Body composition modifications in people with chronic spinal cord injury after supervised physical activity

Background

Quantification of body composition variables is important for planning of better activities in relation to individuals with spinal cord injury (SCI).

Objectives

(1) To evaluate changes in body composition in patients with SCI after a supervised physical activity process; (2) To correlate total body fat with time since injury.

Design

Pre-post intervention.

Setting

Sarah Rehabilitation Hospital Network, Brazil.

Participants

Fifty-three men with SCI aged 18–52 years with duration of injury >3 years.

Interventions

The subjects were divided into three groups: tetraplegia (TT) (C5–C8), high paraplegia (HP) (T1–T6), and low paraplegia (LP) (T7–L2). Body composition was estimated in the first and last weeks of hospitalization.

Outcome measures

Body weight (kg), skinfolds sum (mm), absolute (kg), and relative (%) fat and lean body mass.

Results

Body weight increased in TT and decreased in HP (0.8 kg, 95%CI 0.1–1.5; and −1.0 kg, 95%CI −2.0 to 0.0, respectively; P < 0.05). Skinfolds sum decreased only in HP (−13.1 mm, 95%CI −20.7 to −5.5; P < 0.05). Absolute and relative body fat decreased significantly in the paraplegia groups. Lean body mass (LBM) percentage increased significantly in the paraplegia groups. Absolute LBM increased in TT and LP (0.8 kg, 95%CI 0.3–1.3; and 1.3 kg, 95%CI 0.8 to 1.8, respectively; P < 0.05). There was no correlation between time since injury and skinfolds sum for the three groups (P < 0.05).

Conclusion

TT, HP, and LP demonstrated favorable changes in body composition after 29 days of supervised physical activity. However, these changes were different in direction and magnitude.     

Effect of choice of recovery patterns on handrim kinetics in manual wheelchair users with paraplegia and tetraplegia

Background

Impact forces experienced by the upper limb at the beginning of each wheelchair propulsion (WCP) cycle are among the highest forces experienced by wheelchair users.

Objective

To determine whether the magnitude of hand/forearm velocity prior to impact and effectiveness of rim impact force are dependent on the type of hand trajectory pattern chosen by the user during WCP. Avoiding patterns that inherently cause higher impact force and have lower effectiveness can be another step towards preserving upper limb function in wheelchair users.

Methods

Kinematic (50 Hz) and kinetic (2500 Hz) data were collected on 34 wheelchair users (16 with paraplegia and 18 with tetraplegia); all participants had motor complete spinal cord injuries ASIA A or B. The four-hand trajectory patterns were analyzed based on velocity prior to contact, peak impact force and the effectiveness of force at impact.

Results

A high correlation was found between the impact force and the relative velocity of the hand with respect to the wheel (P < 0.05). The wheelchair users with paraplegia were found to have higher effectiveness of force at impact as compared to the users with tetraplegia (P < 0.05). No significant differences in the impact force magnitudes were found between the four observed hand trajectory patterns.

Conclusion

The overall force effectiveness tended to be associated with the injury level of the user and was found to be independent of the hand trajectory patterns.     

Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: a randomized control trial

Objective/background

People with spinal cord injury (SCI) paraplegia can develop shoulder problems over time, which may also cause pain. Shoulder pain may complicate or interfere with a person''s daily activities, social events, and their overall quality of life (QOL). The purpose of this study was to examine changes in social interaction and QOL after an exercise treatment for shoulder pain in people with SCI paraplegia.

Design

Fifty-eight participants with SCI paraplegia who were also experiencing shoulder pain were selected and randomized to either an exercise treatment or a control group. Participants in the treatment group participated in a 12-week, at-home, exercise and movement optimization program designed to strengthen shoulder muscles and modify movements related to upper extremity weight bearing.

Methods

Participants filled out self-report measures at baseline, 12 weeks later at the end of treatment, and at a 4-week follow-up.

Outcome measures

The Wheelchair User''s Shoulder Pain Index (WUSPI), the Social Interaction Inventory (SII), and the Subjective Quality of Life Scale.

Results

From the baseline to the end of treatment, repeated-measures analysis of variance revealed a significant interaction between WUSPI and SII scores, P < 0.001, and between WUSPI and QOL scores, P < 0.001.

Conclusion

Reductions in shoulder pain were related to significant increases in social participation and improvements in QOL. However, increases in social participation did not significantly affect improvements in QOL.     

Etanercept treatment enhances clinical and neuroelectrophysiological recovery in partial spinal cord injury

Purpose

To investigate the effect of an anti-TNF-α agent (etanercept) on recovery processes in a partial spinal cord injury (SCI) model using clinical and electrophysiological tests.

Methods

Twenty-four New Zealand rabbits were divided into three groups: group 1 [SCI + 2 ml saline intramuscular (i.m.), n = 8], group 2 (SCI + 2.5 mg/kg etanercept, i.m., 2–4 h after SCI, n = 8) and group 3 (SCI + 2.5 mg/kg etanercept, i.m., 12–24 h after SCI, n = 8). Rabbits were evaluated before SCI, immediately after SCI, 1 week after, and 2 weeks after SCI, clinically by Tarlov scale and electrophysiologically by SEP.

Results

Tarlov scores of groups 2 and 3 were significantly better than group 1, 2 weeks after SCI. SEP recovery was significantly better in groups 2 and 3 than group 1, 2 weeks after SCI.

Conclusions

These results show that blocking TNF-α mediated inflammation pathway by an anti-TNF-α agent enhances clinical and electrophysiological recovery processes in partial SCI model.     

Soleus H-reflex modulation after motor incomplete spinal cord injury: effects of body position and walking speed

Objective:

To examine position-dependent (semireclined to standing) and walking speed–dependent soleus H-reflex modulation after motor incomplete spinal cord injury (SCI).

Participants:

Twenty-six patients with motor incomplete SCI (mean: 45 ± 15 years) and 16 noninjured people (mean: 38 ± 14 years).

Methods:

Soleus H-reflexes were evoked by tibial nerve stimulation. Patients were tested in semireclined and standing positions (experiment 1) and in midstance and midswing positions (experiment 2).

Results:

H-reflexes were significantly greater after SCI in all positions compared with noninjured people (P < 0.05). Position-dependent modulation from semireclined to standing (normally observed in noninjured people) was absent after SCI. In SCI patients, H-reflex modulation was not significantly different at 1.2 m/s compared with 0.6 m/s treadmill walking speed; in noninjured people, H-reflex modulation was significantly greater at 1.2 m/s compared with 0.6 m/s treadmill walking speed. There was a significant positive correlation between modified Ashworth scores, a clinical measure of spasticity and soleus H-reflex amplitudes tested in all positions. A significant negative correlation was also found between H-reflexes in standing and midstance positions and the amount of assistance patients required to walk.

Conclusions:

An improvement in position-dependent and walking speed–dependent reflex modulation after SCI may indicate functional recovery. Future studies will use H-reflex testing to track changes as a result of therapeutic interventions.     

Effectiveness of local cooling for enhancing tissue ischemia tolerance in people with spinal cord injury

Objective

To investigate the effects of localized cooling and cooling rate on pressure-induced ischemia for people with and without neurological deficits.

Design

A 2 × 3 mixed factorial design with two groups: (1) people with spinal cord injury (SCI) and (2) people without neurological deficits (control), and three test conditions: (1) pressure only, (2) pressure with fast cooling (−4°C/min), and (3) pressure with slow cooling (−0.33°C/min).

Setting

University laboratory.

Participants

Fourteen controls and 14 individuals with SCI.

Interventions

Pressure on the sacrum was 0.4 kPa for 5 minutes, then 8 kPa for 20 minutes, and finally 0.4 kPa for 15 minutes. Fast and slow cooling to 25°C applied during 8 kPa of pressure.

Outcome measures

Reactive hyperemia and its spectral densities in the metabolic, neurogenic, and myogenic frequency ranges.

Results

In controls, reactive hyperemia was greater in pressure only as compared with both cooling conditions. No change was noted in all spectral densities in both cooling conditions, and only neurogenic spectral density increased without cooling. In subjects with SCI, no difference was noted in reactive hyperemia among conditions. However, metabolic and myogenic spectral densities increased without cooling and all spectral densities increased with slow cooling. No change was noted in all spectral densities with fast cooling.

Conclusion

Local cooling reduced the severity of ischemia in controls. This protective effect may be masked in subjects with SCI due to chronic microvascular changes; however, spectral analysis suggested local cooling may reduce metabolic vasodilation. These findings provide evidence towards the development of support surfaces with temperature control for weight-bearing soft tissues.     

Trunk strength and function using the multidirectional reach distance in individuals with non-traumatic spinal cord injury

Context

Trunk control is essential to engage in activities of daily living. Measuring trunk strength and function in persons with spinal cord injury (SCI) is difficult. Trunk function has not been studied in non-traumatic SCI (NTSCI).

Objectives

To characterize changes in trunk strength and seated functional reach in individuals with NTSCI during inpatient rehabilitation. To determine if trunk strength and seated reach differ between walkers and wheelchair users. To explore relationships between trunk and hip strength and seated functional reach.

Design

Observational study.

Setting

Two SCI rehabilitation facilities.

Participants

32 subacute inpatients (mean age 48.0 ± 15.4 years).

Outcome measures

Isometric strength of trunk and hip and function (Multidirectional Reach Test: MDRT) were assessed at admission and within 2 weeks of discharge. Analysis of variance was conducted for admission measures (MDRT, hip and trunk strength) between walkers and wheelchair users. Changes in MDRT, hip and trunk strength were evaluated using parametric and non-parametric statistics. The level of association between changes in values of MRDT and strength was also examined.

Results

Significant differences between walkers and wheelchair users were found for strength measures (P < 0.05) but not for MDRT. Left- and right-sided reaches increased in wheelchair users only (P < 0.05). Associations between changes in hip strength, trunk strength, and reach distance were found (R = 0.67–0.73).

Conclusion

In clinical settings, it is feasible and relevant to assess trunk, hip strength, and MRDT. Future studies require strategies to increase the number of participants assessed, in order to inform clinicians about relevant rehabilitation interventions.     

Feasibility for developing cardiovascular exercise recommendations for persons with motor-complete paraplegia based on manual wheelchair propulsion; A protocol and preliminary data

Background

The Center for Disease Control, American Heart Association, and American College of Sports Medicine recommendations for duration and intensity of exercise are based on the amount of energy expenditure required to maintain cardiovascular health in able body individuals; 1000 Kilocalories (Kcals) per week of energy expenditure has been demonstrated to achieve this effect. Manual wheelchair propulsion (MWP) represents a practical and accessible form of exercise for individuals with paraplegia.

Objective

To describe a method to determine the duration of MWP required to expend 1000 Kcals, when performed by individuals with paraplegia due to motor-complete spinal cord injury (SCI).

Study Design

Cross-sectional study.

Setting

Rehabilitation Research Laboratory.

Participants

Sixteen adults with motor complete T3-T12 paraplegia (body mass index < 35, duration of paraplegia > 3 months).

Interventions

Not applicable.

Main Outcome Measures

Indirect calorimetry during MWP was measured in order to calculate caloric expenditure per minute. These data were used to calculate the number of minutes of MWP required to expend 1000 Kcal in one week.

Results

During MWP, participants expended 3.3 ± 1.0 Kcal/minute. Based on this figure, 1000 Kcal of energy expenditure in one week would require 303 minutes of MWP per week, or 43.3 minutes per day, 7 days per week.

Conclusions

Our data suggest that it is feasible to create a practical and accessible exercise recommendation based on manual wheelchair propulsion for individuals with paraplegia due to motor-complete SCI. Larger studies are needed in order to develop accurate exercise recommendations for persons with SCI.     

Psychosocial outcomes among youth with spinal cord injury by neurological impairment

Objective

Examine psychosocial outcomes of youth with spinal cord injury (SCI) as a function of neurological level (paraplegia/tetraplegia) and severity (American Spinal Injury Association (ASIA) Impairment Scale (AIS)).

Design

Survey research.

Setting

Three pediatric SCI specialty centers in the USA.

Participants

Youth with SCI ages 5–18 with neurological impairment classifications of: tetraplegia AIS ABC (tetraplegia ABC), paraplegia AIS ABC (paraplegia ABC), or AIS D.

Outcome Measures

Children''s Assessment of Participation and Enjoyment, Pediatric Quality of Life Inventory, Revised Children''s Manifest Anxiety Scale, and Children''s Depression Inventory.

Results

Three hundred and forty youth participated; 57% were male; 60% were Caucasian, 21% Hispanic, 7% African-American, 2% Native American, and 3% reported “other”. Their mean age was 8.15 years (standard deviation (SD) = 5.84) at injury and 13.18 years (SD = 3.87) at interview. Ninety-six youth (28%) had tetraplegia ABC injuries, 191 (56%) paraplegia ABC injuries, and 53 (16%) AIS D injuries. Neurological impairment was significantly related to participation and quality of life (QOL). Specifically, youth with paraplegia ABC and AIS D injuries participated in more activities than youth with tetraplegia ABC (P = 0.002; P = 0.018, respectively) and youth with paraplegia ABC participated more often than youth with tetraplegia ABC (P = 0.006). Youth with paraplegia ABC reported higher social QOL than youth with tetraplegia ABC (P = 0.001) and AIS D injuries (P = 0.002). Groups did not differ regarding mental health.

Conclusion

Interventions should target youth with tetraplegia ABC, as they may need support in terms of participation, and both youth with tetraplegia ABC and AIS D injuries in terms of social integration.     

Muscle spasticity associated with reduced whole-leg perfusion in persons with spinal cord injury

Objective

To determine the association between peripheral blood flow and spasticity in individuals with spinal cord injury (SCI).

Design

A cross-sectional study with measurements of muscle spasticity and whole-limb blood flow in individuals with SCI.

Setting

University of Texas at Austin and Brain & Spine Recovery Center, Austin, TX, USA.

Participants

Eighteen individuals (14 males and 4 females) with SCI were classified into high (N = 7), low (N = 6), and no (N = 5) spasticity groups according to the spasticity levels determined by the modified Ashworth scale scores.

Interventions

Whole-limb blood flow was measured in the femoral and brachial arteries using Doppler ultrasound and was normalized to lean limb mass obtained with dual-energy X-ray absorptiometry.

Outcome measures

Limb blood flow and muscle spasticity.

Results

Age, time post-SCI, and the American Spinal Injury Association impairment scale motor and sensory scores were not different among groups with different muscle spasticity. Femoral artery blood flow normalized to lean leg mass was different (P = 0.001) across the three spasticity groups (high 78.9 ± 16.7, low 98.3 ± 39.8, no 142.5 ± 24.3 ml/minute/kg). Total leg muscle spasticity scores were significantly and negatively correlated with femoral artery blood flow (r = −0.59, P < 0.01). There was no significant difference in brachial artery blood flow among the groups.

Conclusions

Whole-leg blood flow was lower in individuals with greater spasticity scores. These results suggest that a reduction in lower-limb perfusion may play a role, at least in part, in the pathogenesis leading to muscle spasticity after SCI.     

Mortality in patients with traumatic spinal cord injury: descriptive analysis of 62 deceased subjects

Study design

Retrospective study.

Objective

To investigate the causes of death in patients who were ≤50 years at the time of traumatic spinal cord injury (tSCI).

Setting

Convenience sample of a tertiary rehabilitation center.

Methods

All deceased patients with tSCI who survived a minimum of 10 years post-injury, were included. In addition, causes of death were compared between subjects surviving <10 years and ≥10 years. Neurological assessments were performed according to the American Spinal Injury Association scale. Data on causes of death were analyzed using the ICD-10 classifications. Differences were calculated using the Mann–Whitney and chi-square tests.

Results

A total of 100 patients, with 38 and 62 surviving <10 and ≥10 years, respectively, were included. No significant differences in causes of death were identified between these two groups. In patients surviving ≥10 years, paraplegia was associated with a higher life expectancy compared with tetraplegia, 34 and 25 years (p = 0.008), respectively, and the leading causes of death were septicemia (n = 14), ischemic heart disease (n = 10), neoplasms (n = 9), cerebrovascular diseases (n = 5), and other forms of heart diseases (n = 5). Septicemia, influenza/pneumonia, and suicide were the leading causes of death in tetraplegics, whereas ischemic heart disease, neoplasms, and septicemia were the leading causes of death in paraplegia.

Conclusion

Our monocentric study showed that in 62 deceased patients with SCI, the leading causes of death were septicemia, cardiovascular diseases, neoplasms, and cerebrovascular diseases. In addition, no significant differences were identified between causes of death among patients surviving <10 years and ≥10 years post-injury.     

Elevated leptin expression in rat model of traumatic spinal cord injury and femoral fracture

Background

Few studies have reported a relationship between leptin induced by spinal cord injury (SCI) and healing bone tissue.

Objective

To observe serum and callus leptin expression within the setting of fracture and traumatic SCI.

Methods

Seventy-two male Sprague Dawley rats were randomized equally into four groups: control, SCI group, fracture group, and fracture/SCI group. Rats were sacrificed at 7, 14, 21, and 28 days post-fracture/SCI. Serum leptin was detected using radioimmunoassay at 1, 7, 14, 21, and 28 days, and callus formation was measured radiologically at 14, 21, and 28 days. Callus leptin was analyzed by means of immunohistochemistry.

Results

Serum leptin in the fracture group, SCI group, and combined fracture/SCI group were all significantly increased compared to control group at the 1, 7, 14, and 2-day time points (P < 0.05). Serum leptin in the combined fracture/SCI group was significantly higher than in the fracture group at 7, 14, and 21 days (P < 0.05), and higher than in SCI groups at 14 and 21days after operation (P < 0.05). The percentage of leptin-positive cells in the fracture/SCI callus, and callus volume was significantly higher than in the fracture-only group (P < 0.001).

Conclusions

Overall, elevated leptin expression was demonstrated within healing bone especially in the 21 days of a rat model combining fracture and SCI. A close association exists between leptin levels and the degree of callus formation in fractures.     

A survey of protective cushion usage in individuals with spinal cord injury while traveling in a motor vehicle and on a commercial airliner

Objective

While there are specific recommendations for pressure relieving cushions when seated in a wheelchair, there is a paucity of information regarding prescribed wheelchair cushions for persons with spinal cord injury (SCI) when traveling and not in their wheelchair seat. A questionnaire was designed to ascertain if individuals with SCI who are primarily wheelchair users utilize a prescribed wheelchair cushion when traveling in a motor vehicle (MV) or on a commercial airliner, as not utilizing one may be a causative factor in developing pressure ulcers.

Design and setting

Survey design in an outpatient SCI rehabilitation setting.

Participants

Full-time wheelchair users, with chronic (>1 year) SCI.

Results

Forty-two participants completed the survey, with a mean age of 39 years old and time post-injury of 10.4 years. All subjects used a prescribed wheelchair cushion when seated in their wheelchair. Twenty-seven subjects reported transferring to a MV seat (59.5% of sample), with 25 (92.6%) reporting not using a prescribed wheelchair cushion when sitting directly on the MV seat. For subjects who traveled on an airplane (n = 23–54.8%), 19 (82.6%) reported that they do not sit on a prescribed specialty cushion.

Conclusion

Persons with chronic SCI, who are primary wheelchair users, utilize prescribed wheelchair cushions when sitting in their wheelchair, but most do not utilize a prescribed wheelchair cushion when seated in a MV (if they transfer out of their chair) or on a airplane seat. Studies to determine the pressures over the bony prominences on their travel surfaces may need to be undertaken to see whether the pressures are appropriate, as they may be a source of skin breakdown.     

Pushrim Kinetics During Advanced Wheelchair Skills in Manual Wheelchair Users With Spinal Cord Injury

Objective:

To assess the peak force during wheelchair propulsion of individuals with spinal cord injury propelling over obstacles from the Wheelchair Skills Test.

Participants/Methods:

Twenty-three individuals with spinal cord injury (SCI) who are full-time manual wheelchair users were included in this prospective study. A SmartWheel (Three Rivers Holdings, LLC) was used to analyze each push while subjects negotiated standardized obstacles used in the Wheelchair Skills Test, including tile, carpet, soft surface, 5° and 10° ramps, 2 cm, 5 cm, and 15 cm curbs.

Results:

When the peak forces of the advanced skills were compared to level 10 m tile/10 m carpet, there was a statistically significant increase in all peak forces (P value ranged from .0001 to .0268).

Discussion:

It is well documented that a large number of individuals with SCI develop upper limb pain. One of the recommendations to preserve the upper limb is to minimize force during repetitive tasks.

Conclusion:

Advanced wheelchair skills require an increase in force to accomplish. The increase in forces ranged from 18% to 130% over that required for level 10 m tile/10 m carpet.     

Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury

Study Design:

Prospective clinical study.

Background:

Pressure ulcers interfere with the rehabilitation process in patients with spinal cord injury (SCI) and are a significant deterrent to participation in activities that contribute to independent, productive, and satisfying life.

Objective:

To evaluate the effect of surgery for pressure ulcers on general health and quality of life in patients with SCI.

Setting:

Tertiary care center in northern India.

Methods:

Various types of flap surgery were performed on 30 patients with SCI and 32 pressure ulcers (stages III and IV). Outcome was evaluated using general improvement in health (hemoglobin, serum proteins, and general well-being), patient satisfaction, and global quality of life scores (according to the visual analog scale).

Results:

At admission, the mean values of global quality of life, hemoglobin, serum albumin, and total serum proteins were 50.15 (range, 30–65), 8.75 g/dL (range, 6–12 g/dL), 3.12 g/dL (range, 2.9–4.3 g/dL), and 5.21 (range, 5–6.2 g/dL), respectively. At 6-month follow up, mean values of global quality of life score, hemoglobin, serum albumin, and total serum proteins were 87.36 (range, 44–96), 10.85 g/dL (range, 8.2–13.5 g/dL), 3.89 g/dL (range, 3.2–4.5 g/dL), and 6.43 g/dL (range, 5.85–6.70 g/dL), respectively. The overall rise in quality of life scores, hemoglobin, serum albumin, and total serum proteins was statistically significant. Most of the patients (76.7%) reported improvement in subjective well-being, and 83.3% were satisfied with the ultimate outcome of the surgery.

Conclusion:

Results suggest that surgery for stages III and IV pressure ulcers offers the greatest benefit to the patients in terms of improvement in general health (anemia, hypoproteinemia, and general well-being) and quality of life.     

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

Objective

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

Design

Cross-sectional, observational study.

Setting

Spinal cord unit.

Methods

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

Results

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

Conclusions

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