Correction to: Electrocardiogram-based predictors for arrhythmia after spinal cord injury.

There is a typographical error in the formula presented for QTVI. While the formula was correctly applied to the data presented, the description of the formula has an incorrectly placed parenthesis. It should read.

Autonomic testing for prediction of competition performance in Paralympic athletes.

While we now appreciate that autonomic dysfunction can impact wheelchair rugby performance, this is currently not being assessed during classification, largely due to lack of a standardized and evidence-based strategy to assess autonomic function. Our aim, therefore, was to establish the optimal autonomic testing protocol that best predicts cardiovascular capacity during competition by comprehensively examining autonomic function in elite wheelchair rugby athletes with cervical SCI and thereby enhance the standardized classification. Twenty-six individuals with cervical SCI (C4-C8; AIS A, B, C) participated in this study during the 2015 Parapan American Games in Toronto, Canada. Clinic autonomic testing included: sympathetic skin responses, baseline hemodynamics, orthostatic challenge test, and cold-pressor tests. Further, we completed standard motor/sensory assessments and obtained each participants' International Wheelchair Rugby Federation classification. These clinic metrics were correlated to in-competition heart rate monitoring obtained during competition. The current study provides novel evidence that the change in systolic blood pressure during an orthostatic challenge test predicts approximately 50% of the in-competition peak heart rate (P<.001). Conversely, International Wheelchair Rugby Federation classification was poorly associated with in-competition peak heart rate (R2 =.204; P<.05). Autonomic testing provides deep insight regarding preserved autonomic control after SCI that is associated with performance in elite wheelchair rugby athletes. As such, incorporating assessments of cardiovascular capacity in classification will help to ensure a level playing field and may obviate the need for practices such as boosting to gain an advantage due to poor cardiovascular control.

Cardiovascular response during urodynamics in individuals with spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To establish the frequency and severity of autonomic dysreflexia (AD) during urodynamics among individuals with chronic spinal cord injury (SCI) and to investigate the possible effect of the number of years since SCI on the severity of AD. SETTING: SCI outpatient clinic. METHODS: A retrospective chart review was undertaken of individuals with SCI who were seen at an outpatient clinic and could potentially develop an episode of AD (T6 and above). Data regarding age, gender, urodynamic examination, lower urinary tract function, cardiovascular parameters and SCI were collected. In addition, information on signs and symptoms of AD were retrieved. RESULTS: A total of 76 individuals with SCI were examined with blood pressure (BP) monitoring. The majority had cervical SCI (79%). The mean age was 47.8±13.9 years. The median duration after SCI was 51.5 months. During urodynamics, a total of 48 (63.2%) individuals showed an increase in systolic BP>20 mm Hg, meeting the criteria for AD. Indicators for higher incidences of AD were cervical SCI, being >2 years after SCI, the presence of detrusor sphincter dyssynergia (DSD) and low bladder compliance. AD was more severe in individuals with complete (American Spinal Cord Association (ASIA) impairment scale (AIS) A) injuries, worse with greater time after SCI. CONCLUSION: Individuals with cervical SCI, DSD, poor bladder compliance or >2 years after SCI were associated with a higher possibility of developing AD during urodynamics. Furthermore, AD was more severe in complete (AIS A) individuals and was exacerbated with time after injury.

Movement repetitions in physical and occupational therapy during spinal cord injury rehabilitation.

STUDY DESIGN: Longitudinal observational study. OBJECTIVE: To quantify the amount of upper- and lower-extremity movement repetitions (that is, voluntary movements as part of a functional task or specific motion) occurring during inpatient spinal cord injury (SCI), physical (PT) and occupational therapy (OT), and examine changes over the inpatient rehabilitation stay. SETTING: Two stand-alone inpatient SCI rehabilitation centers. METHODS: Participants: A total of 103 patients were recruited through consecutive admissions to SCI rehabilitation. INTERVENTIONS: Trained assistants observed therapy sessions and obtained clinical outcome measures in the second week following admission and in the second to last week before discharge. MAIN OUTCOME MEASURES: PT and OT time, upper- and lower-extremity repetitions and changes in these outcomes over the course of rehabilitation stay. RESULTS: We observed 561 PT and 347 OT sessions. Therapeutic time comprised two-thirds of total therapy time. Summed over PT and OT, the median upper-extremity repetitions in patients with paraplegia were 7 repetitions and in patients with tetraplegia, 42 repetitions. Lower-extremity repetitions and steps primarily occurred in ambulatory patients and amounted to 218 and 115, respectively (summed over PT and OT sessions at discharge). Wilcoxon-signed rank tests revealed that most repetition variables did not change significantly over the inpatient rehabilitation stay. In contrast, clinical outcomes for the arm and leg improved over this time period. CONCLUSIONS: Repetitions of upper- and lower-extremity movements are markedly low during PT and OT sessions. Despite improvements in clinical outcomes, there was no significant increase in movement repetitions over the course of inpatient rehabilitation stay.

An evaluation of the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury: input from the international community.

STUDY DESIGN: Interactive workshops with a presurvey-postsurvey. OBJECTIVES: To describe a series of workshops held at international meetings to inform the spinal cord injury (SCI) community about the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) and to obtain feedback on both the workshop and the ISAFSCI assessment. SETTING: Three international conferences of SCI practitioners in Toronto, Las Vegas and Vancouver held between 2012 and 2013. METHODS: The workshops included an overview of the ISAFSCI, sharing experiences using it in clinical practice and interactive cases illustrating how to complete the scoring. A presurvey-postsurvey was administered to obtain feedback on the workshops and the ISAFSCI assessment. RESULTS: One hundred and fourteen participants completed the workshop surveys and 96% (109/114) completed both presurvey and postsurvey. Prior to the workshop, 41% (47/114) of those who had completed the survey reported assessing autonomic function in their practice, and of those, 53% (25/47) reported using the ISAFSCI. After the workshop, 74% (84/114) of participants reported that the case studies were helpful, and 57% (65/114) reported that they wanted to start or continue to use the ISAFSCI in their clinical practice. Suggestions for improving the ISAFSCI included providing further areas to consider when performing the assessment, addressing ambiguity of terms and reporting foreseeable implementation challenges. CONCLUSION: Results from this workshop suggest that more work is needed to inform the SCI community on the ISAFSCI assessment and to further clarify its language. Results from this study will inform future revisions to the ISAFSCI.

Rigid and remodelled: cerebrovascular structure and function after experimental high-thoracic spinal cord transection.

High-thoracic or cervical spinal cord injury (SCI) is associated with several critical clinical conditions related to impaired cerebrovascular health, including: 300-400% increased risk of stroke, cognitive decline and diminished cerebral blood flow regulation. The purpose of this study was to examine the influence of high-thoracic (T3 spinal segment) SCI on cerebrovascular structure and function, as well as molecular markers of profibrosis. Seven weeks after complete T3 spinal cord transection (T3-SCI, n = 15) or sham injury (Sham, n = 10), rats were sacrificed for either middle cerebral artery (MCA) structure and function assessments via ex vivo pressure myography, or immunohistochemical analyses. Myogenic tone was unchanged, but over a range of transmural pressures, inward remodelling occurred after T3-SCI with a 40% reduction in distensibility (both P < 0.05), and a 33% reduction in vasoconstrictive reactivity to 5-HT trending toward significance (P = 0.09). After T3-SCI, the MCA had more collagen I (42%), collagen III (24%), transforming growth factor ß (47%) and angiotensin II receptor type 2 (132%), 27% less elastin as well as concurrent increased wall thickness and reduced lumen diameter (all P < 0.05). Sympathetic innervation (tyrosine hydroxylase-positive axon density) and endothelium-dependent dilatation (carbachol) of the MCA were not different between groups. This study demonstrates profibrosis and hypertrophic inward remodelling within the largest cerebral artery after high-thoracic SCI, leading to increased stiffness and possibly impaired reactivity. These deleterious adaptations would substantially undermine the capacity for regulation of cerebral blood flow and probably underlie several cerebrovascular clinical conditions in the SCI population.

Cardiovascular control, autonomic function, and elite endurance performance in spinal cord injury.

We aimed to determine the relationship between level of injury, completeness of injury, resting as well as exercise hemodynamics, and endurance performance in athletes with spinal cord injury (SCI). Twenty-three elite male paracycling athletes (C3-T8) were assessed for neurological level/completeness of injury, autonomic completeness of injury, resting cardiovascular function, and time to complete a 17.3-km World Championship time-trial test. A subset were also fitted with heart rate (HR) monitors and their cycles were fitted with a global positioning systems device (n = 15). Thoracic SCI exhibited higher seated systolic blood pressure along with superior time-trial performance compared with cervical SCI (all P < 0.01). When further stratified by autonomic completeness of injury, the four athletes with cervical autonomic incomplete SCI exhibited a faster time-trial time and a higher average speed compared with cervical autonomic complete SCI (all P < 0.042). Maximum and average HR also tended to be higher in cervical autonomic incomplete vs autonomic complete. There were no differences in time-trial time, HR, or speed between thoracic autonomic complete vs incomplete SCI. In conclusion, autonomic completeness of injury and the consequent ability of the cardiovascular system to respond to exercise appear to be a critical determinant of endurance performance in elite athletes with cervical SCI.

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review.

STUDY DESIGN: This is a systematic review. OBJECTIVE: The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD). SETTING: This study was conducted in an international setting. METHODS: A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded. RESULTS: Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling. CONCLUSION: The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.

Assessment of clinical adherence to the international autonomic standards following spinal cord injury.

STUDY DESIGN: Retrospective chart analysis. OBJECTIVES: To investigate the use of the International Autonomic Standards (IAS, 2009 edition) for classification of remaining autonomic function following spinal cord injury (SCI) over a 1-year period in a rehabilitation center, to determine clinical adherence to use of the IAS, and to examine the most common autonomic dysfunctions, as determined by using the IAS. SETTING: Tertiary rehabilitation hospital. METHODS: A retrospective study was conducted on the use of the IAS at admission and discharge over a 1-year period on patients admitted to an in-patient SCI unit in a tertiary rehabilitation center. We examined the consistency of the form completion, as well as the completion of separate components of the forms. Finally, we examined the prevalence of each autonomic impairment. RESULTS: A total of 70 patients were admitted to the unit. The clinical adherence to the IAS was lower than the International Standards for Neurological Classification of SCI (ISNCSCI) at both admission (63% and 93%, respectively) and discharge (39% and 78%, respectively). Blood pressure dysfunction was most common among the general autonomic function disorders. However, urinary, bowel and sexual dysfunctions were present in almost all individuals with acute SCI. CONCLUSION: The IAS is in the initial stages of being incorporated into routine admission and discharge clinical examinations of individuals with SCI. The current results suggest that the clinical adherence to the IAS is low; however, it is expected that increased education, experience, and accumulating evidence for the IAS will improve its use.

Applanation tonometry: a reliable technique to assess aortic pulse wave velocity in spinal cord injury.

STUDY DESIGN: Within-subject repeated measures. OBJECTIVES: To determine the intra- and inter-tester reliability of aortic pulse wave velocity (aPWV) measurements collected using applanation tonometry in individuals with spinal cord injury (SCI). SETTING: Inpatient Rehabilitation Centre and outpatient Clinic in Vancouver, BC, Canada. METHODS: Fifteen men and three women with traumatic SCI (age: 46±16 years; C3-L1; American Spinal Injury Association Impairment Scale A-D; 2-284 months post injury) participated in two testing sessions separated by an average of 2 days. During each testing session, aPWV measurements were collected in the supine position following 10 min of rest. Arterial blood pressure waveforms were collected simultaneously by two trained raters at the carotid and femoral arterial sites using applanation tonometry. Heart rate was continuously measured using a single-lead electrocardiogram, whereas brachial blood pressures were measured at 5-min intervals using an automated device. RESULTS: Intra- and inter-tester aPWV measurements demonstrated almost perfect reliability with intraclass correlation coefficients of 0.91 and 0.98 (P<0.001), and coefficients of variation of 5.9% and 3.4%, respectively. The smallest detectable differences (SDDs) for intra- and inter-tester measurements were 0.9 m s(-1) and 0.6 m s(-1), respectively. There were no significant differences in heart rate or blood pressure between intra- and inter-testing sessions. CONCLUSION: Applanation tonometry measurements of aPWV are reliable in individuals with SCI. In addition, the SDDs were smaller than a clinically relevant value, suggesting that this measurement is suitable for repeated measures study designs in SCI.

Effect of and satisfaction with www.elearnSCI.org for training of nurse students: a submodule pilot study.

STUDY DESIGN: Interventional training session. OBJECTIVE: To investigate the effect and satisfaction with didactic training using printed text of a submodule of www.elearnSCI.org for nurse students and to assess the answers of each question. SETTING: A Peking University teaching hospital. METHODS: Twenty-eight nurse students in two groups (14 in each) were involved. Only group A received a translated print-out of the slides from the 'Nursing management' submodule in www.elearnSCI.org for 1-h self-study before the class. At the beginning of class, both groups were tested using the self assessment questions. Then, a lecture according to the content of this submodule was carried out and afterwards both groups answered the self assessment questions again. Finally, both groups filled in a training course satisfaction questionnaire. RESULTS: At the beginning of the class, the mean score (max 9) of the self assessment in group A was 7.1 ± 1.1, which was significantly higher than that in group B (4.9 ± 1.7, P = 0.001). After the lecture, the mean score of the self assessment in group A had insignificantly increased to 7.4 ± 1.3, whereas in group B it increased significantly to 6.9 ± 0.8 (P < 0.001). The mean score (max 50) of the training course satisfaction questionnaire was 42.8 ± 5.2. Sixty-four percentage of the students indicated that they were very satisfied (overall score ⩾ 42) with the training and no students were unsatisfied (overall score < 30). CONCLUSION: Self-study and lecture presentation are effective methods for training the content of www.elearnSCI.org to nurse students. The training satisfaction of this submodule within the www.elearnSCI.org is favorable.

Postpartum hypogalactia in a woman with Brown-Séquard-plus syndrome: a case report.

STUDY DESIGN: A case report. OBJECTIVES: To present a case of postpartum hypogalactia in a woman with Brown-Séquard-plus syndrome (BSPS). SETTING: Outpatient spinal cord injury (SCI) clinic. CASE REPORT: A 33-year-old woman with C4 AIS D tetraplegia (American Spinal Injury Association Impairment Scale) was followed at the outpatient SCI clinic for the past 5 years. Her right side presents with increased tone, increased spasticity and decreased sensitivity to light touch. Conversely, her left side presents with minimal changes in tone and no motor function deficits, but decreased sensitivity to pinprick and temperature sensation. These findings are consistent with BSPS. After inpatient rehabilitation, she was engaged, married, and 8 months ago delivered a healthy child. After an uncomplicated delivery, breastfeeding was attempted, but a significant lack of lactation was noted the first month postpartum from the right breast. Despite the implementation of measures to increase lactation, the lack of lactation from the right breast persisted, and required initiation of formula feeding. The right breast in this case lost not only sensory proprioception, but also autonomic control, which could contribute to this instance of asymmetric lactation. CONCLUSION: In addition to motor and sensory dysfunctions following SCI, autonomic dysfunctions are commonly seen in individuals with these devastating injuries. The lactation on the right side, which had interrupted descending spinal autonomic pathways, was decreased by approximately 83%. This case provides us with interesting information regarding attention that clinicians should be paying when discussing the breastfeeding options for women with SCI.

Training effectiveness when teaching the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to medical students.

STUDY DESIGN: Interventional training sessions. OBJECTIVES: To examine the effectiveness of training medical students in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). SETTING: A Peking University teaching hospital. METHODS: A total of 46 medical students were involved in the study. First, they had a 2-h self-study session with the ISNCSCI booklet, followed by a 10-item questionnaire. The booklet was allowed for use as a reference during this assessment. Two days later, the questionnaire was repeated without the use of reference. Students then had a session with case discussion, followed by a final questionnaire. RESULTS: After the initial self-study session, the mean score (max. 10) on the questionnaire was 7.67 ± 1.49. Two days later, the mean score of the second test was 7.96 ± 1.15. All key points of the ISNCSCI were supplemented during the second session with case presentations. The mean score of the final test increased significantly to 9.61 ± 0.88 (P<0.01) in comparison with the previous tests. The overall correct response rates by students in determining sensory level, motor level and American Spinal Injury Association Impairment Scale of the training case were 89.1%, 84.8% and 91.3%, respectively. CONCLUSION: The training effectiveness of ISNCSCI through self-study is reliable. The correct answers to key points could remain for at least 2 days without the need to use a reference. However, some specialized knowledge could not be transmitted without more detailed discussions and case presentations. Utilization of cases is a valuable method in training ISNCSCI and can improve the overall training effectiveness.

Effects of training status on arterial compliance in able-bodied persons and persons with spinal cord injury.

STUDY DESIGN: An investigation on large and small artery compliance in 36 able-bodied persons and persons with spinal cord injury (SCI). OBJECTIVE: To evaluate the effect of various training states (endurance-trained vs untrained) on arterial compliance in individuals with chronic SCI of traumatic origin and in able-bodied individuals (matched for age, sex, height, and weight). SETTING: Tertiary rehabilitation center in Canada. METHODS: Large and small artery compliance were measured at the radial artery and physical activity was assessed via questionnaire. RESULTS: There was no significant difference in large artery compliance between groups. Small artery compliance was reduced markedly (5.8±3.1 ml mm Hg(-1) × 100) in untrained persons with SCI, in comparison to all other groups. Small artery compliance of endurance-trained individuals with SCI was slightly (4%) higher than that observed in the untrained able-bodied individuals (8.6±1.5 vs. 8.2±1.4 ml mm Hg(-1) × 100, respectively). Endurance-trained, able-bodied persons had greater small artery compliance (10.6±2.3 ml mm Hg(-1) × 100) in comparison to the all other groups. CONCLUSION: Endurance training is related to increased small artery compliance in able-bodied individuals and persons with SCI (who are matched for age, sex, height and weight). Endurance training may attenuate the decline in small artery compliance seen with SCI.

Autonomic dysreflexia severity during urodynamics and cystoscopy in individuals with spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To compare autonomic dysreflexia (AD) severity during urodynamics and cystoscopy in individuals with spinal cord injury (SCI). SETTING: Outpatient urological clinic. METHODS: Demographic and clinical data were collected from charts of individuals with SCI who had blood pressure (BP) monitoring during urological procedures. Cardiovascular parameters were collected at baseline and during the various stages of two examinations. RESULTS: A total of 21 SCI individuals (mean age 49.4 years) who underwent both procedures developed episodes of AD. The majority of individuals had cervical SCI (85.7%). The median duration of injury was 183 months (ranging from 3 to 530 months). There was statistically more of an increase (P=0.039) in systolic BP during cystoscopy (67.1±33.8 mm Hg) in comparison with urodynamics (51.8±21.8 mm Hg). The BP response during episodes of AD was more pronounced in individuals with more than 2 years post SCI than with less than 2 years post SCI during both urodynamics and cystoscopy (P=0.047 and P=0.010, respectively). CONCLUSION: Even though cystoscopy filled the bladder to lesser volumes than did urodynamics (150 ml vs 500 ml), during cystoscopy the individuals developed greater changes in systolic BP, indicating that stimulation of the urethra/prostate/internal sphincter region probably is a more potent stimulus of AD than just the filling of the bladder. The severity of AD also increased with time post SCI during both procedures. Considering the high incidence of silent episodes of AD during the urological procedures, it is recommended that monitoring of cardiovascular parameters during these procedures be routinely performed.

The temporal burden of preparing catheters for re-use in adults with spinal cord injury: a cross-sectional study.

STUDY DESIGN: Cross-sectional OBJECTIVES: Neurogenic lower urinary tract dysfunction is common among people with spinal cord injury (SCI). Although single-use clean intermittent catheterization is recommended to facilitate routine bladder emptying, catheter re-use is common. Barriers associated with the preparation (i.e., cleaning) of catheters for re-use are unknown. This study examined barriers to catheter re-use in adult individuals with SCI by assessing (1) the time needed to clean a catheter, and (2) the perceived difficulty of the catheter cleaning routine. SETTING: Laboratory METHODS: Twenty individuals with chronic SCI ( ≥ 1 year since injury; Group 1 = 10 with tetraplegia; Group 2 = 10 with paraplegia) completed the study. Using a standardized cleaning procedure (i.e., Milton method), catheter cleaning was timed for each participant. Perceived difficulty was assessed using a 5-point Likert scale. Functional impairment was assessed with the Upper Extremity Motor Score (UEMS). RESULTS: Significant between-group differences were observed for total cleaning time (Group 1 = 1584.1 ± 179.8 s; Group 2 = 1321.0 ± 93.8 s, p = 0.004) and perceived difficulty [Group 1 = 2.6 (2, 3); Group 2 = 2 (1.7, 2.3), p = 0.028]. Total cleaning time was significantly correlated with UEMS (ρ = -0.709, p ≤ 0.001) and perceived difficulty (ρ = 0.468, p = 0.037). UEMS emerged as an independent predictor of total cleaning time (R2 = 0.745, ß = -0.833, p ≤ 0.001). CONCLUSIONS: Preparing catheters for re-use is time-intensive and difficult for people with higher SCI level, severity and more pronounced upper limb motor impairment, which was independently associated with total cleaning time. Performing this routine on a consistent basis would require a substantial time commitment and would have a profoundly negative impact on overall quality of life.

Electrocardiogram-based predictors for arrhythmia after spinal cord injury.

PURPOSE: Individuals with spinal cord injury (SCI) have an increased risk of cardiac arrhythmias, particularly during autonomic dysreflexia (acute hypertensive episodes). This may be partly due to impaired autonomic control of the heart after SCI. The interval between the peak and end of the T-wave of the electrocardiograph (ECG) provides an index of transmural dispersion of repolarisation, a factor underlying the development of ventricular arrhythmias. Another ECG-based risk factor for ventricular arrhythmias is variability in the QT segment, the QT variability index (QTVI). Similarly, P-wave variability may be correlated with risk for atrial arrhythmias. We aimed to: (1) determine whether there are abnormalities in these parameters at rest in those with SCI; (2) determine correlations between these ECG parameters and severity of autonomic impairment after SCI. METHODS: ECG intervals were determined using customised software from a 15 min ECG recording (lead II) in 28 SCI subjects and 27 controls. Autonomic severity of SCI was determined from sympathetic skin responses, low frequency systolic blood pressure variability, and plasma noradrenaline levels. RESULTS: T(peak)-T(end) variability and QTVI were increased in those with autonomically complete SCI compared to controls. P-wave variability was increased in SCI individuals compared to controls, and was negatively correlated with plasma noradrenaline. CONCLUSION: The higher T(peak)-T(end) variability, QTVI and P-wave variability in individuals with SCI could be markers of severity of injury to cardiac autonomic (sympathetic) pathways after SCI, and may represent new risk assessment parameters for predisposition to cardiac arrhythmias in this population.

Influence of the neurological level of spinal cord injury on cardiovascular outcomes in humans: a meta-analysis.

BACKGROUND: Although motor and sensory deficits following spinal cord injury (SCI) are well known, there are still contrasting reports on how SCI affects baseline cardiovascular (CV) parameters and other autonomic functions. STUDY DESIGN: Meta-analysis is performed. OBJECTIVES: To examine the effect of injury level on supine and seated CV function in individuals with SCI. METHODS: A total of 98 studies representing 1968 individuals were retrieved for analysis. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were abstracted from the studies and compared between four groups according to the neurological lesion level, cervical (C) SCI (C4-C8), high-thoracic (HT) SCI (T1-T6), low-thoracic lumbar (LTL) SCI (below T6) and able-bodied (AB) controls. RESULTS: In the supine position, SBP, DBP and HR were lower in C compared with HT, LTL and AB (all P<0.04). In the seated position, SBP and DBP were significantly lower in C compared with LTL and AB (all P<0.003) and HR was significantly lower in C compared with LTL only (P=0.01). A final finding was that C exhibited a lower resting SBP in the seated compared with the supine position (P<0.001). CONCLUSION: Individuals with SCI exhibit a lesion-dependent impairment in resting CV function, whereby those with the highest injury had the greatest degree of CV dysfunction. A further finding was that individuals with a C injury exhibited a lower resting SBP in the seated vs supine position. Thus, clinicians and researchers should consider lesion level and body position when measuring and interpreting CV parameters in individuals with SCI.

Autonomic dysreflexia and myocardial ischemia.

STUDY DESIGN: A case report of silent myocardial ischemia in a man with C5 AIS A (American Spinal Injury Association Impairment Scale) tetraplegia during an episode of autonomic dysreflexia (AD). OBJECTIVE: The aim of this study was to show a clinical presentation of myocardial ischemia in individuals with spinal cord injury (SCI). CASE REPORT: A 45-year-old man with chronic C5 complete SCI presented with an episode of uncontrolled AD. He denied any symptoms of typical myocardial ischemia. Despite initiation of the AD management protocol, his blood pressure remained elevated. Additional testing revealed an unexpected horizontal ST depression in the lateral leads with a significant elevation of troponins. A follow-up cardiac angiography and MIBI cardiac perfusion scan revealed normal left ventricular contractility and no evidence of coronary artery occlusion. CONCLUSIONS: In individuals with SCI, the loss of sensory input from the myocardium to supraspinal structures predisposes them to asymptomatic myocardial ischemia. Furthermore, during an episode of AD, a significant increase in visceral sympathetic activity with coronary artery constriction can result in myocardial ischemia, even in the absence of coronary artery disease.