Cannabinoids and an anti-inflammatory diet for the treatment of neuropathic pain after spinal cord injury (The CATNP Study): study protocol for a randomized controlled trial.

STUDY DESIGN: Multicenter, randomized, double-blind, placebo controlled, clinical trial. OBJECTIVE: The objective of this paper is to evaluate the effectiveness of cannabinoids and an anti-inflammatory diet, alone and in combination, for the management of neuropathic pain (NP) after spinal cord injury (SCI). SETTING: Two Canadian SCI rehabilitation centers. METHODS: A sample of 144 individuals with SCI will receive either an anti-inflammatory diet, cannabinoids or a placebo for 6 weeks. Following this, a combined effect of these treatments will be evaluated for a further 6 weeks. The primary outcome measure will be the change in NP as assessed by the numeric rating scale (NRS). Secondary outcomes will include changes in inflammation, mood, sleep, spasticity, cost-effectiveness, and function. CONCLUSION: This study will assess the efficacy of an anti-inflammatory diet and cannabinoids (individually and in combination) for the treatment of NP following SCI. Results may reveal a cost-effective, side-effect free intervention strategy which could be utilized for the long-term management of NP following SCI.

Supporting sexual adjustment from the perspective of men living with spinal cord injury.

STUDY DESIGN: Descriptive phenomenological approach. OBJECTIVES: This study explored the lived experience of sexuality for men after spinal cord injury (SCI) and described the current state of tools and resources available to assist with sexual adjustment from the perspective of men living with SCI. SETTING: Men living in the community in Ontario, Canada. METHODS: Six men (age 24-49 years) with complete or incomplete SCI (C4-T12; <1-29 years post injury) participated in one individual, in-depth, standardized, open-ended interview (68-101 min). Analysis was conducted using Giorgi's method, and involved within case analysis followed by cross-case analysis. RESULTS: All participants reported that resources available to support sexual adjustment after SCI were inadequate, and the majority of men felt their healthcare providers lacked knowledge regarding, and comfort discussing sexuality after SCI. Men reported sexuality was not a priority of the rehabilitation centers and felt that healthcare providers did not understand the importance of addressing sexuality. Existing resources were described as too clinical and not necessarily relevant given changes in sensation and mobility post injury. Participants provided recommendations for the effective delivery of relevant sexual education information. CONCLUSIONS: To improve quality of life for men after SCI, suitable resources must be available to support sexual rehabilitation post injury. Future research should focus on developing strategies to facilitate discussions about sexuality between individuals with SCI and healthcare providers, and on developing resources that are effective and relevant for these men.

Cardiac parasympathetic activity and ventricular diastolic interactions in individuals with spinal cord injury.

STUDY DESIGN: Cohort cross-sectional study. OBJECTIVE: To investigate the relationship between cardiac vagal activity and left ventricular filling at rest and during vagal stimulation, via the cold face test (CFT), in individuals with spinal cord injury (SCI). SETTING: University-based laboratory at Brock University, St. Catharines, ON, Canada. METHODS: A total of 12 able-bodied (age: 40 ± 8.5 years) and 13 SCI individuals (age: 41 ± 8.5 years; C4-T6; AIS: A-D) were recruited. Cardiac parasympathetic activity was assessed via heart rate variability (HRV) while LV filling was assessed by conventional echocardiography. All indices of HRV and diastolic function were obtained at rest and during cardiac vagal stimulation via the CFT. RESULTS: At baseline, the able-bodied group demonstrated strong positive correlations between HRV and early diastolic filling; however, such correlations were absent in the SCI group. The CFT resulted in elevated HRV with concomitant bradycardia in the able-bodied group, while the SCI group experienced no change in HRV or heart rate during the CFT. Able-bodied individuals showed a positive correlation between the change in HRV and the change in LV diastole during the CFT, which was attributed to increased cardiac vagal tone and not the change in heart rate, however, no relationships were observed in the SCI group. CONCLUSION: In able-bodied individuals, cardiac parasympathetic activity is associated with LV filling at rest and during elevated cardiac vagal tone. After SCI, there is a discord between vagal and LV diastolic activity, where changes in autonomic function do not influence LV filling, suggesting a disconnect between parasympathetic and cardiac function.

A call to reevaluate cardiac autonomic assessment after spinal cord injury.

This "Perspectives" article puts forward the notion that measuring heart rate variability, or other forms of cardiac autonomic regulation, after spinal cord injury must be performed during a test of autonomic stress. Resting values of heart rate variability are often similar to those obtained from able-bodied individuals, which may therefore be falsely interpreted as normal or healthy autonomic regulation. However, evidence shows that despite normal resting values, cardiac autonomic control is impaired when individual with spinal cord injury are subjected to a cold face test, head-up tilt, or recovery from exercise. Accordingly, examination of cardiac autonomic function must be performed during an autonomic challenge, as resting measures do not accurately reflect the state of cardiovascular regulation after spinal cord injury and can provide false information.

Comparison of a Web-Based Teaching Tool and Traditional Didactic Learning for In Vitro Fertilization Patients: A Preliminary Randomized Controlled Trial.

OBJECTIVE: The objective of this prospective RCT was to compare the efficacy of a web-based teaching tool to traditional didactic teaching in IVF patients. METHODS: Forty women undergoing their first IVF cycle were randomly allocated to an interactive web-based teaching session or a nurse-led didactic teaching session. The primary outcome measure was participant knowledge regarding the IVF process, risks, and logistics assessed before and after the respective teaching session. Secondary outcomes included patient stress, assessed before and after the respective teaching session, and patient satisfaction, assessed following the respective teaching session and on the day of embryo transfer (following implementation of the teaching protocol). RESULTS: Both groups demonstrated similar and significant improvements in knowledge and stress after exposure to their respective teaching sessions. The web-based group was significantly more satisfied than the didactic teaching group. Web-based teaching was also shown to be equally effective for participants of high versus low income and education status for knowledge, stress, and satisfaction. CONCLUSION: This study provides preliminary support for the use of web-based teaching as an equally effective tool for increasing knowledge and reducing stress compared to traditional didactic teaching in IVF patients, with the added benefit of increased patient satisfaction.

Correction: Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline.

Authors Victoria L. Goosey-Tolfrey and Karen M. Smith were listed under the incorrect affiliations at the time of publication.

Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline.

OBJECTIVES: To describe the process and outcomes of using a new evidence base to develop scientific guidelines that specify the type and minimum dose of exercise necessary to improve fitness and cardiometabolic health in adults with spinal cord injury (SCI). SETTING: International. METHODS: Using Appraisal of Guidelines, Research and Evaluation (AGREE) II reporting criteria, steps included (a) determining the guidelines' scope; (b) conducting a systematic review of relevant literature; (c) holding three consensus panel meetings (European, Canadian and International) to formulate the guidelines; (d) obtaining stakeholder feedback; and (e) process evaluation by an AGREE II consultant. Stakeholders were actively involved in steps (c) and (d). RESULTS: For cardiorespiratory fitness and muscle strength benefits, adults with a SCI should engage in at least 20 min of moderate to vigorous intensity aerobic exercise 2 times per week AND 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week (strong recommendation). For cardiometabolic health benefits, adults with a SCI are suggested to engage in at least 30 min of moderate to vigorous intensity aerobic exercise 3 times per week (conditional recommendation). CONCLUSIONS: Through a systematic, rigorous, and participatory process involving international scientists and stakeholders, a new exercise guideline was formulated for cardiometabolic health benefits. A previously published SCI guideline was endorsed for achieving fitness benefits. These guidelines represent an important step toward international harmonization of exercise guidelines for adults with SCI, and a foundation for developing exercise policies and programs for people with SCI around the world.

Targeting inflammation as a treatment modality for neuropathic pain in spinal cord injury: a randomized clinical trial.

BACKGROUND: The purpose of the present study was to examine the effectiveness of an anti-inflammatory intervention as a treatment for neuropathic pain following spinal cord injury (SCI). METHODS: This randomized, parallel-group, controlled clinical trial (NCT02099890) examined 20 participants with varying levels and severities of SCI, randomized (3:2) to either a 12-week anti-inflammatory diet, or control group. Outcome measures consisted of self-determined indices of pain as assessed using the neuropathic pain questionnaire (NPQ) and markers of inflammation as assessed by various pro- and anti-inflammatory cytokines, as well as the eicosanoids PGE2 and LTB4. RESULTS: A significant group × time interaction was found for sensory pain scores (p < 0.01). A Mann-Whitney test revealed that the change scores (3-month baseline) were significantly different between groups for IFN-y (U = 13.0, p = 0.01), IL-1ß (U = 14.0, p = 0.01), and IL-2 (U = 12.0, p = 0.01). A Friedman test revealed the treatment group had a significant reduction in IFN-y (x (2) = 8.67, p = 0.01), IL-1ß (x (2) = 17.78, p < 0.01), IL-6 (x (2) = 6.17, p < 0.05), while the control group showed no significant change in any inflammatory mediator. A stepwise backward elimination multiple regression analysis showed that the change in sensory neuropathic pain was a function of the change in the proinflammatory cytokines IL-2 and IFN-y, as well as the eicosanoid PGE2 (R = 0.689, R (2) = 0.474). CONCLUSIONS: Overall, the results of the study demonstrate the efficacy of targeting inflammation as a means of treating neuropathic pain in SCI, with a potential mechanism relating to the reduction in proinflammatory cytokines and PGE2. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02099890.

Targeting inflammation to influence mood following spinal cord injury: a randomized clinical trial.

BACKGROUND: The purpose of the present study was to examine the efficacy of targeting inflammation as a means of improving mood following spinal cord injury (SCI) and explore the potential mechanisms of action. METHODS: The study was a randomized, parallel-group, controlled, clinical trial (NCT02099890) whereby 20 participants with varying levels and severities of SCI were randomized (3:2) to either the treatment group, consisting of a 12-week anti-inflammatory diet, or control group. Outcome measures were assessed at baseline, 1 and 3 months, and consisted of CES-D scores of depression, markers of inflammation as assessed by various pro- and anti-inflammatory cytokines and several amino acids related to depression. RESULTS: A significant group × time interaction was found for CES-D (Center for Epidemiologic studies Depression Scale) score (p = 0.01), the TRP/LNAA (tryptophan/large neutral amino acid) ratio (p = 0.04), the composite score of pro-inflammatory cytokines (p = 0.04), IL-1ß (interleukin-1 beta) (p = 0.04), and IFN-γ (interferon gamma) (p = 0.03). Pearson's r correlation showed significance between the ∆IL-1ß and both the ∆CES-D score (r = 0.740, p < 0.01) and the ∆KYN/TRP (kynurenine/tryptophan) ratio (r = 0.536, p = 0.02). The ∆KYN/TRP ratio was also significantly correlated with the ∆CES-D score (r = 0.586, p = 0.01). Mediation analysis showed that the relationship between the ∆KYN/TRP ratio and the ∆CES-D score was mediated by the ∆IL-1ß. Subgroup analysis showed that participants with high CES-D scores had significantly higher concentrations of IL-1ß, and all correlations were maintained or strengthened within this subgroup. CONCLUSIONS: Overall, the results demonstrated the effectiveness of targeting inflammation as a means of improving mood in SCI, with potential mechanisms relating to the reduction in IL-1ß and improvements in levels of neuroactive compounds related to the kynurenine pathway. Due to the limited sample size, results should be interpreted with caution; however, they are worthy of further examination due to the potential impact of inflammation on depression. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02099890 .

Sexuality for women with spinal cord injury.

The authors conducted a review of the literature on women's sexuality after spinal cord injury, including studies from 1990 to 2011 retrieved from PubMed. Several facets of a woman's sexuality are negatively affected by after spinal cord injury, and consequently, sexual satisfaction has been shown to decrease, which also negatively affects quality of life. Neurogenic bladder is common after spinal cord injury, and the resulting urinary incontinence is a top therapeutic priority of this population. To improve sexual satisfaction and quality of life for women with spinal cord injury, future research needs to explore the effects of urinary incontinence on various aspects of sexuality.

The common inflammatory etiology of depression and cognitive impairment: a therapeutic target.

Chronic inflammation has been shown to contribute to the development of a wide variety of disorders by means of a number of proposed mechanisms. Depression and cognitive impairment are two such disorders which may share a closely linked inflammatory etiology. The ability of inflammatory mediators to alter the activity of enzymes, from key metabolic pathways, may help explain the connection between these disorders. The chronic up-regulation of the kynurenine pathway results in an imbalance in critical neuroactive compounds involving the reduction of tryptophan and elevation of tryptophan metabolites. Such imbalances have established implications in both depression and cognitive impairment. This may implicate the immune system as a potential therapeutic target in the treatment of these disorders. The most common treatment modalities currently utilized, involve drug interventions which act on downstream targets. Such treatments help to reestablish protein balances, but fail to treat the inflammatory basis of the disorder. The use of anti-inflammatory interventions, such as regular exercise, may therefore, contribute to the effectiveness of current drug interventions in the treatment of both depression and cognitive impairment.

Effects of FES-Ambulation Training on Locomotor Function and Health-Related Quality of Life in Individuals With Spinal Cord Injury.

BACKGROUND: The combination of body weight-supported gait training with functional electrical stimulation (FES) may provide the optimal stimulus for improving overground walking after spinal cord injury (SCI). This potential benefit is likely due to the combination of specificity with the maximization of muscle contractions. OBJECTIVES: To investigate the effects of 12 weeks of FES-ambulation on overground walking and health-related quality of life (HRQOL) in individuals with SCI. METHODS: Six individuals (60.5 ± 13.2 years) with SCI (C4-L3; AIS D; 9.3 ± 12.0 years post injury), completed a thrice-weekly, 12-week FES-ambulation training program. Locomotor function was assessed via the Walking Index for Spinal Cord Injury II (WISCI II), the 6-minute walk test (6MWT), the 10-meter walk test (10MWT), and the body-weight support required during training. HRQOL was assessed via the Short Form-36, the Perceived Stress Scale, and the Center of Epidemiological Studies for Depression scale. RESULTS: Participants showed significant improvements in the 6MWT (223.6 ± 141.5 m to 297.3 ± 164.5 m; P = .03), the required body weight support (55.3% ± 12.6% to 14.7% ± 23.2%; P = .03), and a nonsignificant trend toward an increase in walking speed during the 10MWT (0.69 ± 0.4 m/s to 0.9 ± 0.5 m/s; P = .08) following the training program. Four participants showed improvements on the WISCI II (1-4 points). Participants also showed a decrease in the Short Form-36 pain score (6.5 ± 1.2 to 5.0 ± 1.7; P = .04) and an increase in the overall mental health score (47.8 ± 12.6 to 54.2 ± 6.7; P = .04). CONCLUSION: FES-ambulation was associated with enhanced overground walking in individuals with AIS D SCI, reduced pain, and improved mental health.

Exploring the Lived Experiences of Individuals With Spinal Cord Injury During the COVID-19 Pandemic.

The global spread of severe acute respiratory syndrome coronavirus 2019 (COVID-19) has affected over 100 countries and has led to the tragic loss of life, overwhelmed health care systems and severely impacted the global economy. Specifically, individuals living with spinal cord injury (SCI) are particularly vulnerable during the COVID-19 pandemic as they often face adverse impacts on their health, emotional well-being, community participation, and life expectancy. The objective of this study was to investigate the lived experience of individuals with SCI during the COVID-19 pandemic in Ontario, Canada. An exploratory design with a qualitative descriptive approach was used to address the study objective. Nine semi-structured interviews were conducted with individuals with traumatic and non-traumatic SCI (37-69 years, C3-L5, AIS A-D, and 5-42 years post-injury). Using reflexive thematic analysis, the following themes were created: (1) Caregiver exposure to COVID-19; (2) Staying physically active in quarantine; (3) Living in social isolation; (4) Difficulty obtaining necessary medical supplies; (5) Access to health services and virtual care during COVID-19; and (6) Fighting COVID-19 misinformation. This is one of the first studies to explore the impact of COVID-19 on individuals living with SCI in Ontario. This study contributes to a greater understanding of the challenges faced by individuals living with SCI and provides insight into how to better support and respond to the specific and unique needs of individuals with SCI and their families during a national emergency or pandemic.

Changes in Body Mass, Physical Activity, and Dietary Intake during the COVID-19 Pandemic Lockdowns in Canadian University Students.

This study examined changes in body mass and body mass index (BMI), physical activity, and dietary intake in Canadian university students during the first year of the COVID-19 pandemic. Two self-reported recall surveys were conducted: after the first lockdown in September 2020 (T1) and following the second lockdown in March 2021 (T2). Eligible participants were full-time undergraduate students attending a Canadian university and residing in Canada during the first year of the pandemic. At T1, 510 students (99 male, 411 female) completed the survey, and of those, 135 (32 males, 103 females) completed the survey at T2 (73% attrition). At both T1 and T2, most participants were 18-24 years of age (93% and 90%, respectively), Caucasian (73% and 78%, respectively), and resided in the province of Ontario (79% and 80%, respectively). Body mass increased from T1 to T2 (+0.91 ± 3.89 kg t(132) = -2.7, p = 0.008). BMI also increased from T1 to T2 (+0.30 ± 1.33 kg/m2 [t(130) = -2.5, p = 0.012), with a greater number of participants within the overweight range (19.8% versus 24.4%, respectively). At T1, 38% of the participants reported a decrease in physical activity, while the number of students reporting a decrease in activity increased to 56% at T2. Dietary energy intake decreased from 1678 ± 958 kcal/day at T1 to 1565 ± 842 kcal/day at T2 [c2(1) = 7.2, p = 0.007]. Diet quality also decreased, with participants not meeting the recommended daily allowance for essential macro and micronutrients. A decrease was observed in daily servings of fruits (-27%, p < 0.001), vegetables (-72%, p < 0.001), and grains (-68%, p < 0.001). In conclusion, despite a small decrease in dietary energy intake, a modest weight gain occurred during the first year of the COVID-19 pandemic in this cohort of Canadian university students, which was potentially related to decreased physical activity and diet quality.

Effects of Creatine Supplementation and Progressive Resistance Training in Stroke Survivors.

The purpose was to investigate the effects of progressive resistance training (PRT) and creatine supplementation in stroke survivors. Participants were randomized to one of two groups: creatine (n = 5; 51 ± 16y) or placebo (n = 3; 73 ± 8y) during 10 weeks of supervised PRT. Prior to and following PRT and supplementation, assessments were made for body composition (lean tissue and fat mass), muscle thickness, muscle strength (1-repetition maximum), functional exercise capacity (6-minute walk test, Berg Balance Scale; BBS), cognition (Montreal Cognitive Assessment; MoCA), and symptoms of anxiety (Generalized Anxiety Disorder Assessment-7; GAD-7) and depression (Center for Epidemiological Studies Depression Scale; CES-D). There were time main effects for leg press strength (increased; p = 0.001), chest press strength (increased; p = 0.003), elbow flexor muscle thickness (increased; p = 0.007), BBS (increased; p = 0.002), MoCA (increased; p = 0.031) and CES-D (decreased; p = 0.045). There was a group x time interaction for the 6 minute walk test (p = 0.039). The creatine group significantly increased walking distance over time (p = 0.002) with no change in the placebo group (p = 0.120). Ten weeks of PRT had some positive effects on measures of muscle strength and size, balance, cognition and depression. The addition of creatine to PRT significantly improved walking performance in stroke survivors.

Effects of autonomic blockade on nonlinear heart rate dynamics.

INTRODUCTION: Analysis of nonlinear heart rate (HR) dynamics may provide greater insight into neurocardiac influences during exercise and disease than traditional HR variability. However, the physiological basis of nonlinear HR dynamics has not been investigated in individuals with spinal cord injury (SCI). The purpose of this study was to compare the effects of autonomic blockade in SCI and able-bodied participants. METHODS: Five participants (42 +/- 13 years) with SCI (C4-C7, AIS B-D, 13 +/- 13 years post-injury) and four able-bodied controls (33 +/- 8 years) underwent beta(1)-adrenergic and vagal blockade in the supine and cardiovascular stress positions. Cardiovascular stress consisted of 40 degrees tilt plus sustained isometric jaw contraction and cold water submersion of the right hand. RESULTS: In both SCI and able-bodied participants, vagal blockade significantly increased HR (p < 0.05) and resulted in significant reductions in sample entropy and correlation dimension in the supine and cardiovascular stress positions (p < 0.05). During the cardiovascular stress position, baseline sample entropy (p < 0.05) and correlation dimension (p < 0.05) were lower in participants with SCI. Nonlinear measures were also significantly correlated with HR (p < 0.05). CONCLUSION: The results suggest that vagal modulations are a primary modulator of nonlinear HR signals in both SCI and able-bodied participants, while the role of the beta(1)-adrenergic system remains less defined. Further study is required to elucidate the role of the autonomic nervous system in nonlinear HR dynamics in both SCI and able-bodied populations.

Comparison of two TAGteach error-correction procedures to teach beginner yoga poses to adults.

Teaching with acoustical guidance involves auditory feedback (e.g., a click sound when a desired behavior occurs) as part of a multicomponent intervention known as TAGteach. TAGteach has been found to improve performance in sport, dance, surgical technique, and walking. We compared the efficacy and efficiency of the standard TAGteach error-correction procedure and a modified TAGteach error-correction procedure to teach 4 novice adult yoga practitioners beginner yoga poses. Both error-correction procedures were effective for all participants; however, the relative efficiency of these error-correction procedures was unclear. Results are discussed in terms of limitations and considerations for future research.

Exercise therapy after spinal cord injury: the effects on heath and function.

Individuals with spinal cord injury (SCI) are susceptible to an array of secondary health complications. Some of these health concerns are attributable to the SCI per se, but many are secondary to the resulting immobility. For example, the incidence of pressure ulcers, type 2 diabetes, and cardiovascular disease are greatly increased in this population. Despite the need for exercise training as a means to reverse these health risks, individuals with SCI have traditionally been one of the most inactive segments of society. Physical activity programs and information about how activity can promote health are two of the services most desired but least available to people with SCI. Recently, efforts have been made to increase exercise options for individuals with SCI and to study the health benefits of exercise in this population. Accessible resistance and aerobic exercise training, functional electrically stimulated exercise, and body weight-supported treadmill training have all shown promise as ways to reverse some of the physiological consequences of SCI. Future research will determine whether these physiological adaptations actually translate to a long-term reduction in disease and mortality.

Accessible exercise equipment and individuals with multiple sclerosis: Aerobic demands and preferences.

BACKGROUND: Although exercise training has benefits for individuals with multiple sclerosis (MS), research regarding the type of exercise equipment that requires the greatest aerobic demand, and consumer-based preferences, is lacking. OBJECTIVE: To determine the aerobic demands of various pieces of accessible exercise equipment and consumer-based preferences on several domains. METHODS: Ten individuals with moderate-severity MS had their VO2 measured during 10 minutes of moderate-intensity arm ergometry (AE), body-weight support treadmill training (BWSTT), recumbent arm-leg exercise (NuStep), FES-arm exercise (RT300), FES-leg exercise (RT300) and FES arm-leg exercise (RT200). VO2peak test was also measured on the NuStep and the RT200. Equipment preferences were determined by questionnaire after moderate exercise sessions. RESULTS: AE required a lower VO2 compared to the NuStep (p = 0.02), and FES-arm exercise required a lower VO2 compared to the NuStep (p = 0.01) and FES arm-leg exercise (p = 0.04). There was no difference in VO2peak when using the NuStep or FES arm-leg exercise. AE was perceived as safer than BWSTT, but otherwise there were no preferences for any equipment. CONCLUSIONS: For individuals with moderate-severity MS, arm-only exercise requires less aerobic demands than combined arm-leg exercise at a moderate intensity. Perceived risks may be greater when exercise requires a transfer, upright positioning, or assistance.