Dietetics After Spinal Cord Injury: Current Evidence and Future Perspectives

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

Spinal Myoclonus After Spinal Cord Injury

Abstract

Background/Objective: In the course of examining spinal motor function in many hundreds of people with traumatic spinal cord injury, we encountered 6 individuals who developed involuntary and rhythmic contractions in muscles of their legs. Although there are many reports of unusual muscle activation patterns associated with different forms of myoclonus, we believe that certain aspects of the patterns seen with these 6 subjects have not been previously reported. These patterns share many features with those associated with a spinal central pattern generator for walking.

Methods: Subjects in this case series had a history of chronic injury to the cervical spinal cord, resulting in either complete (ASIA A; n = 4) or incomplete (ASIA D; n = 2) quadriplegia. We used multi-channel electromyography recordings of trunk and leg muscles of each subject to document muscle activation patterns associated with different postures and as influenced by a variety of sensory stimuli.

Results: Involuntary contractions spanned multiple leg muscles bilaterally, sometimes including weak abdominal contractions. Contractions were smooth and graded and were highly reproducible in rate for a given subject (contraction rates were 0.3-0.5 Hz). These movements did not resemble the brief rapid contractions (ie, "jerks") ascribed to some forms of spinal myoclonus. For all subjects, the onset of involuntary muscle contraction was dependent upon hip angle; contractions did not occur unless the hips (and knees) were extended (ie, subjects were supine). In the 4 ASIA A subjects, contractions occurred simultaneously in all muscles (agonists and antagonists) bilaterally. In sharp contrast, contractions in the 2 ASIA D subjects were reciprocal between agonists and antagonists within a limb and alternated between limbs, such that movements in these 2 subjects looked just like repetitive stepping. Finally, each of the 6 subjects had a distinct pathology of their spinal cord, nerve roots, distal trunk, or thigh; in 4 of these subjects, treatment of the pathology eliminated the involuntary movements.

Conclusion: The timing, distribution, and reliance upon hip angle suggest that these movement patterns reflect some elements of a central pattern generator for stepping. Emergence of these movements in persons with chronic spinal cord injury is extremely rare and appears to depend upon a combination of the more rostrally placed injury and a pathologic process leading to a further enhancement of excitability in the caudal spinal cord.     

Worklife After Traumatic Spinal Cord Injury

Abstract

Objective: To develop predictive models to estimate worklife expectancy after spinal cord injury (SCI).

Design: Inception cohort study.

Setting: Model SCI Care Systems throughout the United States.

Participants: 20,143 persons enrolled in the National Spinal Cord Injury Statistical Centerdatabase since 1973.

Intervention: Not applicable.

Main Outcome Measure: Postinjury employment rates and worklife expectancy.

Results: Using logistic regression, we found a greater likelihood of being employed in any given year to be significantly associated with younger age, white race, higher education level, being married, having a nonviolent cause of injury, paraplegia, ASIA D injury, longer time postinjury, being employed at injury and during the previous postinjury year, higher general population employment rate, lower level of Social Security Disability Insurance benefits, and calendar years after the passage of the Americans with Disabilities Act.

Conclusions: The likelihood of postinjury employment varies substantially among persons with SCI. Given favorable patient characteristics, worklife should be considerably higher than previous estimates.     

Urodynamic Monitoring After Spinal Cord Injury

Abstract

Urinary tract infection (UTI) continues to be a major cause of mortality in patients with neurogenic bladders. Even patients who void reflexly and have unobstructed voiding with external condom drainage have a high incidence of chronic recurrent bacteriuria. Our recent studies have described the difficulty of diagnosing and localizing UTI in patients with neurogenic bladders. Symptoms correlated poorly with significant bacteriuria (> 10⁵ colonies/ml) and the use of the Fairley washout test gave less than optimal results in our studied population. Breakdown of endogenous host defenses, development of drug resistant organisms, and external contamination from urinary drainage appliances and fecal incontinence should be considered in diagnosis and management of these patients. Adequate bladder drainage is the most effective prophylactic measure against recurrent urinary tract infections. Our methods of bladder drainage include use of alpha blockers, transurethral sphincterotomy, and in selected paraplegics, long-term intermittent self-catheterization. We stress decreasing pathogenic bacterial skin colonization through daily perineal washing with soap and water, and cleaning drainage appliances at least once daily with 0.06% sodium hypochlorite. We treat the symptomatic patients and patients with positive urine cultures with potential stone forming organisms. Antibiotic therapy in asymptomatic patients should be guided by an inflammatory response with white blood cell count of > 10⁴ colonies/ml in the urine and positive bacterial culture of > 10⁵ colonies/ml.     

Intractable Pruritus After Traumatic Spinal Cord Injury

Background:

This report describes a young woman with incomplete traumatic cervical spinal cord injury and intractable pruritus involving her dorsal forearm.

Method:

Case report.

Findings:

Anatomic distribution of the pruritus corresponded to the dermatomal distribution of her level of spinal cord injury and vertebral fusion. Symptoms were attributed to the spinal cord injury and possible cervical root injury. Pruritus was refractory to all treatments, including topical lidocaine, gabapentin, transcutaneous electrical nerve stimulation, intravenous Bier block, stellate ganglion block, and acupuncture.

Conclusions:

Further understanding of neuropathic pruritus is needed. Diagnostic workup of intractable pruritus should include advanced imaging to detect ongoing nerve root compression. If diagnostic studies suggest radiculopathy, epidural steroid injection should be considered. Because the autonomic nervous system may be involved in complex chronic pain or pruritic syndromes, sympatholysis via such techniques as stellate ganglion block might be effective.     

Spinal Cord Protection During Thoracoabdominal Aneurysm Repair

Spinal cord injury after thoracoabdominal aortic surgery remains a devastating and unpredictable complication, caused by clamping of the thoracoabdominal aorta, resulting in exclusion of blood flow in critical and essential intercostal arteries. Various protective methods against spinal cord ischemia have been proposed and performed clinically. These include preoperative spinal angiography, distal aortic perfusion, hypothermia, reattachment of the intercostal artery, cerebrospinal fluid drainage, administration of neuroprotective agents, and monitoring of somatosensory and motor-evoked potentials. The information to date suggests that multimodality approaches should be used to prevent spinal cord injury after thoracic and thoracoabdominal aneurysm repair.     

Colonic Transit Time After Spinal Cord Injury

Abstract

Colonic transit time (CTT) was measured with abdominal radiographs using Chaussade’s technique in 30 spinal cord injured patients (ASIA A and B) following ingestion of 20 radiomarkers per day for three days . A significant increase in total CTT (p=0.0001) and segmental CTT of the right colon (p=0.0004) and of the left colon (p=0.0001) was shown. While using on the average only 2.3 films of the abdomen per patient, we obtained results comparable with other radiologic techniques which use radiomarkers to measure CTT. The clinical relevance of these results is not clear and their correlation with intestinal symptoms remains to be investigated. (J Spinal Cord Med 1997;20:416-421)     

干细胞与脊髓损伤的治疗

脊髓损伤的治疗一直是世界性的难题,促进脊髓损伤后神经组织的修复,传统的手术和相应的辅助治疗并未取得突破性进展。组织工程学的发展,为神经组织的修复提供了良好的可能。被移植到患者脊髓损伤区域的干细胞,通过替换受损细胞、减少胶质瘢痕的形成、促进残存神经元细胞轴突再生及突触形成等,可促进脊髓形态及功能恢复。我们就目前应用干细胞治疗脊髓损伤的研究现状进行概述,并对其临床应用前景进行展望。     

Treatment of Heterotopic Ossification After Spinal Cord Injury

Abstract

A new protocol in management of heterotopic ossification (HO) was evaluated in 46 patients after spinal cord injury (SCI). A group of 24 paraplegic and 22 tetraplegie patients was involved in a prospective study. Diagnosis of HO was made by bone scintigraphy and radiographic evaluation. Patients were divided into two groups. Group I was made up of 33 patients with positive bone scintigraphy and negative evidence of HO and Group II was made up of 13 patients with positive bone scintigraphy and positive radiographic evidence of HO. Etidronate was started intravenously (300 mg/day) for three days followed by oral therapy for six months (20 mg/kg/day). Follow-up of patients was 15.7±8 months after SCI. In Group I, etidronate therapy prevented the development of HO in 79 percent of patients; in 21 percent of patients, a low degree of tissue ossification was found which was not clinically significant. In Group II, there was an inhibitory effect of etidronate on progression of soft tissue ossification in six patients. The remaining seven patients did not respond to therapy and showed an increased growth of HO. Our data indicate that etidronate may prevent HO in the majority of patients when administered at an early stage of HO development and in higher doses than are routinely recommended. (J Spinal Cord Med 1997; 20:60-65)     

Physiological Responses to Exergaming After Spinal Cord Injury

Purpose:

To investigate whether exergaming satisfies guideline-based intensity standards for exercise conditioning (40%/50% oxygen uptake reserve [VO₂R] or heart rate reserve (HRR), or 64%/70% of peak heart rate [HR_peak]) in persons with paraplegia.

Methods:

Nine men and women (18-65 years old) with chronic paraplegia (T1-L1, AIS A-C) underwent intensity-graded arm cycle exercise (AE) to evaluate VO2_peak and HR_peak. On 2 randomized nonconsecutive days, participants underwent graded exercise using a custom arm cycle ergometer that controls the video display of a Nintendo Gamecube (GameCycle; Three Rivers Holdings LLC, Mesa, AZ) or 15 minutes of incrementally wrist-weighted tennis gameplay against a televised opponent (XaviX Tennis System; SSD Co Ltd, Kusatsu, Japan).

Results:

GameCycle exergaming (GCE) resistance settings ≥0.88 Nm evoked on average ≥50% VO₂R. During XaviX Tennis System exergaming (XTSE) with wrist weights ≥2 lbs, average VO₂ reached a plateau of ~40% VO₂R. Measurements of HR were highly variable and reached average values ≥50% HRR during GCE at resistance settings ≥0.88 Nm. During XTSE, average HR did not reach threshold levels based on HRR for any wrist weight (20%-35% HRR).

Conclusions:

On average, intensity responses to GCE at resistance setting ≥0.88 Nm were sufficient to elicit exercise intensities needed to promote cardiorespiratory fitness in individuals with SCI. The ability of XTSE to elicit cardiorespiratory fitness benefits is most likely limited to individuals with very low fitness levels and may become subminimal with time if used as a conditioning stimulus.     

Clinical Applications of Electrical Stimulation After Spinal Cord Injury

Abstract

Summary: During the last one-half century, electrical stimulation has become dinically significant for improving health and restoring useful function afterspinal cord injury. Short-term stimulation can be provided by electrodes on the skin or percutaneous fine wires, but implanted systems are preferable for long-term use. Electrical stimulation of intact lower motor neurons can exercise paralyzed musdes and reverse wasting; improve strength, endurance, and cardiovascular fitness; and may reduce the progression of osteoporosis. Other potential therapeutic uses being investigated indude reduction of spasticity, prevention of deep vein thrombosis, and improvement of tissue health. Pacing of intact phrenic nerves in high tetraplegia can produce effective respiration without mechanical ventilation, allowing improved speech, increased mobility, and increased sense of well-being. lmprovement of cough has also been demonstrated. Stimulation of intact sacral ne.rves can produce effective micturition and reduce urinary tract infection; it can also improve bowel function and erection. lt is usually combined with posterior sacral rhizotomy to improve continence and bladder capacity, and the combination has been shown to reduce costs of care. Electroejaculation can now produce semen in most men with spinal cord injury. Significant achievements have also been made in restoring limb function . Useful hand grasp can be provided in CS and C6 tetraplegia, reducing dependence on adapted equipment and assistants. Standing, assistance with transfers, and walking for short distances can be provided to selected persons with paraplegia, improving their access to objects, places, and opportunities that are inaccessible from a wheelchair. This review summarizes the current state of therapeutic and neuroprosthetic applications of electrical stimulation afterspinal cord injury and identifies some future directions of research and dinical and commercial development.     

Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury

Persons with spinal cord injury (SCI) are at high risk for developing neurogenic obesity due to muscle paralysis and obligatory sarcopenia, sympathetic blunting, anabolic deficiency, and blunted satiety. Persons with SCI are also at high risk for shoulder, elbow, wrist, and hand injuries, including neuromusculoskeletal pathologies and nociceptive pain, as human upper extremities are poorly designed to facilitate chronic weight-bearing activities, including manual wheelchair propulsion, transfers, self-care, and day-to-day activities. This article reviews current literature on the relationship between obesity and increased body weight with upper extremity overuse injuries, detailing pathology at the shoulders, elbows, and wrists that elicit pain and functional decline and stressing the importance of weight management to preserve function.     

Prevention and Treatment Of Heterotopic Ossification After Spinal Cord Injury

Abstract

Background/Objectives: Heterotopic ossification (HO) is a frequent, irreversible complication afterspinal cord injury (SCI). The objective of this article is to explain the etiology of HO; present new advances in prevention, diagnosis, and management of this complication; and provide a suggested algorithm for clinical management.

Etiology: Although still hypothetical, trauma and overexpression of bone morphogenic protein(s) in traumatized soft tissue appear to play important roles as initiating factors of HO.

Prevention: Preventive use of nonsteroidal antiinflammatory agents (NSAIDs) reduces the incidence of HO by a magnitude of 2 to 3.

Management: Early determination of serum creatine phosphokinase may have a diagnostic value in predicting the onset and severity of HO, and an NSAID may be added to etidronate therapy in the initial inflammatory phase of HO formation until C-reactive protein Ieveis return to normal range. Surgery is indicated in a subset of patients, and a regimenthat includes radiation therapy may prevent postoperative recurrence.

Conclusion: Significant progress has been made in the early prevention and management of HO. Further studies are needed to elucidate the etiology.     

Measurement of Sexual Functioning After Spinal Cord Injury: Preferred Instruments

Background/Objective:

To determine the utility of certain instruments to assess sexuality and fertility after SCI, an expert panel identified key areas to study and evaluated available instruments. These were rated according to certain predefined criteria.

Methods:

The authors divided sexual issues into male and female sexual function, male reproductive function, and female reproductive function. The instruments that have been used most frequently to measure these aspects of sexual function over the past 5 years were identified by expert consensus. Finally, these instruments were subjected to a critical review.

Results:

The Female Sexual Function Index (FSFI), measurement of vaginal pulse amplitude (VPA), the International Index of Erectile Function (IIEF), and the measurement of ejaculatory function and semen quality were considered appropriate measures to assess sexual responses and reproductive function after SCI. There were no measures identified to assess female reproductive function.

Conclusions:

For clinical trials aiming to improve sexual function after SCI, the FSFI or the IIEF is currently preferred. Although VPA is an appropriate means to assess female sexual responses, it is only useful for laboratory studies and is too invasive for use in clinical trials. For assessment of male fertility potential, assessment of ejaculatory capacity and semen analysis are recommended.     

Aging After Spinal Cord Injury: A 30-Year Longitudinal Study

Abstract

Background/Objective: This longitudinal study investigated changes in life satisfaction, general health, activities, and adjustment over 3 decades among individuals with spinal cord injury (SCI).

Participants: The cohort of participants was identified from outpatient records of a large Midwestern United States university hospital. In 1973, 256 individuals completed an initial survey. There were 5 subsequent follow-up surveys, with the most recent being in 2002. Seventy-eight participants completed materials on all 6 occasions.

Methods: The Life Situation Questionnaire was used to identify changes over the 30-year period in 6 areas of life satisfaction, self-rated adjustment (current and predicted), employment status, activities, and medical treatments.

Analyses: These analyses used data from 3 points in time, separated by approximately 15-year intervals. One-way analysis of variance with repeated measures was used to identify changes in outcomes between 1973, 1988, and 2002 for all continuous variables.

Results: We found a mixed pattern of changes over the 30 years, with increases noted during the first 15- year period in sitting tolerance, educational and employment outcomes, satisfaction with employment, and adjustment. Although these changes tended to remain stable during the last 15 years, subtle declines were suggested in some areas, with clear declines noted in terms of diminished sitting tolerance, an increase in the number of physician visits, and decreased satisfaction with social life and sex life.

Conclusions: The results suggest that many positive changes occur within the first 2 decades after SCI, followed by a period of stability in some life areas, but decline with aging in some participation and health-related aspects of life.     

Measurement of Sexual Functioning After Spinal Cord Injury: Preferred Instruments

Background/Objective: To determine the utility of certain instruments to assess sexuality and fertility after SCI, an expert panel identified key areas to study and evaluated available instruments. These were rated according to certain predefined criteria.

Methods: The authors divided sexual issues into male and female sexual function, male reproductive function, and female reproductive function. The instruments that have been used most frequently to measure these aspects of sexual function over the past 5 years were identified by expert consensus. Finally, these instruments were subjected to a critical review.

Results: The Female Sexual Function Index (FSFI), measurement of vaginal pulse amplitude (VPA), the International Index of Erectile Function (IIEF), and the measurement of ejaculatory function and semen quality were considered appropriate measures to assess sexual responses and reproductive function after SCI. There were no measures identified to assess female reproductive function.

Conclusions: For clinical trials aiming to improve sexual function after SCI, the FSFI or the IIEF is currently preferred. Although VPA is an appropriate means to assess female sexual responses, it is only useful for laboratory studies and is too invasive for use in clinical trials. For assessment of male fertility potential, assessment of ejaculatory capacity and semen analysis are recommended.