCI has yet to be identified, despite the knowledge that it has been designated as an independent risk factor for cardiometabolic dysfunction and premature mortality in other clinical populations. In persons with SCI, the distribution of adipose tissue has been suggested to be a function of sex, level of injury, and age. To date, there is no SCI-specific WC or AC cutoff value to provide anthropometric prediction of VAT and diagnostic capability of persons at risk for central obesity, CMS, and cardiovascular disease after SCI. The purpose of the current review is to summarize the factors contributing to visceral adiposity in persons with SCI and to develop an SCI-specific anthropometric prediction equation for this population. Furthermore, a proposed WC cutoff will be discussed as a surrogate index for central obesity, CMS, and cardiovascular disorders after SCI.

Accuracy of body mass index in categorizing weight status in children with intellectual and developmental disabilities

PURPOSE

To identify the accuracy of Body Mass Index (BMI) to categorize body weight in a sample of children with spina bifida and Down syndrome as compared to typically developing peers.

METHODS

A secondary analysis of 32 children with spina bifida, Down syndrome or no chronic illness. A calculated BMI was plotted on the Centers for Disease Control and Prevention age- and sex-specific BMI growth charts to determine each child's weight status. Percentage of body fat, obtained by labeled water, was plotted on two different body fat percentile reference curves, one derived from a whole body measure (DXA) of body fat and one by skin-fold measure. Differences in weight categories between calculated BMI and body fat percentile curves were reported.

RESULTS

The calculated BMI for children with a disability had significant misclassifications as a screening tool for body fat when compared to children without a disability. Misclassifications were increased with the body fat percentile reference curve derived from skin-fold measures and for children who primarily used a wheelchair.

CONCLUSION

The current recommendation to use BMI to categorize weight status is not useful for many children with disabilities. Further research to identify an alternative pragmatic strategy is necessary.

Nutrition, metabolic syndrome, and obesity: Guidelines for the care of people with spina bifida

Nutritional challenges and a lack of activity can lead to health problems across the lifespan for people with spina bifida. Children and adults with spina bifida are also at greater risk of being classified as overweight or obese compared to their peers without the condition. Therefore, early recognition of nutrition problems, weight management counseling, and timely referrals for evaluation and management of diet and activity can help those with spina bifida and their families achieve a healthy lifestyle. This article details the development of the Nutrition, Metabolic Syndrome and Obesity Guidelines, which are part of the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida. It discusses the identification and management of poor nutrition and prevention of obesity for children, adolescents, and adults with spina bifida and highlights areas requiring further research.

Hepatic dysfunction after spinal cord injury: A vicious cycle of central and peripheral pathology?

The liver is essential for numerous physiological processes, including filtering blood from the intestines, metabolizing fats, proteins, carbohydrates and drugs, and regulating iron storage and release. The liver is also an important immune organ and plays a critical role in response to infection and injury throughout the body. Liver functions are regulated by autonomic parasympathetic innervation from the brainstem and sympathetic innervation from the thoracic spinal cord. Thus, spinal cord injury (SCI) at or above thoracic levels disrupts major regulatory mechanisms for hepatic functions. Work in rodents and humans shows that SCI induces liver pathology, including hepatic inflammation and fat accumulation characteristic of a serious form of non-alcoholic fatty liver disease (NAFLD) called non-alcoholic steatohepatitis (NASH). This hepatic pathology is associated with and likely contributes to indices of metabolic dysfunction often noted in SCI individuals, such as insulin resistance and hyperlipidemia. These occur at greater rates in the SCI population and can negatively impact health and quality of life. In this review, we will: 1) Discuss acute and chronic changes in human and rodent liver pathology and function after SCI; 2) Describe how these hepatic changes affect systemic inflammation, iron regulation and metabolic dysfunction after SCI; 3) Describe how disruption of the hepatic autonomic nervous system may be a key culprit in post-injury chronic liver pathology; and 4) Preview ongoing and future research that aims to elucidate mechanisms driving liver and metabolic dysfunction after SCI.

Activity/exercise-induced changes in the liver transcriptome after chronic spinal cord injury

Multi-organ dysfunction is a major complication after spinal cord injury (SCI). In addition to local injury within the spinal cord, SCI causes major disruption to the peripheral organ innervation and regulation. The liver contains sympathetic, parasympathetic, and small sensory axons. The bi-directional signaling of sensory dorsal root ganglion (DRG) neurons that provide both efferent and afferent information is of key importance as it allows sensory neurons and peripheral organs to affect each other. SCI-induced liver inflammation precedes and may exacerbate intraspinal inflammation and pathology after SCI, which may be modulated by activity and exercise. In this study, we collected comprehensive gene expression data through RNA sequencing of liver tissue from rats with chronic SCI to determine the effects of activity and exercise on those expression patterns. The sequenced data are of high quality and show a high alignment rate to the Rn6 genome. Gene expression is demonstrated for genes associated with known liver pathologies. UCSC Genome Browser expression tracks are provided with the data to facilitate exploration of the samples.

Following spinal cord injury, PDE4B drives an acute, local inflammatory response and a chronic, systemic response exacerbated by gut dysbiosis and endotoxemia

Emerging evidence links changes in the gut microbiome and intestinal barrier function to alterations in CNS function. We examined the role of endotoxin-responsive, cAMP-specific, Pde4 subfamily b (Pde4b) enzyme in gut dysbiosis induced neuro-inflammation and white matter loss following spinal cord injury (SCI). Using a thoracic contusion model in C57Bl/6 wild type female mice, SCI led to significant shifts in the gut bacterial community including an increase in the phylum Proteobacteria, which consists of endotoxin-harboring, gram-negative bacteria. This was accompanied by increased systemic inflammatory marker, soluble CD14, along with markers of the endoplasmic reticulum stress response (ERSR) and inflammation in the SCI epicenter. Deletion of Pde4b reduced epicenter expression of markers for the ERSR and inflammation, at both acute and chronic time points post-SCI. Correspondingly, expression of oligodendrocyte mRNAs increased. Within the injury penumbra, inflammatory protein markers of activated astrocytes (GFAP), macrophage/microglia (CD11b, Iba1), and the proinflammatory mediator Cox2, were decreased in Pde4b^-/- mice. The absence of Pde4b improved white matter sparing and recovery of hindlimb locomotion following injury. Importantly, SCI-induced gut dysbiosis, bacterial overgrowth and endotoxemia were also prevented in Pde4b^-/- mice. Taken together, these findings indicate that PDE4B plays an important role in the development of acute and chronic inflammatory response and consequent recovery following SCI.

Dietary Green Tea Extract Prior to Spinal Cord Injury Prevents Hepatic Iron Overload but Does Not Improve Chronic Hepatic and Spinal Cord Pathology in Rats

Spinal cord injury (SCI) disrupts autonomic regulation of visceral organs. As a result, a leading cause of mortality in the SCI population is metabolic dysfunction, and an organ central to metabolic control is the liver. Our recent work showed that rodent SCI promotes Kupffer cell (hepatic macrophage) activation, pro-inflammatory cytokine expression, and liver steatosis. These are symptoms of nonalcoholic steatohepatitis (NASH), the hepatic manifestation of metabolic syndrome, and these pre-clinical data replicate aspects of post-SCI human metabolic dysfunction. Because metabolic profile is highly dependent on lifestyle, including diet, it is likely that lifestyle choices prior to injury influence metabolic and hepatic outcomes after SCI. Therefore, in this study we tested if a diet rich in green tea extract (GTE), a known hepatoprotective agent, that began 3 weeks before SCI and was maintained after injury, reduced indices of liver pathology or metabolic dysfunction. GTE treatment significantly reduced post-SCI hepatic iron accumulation and blunted circulating glucose elevation compared with control-diet rats. However, GTE pre-treatment did not prevent Kupffer cell activation, hepatic lipid accumulation, increased serum alanine transaminase, or circulating non-esterified fatty acids, which were all significantly increased 6 weeks post-injury. Spinal cord pathology also was unchanged by GTE. Thus, dietary GTE prior to and after SCI had only a minor hepatoprotective effect. In general, for optimal health of SCI individuals, it will be important for future studies to evaluate how other lifestyle choices made before or after SCI positively or negatively impact systemic and intraspinal outcomes and the overall metabolic health of SCI individuals.

Care for Adults with Spina Bifida: Current State and Future Directions

The care for adults with spina bifida is an important area to study. As increasing numbers of patients with spina bifida survive into adulthood, they expect to thrive and receive the best possible care into adulthood to maintain their health. Understanding the health needs in this emerging and changing population will help clinicians provide the best anticipatory care for adults with spina bifida and continue to improve outcomes. This will also impact pediatric care by improving the ability to determine preventive methods from early on and understand the impacts of pediatric care and decisions over the lifespan.

The Musculoskeletal Aspects of Obesity in Neuromuscular Conditions

Obesity is a common problem in children and adolescents with neuromuscular disease. The available literature on obesity in cerebral palsy, spina bifida, and Duchenne muscular dystrophy as it relates to orthopedic treatment is reviewed, including the demographics and measurement of obesity as well as the mechanisms of obesity in these individuals. In addition, the effect of obesity on function, patient evaluation, and orthopedic treatment are reviewed.

Exercise Prescription Using a Group-Normalized Rating of Perceived Exertion in Adolescents and Adults With Spina Bifida

BACKGROUND

People with spina bifida (SB) face personal and environmental barriers to exercise that contribute to physical inactivity, obesity, risk of cardiovascular disease, and poor aerobic fitness. The WHEEL rating of perceived exertion (RPE) Scale was validated in people with SB to monitor exercise intensity. However, the psycho-physiological link between RPE and ventilatory breakpoint (Vpt), the group-normalized perceptual response, has not been determined and would provide a starting point for aerobic exercise in this cohort.

OBJECTIVES

The primary objectives were to determine the group-normalized RPE equivalent to Vpt based on WHEEL and Borg Scale ratings and to develop a regression model to predict Borg Scale (conditional metric) from WHEEL Scale (criterion metric). The secondary objective was to create a table of interchangeable values between WHEEL and Borg Scale RPE for people with SB performing a load incremental stress test.

DESIGN

Cross-sectional observational.

SETTING

University laboratory.

PARTICIPANTS

Twenty-nine participants with SB.

METHODS

Participants completed a load incremented arm ergometer exercise stress test. WHEEL and Borg Scale ratings were recorded the last 15 seconds of each 1-minute test phase.

OUTCOME MEASURES

WHEEL and Borg Scale ratings, metabolic measures (eg, oxygen consumption, carbon dioxide production). Determined Vpt via plots of oxygen consumption and carbon dioxide production against time.

RESULTS

Nineteen of 29 participants achieved Vpt (Group A). The mean ± standard deviation peak oxygen consumption at Vpt for Group A was 61.76 ± 16.26. The WHEEL and Borg Scale RPE at Vpt were 5.74 ± 2.58 (range 0-10) and 13.95 ± 3.50 (range 6-19), respectively. A significant linear regression model was developed (Borg Scale rating = 1.22 × WHEEL Scale rating + 7.14) and used to create a WHEEL-to-Borg Scale RPE conversion table.

CONCLUSION

A significant linear regression model and table of interchangeable values was developed for participants with SB. The group-normalized RPE (WHEEL, 5.74; Borg, 13.95) can be used to prescribe and self-regulate arm ergometer exercise intensity approximating the Vpt.

LEVEL OF EVIDENCE

III.

Paradigms of Lower Extremity Electrical Stimulation Training After Spinal Cord Injury

Skeletal muscle atrophy, increased adiposity and reduced physical activity are key changes observed after spinal cord injury (SCI) and are associated with numerous cardiometabolic health consequences. These changes are likely to increase the risk of developing chronic secondary conditions and impact the quality of life in persons with SCI. Surface neuromuscular electrical stimulation evoked resistance training (NMES-RT) was developed as a strategy to attenuate the process of skeletal muscle atrophy, decrease ectopic adiposity, improve insulin sensitivity and enhance mitochondrial capacity. However, NMES-RT is limited to only a single muscle group. Involving multiple muscle groups of the lower extremities may maximize the health benefits of training. Functional electrical stimulation-lower extremity cycling (FES-LEC) allows for the activation of 6 muscle groups, which is likely to evoke greater metabolic and cardiovascular adaptation. Appropriate knowledge of the stimulation parameters is key to maximizing the outcomes of electrical stimulation training in persons with SCI. Adopting strategies for long-term use of NMES-RT and FES-LEC during rehabilitation may maintain the integrity of the musculoskeletal system, a pre-requisite for clinical trials aiming to restore walking after injury. The current manuscript presents a combined protocol using NMES-RT prior to FES-LEC. We hypothesize that muscles conditioned for 12 weeks prior to cycling will be capable of generating greater power, cycle against higher resistance and result in greater adaptation in persons with SCI.

Impact of neurological level and spinal curvature on pulmonary function in adults with spina bifida

PURPOSE

To describe pulmonary function and determine the impact of neurological level, scoliosis, and obesity on pulmonary function in people with spina bifida (SB).

METHODS

Participants with SB (N= 29) (15 females; age, 30 ± 12 years) completed spirometry and body plethysmographic lung volume testing. Univariate and multivariate regression analyses were used to describe the factors associated with pulmonary function in people with SB.

RESULTS

Distribution of category of impairment in pulmonary function was: 55% (n= 16) restricted, 6.9% (n= 2) spirometric restricted, 1 combined obstructed and restricted, and 35.5% (n= 10) normal. In univariate analyses, neurological level was negatively associated with pulmonary function parameters, i.e., forced vital capacity (FVC) (p= 0.005), forced expiratory volume in 1 second (FEV1) (p= 0.008), total lung capacity (TLC) (p= 0.001), and degree of scoliosis were inversely associated with FVC (p= 0.005), FEV1 (p= 0.003), and TLC (p= 0.004). In multivariate models, level of lesion and degree of scoliosis independently contributed to the degree of lung function impairment. Restrictive pulmonary function was observed in 9/10 (90%) of those with thoracic neurological levels and was associated with decreased inspiratory capacity (IC) and expiratory reserve volume (ERV). Lumbar level lesions were associated with either normal lung function or an isolated reduction in FVC due to reduction in only ERV and preserved TLC representing spirometric restriction.

CONCLUSIONS

High prevalence of restrictive pulmonary physiology is present in people with SB, with more rostral neurological levels and greater degree of scoliosis associated with a higher degree of pulmonary function impairment.

Obesity and anthropometry in spina bifida: What is the best measure

OBJECTIVE

Diagnosis of obesity using traditional body mass index (BMI) using length may not be a reliable indicator of body composition in spina bifida (SB). We examine traditional and surrogate measures of adiposity in adults with SB, correlated with activity, metabolic disease, attitudes towards exercise and quality of life.

DESIGN

Adult subjects with SB underwent obesity classification using BMI by length and arm span, abdominal girth and percent trunk fat (TF) on dual energy X-ray absorptiometry (DXA). Quality of life measures, activity level and metabolic laboratory values were also reviewed.

RESULTS

Among eighteen subjects (6 male, 12 female), median age was 26.5 (range 19-37) years, with level of lesion 16.7% ≤L2, 61.1% L3-4, and 22.2% ≥L5, respectively. Median weight was 71.8 (IQR 62.4, 85.8) kg, similar between sexes (P = 0.66). With median length of 152.0 (IQR 141.8, 163.3) cm, median conventional BMI was 29.4 m/kg², with 7 (43.8%) subjects with BMI >30. Median BMI by arm span was 30.2 m/kg², abdominal girth of 105.5 cm, and TF 45.7%. More subjects were classified as obese using alternate measures, with 9 (56.3%) by arm span, 14 (82.4%) by abdominal girth and 15 (83.3%) by TF (P = 0.008). Reclassification of obesity from conventional BMI was significant when using TF (P = 0.03). No difference in quality of life measures, activity level and metabolic abnormalities was demonstrated between obese and non-obese subjects.

CONCLUSIONS

Conventional determination of obesity using BMI by length is an insensitive marker in adults with SB. Adults with SB are more often classified as obese using TF by DXA.

Gut Microbiota Are Disease-Modifying Factors After Traumatic Spinal Cord Injury

Spinal cord injury (SCI) disrupts the autonomic nervous system (ANS), impairing its ability to coordinate organ function throughout the body. Emerging data indicate that the systemic pathology that manifests from ANS dysfunction exacerbates intraspinal pathology and neurological impairment. Precisely how this happens is unknown, although new data, in both humans and in rodent models, implicate changes in the composition of bacteria in the gut (i.e., the gut microbiota) as disease-modifying factors that are capable of affecting systemic physiology and pathophysiology. Recent data from rodents indicate that SCI causes gut dysbiosis, which exacerbates intraspinal inflammation and lesion pathology leading to impaired recovery of motor function. Postinjury delivery of probiotics containing various types of "good" bacteria can partially overcome the pathophysiologal effects of gut dysbiosis; immune function, locomotor recovery, and spinal cord integrity are partially restored by a sustained regimen of oral probiotics. More research is needed to determine whether gut dysbiosis varies across a range of clinically relevant variables, including sex, injury level, and injury severity, and whether changes in the gut microbiota can predict the onset or severity of common postinjury comorbidities, including infection, anemia, metabolic syndrome, and, perhaps, secondary neurological deterioration. Those microbial populations that dominate the gut could become "druggable" targets that could be manipulated via dietary interventions. For example, personalized nutraceuticals (e.g., pre- or probiotics) could be developed to treat the above comorbidities and improve health and quality of life after SCI.

Total energy expenditure and body composition of children with developmental disabilities

BACKGROUND

Obesity prevalence is increased in children with developmental disabilities, specifically in children with spina bifida and Down syndrome. Energy expenditure, a critical aspect of weight management, has been extensively studied in the typically developing population, but not adequately studied in children with developmental disabilities.

OBJECTIVE

Determine energy expenditure, fat-free mass and body fat percentile and the impact of these findings on recommended caloric intake in children with spina bifida and Down syndrome.

METHODS/MEASURES

This pilot study included 36 children, 18 with spina bifida, 9 with Down syndrome and 9 typically developing children. Half of the children with spina bifida were non-ambulatory. Doubly labeled water was used to measure energy expenditure and body composition. Descriptive statistics described the sample and MANOVA and ANOVA methods were used to evaluate differences between groups.

RESULTS

Energy expenditure was significantly less for children with spina bifida who primarily used a wheelchair (p = .001) and children with Down syndrome (p = .041) when compared to children without a disability when adjusted for fat-free mass. However, no significant difference was detected in children with spina bifida who ambulated without assistance (p = .072).

CONCLUSIONS

Children with spina bifida and Down syndrome have a significantly decreased energy expenditure which directly impacts recommended caloric intake. No significant difference was detected for children with spina bifida who ambulated, although the small sample size of this pilot study may have limited these findings. Validating these results in a larger study is integral to supporting successful weight management of these children.

A chronic care model for spina bifida transition

Providing comprehensive transition care for adolescents and young adults with spina bifida (AYASB) requires a structured approach to addressing chronic condition management, self-management, care coordination, and health care navigation that is adaptable to the various levels of cognitive ability, physical function, and family/community environments within the population. This commentary (1) highlights AYASB transition program needs identified in the literature and within a local community, (2) analyzes advantages and limitations of published AYASB transition care models in addressing these needs, (3) demonstrates how a spina bifida (SB) transition clinic used the Chronic Care Model (CCM) to develop a comprehensive AYASB transition program, and (4) examines the potential feasibility in adapting this model to other SB clinics. A SB-specific transition clinic based on the CCM model facilitates the complex chronic care management and transition planning for AYASB. Further study is needed to evaluate health care outcomes using the CCM for SB transition.

Chronic spinal cord changes in a high-fat diet-fed male rat model of thoracic spinal contusion

Individuals that suffer injury to the spinal cord can result in long-term, debilitating sequelae. Spinal cord-injured patients have increased risk for the development of metabolic disease, which can further hinder the effectiveness of treatments to rehabilitate the cord and improve quality of life. In the present study, we sought to understand the impact of high-fat diet (HFD)-induced obesity on spinal cord injury (SCI) by examining transcriptome changes in the area of the injury and rostral and caudal to site of damage 12 wk after injury. Adult, male Long-Evans rats received either thoracic level contusion of the spinal cord or sham laminectomy and then were allowed to recover on normal rat chow for 4 wk and further on HFD for an additional 8 wk. Spinal cord tissues harvested from the rats were processed for Affymetrix microarray and further transcriptomic analysis. Diverse changes in gene expression were identified in the injured cord in genes such as MMP12, APOC4, GPNMB, and IGF1 and 2. The greatest signaling changes occurred in pathways involved in cholesterol biosynthesis and immune cell trafficking. Together, the cord changes in the chronically obese rat following thoracic SCI reveal further potential targets for therapy. These could be further explored as they overlap with genes involved in metabolic disease.

FEV1 and FVC and systemic inflammation in a spinal cord injury cohort

Background

Systemic inflammation has been associated with reduced pulmonary function in individuals with and without chronic medical conditions. Individuals with chronic spinal cord injury (SCI) have clinical characteristics that promote systemic inflammation and also have reduced pulmonary function. We sought to assess the associations between biomarkers of systemic inflammation with pulmonary function in a chronic SCI cohort, adjusting for other potential confounding factors.

Methods

Participants (n = 311) provided a blood sample, completed a respiratory health questionnaire, and underwent spirometry. Linear regression methods were used to assess cross-sectional associations between plasma C-reactive protein (CRP) and interleukin-6 (IL-6) with forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), and FEV₁/FVC.

Results

There were statistically significant inverse relationships between plasma CRP and IL-6 assessed in quartiles or continuously with FEV₁ and FVC. In fully adjusted models, each interquartile range (5.91 mg/L) increase in CRP was associated with a significant decrease in FEV₁ (−55.85 ml; 95% CI: -89.21, −22.49) and decrease in FVC (−65.50 ml; 95% CI: -106.61, −24.60). There were similar significant findings for IL-6. There were no statistically significant associations observed with FEV₁/FVC.

Conclusion

Plasma CRP and IL-6 in individuals with chronic SCI are inversely associated with FEV₁ and FVC, independent of SCI level and severity of injury, BMI, and other covariates. This finding suggests that systemic inflammation associated with chronic SCI may contribute to reduced pulmonary function.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-017-0459-6) contains supplementary material, which is available to authorized users.

From Disease to Health: Physical Therapy Health Promotion Practices for Secondary Prevention in Adult and Pediatric Neurologic Populations

BACKGROUND AND PURPOSE

Over the last decade there has been a substantial increase in efforts to better understand how targeted physical activity and exercise interventions can be used to minimize secondary consequences arising from neurological damage in both adult and pediatric populations. This article offers an overview of contemporary research that addresses mediators of functional and neuroplastic adaptations associated with physical activity and exercise. We emphasize the important role that physical therapists can play to increase participation and improve well-being in adults and children with neurological disorders. We further highlight potential strategies to foster translation of evidence-based findings for use by clinicians and consumers.

SUMMARY OF KEY POINTS

Engagement in physical activity can serve as a powerful promoter of health and well-being in adults and youth with neurologic disease, and has the potential to alter the course of disease processes. Physical therapists can play a key role in promoting fitness and wellness by encouraging active living, providing early diagnosis of disease and prescribing targeted activity interventions to improve fitness and participation, and helping individuals overcome personal and environmental barriers to an active lifestyle.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Physical therapists must adopt a model of rehabilitation that emphasizes secondary prevention in adults and youth with neurologic diseases. Physical therapists have a unique role in developing forward-thinking approaches in using innovative health and wellness strategies to promote positive changes in activity and exercise behaviors.

Obesity Prevention for Individuals with Spina Bifida

PURPOSE OF REVIEW

Obesity is a common comorbidity in individuals with spina bifida. Carrying excess weight exacerbates the inherent health challenges associated with spina bifida, impedes the individual's ability to self-manage their condition, and creates further challenges for family members and caregivers. This manuscript provides a narrative review of key issues for understanding and prevention of obesity in persons with spina bifida within the context of the social ecological model.

RECENT FINDINGS

Specific variables related to obesity and spina bifida include individual factors (i.e., body composition and measurement issues, energy needs, eating patterns, physical activity, and sedentary activity) family factors (i.e., parenting/family, peers), community factors (i.e., culture, built environment, healthcare and healthcare providers, and school), and societal factors (i.e., policy issues). Due to the complex etiology of obesity and its increased prevalence in individuals with spina bifida, it is critical to initiate prevention efforts early with a multifactorial approach for this at-risk population. Increased research is warranted to support these efforts.

Effects of Testosterone and Evoked Resistance Exercise after Spinal Cord Injury (TEREX-SCI): study protocol for a randomised controlled trial

INTRODUCTION

Individuals with spinal cord injury (SCI) are at a lifelong risk of obesity and chronic metabolic disorders including insulin resistance and dyslipidemia. Within a few weeks of injury, there is a significant decline in whole body fat-free mass, particularly lower extremity skeletal muscle mass, and subsequent increase in fat mass (FM). This is accompanied by a decrease in anabolic hormones including testosterone. Testosterone replacement therapy (TRT) has been shown to increase skeletal muscle mass and improve metabolic profile. Additionally, resistance training (RT) has been shown to increase lean mass and reduce metabolic disturbances in SCI and other clinical populations.

METHODS AND ANALYSIS

26 individuals with chronic, motor complete SCI between 18 and 50 years old were randomly assigned to a RT+TRT group (n=13) or a TRT group (n=13). 22 participants completed the initial 16-week training phase of the study and 4 participants withdrew. 12 participants of the 22 completed 16 weeks of detraining. The TRT was provided via transdermal testosterone patches (4-6 mg/day). The RT+TRT group had 16 weeks of supervised unilateral progressive RT using surface neuromuscular electrical stimulation with ankle weights. This study will investigate the effects of evoked RT+TRT or TRT alone on body composition (muscle cross-sectional area, visceral adipose tissue, %FM) and metabolic profile (glucose and lipid metabolism) in individuals with motor complete SCI. Findings from this study may help in designing exercise therapies to alleviate the deterioration in body composition after SCI and decrease the incidence of metabolic disorders in this clinical population.

ETHICS AND DISSEMINATION

The study is currently approved by the McGuire VA Medical Center and Virginia Commonwealth University. All participants read and signed approved consent forms. Results will be submitted to peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

Pre-result, NCT01652040.

Fasting serum blood measures of bone and lipid metabolism in children with myelomeningocele for early detection of cardiovascular and bone fragility risk factors

OBJECTIVE

This study examined serum levels in children with myelomeningocele to identify the prevalence of pre-clinical signs of disease.

DESIGN

A prospective, cross-sectional study.

SETTING

Patients were actively recruited from multidisciplinary care clinics at tertiary children's hospitals from 2010-2012. The control comparison group was recruited by word-of-mouth.

PATIENTS

Twenty-eight children with myelomeningocele (93% Hispanic; 17 males; 10.0 ± 2.1 years) and 58 controls (84% Hispanic; 30 males; 10.4 ± 2.4 years) provided ≥ 8-hour fasting blood samples with concomitant dual-energy x-ray absorptiometry measurements of body fat.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The serum analysis included a lipid panel (cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein), insulin, glucose, leptin, aspartate aminotransferase, alanine transaminase, alkaline phosphatase, albumin, creatinine, calcium, phosphatase, parathyroid hormone, and vitamin D.

RESULTS

Children with myelomeningocele had higher body fat (35.2% versus 29.9%, p=0.01) and altered lipid profiles (lower high-density lipoprotein levels, 43.9 mg/dL versus 51.6 mg/dL, P = 0.03) suggesting elevated risk of metabolic syndrome. They also had a higher prevalence of vitamin D deficiency (43% versus 17%, p=0.02) and significantly lower levels of calcium (9.4 mg/dL versus 9.7 mg/dL, P = 0.003) and alkaline phosphatase (187.0 U/L versus 237.0 U/L, P = 0.003). Unexpectedly children with myelomeningocele had lower parathyroid hormone levels (14.5 pg/mL versus 18.4 pg/mL, P = 0.02) than controls despite lower calcium, vitamin D and alkaline phosphatase levels. This suggests an alteration in the sensing mechanism or response of the parathyroid gland to normal physiological stimuli in patients with myelomeningocele.

CONCLUSIONS

Children with myelomeningocele have abnormal biochemical markers for cardiovascular disease, insulin resistance and bone and mineral metabolism. Early recognition and monitoring of these risk factors in patients with myelomeningocele may help prevent later complications.

Gut dysbiosis impairs recovery after spinal cord injury

Kigerl et al. show that spinal cord injury causes profound changes in gut microbiota and that these changes in gut ecology are associated with activation of GALT immune cells. They show that feeding mice probiotics after SCI confers neuroprotection and improves functional recovery.

The trillions of microbes that exist in the gastrointestinal tract have emerged as pivotal regulators of mammalian development and physiology. Disruption of this gut microbiome, a process known as dysbiosis, causes or exacerbates various diseases, but whether gut dysbiosis affects recovery of neurological function or lesion pathology after traumatic spinal cord injury (SCI) is unknown. Data in this study show that SCI increases intestinal permeability and bacterial translocation from the gut. These changes are associated with immune cell activation in gut-associated lymphoid tissues (GALTs) and significant changes in the composition of both major and minor gut bacterial taxa. Postinjury changes in gut microbiota persist for at least one month and predict the magnitude of locomotor impairment. Experimental induction of gut dysbiosis in naive mice before SCI (e.g., via oral delivery of broad-spectrum antibiotics) exacerbates neurological impairment and spinal cord pathology after SCI. Conversely, feeding SCI mice commercial probiotics (VSL#3) enriched with lactic acid–producing bacteria triggers a protective immune response in GALTs and confers neuroprotection with improved locomotor recovery. Our data reveal a previously unknown role for the gut microbiota in influencing recovery of neurological function and neuropathology after SCI.

The measurement of body composition in children with spina bifida: Feasibility and preliminary findings

PURPOSE

To assess the feasibility of obtaining and comparing various methods of height and body composition (BC) measurements in children with spina bifida (SB).

METHODS

Fifteen children (7M/8F) with SB (4-18 years old) underwent weight, four height measurements (arm span, wall-mounted stadiometer, segmental and recumbent length) and five BC measurements: (BMI; BodPod®; DEXA; Bioelectrical Impedance Analysis; and skinfold). Data collectors, parents, and study participants evaluated procedures. The four heights as paired with the BC measurements were compared to the gold standard DEXA measurements.

RESULTS

Procedures were successfully completed in 14 of 15 children. Skinfolds and segmental length had a midlevel ranking of comfort. While no measures substituted for the DEXA scan, preliminary findings suggest that an algorithm may estimate BC in this high-risk population. Currently, arm span used within BodPod® measurements provided the closest agreement with the DEXA scan.

CONCLUSION

Study protocol was feasible and provided necessary information, including recommended modifications, for successful implementation of the planned subsequent study.

Cross-sectional associations of pulmonary function with systemic inflammation and oxidative stress in individuals with chronic spinal cord injury

CONTEXT/OBJECTIVE

Systemic inflammation, and to a lesser extent oxidative stress, have been associated with reduced pulmonary function. Our objective was to evaluate the associations between biomarkers of inflammation (C-reactive protein (CRP), interleukin-6 (IL-6)) and novel makers of global oxidative stress (fluorescent oxidation products (FLOx)) with spirometric and lung volume measures in individuals with chronic spinal cord injury (SCI).

DESIGN

Cross-sectional study.

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

One-hundred thirty-seven men with chronic SCI participating in an epidemiologic study.

METHODS

Participants provided a blood sample, completed health questionnaires, and underwent pulmonary function testing, including helium dilution measurement of functional residual capacity (FRC). General linear models were used to model associations between increasing quartiles of inflammation or oxidative stress with each outcome measure, after adjustment for a number of potential confounders.

OUTCOME MEASURES

Percent-predicted forced vital capacity in one second (FEV1), percent-predicted forced vital capacity (FVC), FEV1/FVC, percent-predicted residual volume (RV), percent-predicted FRC, and percent-predicted total lung capacity (TLC).

RESULTS

After adjustment for a number of confounders, participants with higher levels of CRP and IL-6 had lower percent-predicted FEV1 and FVC measurements. There were no clear patterns of association with any of the oxidative stress biomarkers or other outcome measures.

CONCLUSION

Increased systemic inflammation was associated with reductions in FEV1 and FVC independent of a number of covariates. Although the mechanism is uncertain, these results suggest that reductions in pulmonary function in SCI are associated with systemic inflammation.

Effects of Use and Disuse on Non-paralyzed and Paralyzed Skeletal Muscles

Skeletal muscle is an integral part of the somatic nervous system and plays a primary role in the performance of physical activities. Because physical activity is vital to countering the effects of aging and age related diseases and is a key component in the maintenance of healthy body composition it is important to understand the effects of use and disuse on skeletal muscle. While voluntary muscle activity provides optimal benefits to muscle and the maintenance of healthy body composition, neuromuscular electrical stimulation may be a viable alternative activity for individuals with paralysis. Body composition with a healthy muscle to fat ratio has been associated with healthy blood lipid and glucose profiles that may decrease the risk of cardiovascular and metabolic diseases.

Comparison of Fat Mass Percentage and Body Mass Index in Koreans With Spinal Cord Injury According to the Severity and Duration of Motor Paralysis

OBJECTIVE

To analyze the relationship of the change in fat mass percentage (FMP) and body mass index (BMI) with the change in obesity rate according to gender, extent of spinal cord injury (SCI) and the duration.

METHODS

The retrospective study was conducted with medical records of 915 patients. FMP was calculated with BMI and bioelectrical impedance analysis (BIA). Statistical analysis of the relationship between FMP and gender, extent of SCI and the duration after SCI was done.

RESULTS

FMP increased in relation to the duration. The mean FMP was higher in the motor complete tetraplegia group, as compared to the motor incomplete group. The rate of obesity was 69.8% with cutoff FMP values of over 22% and 35% for male and female patients, respectively. Rate of obesity was correlated with the duration after SCI and degree of paralysis. The rate of obesity was 17.1% with a cutoff value of BMI 25 kg/m(2) and 51.3% with a cutoff value of 22 kg/m(2). For evaluation of the diagnostic value of BMI to predict obesity according to FMP standards, a cutoff value of 25 kg/m(2) showed a sensitivity level of 22.3% and specificity level of 94.9%. When the cutoff level for BMI was set at 22 kg/m(2), the sensitivity and specificity were 59.3% and 67.0%, respectively.

CONCLUSION

In Korean SCI patients, FMP showed good correlation with the duration of SCI and the extent of SCI, while BMI did not. Especially in the motor complete tetraplegia group, the diagnostic value of BMI decreased as the duration after SCI increased. This study suggested that FMP could be used complementarily when evaluating the obesity of SCI patients.

Inpatient and emergency room visits for adolescents and young adults with spina bifida living in South Carolina

OBJECTIVE

To compare emergency room (ER) and inpatient hospital (IP) use rates for persons with spina bifida (SB) to peers without SB, when transition from pediatric to adult health care is likely to occur; and to analyze those ER and IP rates by age, race, socioeconomic status, gender, and type of residential area.

DESIGN

A retrospective cohort study.

SETTING

Secondary data analysis in South Carolina.

PARTICIPANTS

We studied individuals who were between 15 and 24 years old and enrolled in the State Health Plan (SHP) or state Medicaid during the 2000-2010 study period.

METHODS

Individuals with SB were identified using ICD-9 billing codes (741.0, 741.9) in SHP, Medicaid, and hospital uniform billing (UB) data. ER and IP encounters were identified using UB data. Multivariable Generalized Estimating Equation (GEE) Poisson models were estimated to compare rates of ER and IP use among the SB group to the comparison group.

MAIN OUTCOME MEASURES

Total ER rate and IP rate, in addition to cause-specific rates for ambulatory care sensitive conditions (ACSC) and other condition categories.

RESULTS

We found higher rates of ER and IP use in persons with SB compared to the control group. Among individuals with SB, young adults (those 20-24 years old) had higher rates of ER use due to all ACSC (P = .023), other ACSC (P = .04), and urinary tract infections (UTI; P = .002) compared to adolescents (those 15-19 years old).

CONCLUSIONS

Young adulthood is associated with increased ER use overall, as well as in specific condition categories (most notably UTI) in individuals 15-24 years old with SB. This association may be indicative of changing healthcare access as people with SB move from adolescent to adult health care, and/or physiologic changes during the age range studied.

Validity of a Wheelchair Perceived Exertion Scale (Wheel Scale) for Arm Ergometry Exercise in People with Spina Bifida

This study assessed the concurrent and construct validity of the Borg 6–20 Scale and WHEEL Scale during arm ergometry exercise stress testing in ( n = 24) adolescents and adults with spina bifida. Significant, moderate, positive correlations were observed between power output and relative heart rate and power output to relative VO2peak. Further, a moderate, significant correlation between physiologic criterion variables and the rating of perceived exertion derived from the Borg Scale and the WHEEL Scale was found. Concurrent validity was supported by the following findings: (1) relative heart rate was significantly correlated with the Borg (Kendall's τ = .41) and WHEEL Scales (τ = .44), and relative VO2 was significantly correlated with the Borg (τ = .46) and WHEEL Scales (τ = .47); (2) content validity was supported by the finding that the Borg and WHEEL Scales shared significant variance (τ = .70), demonstrating internal consistency. The WHEEL Scale shows strong potential for use in this cohort subsequent to further testing and validation.

Effects of spinal cord injury on body composition and metabolic profile - part I

Several body composition and metabolic-associated disorders such as glucose intolerance, insulin resistance, and lipid abnormalities occur prematurely after spinal cord injury (SCI) and at a higher prevalence compared to able-bodied populations. Within a few weeks to months of the injury, there is a significant decrease in total lean mass, particularly lower extremity muscle mass and an accompanying increase in fat mass. The infiltration of fat in intramuscular and visceral sites is associated with abnormal metabolic profiles. The current review will summarize the major changes in body composition and metabolic profiles that can lead to comorbidities such as type 2 diabetes mellitus and cardiovascular diseases after SCI. It is crucial for healthcare specialists to be aware of the magnitude of these changes. Such awareness may lead to earlier recognition and treatment of metabolic abnormalities that may reduce the co-morbidities seen over the lifetime of persons living with SCI.

Spinal cord injury causes chronic liver pathology in rats

Traumatic spinal cord injury (SCI) causes major disruption to peripheral organ innervation and regulation. Relatively little work has investigated these post-SCI systemic changes, however, despite considerable evidence that multiple organ system dysfunction contributes to chronic impairments in health. Because metabolic dysfunction is common after SCI and the liver is a pivotal site for metabolic homeostasis, we sought to determine if liver pathology occurs as a result of SCI in a rat spinal contusion model. Histologic evidence showed excess lipid accumulation in the liver for at least 21 days post-injury after cervical or midthoracic SCI. Lipidomic analysis revealed an acute increase in hepatic ceramides as well as chronically elevated lactosylceramide. Post-SCI hepatic changes also included increased proinflammatory gene expression, including interleukin (IL)-1α, IL-1β, chemokine ligand-2, and tumor necrosis factor-α mRNA. These were coincident with increased CD68+ macrophages in the liver through 21 days post-injury. Serum alanine transaminase, used clinically to detect liver damage, was significantly increased at 21 days post-injury, suggesting that early metabolic and inflammatory damage preceded overt liver pathology. Surprisingly, liver inflammation was even detected after lumbar SCI. Collectively, these results suggest that SCI produces chronic liver injury with symptoms strikingly similar to those of nonalcoholic steatohepatitis (fatty liver disease). These clinically significant hepatic changes after SCI are known to contribute to systemic inflammation, cardiovascular disease, and metabolic syndrome, all of which are more prevalent in persons with SCI. Targeting acute and prolonged hepatic pathology may improve recovery and reduce long-term complications after SCI.

Longitudinal study of body composition in spinal cord injury patients

BACKGROUND

Bone mass loss and muscle atrophy are the frequent complications occurring after spinal cord injury (SCI). The potential risks involved with these changes in the body composition have implications for the health of the SCI individual. Thus, there is a need to quantitate and monitor body composition changes accurately in an individual with SCI. Very few longitudinal studies have been reported in the literature to assess body composition and most include relatively small number of patients. The present prospective study aimed to evaluate the body composition changes longitudinally by DEXA in patients with acute SCI.

MATERIALS AND METHODS

Ninety five patients with acute SCI with neurological deficits were evaluated for bone mineral content (BMC), body composition [lean body mass (LBM) and fat mass] by dual-energy X-ray absorptiometry during the first year of SCI.

RESULTS

There was a significant decrease in BMC (P < 0.05) and LBM (P < 0.05) and increase in total body fat mass (TBFM) and percentage fat at infra-lesional sites. The average decrease was 14.5% in BMC in lower extremities, 20.5% loss of LBM in legs and 15.1% loss of LBM in trunk, and increase of 0.2% in fat mass in legs and 17.3% increased fat in the lower limbs at 1 year. The tetraplegic patients had significant decrease in arm BMC (P < 0.001), arm LBM (P < 0.01) and fat percentage (P < 0.01) compared to paraplegics. Patients with complete motor injury had higher values of TBFM and fat percentage, but comparable values of BMC and LBM to patients with incomplete motor injury.

CONCLUSIONS

Our findings suggest that there is a marked decrease in BMC and LBM with increase in adiposity during the first year of SCI. Although these changes depend on the level and initial severity of lesions, they are also influenced by the neurological recovery after SCI.

Low-grade systemic inflammation and leptin levels were improved by arm cranking exercise in adults with chronic spinal cord injury

OBJECTIVE

To ascertain the effect of arm cranking exercise on improving plasma levels of inflammatory cytokines and adipokines in untrained adults with chronic spinal cord injury (SCI).

DESIGN

Longitudinal study.

SETTING

Community-based supervised intervention.

PARTICIPANTS

Men (N=17) with complete SCI at or below T5 volunteered for this study. Participants were randomly allocated to the intervention (n=9) or control group (n=8) using a concealed method.

INTERVENTION

A 12-week arm cranking exercise program of 3 sessions per week consisted of warm-up (10-15min), arm crank (20-30min; increasing 2min and 30s every 3wk) at a moderate work intensity of 50% to 65% of heart rate reserve (starting at 50% and increasing 5% every 3wk), and cool-down (5-10min).

MAIN OUTCOME MEASURES

Plasma levels of leptin, adiponectin, plasminogen activator inhibitor-1, tumor necrosis factor-alpha, and interleukin-6 were determined. Furthermore, physical fitness (maximum oxygen consumption [V˙O2max]) and body composition (anthropometric index, waist circumference, and body mass index) were also assessed.

RESULTS

Plasma levels of leptin, tumor necrosis factor-alpha, and interleukin-6 were significantly decreased after the completion of the training program. Similarly, the anthropometric index and waist circumference were diminished too. A moderate correlation was found between leptin and the anthropometric index. Finally, V˙O2max was significantly increased, suggesting an improvement of physical fitness in the intervention group. No changes were found in the control group.

CONCLUSIONS

Arm cranking exercise improved low-grade systemic inflammation by decreasing plasma levels of inflammatory cytokines. Furthermore, it also reduced plasma leptin levels. Long-term, well-conducted studies are still required to determine whether these changes may improve clinical outcomes of adults with chronic SCI.