Cardiovascular disease and spinal cord injury: results from a national population health survey

'Time is of the essence': upper-body aerobic exercise to improve cardiovascular health during inpatient rehabilitation within the first year following spinal cord injury - protocol for a randomised clinical trial

INTRODUCTION

Individuals with spinal cord injury (SCI) face heightened cardiovascular disease (CVD) risks. While general exercise guidelines are promoted for SCI individuals, when and how to incorporate exercise during the subacute phase post-SCI remains unclear. Consequently, early aerobic exercise to reduce CVD risks is not standard practice in subacute SCI care, potentially missing an opportunity for optimal cardiovascular rehabilitation, especially given observed reductions in cardiac structure and function within the first year post-SCI. Addressing this gap could improve long-term cardiovascular health and health-related quality of life (HRQOL) for individuals with SCI. Early intervention might prevent worsening cardiovascular function and establish beneficial exercise habits. However, few studies have evaluated the effectiveness of early exercise interventions in this population. This study aims to provide insight into the impact of moderate-intensity arm-crank exercise training (ACET) on cardiometabolic, HRQOL, functional and fitness parameters in individuals with subacute (<12 months postinjury) SCI.

METHODS AND ANALYSIS

We will conduct a single-centre, two-group, single-blind randomised controlled trial with 42 participants who have sustained a cervical or thoracic SCI within the past year. The non-intervention group will receive hospital standard of care (control group) while the intervention group will receive hospital standard of care plus moderate-intensity ACET for 10 weeks in line with the SCI-specific exercise guidelines to improve cardiometabolic health. The primary outcome measure will be central arterial stiffness (carotid-to-femoral pulse wave velocity). Secondary outcomes include assessments of (1) blood biomarkers linked to CVD, (2) cardiac structure and function, (3) extracranial vasculature, (4) HRQOL, (5) cognitive function, (6) physical activity level, (7) cardiorespiratory fitness, (8) motor function and (9) feasibility outcomes. Assessments will occur at baseline (rehabilitation centre admission, -2 weeks), preintervention (0 weeks), postintervention (10 weeks) and follow-up (6 months after postintervention), for HRQOL outcomes only.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Wales Research Ethics Committee (HREC 22/WA/0329). Outcome data will be presented at international conferences, patient advocacy groups, health professional networks and community health events. Findings will be published in peer-reviewed journals and widely disseminated through strategic channels to reach researchers, healthcare providers, patients and the public.

TRIAL REGISTRATION NUMBER

ISRCTN99941302.

Activity-based recovery training with spinal cord epidural stimulation improves standing performance in cervical spinal cord injury

BACKGROUND

Individuals with a clinically complete spinal cord injury are unable to stand independently without external assistance. Studies have shown the combination of spinal cord epidural stimulation (scES) targeted for standing with activity-based recovery training (ABRT) can promote independence of standing in individuals with spinal cord injury. This cohort study aimed to assess the effects of stand-ABRT with scES in individuals with cervical chronic spinal cord injury. We evaluated the ability of these individuals to stand independently from physical assistance across multiple sessions.

METHODS

Thirty individuals participated in this study, all unable to stand independently at the start of the intervention. Individuals were participating in a randomized clinical trial and received stand-ABRT in addition to targeted cardiovascular scES or voluntary scES. During the standing intervention, participants were asked to stand 2 h a day, 5 days a week for 80 sessions (Groups 1 and 2) or 160 sessions (Groups 3 and 4).

RESULTS

A total of 3,524 training days were considered for analysis. Group 1 had 507 days, group 2 with 578 days, and 1152 and 1269 days for groups 3 and 4 respectively. 71% of sessions reached the two-hour standing goal. All individuals achieved outcomes of lower limb independent extension with spinal cord epidural stimulation, with a wide range throughout a training day. Sixteen participants achieved unassisted hip extension while maintaining unassisted bilateral knee and trunk extension. Participants receiving initial voluntary scES training performed better in unassisted bilateral knee and trunk extension than those receiving initial cardiovascular scES. The lower-limb standing activation pattern changes were consistent with the greater standing independence observed by all groups.

CONCLUSIONS

Individuals with chronic cervical spinal cord injury were able to achieve various levels of extension without manual assistance during standing with balance assist following stand-ABRT with scES. These results provide evidence that scES modulates network excitability of the injured spinal cord to allow for the integration of afferent and supraspinal descending input to promote standing in individuals with spinal cord injury.

TRIAL REGISTRATION

The study was registered on Clinical Trials.gov (NCT03364660) prior to subject enrollment.

Effectiveness of a Community-Based Exercise Program for Ambulatory Individuals With Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of a community-based structured exercise program, compared with usual care, in enhancing physical, functional, and psychological outcomes for ambulatory individuals with spinal cord injury (SCI).

DESIGN

Randomized controlled trial comparing exercise group with usual care group.

SETTING

One university-affiliated rehabilitation hospital.

PARTICIPANTS

Fifty-seven participants with chronic SCI who could walk more than 10 m.

INTERVENTIONS

A supervised 20-session program focusing on flexibility, aerobic, and strengthening exercises was provided over 8 weeks for the exercise group, whereas the usual care group maintained their regular daily exercise routines.

MAIN OUTCOME MEASURES

Primary outcome included 6-minute walk test, and secondary outcomes assessed EuroQol-5 Dimensions 5-Level, Spinal Cord Independence Measure III, Berg Balance Scale, Timed Up and Go, grip strength, 30-second sit-to-stand test, sit and reach test, Beck Anxiety Inventory, Beck Depression Inventory, and bioelectrical impedance analysis.

RESULTS

The 51 participants were allocated to intervention (n=36) and usual care (n=15) groups, consisting of 34 males and 17 females (average age, 59.78±13.19y). The participants included 24 with cervical, 17 with thoracic, 8 with lumbar, and 2 with sacral lesions, with all participants having motor incomplete injuries. The exercise group showed significant improvement compared with the usual care group in the 6-minute walk test by 49.80 m (95% confidence interval [CI], 13.04-86.55), Berg Balance Scale scores by 3.50 (95% CI, 0.96-6.03), 30-second sit-to-stand by 2.38 (95% CI, 0.29-4.47), and sit and reach test by 3.89 cm (95% CI, 0.96-6.82). The adherence rate was remarkably high at 89.6%, suggesting the feasibility of community exercise programs for this population. However, no significant changes were observed in psychological and quality-of-life measures.

CONCLUSIONS

Community-based structured exercise programs have been shown to be both feasible and effective in improving walking capacity, balance, lower extremity strength, and flexibility in ambulatory individuals with SCI.

Comparison of the prevalence of metabolic syndrome between individuals with spinal cord injury and the general population based on the cutoff values of abdominal obesity

BACKGROUND

Metabolic syndrome (MetS) is a cluster of cardiovascular disease (CVD) risk factors. Accurate diagnosis, in spinal cord injury (SCI) patients, is vital for effective CVD prevention.

OBJECTIVE

This study aimed to identify factors related to MetS prevalence by comparing MetS prevalence trends in SCI and the general population (GP) and to examine differences in MetS prevalence in patients with SCI according to the cutoff reference value for abdominal obesity.

METHODS

This retrospective cohort study analyzed data from the National Health Insurance Corporation from 2015 to 2019. MetS was defined using the National Cholesterol Education Program criteria with an adjusted waist circumference of 81.3 cm for patients with SCI. Data were collected on age, gender, smoking, alcohol consumption, BMI, waist circumference, lipid profiles, blood pressure, fasting glucose, and socioeconomic status. Each year, SCI patients (n = 3,140, n = 3,201, n = 3,503, n = 1,590, n = 1544) were matched with GP individuals (m = 31,400, m = 32,040, m = 35,030, m = 15,900, m = 15,440).

RESULTS

Over 5 years, MetS prevalence increased in both groups, consistently higher in the SCI group. Older age and lower income were risk factors in both groups (p < 0.05). Smoking and alcohol intake were significant only in the GP (p < 0.0001). Using the adjusted obesity criterion, MetS prevalence was 1.4 times higher in SCI patients than in the GP (p < 0.0001).

CONCLUSIONS

Exclusively relying on GP criteria for diagnosing MetS in patients with SCI may lead to an underestimation of MetS prevalence and overlooked opportunities for CVD prevention. Therefore, the development of diagnostic and preventive strategies for MetS considering SCI characteristics is needed.

The Prevalence of Adrenal Insufficiency in Individuals with Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis

Background/Objectives: Spinal cord injury (SCI) causes profound autonomic and endocrine dysfunctions, giving rise to adrenal insufficiency (AI), which is marked by a reduction in steroid hormone production. Left unaddressed, SCI-related AI (SCI-AI) can lead to life-threatening consequences such as severe hypotension and shock (i.e., adrenal crisis). However, symptoms are often non-specific, making AI challenging to distinguish from similar or overlapping cardiovascular conditions (e.g., orthostatic hypotension). Additionally, the etiology of SCI-AI remains unknown. This review aimed to synthesize the current literature reporting the prevalence, symptomology, and management of SCI-AI. Methods: A systematic search was performed to identify studies reporting AI following the cessation of glucocorticoid treatments in individuals with traumatic SCI. A random-effects meta-analysis was conducted to investigate the overall prevalence of SCI-AI. Results: Thirteen studies involving 545 individuals with traumatic SCI, most with cervical level injuries (n = 256), met the review criteria. A total of 4 studies were included in the meta-analysis. Primary analysis results indicated an SCI-AI pooled prevalence of 24.3% (event rate [ER] = 0.243, 95% confidence interval [CI] = 0.073-0.565, n = 4). Additional sensitivity analyses showed a pooled prevalence of 46.3% (ER = 0.463, 95%CI = 0.348-0.582, n = 2) and 10.8% (ER = 0.108, 95%CI = 0.025-0.368, n = 2) for case-control and retrospective cohort studies, respectively. High-dose glucocorticoid administration after SCI as well as the injury itself appear to contribute to the development of AI. Conclusions: The estimated prevalence of AI in people with traumatic SCI was high (24%). Prevalence was also greater among individuals with cervical SCI than those with lower-level lesions. Clinicians should be vigilant in recognizing the symptomatology and onset of SCI-AI. Further research elucidating its underlying pathophysiology is needed to optimize glucocorticoid administration for remediating AI in this vulnerable population.

Treatment of obesity in spinal cord injury with tirzepatide: a case report

INTRODUCTION

Individuals with spinal cord injury (SCI) experience alterations in metabolism that result in increased central obesity, insulin resistance, and dyslipidemia placing them at elevated risk for developing cardiometabolic disease (CMD). Increased exercise and dietary modifications are the primary interventions for preventing CMD. However, people with SCI face unique challenges that prevent them from increasing their physical activity and easily modifying their nutritional intake. Tirzepatide is a medication that has been approved by the Food and Drug Administration to be used in conjunction with lifestyle changes to treat obesity in adults with type 2 diabetes mellitus.

CASE PRESENTATION

A male in his 40's with C6 American Spinal Injury Association Impairment Scale B SCI 15 years prior with a body mass index of 32 presented to his primary care provider for treatment of obesity. He previously worked with multiple dietitians and increased his physical activity to lose weight. Despite these interventions, he was unable to reduce his weight. He was started on tirzepatide. After 3 months of treatment, he lost 31 pounds and saw improvements in his lipid profile. The only adverse effect reported was heartburn.

DISCUSSION

The metabolic dysfunction associated with SCI and barriers to adequate exercise for weight loss place individuals with SCI at increased risk for obesity and developing CMD. Tirzepatide may be an effective adjunct therapy to lifestyle interventions to help prevent CMD in those with SCI. Further research is indicated to examine the long-term efficacy, benefits, and adverse effects that may be associated with tirzepatide.

Risk of adverse cardiovascular events following spinal cord injury in patients with osteoporosis: Real-world evidence

Introduction

Spinal cord injury (SCI) is associated with increased cardiovascular risks, and cardiovascular disease (CVD) remains a leading cause of death for individuals with SCI. Osteoporosis, a condition associated with SCI, has been linked to CVD. However, the cardiovascular risk profile of individuals with SCI with osteoporosis remains unclear.

Methods

We conducted a retrospective cohort study by using data from the TriNetX Research Network. We included adults with osteoporosis with or without a diagnosis of SCI between 2015 and 2020: case (SCI group, N = 7,308) and control (non-SCI group, N = 843,235) cohorts. Propensity score matching was performed to balance baseline characteristics between the cohorts (N = 7,296 in each group). A Cox regression model was employed to estimate the hazard ratio (HR) for the primary outcomes: the development of acute myocardial infarction (AMI), atrial fibrillation (AF), or heart failure (HF).

Results

Individuals with SCI with osteoporosis have a significantly higher risk of cardiovascular events (HR: 1.15, 95 % confidence interval [CI]: 1.08-1.22)-including AMI (HR: 1.17 95 % CI: 1.02-1.33), AF (HR: 1.14, 95 % CI: 1.04-1.24), and HF (HR: 1.14, 95 % CI: 1.05-1.24)-than do those without SCI. Furthermore, mortality risk is higher in individuals with SCI, particularly those with pathological fracture. Subgroup analyses based on sex and age supported these findings.

Conclusion

The complex interplay between SCI, osteoporosis, and cardiovascular health underscores the requirement for comprehensive management strategies for individuals with SCI who also have osteoporosis.

Cardiovascular safety of transcutaneous spinal cord stimulation in cervical spinal cord injury

This study evaluated whether cervical transcutaneous spinal cord stimulation (tSCS) in conjunction with rehabilitation on upper extremity function alters blood pressure regulation in individuals with cervical spinal cord injury. This study is a secondary analysis of the Up-LIFT trial, a prospective single-arm multicenter trial designed to evaluate the safety and efficacy of tSCS in conjunction with rehabilitation (tSCS ​+ ​rehab) on upper extremity function in individuals with chronic cervical spinal cord injury. Utilizing this large data set obtained from 60 individuals across 14 international sites, we compared blood pressure and heart rate measurements obtained before, during and after each training session during both the wash-in Rehab alone period and the tSCS ​+ ​rehab period of the trial. Blood pressure and heart rate were recorded during each session throughout the protocol in all participants. Sessions of tSCS ​+ ​rehab did not cause significant changes in blood pressure or heart rate compared to Rehab alone (p ​> ​0.05). Further, blood pressure medications did not have an effect on these cardiovascular responses to tSCS (p ​> ​0.05). This study supports the safety profile of cervical tSCS paired with rehabilitation in individuals with cervical spinal cord injury. The lack of adverse effects on blood pressure and heart rate during the intervention, together with the previously reported clinically meaningful improvements in upper extremity strength and function strongly supports the utility of tSCS in this patient population. Further work is required to elucidate potential long-term effects of targeted tSCS on cardiovascular function in people with spinal cord injury.

Cardiac neuromodulation with acute intermittent hypoxia in rats with spinal cord injury

It is well recognized that the interruption in bulbospinal sympathetic projections is the main cause of cardiovascular instability in individuals and experimental animals with spinal cord injury (SCI). Whether interrupted bulbospinal sympathetic projections contribute to cardiac dysfunction directly (i.e. input to the heart) or indirectly (i.e. vascular influences that alter loading conditions on the heart) post-SCI remains unknown, as does the potential effect of SCI-induced alterations in parasympathetic control on heart function. We employed a sequential pharmacological blockade approach to bridge this knowledge gap and additionally examined whether acute intermittent hypoxia (AIH) is capable of neuromodulating the heart post-SCI. In two experiments, rats were given T3 contusion SCI and survived for 2 weeks. At 2 weeks post-SCI, rats were instrumented with left ventricular and arterial catheters to assess cardiovascular function in response to either a sequential pharmacological blockade targeting different sites of the autonomic neuraxis (experiment 1) or AIH (experiment 2). The findings from experiment 1 revealed that impaired direct sympathetic transmission to the heart underlies the majority of the SCI-induced reduction in heart function post-SCI. The findings from experiment 2 revealed that a single-session of AIH increased left ventricular pressure generation and arterial blood pressure immediately and up to 90 min post-AIH. Together, our findings demonstrate that disrupted bulbospinal sympathetic pathways contribute directly to the SCI-induced impairment in left ventricular function. We also show that a single session of AIH is capable of neuromodulating the heart post-SCI. KEY POINTS: The loss of sympathetic transmission to the heart is the main cause of reduced cardiac function in a rodent model of spinal cord injury (SCI). Parasympathetic control remains unaltered post-SCI and does not contribute to reduced cardiac function post-SCI. Acute intermittent hypoxia neuromodulates the heart and increases left ventricular pressure generating capacity.

The Effect of a Low-Glycemic Index Diet on Postprandial Hypotension in Individuals With Chronic Spinal Cord Injury: Results From a Pilot Study

Background

One in two individuals with spinal cord injury (SCI) experiences postprandial hypotension (PPH), a decline (>20 mm Hg) in systolic blood pressure (SBP) within 2 hours after eating. Consuming meals with a low glycemic index (GI) could prevent or lessen PPH.

Objectives

To determine the effect of a low-GI diet on PPH and postprandial glucose and insulin in individuals with chronic SCI (>1 year postinjury).

Methods

Eleven participants (6 males, 5 females; age 43 ± 11 years) with chronic SCI (C4-C7, 7; T4-T12, 4) took part in a randomized crossover study (low GI vs. high GI). On each occasion, BP, glucose, and insulin were measured in the fasted state and for 2 hours after consuming a breakfast meal (60% carbohydrate, 28% fat, 12% protein) in laboratory-controlled conditions. Participants wore an ambulatory BP monitor and continuous glucose monitor for 3 days at home, and consumed study meals that were macronutrient-matched across conditions.

Results

The maximum decrease in systolic blood pressure (SBP) following the laboratory-controlled breakfast meals tended to be lower in the low-GI (14 ± 12 mm Hg) compared to the high-GI (24 ± 25 mm Hg) diet (d = 0.52, P = .056). Serum glucose (P < .01) and insulin (P = .026) concentrations were lower at 30 minutes in the low-GI diet. In the home setting, peak glucose concentrations were lower after lunch (P = .011) and dinner (P < .01) in the low-GI diet.

Conclusion

A low-GI meal may be an effective solution to reduce the magnitude of PPH and peak glucose concentrations in individuals with chronic SCI.

A randomized comparative effectiveness trial to evaluate two programs for promotion of physical activity after spinal cord injury in manual wheelchair users

Objective

The goal of this study was to determine the effectiveness of a novel whole of day activity accumulation (WODAA) physical exercise program. WODAA physical activity and physiological outcomes were compared to outcomes from individuals using a traditional planned arm crank exercise (PACE) program. Both programs included progressive exercise instruction and goal setting over a 4-month period, and utilization of a wrist-worn activity monitor (Fitbit Blaze/Versa, Fitbit Inc., San Francisco, CA).

Design

Longitudinal, randomized, comparative effectiveness trial with collaborative goal setting.

Setting

Research laboratory at a rehabilitation hospital and in participants' homes and communities.

Participants

Forty-nine manual wheelchair users with paraplegia.

Outcome measures

Physical activity measurements and cardiometabolic data were collected before, during, and after the program. The primary measures were amount of daily arm activity (Steps) and time spent in different activity and heart rate zones.

Results

Relative to baseline measures, participants in the WODAA group had significantly more daily arm movement/propulsion activity (Steps) and time spent in the Fairly and Very Active Zones and the Cardio Heart Rate Zone compared to those in the PACE group over the final month of the intervention (p < 0.05). Minutes spent in other Activity and Heart Rate Zones were similar between groups. At final evaluation, diastolic blood pressure after a 6-Minute Push Test was significantly lower in the WODAA group, while no differences were found in distance traveled, systolic, or pre-test diastolic blood pressures. Metabolic bloodwork and shoulder pain scores did not change and were similar between groups.

Conclusion

Depending on the measure used, these findings suggest that a WODAA approach to PA is comparable or more effective than a traditional PACE program in promoting physical activity in low-active manual wheelchair users with paraplegia.

Making the Invisible Visible: Understanding Autonomic Dysfunctions Following Spinal Cord Injury

Autonomic dysfunctions are a major challenge to individuals following spinal cord injury. Despite this, these consequences receive far less attention compared with motor recovery. This review will highlight the major autonomic dysfunctions following SCI predominantly based on our present understanding of the anatomy and physiology of autonomic control and available clinical data.

Acute intermittent hypoxia elicits sympathetic neuroplasticity independent of peripheral chemoreflex activation and spinal cord tissue hypoxia in a rodent model of high-thoracic spinal cord injury

The loss of medullary control of spinal circuits controlling the heart and blood vessels is a unifying mechanism linking both hemodynamic instability and the risk for cardiovascular diseases (CVD) following spinal cord injury (SCI). As such, new avenues to regulate sympathetic activity are essential to mitigate CVD in this population. Acute intermittent hypoxia (AIH) induces a type of neuroplasticity known as long-term facilitation (LTF), a persistent increase in nerve activity post-AIH in spinal motor circuits. Whether LTF occurs within the sympathetic circuit following SCI is largely unknown. We aimed to test whether AIH elicits sympathetic LTF (i.e., sLTF) and attenuates hypoactivity in sub-lesional splanchnic sympathetic circuits in a male rat model of SCI. In 3 experimental series, we tested whether 1) high-thoracic contusion SCI induces hypoactivity in splanchnic sympathetic nerve activity, 2) AIH elicits sLTF following SCI, and 3) sLTF requires carotid chemoreflex activation or spinal cord tissue hypoxia. Our results indicate that a single-session of AIH therapy (10 × 1 min of FiO2 = 0.1, interspersed with 2 min of FiO2 = 1.0) delivered at 2 weeks following SCI attenuates SCI-induced sympathetic hypoactivity by eliciting sLTF 90 min post-treatment that is independent of peripheral chemoreflex activation and/or spinal cord hypoxia. These findings advance our mechanistic understanding of AIH in the field and yield new insights into factors underpinning AIH-induced sLTF following SCI in a rat model. Our findings also set the stage for the chronic application of AIH to alleviate secondary complications resulting from sympathetic hypoactivity following SCI.

People with spinal cord injury or stroke are able to reach moderate-to-vigorous intensity while exercising on an end-effector robot assisted gait trainer: A pilot study

Background: Spinal cord injury and stroke are neurological disorders that lead to aerobic deconditioning and increased likelihood of cardiovascular disease. Sessions of at least 20 minutes of moderate-to-vigorous intensity exercise is recommended but decreased mobility limits engagement in such exercise. The aim of the study was to assess whether individuals can achieve exercise recommendations with the assistance of an end-effector robot assisted gait trainer (E-RAGT). Methods: We conducted an observational study during which participants were required to complete one exercise session on an E-RAGT. Heart rate, dyspnea, lower limb fatigue and enjoyment were monitored. Based on current guidelines, participants were considered to have reached exercise recommendations if they reached prespecified intensity thresholds for at least 20 minutes. Results: Five people with spinal cord injury and ten people with stroke agreed to participate. Every participant was able to reach moderate-to-vigorous exercise intensity and 3 out of 5 participants with spinal cord injury and 4 out of 10 participants with stroke were able to maintain this intensity for at least 20 minutes. Overall, participants rated their session as very enjoyable with a median score of 4 out of 5 on a Likert Scale (IQR 3 to 4). Discussion: Individuals with spinal cord injury or stroke who use an E-RAGT can reach moderate-to-vigorous exercise intensity, but not all are able to maintain this intensity of exercise according to disease-specific recommendations. Future research should explore the effectiveness of a training program using an E-RAGT.

Exploring lifestyle components and associated factors in newly injured individuals with spinal cord injury

STUDY DESIGN

Cross-sectional analysis from the Inception Cohort of the Swiss Spinal Cord Injury Study (SwiSCI).

OBJECTIVES

To describe five lifestyle components in newly injured individuals with spinal cord injury (SCI), explore co-occurrence of these components, and identify associated personal and clinical factors.

SETTINGS

Initial rehabilitation stay following traumatic and non-traumatic SCI.

METHODS

Lifestyle components including overweight/obesity, low diet score, physical inactivity, smoking, and alcohol consumption were used independently and to calculate a composite lifestyle score. Analyses were conducted using descriptive statistics, co-occurrence analysis, and multivariate logistic regression.

RESULTS

We included 251 individuals, of whom 77.7% were male, 73.7% suffered from traumatic SCI, and 59.8% had paraplegia. The median age was 51 years (IQR 36-64). Approximately twelve weeks after the injury, more than two-thirds of the study population met the criteria for overweight/obesity, and consumed insufficient amounts of fruits and vegetables, and excessive amounts of meat. Alcohol was consumed by 85.3% of individuals, and 26.8% were current smokers. Almost all study participants met the physical activity guidelines (90 min of moderate to strenuous activity physical activity per week). One-quarter of study participants experienced the co-occurrence of overweight/obesity, low diet score and alcohol consumption. Female sex, younger age and higher education were associated with healthier lifestyle components.

CONCLUSION

Despite methodological limitations, this study underscores the complexities of healthy lifestyle adherence among individuals newly injured with SCI. It highlights the necessity of improving and implementing screening strategies throughout the continuum of SCI care as early as possible following the trauma.

Neuroprotective agents ineffective in mitigating autonomic dysreflexia following experimental spinal cord injury

BACKGROUND AND OBJECTIVES

Loss of supraspinal cardiovascular control and secondary damage following spinal cord injury (SCI) lead to cardiovascular dysfunction, where autonomic dysreflexia (AD), triggered by stimuli below the injury, can cause uncontrolled blood pressure (BP) surges, posing severe health risks such as stroke and seizures. While anti-inflammatory neuroprotective agents have been studied for motor recovery, their impact on cardiovascular function remains under investigated. The objective was to assess the efficacy of four clinically approved neuroprotective agents in promoting cardiovascular recovery following SCI.

METHODS

Male Wistar rats received contusion at the third thoracic spinal segment (T3). Fluoxetine, Glyburide, Valproic acid, and Indomethacin were first administered at 1 h or 6 h post-SCI, and every 12 h for two weeks thereafter. Four weeks following SCI, hemodynamics were measured at rest and during colorectal distension. Locomotor function was assessed prior to SCI and weekly for four weeks after SCI, using the Basso-Beattie-Bresnahan (BBB) locomotor scale. Quantitative comparisons of lesion area were performed.

RESULTS

Contrary to the published literature, Indomethacin and Valproic acid resulted in high morbidity and mortality rates 60 % and 40 % respectively) within 2-3 days of administration. Fluoxetine, and Glyburide were well-tolerated. There were no differences in change in systolic BP with colorectal distension compared to control i.e., all experimental groups experienced severe episodes of AD [F(6, 67) = 0.94, p = 0.47]. There was no significant difference in BBB scores in any experimental group compared to control [F(18, 252) = 0.3, p = 0.99]. No between-group differences were observed in tissue sparing at the lesion epicentre [F(6, 422) = 6.98, p = 0.29].

DISCUSSION

Despite promising beneficial effect reported in previous studies, none of the drugs demonstrated improvement in cardiovascular or motor function. Indomethacin and Valproic acid exhibited unexpected high mortality at doses deemed safe in the literature. This emphasizes the necessity for reproducibility studies in pre-clinical research and underscores the importance of publishing null findings to guide future investigations.

Impact of upper-body ergometer rowing exercise on aerobic fitness and cardiometabolic disease risk in individuals with spinal cord injury: A 6-month follow-up study

Objective: We recently demonstrated that upper-body rowing exercise (UBROW) improved aerobic fitness in individuals with spinal cord injury (SCI), with no effect on traditional cardiometabolic risk factors. Here, we tested the hypothesis that the exercise-induced increase in aerobic fitness was maintained at 6-month (6M) follow-up.Design: Six-month follow-up.Setting: University/hospital.Participants: Seventeen wheelchair-dependent participants with SCI.Interventions: 12-week of exercise training (UBROW) or control (CON).Outcome Measures: Aerobic fitness (POpeak and V̇O2peak), body composition, blood pressure, and blood biomarkers of cardiometabolic risk were assessed at 6M follow-up and compared to baseline (BL) and immediately post-intervention (12-week). Minutes of mild, moderate, and heavy intensity leisure time physical activity (LTPA) were assessed by self-report.Results: Fourteen participants returned at 6M follow-up (CON, n = 6; UBROW, n = 8). In UBROW, POpeak (median (Q1-Q3)) increased from BL (70 W (37-84)) to 12-week (77 W (58-109), P = 0.01) and 6M follow-up (81 W (51-96), P = 0.01), with no difference between 12-week and 6M follow-up (P = 0.21). Similarly, V̇O2peak increased from BL (15.4 ml/kg/min (10.5-19.4)) to 12-week (16.6 ml/kg/min (12.8-21.3), P = 0.01) with no difference between 12-week and 6M follow-up (16.3 ml/kg/min (12.9-19.7), P = 0.74). No differences were found in CON for either POpeak (P = 0.22) or V̇O2peak (P = 0.27). There were no changes over time in traditional cardiometabolic risk factors or for minutes of different LTPA intensities.Conclusion: We demonstrate that improvements in aerobic fitness are maintained for at least six months after completion of a 12-week exercise intervention, supporting the use of periodic exercise interventions to boost aerobic fitness level in individuals with SCI.Trial registration: ClinicalTrials.gov identifier: NCT04390087..

Spinal cord injury and risk of overall and type specific cardiovascular diseases: A meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is a growing concern among people with spinal cord injury (SCI). This meta-analysis aims to explore the risk of overall CVD and specific types of cardiovascular events among SCI patients.

METHODS

This meta-analysis is registered on PROSPERO (CRD CRD42024537888). The data sources comprised PubMed, Embase, the Cochrane Library, and reference lists of the included studies. The literature collection span is from database establishment until April 17, 2024. This meta-analysis encompassed observational studies investigating the association between SCI and the risk of overall types of CVD or specific CVD types. Risk of bias was evaluated utilizing the Newcastle-Ottawa Quality Assessment Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) Scale. Odds ratios (ORs) with 95% confidence intervals (CIs) were aggregated using a random-effects model.

RESULTS

Our initial search generated 5357 relevant records form these international databases. This meta-analysis encompassed 9 observational studies involving 2,282,691 individuals, comprising 193,045 patients with SCI and 2,209,646 controls. We observed a 1.56-fold [OR = 1.56, 95% CI (1.43, 1.70), I2 = 91.3%, P < 0.001] rise in the risk of overall types of CVD among SCI patients, with a 1.82-fold increase in males and a 1.76-fold increase in females. SCI patients without comorbidities exhibited a 2.10-fold elevated risk of overall CVD types, while those with comorbidities had a 1.48-fold increased risk. Concerning specific CVD types, SCI patients showed a 1.58-fold [OR = 1.57, 95% CI (1.22, 2.03), I2 = 92.4%] higher risk of myocardial infarction, a 1.52-fold [OR = 1.52, 95% CI (1.07, 2.16), I2 = 88.7%] increase in atrial fibrillation, a 1.64-fold [OR = 1.64, 95% CI (1.22, 2.20), I2 = 95.5%] elevation in heart failure risk, and 2.38-fold [OR = 2.38, 95% CI (1.29, 4.40), I2 = 92.5%] increments in stroke risk. But there was no statistically significant difference in the risk of hypertension [OR = 1.54, 95% CI (0.98, 2.42), I2 = 96.6%].

CONCLUSIONS

The risk of overall CVD in SCI patients surpassed that of the non-SCI control group, with elevated risks of specific cardiovascular events like myocardial infarction, atrial fibrillation, heart failure, and stroke. Clinicians should prioritize awareness of CVD risks in SCI patients.

A Scoping Review of Acute Sedentary Behaviour Studies of People with Spinal Cord Injury

People with a spinal cord injury (SCI) report less physical activity than other populations and may engage in more sedentary behaviour (SB), especially sitting time. SB negatively impacts physiological and psychosocial outcomes in the general population, yet minimal research has explored the effects in people with SCI. The goal of this scoping review was to catalogue and describe the effects of acute SB among people with SCI. We searched four databases before February 2024 for studies in which people with any SCI sat, laid, or reclined for more than one hour in a day, and any physiological, psychological, or behavioural (i.e., SB time) outcome was measured. In total, 2021 abstracts were screened, and eight studies were included (n = 172 participants). The studies were characterized by varied definitions, manipulations, and measures of SB. Most measured outcomes were physiological (e.g., metabolic, blood pressure), followed by behavioural (e.g., SB time) and psychological (e.g., well-being, affect). When SB was interrupted, only postprandial glucose and affect improved. Based on two studies, participants engaged in 1.6 to 12.2 h of SB per day. Average uninterrupted wheelchair sitting bouts lasted 2.3 h. Based on the very limited body of research, it is impossible to draw any conclusions regarding the nature, extent, or impact of SB in people with SCI. There is much work to carry out to define SB, test its effects, and determine if and how people with SCI should reduce and interrupt SB.

Reducing endocrine metabolic disease risk in adults with chronic spinal cord injury: strategic activities conducted by the Ontario-Quebec RIISC team

PURPOSE

The Rehabilitation Interventions for Individuals with a Spinal Cord Injury in the Community (RIISC) team aimed to develop and evaluate innovative rehabilitation interventions to identify endocrine metabolic disease (EMD) risk, intending to reduce the frequency and severity of EMD related morbidity and mortality among adults living with chronic spinal cord injury or disease (SCI/D).

MATERIALS AND METHODS

An interprovincial team from Ontario and Quebec reviewed available EMD literature and evidence syntheses and completed an inventory of health services, policies and practices in SCI/D care. The review outcomes were combined with expert opinion to create an EMD risk model to inform health service transformation.

RESULTS

EMD risk and mortality are highly prevalent among adults with chronic SCI/D. In stark contrast, few rehabilitation interventions target EMD outcomes. The modelled solution proposes: 1) abandoning single-disease paradigms and examining a holistic perspective of the individual's EMD risk, and 2) developing and disseminating practice-based research approaches in outpatient community settings.

CONCLUSIONS

RIISC model adoption could accelerate EMD care optimization, and ultimately inform the design of large-scale longitudinal pragmatic trials likely to improve health outcomes. Linking the RIISC team activities to economic evaluations and policy deliverables will strengthen the relevance and impact among policymakers, health care providers and patients.

Effects of exercise on autonomic cardiovascular control in individuals with chronic, motor-complete spinal cord injury: an exploratory randomised clinical trial

STUDY DESIGN

Secondary analysis of a clinical trial.

OBJECTIVE

To assess the impact of 6 months of arm cycle ergometry training (ACET), or body weight-supported treadmill training (BWSTT), on autonomic cardiovascular responses to a laboratory sit-up test (SUT) in individuals with chronic (≥1-year post-injury) spinal cord injury (SCI).

SETTING

Tertiary Rehabilitation Centre, Vancouver, Canada.

METHODS

Sixteen individuals with motor-complete (American Spinal Injury Association Impairment Scale A-B) SCI between the fourth cervical and sixth thoracic spinal cord segments, aged 39 ± 11 years, were assessed. Participants were randomized to receive 72 sessions of moderate-to-vigorous intensity ACET (n = 8) or passive BWSTT (n = 8). Changes in mean arterial pressure (finger plethysmography), hemodynamics (Modelflow® method), and heart rate/heart rate variability (HR/HRV; electrocardiography) were measured in response to a  SUT before and after 6 months of exercise training. Spontaneous cardiovagal baroreflex sensitivity (cvBRS) was assessed using the sequence method.

RESULTS

Neither ACET nor BWSTT impacted hemodynamic responses to SUT or the incidence of orthostatic hypotension (all P > 0.36). ACET increased HR (P < 0.01, ηp2 = 0.34) and high frequency (HF) power HRV responses (P < 0.01, ηp2 = 0.42) to SUT following 6 months of training while BWSTT did not. Consistent with this, cvBRS improved (P < 0.05, ηp2 = 0.16) only following ACET. Improvements in cvBRS were correlated with both the HR (r = 0.726, P < 0.0001) and HF power (r = -0.484, P < 0.01) responses to SUT.

CONCLUSION

Six months of ACET, but not BWSTT, improved cardiovagal baroreflex control of HR but had no effect on BP responses to SUT in individuals with chronic, motor-complete SCI.

SPONSORSHIP

Canadian Institutes of Health Research (CIHR) CLINICAL TRIAL REGISTRATION: NCT01718977.

Enhancing Spinal Cord Injury Care: Using Wearable Technologies for Physical Activity, Sleep, and Cardiovascular Health

Wearable devices have the potential to advance health care by enabling real-time monitoring of biobehavioral data and facilitating the management of an individual's health conditions. Individuals living with spinal cord injury (SCI) have impaired motor function, which results in deconditioning and worsening cardiovascular health outcomes. Wearable devices may promote physical activity and allow the monitoring of secondary complications associated with SCI, potentially improving motor function, sleep, and cardiovascular health. However, several challenges remain to optimize the application of wearable technologies within this population. One is striking a balance between research-grade and consumer-grade devices in terms of cost, accessibility, and validity. Additionally, limited literature supports the validity and use of wearable technology in monitoring cardio-autonomic and sleep outcomes for individuals with SCI. Future directions include conducting performance evaluations of wearable devices to precisely capture the additional variation in movement and physiological parameters seen in those with SCI. Moreover, efforts to make the devices small, lightweight, and inexpensive for consumer ease of use may affect those with severe motor impairments. Overcoming these challenges holds the potential for wearable devices to help individuals living with SCI receive timely feedback to manage their health conditions and help clinicians gather comprehensive patient health information to aid in diagnosis and treatment.

Document analysis of adaptive sport opportunities at Division-1 universities in the United States

BACKGROUND

Individuals with disabilities are less likely to participate in physical activity, with the greatest decline in participation during college years. Despite known health benefits, there are significant barriers that limit sport and exercise participation for students with disabilities, including adaptive access. To our knowledge, there has been no comprehensive review conducted to examine the number of adaptive sport offerings on a collegiate level.

OBJECTIVE

Assess the availability of adaptive sport opportunities for students at National Collegiate Athletic Association (NCAA) Division-1 Universities to better understand university-affiliated adaptive sport opportunity for students.

METHODS

Website document analysis was conducted by systematically querying the general homepage, athletics page, and campus recreation websites of each NCAA Division-1 University in the United States (US). Institutional and sport-related characteristics were recorded.

RESULTS

Of the 358 NCAA Division-1 Universities, 20.4 % (73/358) marketed adaptive sport opportunities (recreational, club, and/or intercollegiate), with 3.9 % (11/358) acknowledging intercollegiate adaptive sport programs on their websites. Five percent (6/121) of private institutions, and 28.3 % (67/237) of public institutions reported adaptive sport opportunities. The Northeast region had the fewest number of institutions reporting adaptive sport offerings (4/67, 6.0 %). The most commonly offered sport was adaptive recreation (36/358, 10.2 %), followed by wheelchair basketball (26/358, 7.4 %).

CONCLUSION

Over three-quarters of Division-1 Universities in the US lack an online description of adaptive sport opportunity, highlighting the need for expanded resourcing and marketing of adaptive sport at the university level. Future studies are necessary to identify appropriate strategies to effectively promote sport, maximize participation and improve social inclusion.

Neuromodulation in Spinal Cord Injury Using Transcutaneous Spinal Stimulation-Mapping for a Blood Pressure Response: A Case Series

Spinal cord transcutaneous stimulation (scTS) offers a promising approach to enhance cardiovascular regulation in individuals with a high-level spinal cord injury (SCI), addressing the challenges of unstable blood pressure (BP) and the accompanying hypo- and hypertensive events. While scTS offers flexibility in stimulation locations, it also leads to significant variability and lack of validation in stimulation sites utilized by studies. Our study presents findings from a case series involving eight individuals with chronic cervical SCI, examining the hemodynamic effects of scTS applied in different vertebral locations, spanning from high cervical to sacral regions. Stimulation of the lumbosacral vertebrae region (L1/2, S1/2, and also including T11/12) significantly elevated BP, unlike cervical or upper thoracic stimulation. The observed trend, which remained consistent across different participants, highlights the promising role of lumbosacral stimulation in neuromodulating BP.

A systematic review and qualitative synthesis of weight management interventions for people with spinal cord injury

People with spinal cord injury (SCI) are at greater risk of developing obesity and related co-morbidities than those without SCI. The objectives of this systematic review were to examine the effectiveness of weight management interventions for people with SCI and to synthesize the experiences of people involved with SCI weight management (e.g., SCI healthcare professionals and caregivers). Five databases were searched (up to July 31, 2023) and 5,491 potentially eligible articles were identified. Following screening, 22 articles were included, comprising 562 adults. There was considerable heterogeneity in study design and weight loss interventions included behavioral nutritional and exercise education sessions, recalling food diaries, exercise interventions, and pharmaceuticals. The mean percentage change of the pooled body mass data equated to -4.0 ± 2.3%, with a range from -0.5 to -7.6%. In addition, 38% of the individuals with SCI who completed a weight loss intervention (N = 262) had a ≥5% reduction in body weight. Collectively, although on average the included interventions led to moderate weight loss, the finding that just over a third of individuals achieved clinically meaningful 5% weight loss suggests that available interventions for this population may need to be improved.

Ergogenic effects of spinal cord stimulation on exercise performance following spinal cord injury

Cervical or upper-thoracic spinal cord injury (SCI, ≥T6) often leads to low resting blood pressure (BP) and impaired cardiovascular responses to acute exercise due to disrupted supraspinal sympathetic drive. Epidural spinal cord stimulation (invasive, ESCS) and transcutaneous spinal cord stimulation (non-invasive, TSCS) have previously been used to target dormant sympathetic circuits and modulate cardiovascular responses. This case series compared the effects of cardiovascular-optimised ESCS and TSCS versus sham ESCS and TSCS on modulating cardiovascular responses and improving submaximal upper-body exercise performance in individuals with SCI. Seven males with a chronic, motor-complete SCI between C6 and T4 underwent a mapping session to identify cardiovascular responses to spinal cord stimulation. Subsequently, four participants (two ESCS and two TSCS) completed submaximal exercise testing. Stimulation parameters (waveform, frequency, intensity, epidural electrode array configuration, and transcutaneous electrode locations in the lumbosacral region) were optimised to elevate cardiovascular responses (CV-SCS). A sham condition (SHAM-SCS) served as a comparison. Participants performed arm-crank exercise to exhaustion at a fixed workload corresponding to above ventilatory threshold, on separate days, with CV-SCS or SHAM-SCS. At rest, CV-SCS increased BP and predicted left ventricular cardiac contractility and total peripheral resistance. During exercise, CV-SCS increased time to exhaustion and peak oxygen pulse (a surrogate for stroke volume), relative to SHAM-SCS. Ratings of perceived exertion also tended to be lower with CV-SCS than SHAM-SCS. Comparable improvements in time to exhaustion with ESCS and TSCS suggest that both approaches could be promising ergogenic aids to support exercise performance or rehabilitation, along with reducing fatigue during activities of daily living in individuals with SCI.

Measuring Overweight and Obesity in Persons with Spinal Cord Injury: What Do Health Providers Use and What are the Challenges?

INTRODUCTION

Obesity is a significant health concern for veterans and individuals with spinal cord injury, yet screening for overweight/obesity can be challenging. This study examines how healthcare providers screen for overweight/obesity and the challenges encountered in identifying overweight/obesity in veterans and persons with spinal cord injury.

MATERIALS AND METHODS

Healthcare providers who provide care for persons with spinal cord injury completed a semi-structured interview. The interview explored their perspectives on measuring overweight/obesity in persons with spinal cord injury and the challenges they faced. Thematic analysis was used to identify themes that emerged from the interviews.

RESULTS

Twenty-five providers (88% female with an average experience of 9.6 ± 7.3 years in providing care for spinal cord injury patients) participated in the interviews. The themes described the health indicators and equipment used to assess overweight/obesity, provider concerns regarding measurement, and criteria for classifying overweight/obesity. Body weight and body mass index were the most commonly used indicators. However, concerns were raised regarding accuracy of these measures for spinal cord injury patients, as well as issues related to the accessibility, calibration, and usability of the equipment. Many providers reported using standard body mass index ranges and categories instead of those specific to spinal cord injury.

CONCLUSION

This study identified the most commonly used indicators of weight or body composition in veterans and persons with spinal cord injury and highlighted providers' concerns with these measures. Future research is needed to identify the most feasible, accurate, and appropriate health indicators that could be used in a clinical setting to identify overweight and obesity in this population.

Accessible exercise for wheelchair users: comparing the usability of two adapted exercise machines

INTRODUCTION

Exercise is an important occupation for wheelchair users. Limited access to adapted aerobic exercise equipment in the community and lack of knowledge on how to exercise are barriers to exercise participation among wheelchair users. To address these barriers, the adapted rower (aROW) and adapted skier (aSKI) exercise machines and educational materials were created.

PURPOSE

1) To compare wheelchair users' perspectives of the effectiveness and usability of the aROW and aSKI. 2) To explore perceptions of educational materials to support use of the machines.

MATERIALS AND METHODS

A sequential, mixed-methods study design was used. Six wheelchair users trialled the machines, and completed an interview and two usability questionnaires. Qualitative data were analysed using thematic and conventional content analysis. Usability scores of both machines were compared using the Wilcoxon Signed Ranks Test.

RESULTS

Data show high usability of the aROW and aSKI. More set up challenges were reported for the aROW than the aSKI. Participants perceived both machines provided effective cardiovascular workouts, and each met their exercise goals differently. Participants preferred the instructional videos over instructional sheets and provided suggestions for improving both. The Wilcoxon Signed Ranks Test showed no statistically significant difference in usability between the aROW and aSKI.

CONCLUSION

Implementing the aROW and aSKI in the community may address some equity issues that wheelchair users face by providing more aerobic exercise options. Results will inform educational material revisions to support use of the machines.

Sex differences in heart disease prevalence among individuals with spinal cord injury: A population-based study

CONTEXT/OBJECTIVE

The risk for cardiovascular disease is amplified following spinal cord injury, but whether risk differs between the sexes remains unknown. Here, we evaluated sex differences in the prevalence of heart disease among individuals with spinal cord injury, and compared sex differences with able-bodied individuals.

DESIGN

The design was a cross-sectional study. Multivariable logistic regression analysis was conducted, using inverse probability weighting to account for the sampling method and to adjust for confounders.

SETTING

Canada.

PARTICIPANTS

Individuals who participated in the national Canadian Community Health Survey.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Self-reported heart disease.

RESULTS

Among 354 individuals with spinal cord injury, the weighted prevalence of self-reported heart disease was 22.9% in males and 8.7% in females, with an inverse-probability weighted odds ratio of 3.44 (95% CI 1.70-6.95) for males versus females. Among 60,605 able-bodied individuals, the prevalence of self-reported heart disease was 5.8% in males and 4.0% in females, with an inverse probability weighted odds ratio of 1.62 (95% CI 1.50-1.75) for males versus females. The effect of male sex on increasing heart disease prevalence was about two times higher among individuals with spinal cord injury than able-bodied individuals (relative difference in inverse probability weighted odds ratios = 2.12, 95% CI 1.08-4.51).

CONCLUSION

Males with spinal cord injury exhibit a significantly higher prevalence of heart disease, compared with females with spinal cord injury. Moreover, relative to able-bodied individuals, spinal cord injury amplifies sex-related differences in heart disease. Overall, this work will inform targeted cardiovascular prevention strategies, and may also inform a better understanding of cardiovascular disease progression in both able-bodied and individuals with spinal cord injury.

Delayed cerebrovascular reactivity in individuals with spinal cord injury in the right inferior parietal lobe: a breath-hold functional near-infrared spectroscopy study

Cerebrovascular reactivity (CVR) reflects the ability of blood vessels to dilate or constrict in response to a vasoactive stimulus, and allows researchers to assess the brain's vascular health. Individuals with spinal cord injury (SCI) are at an increased risk for autonomic dysfunction in addition to cognitive impairments, which have been linked to a decline in CVR; however, there is currently a lack of brain-imaging studies that investigate how CVR is altered after SCI. In this study, we used a breath-holding hypercapnic stimulus and functional near-infrared spectroscopy (fNIRS) to investigate CVR alterations in individuals with SCI (n = 20, 14M, 6F, mean age = 46.3 ± 10.2 years) as compared to age- and sex-matched able-bodied (AB) controls (n = 25, 19M, 6F, mean age = 43.2 ± 12.28 years). CVR was evaluated by its amplitude and delay components separately by using principal component analysis and cross-correlation analysis, respectively. We observed significantly delayed CVR in the right inferior parietal lobe in individuals with SCI compared to AB controls (linear mixed-effects model, fixed-effects estimate = 6.565, Satterthwaite's t-test, t = 2.663, p = 0.008), while the amplitude of CVR was not significantly different. The average CVR delay in the SCI group in the right inferior parietal lobe was 14.21 s (sd: 6.60 s), and for the AB group, the average delay in the right inferior parietal lobe was 7.08 s (sd: 7.39 s). CVR delays were also associated with the duration since injury in individuals with SCI, in which a longer duration since injury was associated with a shortened delay in CVR in the right inferior parietal region (Pearson's r-correlation, r = -0.59, p = 0.04). This study shows that fNIRS can be used to quantify changes in CVR in individuals with SCI, and may be further used in rehabilitative settings to monitor the cerebrovascular health of individuals with SCI.

A systematic review of the effects of robotic exoskeleton training on energy expenditure and body composition in adults with spinal cord injury

Metabolic diseases disproportionately affect people with spinal cord injury (SCI). Increasing energy expenditure and remodeling body composition may offset deleterious consequences of SCI to improve cardiometabolic health. Evidence is emerging that robotic exoskeleton use increases physical activity in SCI, but little is known about its effects on energy expenditure and body composition. This study therefore aimed to evaluate the impact of robotic exoskeleton training on body composition and energy expenditure in adults with SCI. A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Five databases were searched to retrieve studies meeting pre-set eligibility criteria: adults with SCI, interventions evaluating the effects of robotic exoskeleton devices on body composition or energy expenditure. The PEDro scale guided quality assessments with findings described narratively. Of 2163 records, 10 studies were included. Robotic exoskeleton training does not significantly improve energy expenditure compared to other exercise interventions. Significant changes ( P  < 0.05) in body composition, particularly reduced fat mass, however, were reported. High variability seen with the interventions was coupled with poor quality of the studies. While robotic exoskeleton interventions may propose modest cardiometabolic benefits in adults with SCI, further robust trials in larger samples are needed to strengthen these findings.

Cerebrovascular Reactivity Following Spinal Cord Injury

Background

Spinal cord injuries (SCI) often result in cardiovascular issues, increasing the risk of stroke and cognitive deficits.

Objectives

This study assessed cerebrovascular reactivity (CVR) using functional magnetic resonance imaging (fMRI) during a hypercapnic challenge in SCI participants compared to noninjured controls.

Methods

Fourteen participants were analyzed (n = 8 with SCI [unless otherwise noted], median age = 44 years; n = 6 controls, median age = 33 years). CVR was calculated through fMRI signal changes.

Results

The results showed a longer CVR component (tau) in the grey matter of SCI participants (n = 7) compared to controls (median difference = 3.0 s; p < .05). Time since injury (TSI) correlated negatively with steady-state CVR in the grey matter and brainstem of SCI participants (RS = -0.81, p = .014; RS = -0.84, p = .009, respectively). Lower steady-state CVR in the brainstem of the SCI group (n = 7) correlated with lower diastolic blood pressure (RS = 0.76, p = .046). Higher frequency of hypotensive episodes (n = 7) was linked to lower CVR outcomes in the grey matter (RS = -0.86, p = .014) and brainstem (RS = -0.89, p = .007).

Conclusion

Preliminary findings suggest a difference in the dynamic CVR component, tau, between the SCI and noninjured control groups, potentially explaining the higher cerebrovascular health burden in SCI individuals. Exploratory associations indicate that longer TSI, lower diastolic blood pressure, and more hypotensive episodes may lead to poorer CVR outcomes. However, further research is necessary to establish causality and support these observations.

Development of a Hypercoagulable-Hypofibrinolytic State Early After Spinal Cord Injury

OBJECTIVES

To determine whether spinal cord injury (SCI) is associated with adverse changes in coagulation and fibrinolytic factors that underlie thrombogenesis and contribute to atherothrombotic events such as myocardial infarctions (MIs) and strokes.

DESIGN

Cross-sectional study.

SETTING

Neurorehabilitation hospital and general community.

PARTICIPANTS

Thirty young and middle-aged (20-58 years) adults (N=30) were studied: 14 non-injured community dwelling adults. (11M/4F) and 16 with subacute tetraplegic motor complete SCI during initial inpatient rehabilitation (13M/3F; time since injury: 11.8±5.3 wk).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Circulating markers of coagulation [von Willebrand factor (vWf) and factors VII, VIII, and X], the fibrinolytic system [tissue-type plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) antigen and activity], and fibrin formation (D-dimer) were determined by enzyme immunoassay.

RESULTS

Thirty young and middle-aged (20-58 years) adults were studied: 14 non-injured (11M/4F) and 16 with subacute tetraplegic motor complete SCI (13M/3F; time since injury: range 4-25 wk). Circulating levels of coagulation factors VII, VIII, and X were significantly higher (∼20%-45%; P<.05) in the adults with SCI than non-injured adults, whereas vWf was similar between groups. Fibrinolytic markers were adversely disrupted with SCI with t-PA antigen, PAI-1 antigen and PAI-1 activity were markedly higher (∼50%-800%; P<.05) in adults with SCI compared with non-injured adults. The molar concentration ratio of active t-PA to PAI-1 was significantly higher (∼350%) in adults with SCI. Concordant with coagulation cascade activation and fibrinolytic system inhibition, D-dimer concentrations were markedly ∼70% higher (P<.05) in adults with SCI compared with non-injured adults.

CONCLUSIONS

Subacute tetraplegic motor complete SCI is associated with a prothrombotic hemostatic profile. Adverse changes in the coagulation cascade and fibrinolytic system appear to occur early after injury and may contribute to the increased atherothrombotic risk in adults living with SCI.

Increased Risk of Myocardial Infarction, Heart Failure, and Atrial Fibrillation After Spinal Cord Injury

BACKGROUND

Heart diseases are a growing concern for the spinal cord injury (SCI) population.

OBJECTIVES

This study aims to compare the incidence of heart diseases between SCI survivors and the general non-SCI population.

METHODS

We identified 5,083 SCI survivors and 1:3 age- and sex-matched non-SCI controls. Study outcomes were myocardial infarction (MI), heart failure (HF), and atrial fibrillation (AF). The cohort was followed up from the index date (diagnosis date for SCI or corresponding date for matched controls) until 2019.

RESULTS

SCI survivors showed a higher risk for MI (adjusted HR [aHR]: 2.41; 95% CI: 1.93-3.00), HF (aHR: 2.24; 95% CI: 1.95-2.56), and AF (aHR: 1.84; 95% CI: 1.49-2.28) compared to controls. The risks were further increased for those who were registered in the National Disability Registry within 1 year from the index date (SCI survivors with disability): SCI survivors with severe disability had the highest risks of MI (aHR: 3.74; 95% CI: 2.43-5.76), HF (aHR: 3.96; 95% CI: 3.05-5.14), and AF (aHR: 3.32; 95% CI: 2.18-5.05). Cervical and lumbar SCI survivors had an increased risk of heart disease regardless of disability compared to matched controls; these risks were slightly higher in those with disability. Thoracic SCI survivors with disability had significantly increased risk of heart disease compared to matched controls.

CONCLUSIONS

SCI survivors at all levels were at significantly greater risk for heart disease than non-SCI controls, particularly those with severe disability. Clinicians must be aware of the importance of heart disease in SCI survivors.

Contributing Factors to Endothelial Dysfunction in Individuals with Spinal Cord Injuries

Background

Patients with spinal cord injuries (SCIs) are at a greater risk for the development of cardiovascular diseases (CVDs) than able-bodied individuals due to the high risk of endothelial dysfunction.

Summary

For instance, patients with SCIs lose autonomic control of the heart and vasculature, which results in severe fluctuations in blood pressure. These oscillations between hypotension and hypertension have been shown to damage blood vessel endothelial cells and may contribute to the development of atherosclerosis. Furthermore, the loss of skeletal muscle control results in skeletal muscle atrophy and inward remodeling of the conduit arteries. It has been shown that blood vessels in the legs are chronically exposed to high shear, while the aorta experiences chronically low shear. These alterations to shear forces may adversely impact endothelial vasodilatory capacity and promote inflammatory signaling and leukocyte adherence. Additionally, microvascular endothelial vasodilatory capacity is impaired in patients with an SCI, and this may precede changes in conduit artery endothelial function. Finally, due to immobility and a loss of skeletal muscle mass, patients with SCIs have a higher risk of metabolic disorders, inflammation, and oxidative stress.

Key Messages

Collectively, these factors may impair endothelium-dependent vasodilatory capacity, promote leukocyte adhesion and infiltration, promote the peroxidation of lipids, and ultimately support the development of atherosclerosis. Therefore, future interventions to prevent CVDs in patients with SCIs should focus on the management of endothelial health to prevent endothelial dysfunction and atherosclerosis.

Modification of the Diabetes Prevention Program Lifestyle Intervention in Persons with Spinal Cord Injury: Efficacy for Reducing Major Cardiometabolic Risks, Increased Fitness, and Improved Health-Related Quality of Life

Individuals with chronic spinal cord injury (SCI) face elevated risks of cardiometabolic diseases, including cardiovascular disease and type 2 diabetes, due to factors like physical inactivity, neurogenic obesity, and disrupted glucose and insulin regulation. We conducted a prospective intervention cohort study involving 20 individuals with SCI (aged 28-60) with neurologic injuries at levels C4-T10 and ASIA scale grades A-D, lasting over a year. Our study assessed the impact of a therapeutic lifestyle intervention (TLI) based on the Diabetes Prevention Program (DPP) and its maintenance phase. The TLI comprised circuit resistance training, a Mediterranean-style calorie-restricted diet, and tailored behavioral support. Key outcomes measured included cardiometabolic risks (plasma analytes and disease biomarkers), anthropometrics (body mass, BMI, tissue composition), global metabolism, fitness (aerobic capacity, peak strength), and health-related quality of life (SF36). Results demonstrated a significant reduction in body mass and BMI by 7.5%, a 7% decrease in total fat mass, and substantial improvements in glucose regulation and insulin sensitivity. Lipid profiles improved, with reduced total cholesterol, triglycerides, and LDL-C, and increased HDL-C. Resting energy expenditure and fat oxidation increased by 27.4% and 58.5%, respectively. Aerobic capacity and dynamic strength also improved significantly. The Physical and Mental Composite Scores of the SF36 improved by 22.8% and 30.5%, respectively. Following the maintenance phase, several positive outcomes persisted, indicating a reduction in risk for cardiovascular disease and comorbid disorders. Our findings support the effectiveness of TLI in reducing cardiometabolic risks, enhancing fitness, and improving health-related quality of life in individuals with chronic SCI.

Trial Registration

ClinicalTrials.gov, ID: NCT02853149 Registered August 2, 2016.

Independent association of hypovitaminosis d with non-alcoholic fatty liver disease in people with chronic spinal cord injury: a cross-sectional study

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) and hypovitaminosis D are highly prevalent in people with spinal cord injury (SCI) and could exert an unfavorable influence on cardiovascular profile and rehabilitation outcomes. We aimed to assess the independent association between low 25-hydroxy vitamin D (25(OH)D) levels and NAFLD in people with chronic (> 1 year) SCI.

METHODS

One hundred seventy-three consecutive patients with chronic SCI (132 men and 41 women) admitted to a rehabilitation program underwent clinical/biochemical evaluations and liver ultrasonography.

RESULTS

NAFLD was found in 105 patients (60.7% of the study population). They were significantly older and exhibited a poorer leisure time physical activity (LTPA) and functional independence in activities of daily living, a greater number of comorbidities and a higher prevalence of metabolic syndrome (MetS) and its correlates, including lower HDL and higher values of body mass index (BMI), systolic blood pressure, HOMA-index of insulin resistance and triglycerides. 25(OH)D levels were significantly lower in NAFLD (median: 10.6 ng/ml, range: 2.0-31.0) than in non-NAFLD group (22.5 ng/ml, 4.2-51.6). When all these variables were included in a multiple logistic regression analysis, a significant independent association with NAFLD only persisted for lower 25(OH)D levels, a greater number of comorbidities and a poorer LTPA. The ROC analysis revealed that 25(OH)D levels < 18.25 ng/ml discriminated patients with NAFLD with a sensitivity of 89.0% and a specificity of 73.0% (AUC: 85.7%; 95%CI: 79.6-91.7%). NAFLD was exhibited by 83.9% of patients with 25(OH)D levels < 18.25 ng/ml and by 18% of those with 25(OH)D levels ≥ 18.25 ng/ml (p < 0.0001).

CONCLUSION

In people with chronic SCI, 25(OH)D levels < 18.25 ng/ml may represent a marker of NAFLD independent of MetS-related features. Further studies are warranted to define the cause-effect relationships of this association.

The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI

A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.

Reliability of five-minute vs. one-hour heart rate variability metrics in individuals with spinal cord injury

Background

A previous study showed low reliability of 1-h HRV outcomes in participants with spinal cord injury (SCI), but it was not certain whether the low reliability was due to the unrestricted activity of participants. We aimed to investigate test-retest reliability of HRV metrics in individuals with SCI using a 1-h measurement in a supine position.

Methods

Individuals with SCI underwent two sessions of 1-h recording of the time between consecutive R waves (RR-intervals) in a supine position. HRV outcomes were obtained from a single 5-min data segment and for the full 1-h recording. HRV parameters of interest were: standard deviation of all normal-to-normal R-R intervals (SDNN) and square root of the mean of the squared differences between successive R-R intervals (RMSSD) (time domain); and high frequency power (HF), low frequency power (LF), very low frequency power (VLF), ultra-low frequency power (ULF) and total power (TP) (frequency domain). Relative reliability was assessed by intraclass correlation coefficient (ICC). Absolute reliability was assessed by coefficient of variation (CV) and Bland-Altman limits of agreement (LoA).

Results

Data from 37 individuals (14 with tetraplegia and 23 with paraplegia) were included. Relative reliability was higher for the 1-h (ICCs ranged from 0.13-0.71) than for the 5-min duration (ICCs ranged from 0.06-0.50) in the overall SCI group for all HRV metrics. Participants with tetraplegia had lower relative reliability compared to participants with paraplegia in all HRV metrics for the 5-min duration (ICCs ranged from -0.01-0.34 vs. 0.21-0.57). For the 1-h duration, participants with paraplegia showed higher relative reliability than participants with tetraplegia in all HRV metrics (ICCs ranged from 0.18-0.79 vs. 0.07-0.54) except TP (ICC 0.69 vs. 0.82). In terms of absolute reliability, the CVs and LoAs for the 1-h duration were better than for the 5-min duration. In general, time domain metrics showed better reliability than frequency domain metrics for both durations in participants with tetraplegia and paraplegia. The lowest CV and narrowest 95% LoA were found for SDNN in 5-min and 1-h durations overall and in both lesion levels.

Conclusions

The supine position did not provide better reliability compared to unrestricted activity in participants with SCI. HRV analysis using a 5-min duration is of limited value in SCI due to poor reliability. For the 1-h analysis duration, interpretation of the reliability of HRV varies according to lesion level: it is recommended to take lesion level into account when interpreting reliability measures.

Anti-Siglec-15 Antibody Prevents Marked Bone Loss after Acute Spinal Cord Injury-Induced Immobilization in Rats

Rapid and extensive sublesional bone loss after spinal cord injury (SCI) is a difficult medical problem that has been refractory to available interventions except the antiresorptive agent denosumab (DMAB). While DMAB has shown some efficacy in inhibiting bone loss, its concurrent inhibition of bone formation limits its use. Sialic acid-binding immunoglobulin-like lectin (Siglec)-15 is expressed on the cell surface of mature osteoclasts. Anti-Siglec-15 antibody (Ab) has been shown to inhibit osteoclast maturation and bone resorption while maintaining osteoblast activity, which is distinct from current antiresorptive agents that inhibit the activity of both osteoclasts and osteoblasts. The goal of the present study is to test a Siglec-15 Ab (NP159) as a new treatment option to prevent bone loss in an acute SCI model. To this end, 4-month-old male Wistar rats underwent complete spinal cord transection and were treated with either vehicle or NP159 at 20 mg/kg once every 2 weeks for 8 weeks. SCI results in significant decreases in bone mineral density (BMD, -18.7%), trabecular bone volume (-43.1%), trabecular connectivity (-59.7%), and bone stiffness (-76.3%) at the distal femur. Treatment with NP159 almost completely prevents the aforementioned deterioration of bone after SCI. Blood and histomorphometric analyses revealed that NP159 is able to greatly inhibit bone resorption while maintaining bone formation after acute SCI. In ex vivo cultures of bone marrow cells, NP159 reduces osteoclastogenesis while increasing osteoblastogenesis. In summary, treatment with NP159 almost fully prevents sublesional loss of BMD and metaphysis trabecular bone volume and preserves bone strength in a rat model of acute SCI. Because of its unique ability to reduce osteoclastogenesis and bone resorption while promoting osteoblastogenesis to maintain bone formation, Siglec-15 Ab may hold greater promise as a therapeutic agent, compared with the exclusively antiresorptive or anabolic agents that are currently used, in mitigating the striking bone loss that occurs after SCI or other conditions associated with severe immobilization. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines

Persons with spinal cord injury (SCI) experience gains in fitness, physical and mental health from regular participation in exercise and physical activity. Due to changes in physiological function of the cardiovascular, nervous, and muscular systems, general population physical activity guidelines and traditional exercise prescription methods are not appropriate for the SCI population. Exercise guidelines specific to persons with SCI recommend progressive training beginning at 20 min of moderate to vigorous intensity aerobic exercise twice per week transitioning to 30 min three times per week, with strength training of the major muscle groups two times per week. These population-specific guidelines were designed considering the substantial barriers to physical activity for persons with SCI and can be used to frame an individual exercise prescription. Rating of perceived exertion (i.e., perceptually regulated exercise) is a practical way to indicate moderate to vigorous intensity exercise in community settings. Adapted exercise modes include arm cycle ergometry, hybrid arm-leg cycling, and recumbent elliptical equipment. Body weight-supported treadmill training and other rehabilitation modalities may improve some aspects of health and fitness for people with SCI if completed at sufficient intensity. Disability-specific community programs offer beneficial opportunities for persons with SCI to experience quality exercise opportunities but are not universally available.

Burden of Cardiovascular Risk in Individuals With Spinal Cord Injury and Its Association With Rehabilitation Outcomes: Results From the Swiss Spinal Cord Injury Cohort

OBJECTIVES

The aims of the study are to determine the cardiovascular risk burden rehabilitation discharge and to explore the association between recovery during rehabilitation and cardiovascular disease risk profile.

METHODS

We included adults without cardiovascular disease admitted for rehabilitation. We evaluated rehabilitation outcomes on admission and discharge. Cardiovascular disease risk profile was assessed by Framingham risk score, high-density lipoprotein, and fasting glucose level.

RESULTS

We analyzed data from 706 participants (69.6% men) with a median age of 53.5 yrs. The median time since injury was 14 days, and the admission length was 5.2 months. Majority had paraplegia (53.3%) and motor incomplete injury (53.7%). One third of the cohort had high cardiovascular risk profile before discharge. At discharge, poorer anthropometric measures were associated with higher Framingham risk score and lower high-density lipoprotein levels. Individuals with higher forced vital capacity (>2.72 l) and peak expiratory flow (>3.4 l/min) had 0.16 mmol/l and 0.14 mmol/l higher high-density lipoprotein compared with those with lower respiratory function, respectively. Individuals with higher mobility score (>12.5) and functional independence score (>74) had 0.21 and 0.18 mmol/l higher high-density lipoprotein compared with those with lower scores.

CONCLUSIONS

There is high cardiometabolic syndrome burden and cardiovascular disease risk profile upon rehabilitation discharge. Higher respiratory function, mobility, and overall independence were associated with better cardiovascular disease risk profile, although with study design limitations and short follow-up. Future studies should explore whether rehabilitation outcomes could be used to prioritize screening.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon reading this journal article, the reader is expected to: (1) Determine the burden of cardiometabolic disease in the early phase of spinal cord injury (SCI); (2) Differentiate the proposed SCI cutoff for high-risk obesity from the able-bodied population; and (3) Increase physicians' acuity for detecting cardiometabolic disease in their practice.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Elevated high-sensitivity cardiac troponin T serum concentration in subjects with spinal cord injury

BACKGROUND

The biochemical analysis of high-sensitivity cardiac troponins (hs-cTn) from peripheral blood specimens has been established as biomarker for myocardial injury. Independently of myocardial injury, increased serum hs-cTn concentrations have been described in patients with myopathies. The relevance and frequency of noncardiac hs-cTn elevations in spinal cord injury (SCI) is unknown. Our study aimed to 1) determine the frequency of increased hs-cTn concentrations of supposedly noncardiac origin above the 99th percentile (upper reference limit, URL) in an unselected SCI population and 2) compare the two protagonist analytes cTnT and cTnI with respect to these noncardiac elevations.

METHODS

In this monocentric, cross-sectional study, we sampled blood from n = 30 SCI subjects without cardiac symptoms to test for hs-cTnT and hs-cTnI serum concentrations.

RESULTS

18/30 (60%) of SCI subjects showed increased hs-cTnT concentrations above the URL of 14 ng/l (p < 0.001). In 4 subjects (22.2%) concentrations were >50 ng/l. Moreover, 3 of these four subjects fulfilled the 6-h troponin dynamics criterion for acute myocardial injury in serial hs-cTnT testing. In contrast, no subject demonstrated increased hs-cTnI concentrations according to the URL of 40 ng/l. 6-h troponin dynamics were also unremarkable for hs-cTnI testing.

CONCLUSIONS

SCI subjects frequently have increased hs-cTnT concentrations without clinical and hs-cTnI evidence of myocardial injury. Clinicians must be aware of cTnT "skeletal muscle false-positives" in SCI, which applies to elevated baseline cTnT concentrations and troponin dynamics in serial measurements. In case of diagnostic uncertainty, simultaneous analysis of cTnI might be helpful.

Exercise and aerobic capacity in individuals with spinal cord injury: A systematic review with meta-analysis and meta-regression

BACKGROUND

A low level of cardiorespiratory fitness [CRF; defined as peak oxygen uptake ([Formula: see text]O2peak) or peak power output (PPO)] is a widely reported consequence of spinal cord injury (SCI) and a major risk factor associated with chronic disease. However, CRF can be modified by exercise. This systematic review with meta-analysis and meta-regression aimed to assess whether certain SCI characteristics and/or specific exercise considerations are moderators of changes in CRF.

METHODS AND FINDINGS

Databases (MEDLINE, EMBASE, CENTRAL, and Web of Science) were searched from inception to March 2023. A primary meta-analysis was conducted including randomised controlled trials (RCTs; exercise interventions lasting >2 weeks relative to control groups). A secondary meta-analysis pooled independent exercise interventions >2 weeks from longitudinal pre-post and RCT studies to explore whether subgroup differences in injury characteristics and/or exercise intervention parameters explained CRF changes. Further analyses included cohort, cross-sectional, and observational study designs. Outcome measures of interest were absolute (A[Formula: see text]O2peak) or relative [Formula: see text]O2peak (R[Formula: see text]O2peak), and/or PPO. Bias/quality was assessed via The Cochrane Risk of Bias 2 and the National Institute of Health Quality Assessment Tools. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects models were used in all meta-analyses and meta-regressions. Of 21,020 identified records, 120 studies comprising 29 RCTs, 67 pre-post studies, 11 cohort, 7 cross-sectional, and 6 observational studies were included. The primary meta-analysis revealed significant improvements in A[Formula: see text]O2peak [0.16 (0.07, 0.25) L/min], R[Formula: see text]O2peak [2.9 (1.8, 3.9) mL/kg/min], and PPO [9 (5, 14) W] with exercise, relative to controls (p < 0.001). Ninety-six studies (117 independent exercise interventions comprising 1,331 adults with SCI) were included in the secondary, pooled meta-analysis which demonstrated significant increases in A[Formula: see text]O2peak [0.22 (0.17, 0.26) L/min], R[Formula: see text]O2peak [2.8 (2.2, 3.3) mL/kg/min], and PPO [11 (9, 13) W] (p < 0.001) following exercise interventions. There were subgroup differences for R[Formula: see text]O2peak based on exercise modality (p = 0.002) and intervention length (p = 0.01), but there were no differences for A[Formula: see text]O2peak. There were subgroup differences (p ≤ 0.018) for PPO based on time since injury, neurological level of injury, exercise modality, and frequency. The meta-regression found that studies with a higher mean age of participants were associated with smaller changes in A[Formula: see text]O2peak and R[Formula: see text]O2peak (p < 0.10). GRADE indicated a moderate level of certainty in the estimated effect for R[Formula: see text]O2peak, but low levels for A[Formula: see text]O2peak and PPO. This review may be limited by the small number of RCTs, which prevented a subgroup analysis within this specific study design.

CONCLUSIONS

Our primary meta-analysis confirms that performing exercise >2 weeks results in significant improvements to A[Formula: see text]O2peak, R[Formula: see text]O2peak, and PPO in individuals with SCI. The pooled meta-analysis subgroup comparisons identified that exercise interventions lasting up to 12 weeks yield the greatest change in R[Formula: see text]O2peak. Upper-body aerobic exercise and resistance training also appear the most effective at improving R[Formula: see text]O2peak and PPO. Furthermore, acutely injured, individuals with paraplegia, exercising for ≥3 sessions/week will likely experience the greatest change in PPO. Ageing seemingly diminishes the adaptive CRF responses to exercise training in individuals with SCI.

REGISTRATION

PROSPERO: CRD42018104342.

Sensory Information Modulates Voluntary Movement in an Individual with a Clinically Motor- and Sensory-Complete Spinal Cord Injury: A Case Report

Motor recovery following a complete spinal cord injury is not likely. This is partially due to insurance limitations. Rehabilitation strategies for individuals with this type of severe injury focus on the compensation for the activities of daily living in the home and community and not on the restoration of function. With limited time in therapies, the initial goals must focus on getting the patient home safely without the expectation of recovery of voluntary movement below the level of injury. In this study, we report a case of an individual with a chronic, cervical (C3)-level clinically motor- and sensory-complete injury who was able to perform voluntary movements with both upper and lower extremities when positioned in a sensory-rich environment conducive to the specific motor task. We show how he is able to intentionally perform push-ups, trunk extensions and leg presses only when appropriate sensory information is available to the spinal circuitry. These data show that the human spinal circuitry, even in the absence of clinically detectable supraspinal input, can generate motor patterns effective for the execution of various upper and lower extremity tasks, only when appropriate sensory information is present. Neurorehabilitation in the right sensory-motor environment that can promote partial recovery of voluntary movements below the level of injury, even in individuals diagnosed with a clinically motor-complete spinal cord injury.

Relationships between cardiovascular disease risk, neuropathic pain, mental health, and autonomic function in chronic spinal cord injury

STUDY DESIGN

Multicentre, cross-sectional study.

OBJECTIVES

To determine if clinical measures of poor mental health (MH-) and neuropathic pain (NP) are related to increased CVD risk in individuals with chronic spinal cord injury (SCI), and further elucidate the relationships between CVD risk, autonomic function, NP, and MH-.

SETTING

Eight SCI rehabilitation centres in the Netherlands.

METHODS

Individuals (n = 257) with a traumatic, chronic (≥10 yrs) SCI, with age at injury between 18-35 years, completed a self-report questionnaire and a one-day visit to a rehabilitation centre for testing. CVD risk was calculated using Framingham risk score. NP was inferred using The Douleur Neuropathique 4 clinical examination, and MH- was assessed using the five-item Mental Health Inventory questionnaire. Cardiovascular autonomic function was determined from peak heart rate during maximal exercise (HRpeak).

RESULTS

There was a high prevalence of both NP (39%) and MH- (45%) following SCI. MH- was significantly correlated with an adverse CVD risk profile (r = 0.174; p = 0.01), increased the odds of adverse 30-year CVD risk by 2.2 (CI 0.92-2.81, p = 0.02), and is an important variable in determining CVD risk (importance=0.74, p = 0.05). Females (p = 0.05) and those with a higher HRpeak (p = 0.046) tended to be more likely to have NP.

CONCLUSIONS

Clinical measures of MH-, but not NP, are important factors for increased CVD risk following SCI. NP tended to be more prevalent in those with more preserved cardiovascular autonomic function. The interrelationships between secondary consequences of SCI are complex and need further exploration.