Diagnosis and Management of Cardiovascular Risk in Individuals With Spinal Cord Injury: A Narrative Review.

More than 16 000 Americans experience spinal cord injury (SCI), resulting in chronic disability and other secondary sequelae, each year. Improvements in acute medical management have increased life expectancy. Cardiovascular disease is a leading cause of death in this population, and seems to occur earlier in individuals with SCI compared with the general population. People with SCI experience a high burden of traditional cardiovascular disease risk factors, including dyslipidemia and diabetes, and demonstrate anatomic, metabolic, and physiologic changes alongside stark reductions in physical activity after injury. They also experience multiple, complex barriers to care relating to disability and, in many cases, compounding effects of intersecting racial and socioeconomic health inequities. Given this combination of risk factors, some investigators have proposed that people with SCI are at increased risk for cardiovascular disease, beyond that associated with traditional risk factors, and SCI could be considered a risk-enhancing factor, analogous to other risk-enhancing factors defined by the 2019 American Heart Association/American College of Cardiology Primary Prevention Guidelines. However, more research is needed in this population to clarify the role of traditional risk factors, novel risk factors, health care access, social determinants of health, and intersectionality of disability, race, and socioeconomic status. There is an urgent need for primary care physicians and cardiologists to have awareness of the importance of timely diagnosis and management of cardiac risk factors for people with SCI.

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

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

Reasons for meal termination, eating frequency, and typical meal context differ between persons with and without a spinal cord injury.

Overeating associated with neurogenic obesity after spinal cord injury (SCI) may be related to how persons with SCI experience satiation (processes leading to meal termination), their eating frequency, and the context in which they eat their meals. In an online, cross-sectional study, adults with (n = 688) and without (Controls; n = 420) SCI completed the Reasons Individuals Stop Eating Questionnaire-15 (RISE-Q-15), which measures individual differences in the experience of factors contributing to meal termination on five scales: Physical Satisfaction, Planned Amount, Decreased Food Appeal, Self-Consciousness, and Decreased Priority of Eating. Participants also reported weekly meal and snack frequency and who prepares, serves, and eats dinner with them at a typical dinner meal. Analysis revealed that while Physical Satisfaction, Planned Amount, and Decreased Food Appeal were reported as the most frequent drivers of meal termination in both groups, scores for the RISE-Q-15 scales differed across the groups. Compared to Controls, persons with SCI reported Physical Satisfaction and Planned Amount as drivers of meal termination less frequently, and Decreased Food Appeal and Decreased Priority of Eating more frequently (all p < 0.001). This suggests that persons with SCI rely less on physiological satiation cues for meal termination than Controls and instead rely more on hedonic cues. Compared to Controls, persons with SCI less frequently reported preparing and serving dinner meals and less frequently reported eating alone (all p < 0.001), indicating differences in meal contexts between groups. Individuals with SCI reported consuming fewer meals than Controls but reported a higher overall eating frequency due to increased snacking (p ≤ 0.015). A decrease in the experience of physical fullness, along with a dependence on a communal meal context and frequent snacking, likely contribute to overeating associated with neurogenic obesity after SCI.

Assessing the efficacy of duration and intensity prescription for physical activity in mitigating cardiometabolic risk after spinal cord injury.

PURPOSE OF REVIEW: Spinal cord injury (SCI) heightens susceptibility to cardiometabolic risk (CMR), predisposing individuals to cardiovascular disease. This monograph aims to assess the optimal duration and intensity of physical activity (PA) for managing CMR factors, particularly obesity, after SCI and provide modality-specific PA durations for optimal energy expenditure. RECENT FINDINGS: PA guidelines recommend at least 150 min/week of moderate-intensity activity. However, non-SCI literature supports the effectiveness of engaging in vigorous-intensity PA (≥6 METs) and dedicating 250-300 min/week (≈2000 kcal/week) to reduce CMR factors. Engaging in this volume of PA has shown a dose-response relationship, wherein increased activity results in decreased obesity and other CMR factors in persons without SCI. SUMMARY: To optimize cardiometabolic health, individuals with SCI require a longer duration and higher intensity of PA to achieve energy expenditures comparable to individuals without SCI. Therefore, individuals with SCI who can engage in or approach vigorous-intensity PA should prioritize doing so for at least 150 min/wk. At the same time, those unable to reach such intensities should engage in at least 250-300 min/week of PA at a challenging yet comfortable intensity, aiming to achieve an optimal intensity level based on their abilities. Given the potential to decrease CMR after SCI, increasing PA duration and intensity merits careful consideration in future SCI PA directives.

Patient Perceptions and Clinical Assessments of Cardiometabolic Disease After Subacute Spinal Cord Injury.

OBJECTIVES: To investigate the effectiveness of health care team communication regarding cardiometabolic disease (CMD) risk factors with patients with subacute spinal cord injury (SCI). DESIGN: Multi-site prospective cross-sectional study. SETTING: Five National Institute on Disability, Independent Living, and Rehabilitation Research Model SCI Rehabilitation Centers. PARTICIPANTS: Ninety-six patients with subacute SCI, aged 18-70 years, with SCI (neurologic levels of injury C2-L2, American Spinal Injury Association Impairment Scale grades A-D), and enrolled within 2 months of initial rehabilitation discharge (N=96). INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Objective risk factors of CMD (body mass index, fasting glucose, insulin, high-density lipoprotein cholesterol, triglyceride levels, and resting blood pressure). Patient reported recall of these present risk factors being shared with them by their health care team. Medications prescribed to patients to address these present risk factors were checked against guideline- assessed risk factors. RESULTS: Objective evidence of 197 CMD risk factors was identified, with patients recalling less than 12% of these (P<.0001) being shared with them by their health care team. Thirty-one individuals (32%) met criteria for a diagnosis of CMD, with only 1 of these patients (3.2%) recalling that this was shared by their health care team (P<.0001). Pharmacologic management was prescribed to address these risk factors only 7.2% of the time. CONCLUSIONS: Despite high prevalence of CMD risk factors after acute SCI, patients routinely do not recall being told of their present risk factors. Multifaceted education and professionals' engagement efforts are needed to optimize treatment for these individuals.

Energy expenditure and nutrient intake after spinal cord injury: a comprehensive review and practical recommendations.

Many persons with spinal cord injury (SCI) have one or more preventable chronic diseases related to excessive energetic intake and poor eating patterns. Appropriate nutrient consumption relative to need becomes a concern despite authoritative dietary recommendations from around the world. These recommendations were developed for the non-disabled population and do not account for the injury-induced changes in body composition, hypometabolic rate, hormonal dysregulation and nutrition status after SCI. Because evidence-based dietary reference intake values for SCI do not exist, ensuring appropriate consumption of macronutrient and micronutrients for their energy requirements becomes a challenge. In this compressive review, we briefly evaluate aspects of energy balance and appetite control relative to SCI. We report on the evidence regarding energy expenditure, nutrient intake and their relationship after SCI. We compare these data with several established nutritional guidelines from American Heart Association, Australian Dietary Guidelines, Dietary Guidelines for Americans, Institute of Medicine Dietary Reference Intake, Public Health England Government Dietary Recommendations, WHO Healthy Diet and the Paralyzed Veterans of America (PVA) Clinical Practice Guidelines. We also provide practical assessment and nutritional recommendations to facilitate a healthy dietary pattern after SCI. Because of a lack of strong SCI research, there are currently limited dietary recommendations outside of the PVA guidelines that capture the unique nutrient needs after SCI. Future multicentre clinical trials are needed to develop comprehensive, evidence-based dietary reference values specific for persons with SCI across the care continuum that rely on accurate, individual assessment of energy need.

Inspiratory Muscle Performance Is Related to Seated Balance Function in People With Spinal Cord Injury: An Observational Study.

OBJECTIVE: To examine the relationship between inspiratory muscle performance (IMP) and functional sitting balance (FSB) in persons with chronic spinal cord injury (SCI). We hypothesized that a moderate correlation would be found between IMP and FSB and that individuals with better balance would have better IMP. DESIGN: The SCI-specific modification of the Function in Sitting Test (FIST-SCI) measured FSB. The IMP measures included (1) maximal inspiratory pressure (MIP), (2) sustained MIP (SMIP), and (3) inspiratory duration. Upper extremity motor score (UEMS) and level of injury (LOI) were taken from International Standards for Neurological Classification of Spinal Cord Injury examinations. Spearman correlational analyses assessed relationships among these factors in the sample (N=37). Mann-Whitney U tests explored differences between 2 comparison group pairs (tetraplegia group [TG] vs paraplegia group [PG]; independent transfer group [ITG] vs assisted transfer group [ATG]). Regression analysis examined variables predictive of FSB in the TG. SETTING: Research facility. PARTICIPANTS: Volunteers with tetraplegia (n=21, American Spinal Injury Association Impairment Scale (AIS) A=8, B=7, C=6) and paraplegia (n=16, AIS A=9, B=4, C=3) (N=37). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: IMP, LOI, UEMS, FIST-SCI. RESULTS: UEMS, MIP, SMIP, and LOI had moderate to high correlations with FIST-SCI scores (ρ=0.720 (P<.001), 0.480 (P=.003), 0.467 (P=.004), 0.527 (P=.001), respectively). UEMS, MIP, and FIST-SCI scores were higher in the PG and ITG than the TG and ATG, respectively (PG vs. TG P values=<.001, .008, .002, respectively, and ITG vs. ATG P values=<.001, .032, <.001, respectively). Further, SMIP and UEMS predicted FIST-SCI balance scores in the TG, accounting for 55% of total variance (P<.001) (FIST-SCI=11.88+0.03 [SMIP]+0.425 [UEMS]). CONCLUSIONS: The relationship between IMP and balance appears preserved after SCI. FSB was predicted, in part, via UEMS and SMIP in the TG. Future research should focus on the effect of SCI-based breathing interventions on FSB.

Is Sleep Disordered Breathing Confounding Rehabilitation Outcomes in Spinal Cord Injury Research?

The purpose of this article is to highlight the importance of considering sleep-disordered breathing (SDB) as a potential confounder to rehabilitation research interventions in spinal cord injury (SCI). SDB is highly prevalent in SCI, with increased prevalence in individuals with higher and more severe lesions, and the criterion standard treatment with continuous positive airway pressure remains problematic. Despite its high prevalence, SDB is often untested and untreated in individuals with SCI. In individuals without SCI, SDB is known to negatively affect physical function and many of the physiological systems that negatively affect physical rehabilitation in SCI. Thus, owing to the high prevalence, under testing, low treatment adherence, and known negative effect on the physical function, it is contended that underdiagnosed SDB in SCI may be confounding physical rehabilitation research studies in individuals with SCI. Studies investigating the effect of treating SDB and its effect on physical rehabilitation in SCI were unable to be located. Thus, studies investigating the likely integrated relationship among physical rehabilitation, SDB, and proper treatment of SDB in SCI are needed. Owing to rapid growth in both sleep medicine and physical rehabilitation intervention research in SCI, the authors contend it is the appropriate time to begin the conversations and collaborations between these fields. We discuss a general overview of SDB and physical training modalities, as well as how SDB could be affecting these studies.

Inspiratory Muscle Performance and Anthropometric Measures-Novel Assessments Related to Pulmonary Function in People with Spinal Cord Injury: A Pilot Study.

OBJECTIVE: To investigate the feasibility and validity of using the novel axillary:umbilical (A:U) ratio and sustained maximal inspiratory pressure (SMIP) as supplementary measures in the assessment of respiratory function in people with spinal cord injury. DESIGN: Pilot study with a single day of data collection. All measurements were taken with participants in their personal wheelchairs to best represent normal functioning and positioning for each individual. SETTING: Research institution. PARTICIPANTS: A convenience sample of 30 community dwelling volunteers with chronic spinal cord injury (C2-T12, American Spinal Injury Association Impairment Scale A-D) participated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants underwent anthropometric measurements (trunk height, abdominal circumference, axillary circumference) and assessment of inspiratory muscle performance, incluidng maximal inspiratory pressure, SMIP, and inspiratory duration, as well as standard pulmonary function tests. RESULTS: The A:U ratio and SMIP were recorded for all participants. The SMIP was significantly related to more respiratory performance measures than the maximal inspiratory pressure (P<.05) and the A:U ratio was significantly related to more respiratory performance measures than any other anthropometric measure (P<.05). Additionally, an A:U ratio cutoff point detected individuals with a peak expiratory flow ≥ 80% of their predicted value with a sensitivity and specificity of 85.7% and 91.3%, respectively (area under the curve: 0.92). CONCLUSIONS: It is feasible to capture the A:U Ratio and SMIP in individuals with spinal cord injury. Further, the strong significant relationships of SMIP and the A:U ratio to respiratory performance measures suggests their clinical importance in the pulmonary assessment and risk stratification of people with chronic spinal cord injury.

Acute Spinal Cord Injury Is Associated With Prevalent Cardiometabolic Risk Factors.

OBJECTIVES: To (1) describe the prevalence of cardiometabolic disease (CMD) at spinal cord injury (SCI) rehabilitation discharge; (2) compare this with controls without SCI; and (3) identify factors associated with increased CMD. DESIGN: Multicenter, prospective observational study. SETTING: Five National Institute on Disability, Independent Living, and Rehabilitation Research Model SCI Rehabilitation Centers. PARTICIPANTS: SCI (n=95): patients aged 18-70 years, with SCI (neurologic levels of injury C2-L2, American Spinal Injury Association Impairment Scale grades A-D), and enrolled within 2 months of initial rehabilitation discharge. Control group (n=1609): age/sex/body mass index-matched entries in the National Health and Nutrition Examination Education Survey (2016-2019) (N=1704). INTERVENTIONS: None MAIN OUTCOME MEASURES: Percentage of participants with SCI with CMD diagnosis, prevalence of CMD determinants within 2 months of rehabilitation discharge, and other significant early risk associations were analyzed using age, sex, body mass index, insulin resistance (IR) by fasting glucose and Homeostasis Model Assessment (v.2), fasting triglycerides, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol, total cholesterol, and resting blood pressure (systolic and diastolic). RESULTS: Participants with SCI had significantly higher diastolic blood pressure and triglycerides than those without SCI, with lower fasting glucose and HDL-C. A total of 74.0% of participants with SCI vs 38.5% of those without SCI were obese when applying population-specific criteria (P<.05). Low HDL-C was measured in 54.2% of participants with SCI vs 15.4% of those without (P<.05). IR was not significantly different between groups. A total of 31.6% of participants with SCI had ≥3 CMD determinants, which was 40.7% higher than those without SCI (P<.05). Interplay of lipids and lipoproteins (ie, total cholesterol:HDL-C ratio and triglyceride:HDL-C ratio) were associated with elevated risk in participants with SCI for myocardial infarction and stroke. The only significant variable associated with CMD was age (P<.05). CONCLUSIONS: Individuals with SCI have an increased CMD risk compared with the general population; obesity, IR, and low HDL-C are the most common CMD risk determinants; age is significantly associated with early CMD.

Substrate metabolism during recovery from circuit resistance exercise in persons with spinal cord injury.

INTRODUCTION: Whole body energy expenditure and lipid oxidation (Lox) are upregulated during and after exercise. Persons with spinal cord injury (SCI) generally have a blunted ability to utilize fat during exercise, but it is unknown if their substrate partitioning is affected during recovery from exercise. PURPOSE: To determine the effect of a single session of upper body circuit resistance exercise (CRE) on energy expenditure and Lox during exercise recovery in persons with and without SCI. METHODS: Twenty four persons (3 groups; 7 male and 1 female per group) without paralysis (neurologically intact; N) or with chronic (≥ 1 yr) paraplegia (P) or tetraplegia (T) participated. Energy expenditure and substrate partitioning were assessed via indirect calorimetry before, during, and three times after (up to 120 min after) a single session of CRE, or time-matched seated control (CON). RESULTS: During CRE, all groups experienced a similar relative increase in oxygen consumption (49 ± 13, 55 ± 11, and 48 ± 15% VO2peak for N, P, and T, respectively). The Post0-120 energy expenditure was greater following CRE vs. CON (P < 0.01) and independent of injury characteristics (10.6, 22.6, and 14.3% higher than CON for N, P, and T; P = 0.21). The absolute increase in Lox above CON during recovery was similar for N, P, and T (5.74 ± 2.81, 6.62 ± 3.10, and 4.50 ± 3.91 g, respectively; P = 0.45). CONCLUSIONS: Energy expenditure and lipid utilization was increased similarly following circuit exercise in persons without and with spinal cord injury in a manner independent of level of injury.

Physiological responses to moderate intensity continuous and high-intensity interval exercise in persons with paraplegia.

STUDY DESIGN: Randomized crossover. OBJECTIVES: To test differences in the duration and magnitude of physiological response to isocaloric moderate intensity continuous (MICE) and high-intensity interval exercise (HIIE) sessions in persons with spinal cord injury (SCI). SETTING: Academic medical center in Miami, FL, USA. METHODS: Ten adult men (mean ± s.d.; 39 ± 10 year old) with chronic (13.2 ± 8.8 year) paraplegia (T2-T10) completed a graded exercise test. Then, in a randomized order, participants completed MICE and HIIE for a cost of 120 kcal. MICE was performed at 24.6% POpeak. During HIIE, exercise was completed in 2 min work and recovery phases at 70%:10% POpeak. RESULTS: MICE and HIIE were isocaloric (115.9 ± 21.8 and 116.6 ± 35.0 kcal, respectively; p = 0.903), but differed in duration (39.8 ± 4.6 vs 32.2 ± 6.2 min; p < 0.001) and average respiratory exchange ratio (RER; 0.90 ± 0.08 vs 1.01 ± 0.07; p = 0.002). During MICE, a workrate of 24.6 ± 6.7% POpeak elicited a V̇O2 of 53.1 ± 6.5% V̇O2peak (10.1 ± 2.2 ml kg-1 min-1). During HIIE, a workrate at 70% POpeak elicited 88.3 ± 6.7% V̇O2peak (16.9 ± 4.2 ml kg-1 min-1), and 29.4 ± 7.7% of the session was spent at or above 80% V̇O2peak. During HIIE working phase, RER declined from the first to last interval (1.08 ± 0.07 vs 0.98 ± 0.09; p < 0.001), reflecting an initially high but declining glycolytic rate. CONCLUSIONS: Compared with MICE, HIIE imposed a greater physiological stimulus while requiring less time to achieve a target caloric expenditure. Thus, exercise intensity might be an important consideration in the tailoring of exercise prescription to address the cardiometabolic comorbidities of SCI.

A tele-health intervention to increase physical fitness in people with spinal cord injury and cardiometabolic disease or risk factors: a pilot randomized controlled trial.

STUDY DESIGN: Clinical trial. OBJECTIVES: We used a single-blind parallel-group design to test the feasibility and preliminary efficacy of a telehealth-based physical activity counseling intervention to increase physical fitness in people with SCI. SETTING: Seattle, Washington, United States. METHODS: We recruited under-active, manual wheelchair-using adults at least 1-year post-SCI who had at least two cardiometabolic risk factors/diseases. Participants underwent baseline tests of peak cardiorespiratory fitness; lipids, glucose and insulin; muscle and fat mass; self-reported physical activity, depression, pain and other factors. Participants were assigned 1:1 to treatment vs. usual care (UC) control conditions via concealed computerized randomization. Treatment was delivered via telephone and adapted from the 16-session Diabetes Prevention Program. All baseline tests were repeated at 6 months. Prespecified feasibility goals were to recruit at least nine participants/quarter and retain 85% with complete fitness testing at 6 months. Prespecified efficacy goals were to demonstrate at least a medium treatment effect size (0.50) on fitness, self-reported physical activity, and other outcomes. RESULTS: Seven participants were randomized to treatment, 8 to UC over 15 months. Maximum recruitment was only 5.4 participants/quarter. Thirteen (87%) of participants were retained. The effects of treatment on fitness and most cardiometabolic risk factors did not meet expectations, whereas the effects on self-reported physical activity, depression, and pain did meet expectations. CONCLUSIONS: The study did not meet key efficacy and feasibility objectives, yet there were some promising effects on self-report measures and lessons to be learned for designing future trials.

Psychometric Testing and Clinical Utility of a Modified Version of the Function in Sitting Test for Individuals With Chronic Spinal Cord Injury.

OBJECTIVES: Seated balance (SB) is substantially compromised and greatly impacts the function of individuals living with a spinal cord injury (SCI). A clinically applicable criterion standard measure for SB does not exist for this population. Initial validation and reliability analysis of the Function in Sitting Test (FIST) in SCI has been published, but the authors of this study report that modifications to the tool may be necessary. This study aimed to explore the psychometrics and clinical utility of a modified version of the FIST to better measure SCI-specific functional tasks in sitting. DESIGN: The FIST was modified (FIST-SCI) by an expert panel and used by 2 graders to evaluate the SB of individuals with chronic SCI (cSCI) on 2 separate days. The Motor Assessment Scale item 3 (MAS-SCI) was included as a comparison measure. SETTING: Research facility. PARTICIPANTS: Individuals with cSCI longer than 1 year (N=38) participated in the study. Injury levels of individuals participating in this study spanned C1 to T10 (American Spinal Injury Association Impairment Scale A, 17 subjects; B, 12 subjects; and C, 9 subjects). Thirteen individuals required assistance to transfer. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Validity, reliability, internal consistency, sensitivity, specificity, and responsiveness. RESULTS: Validity testing found a moderate relationship between the MAS-SCI and the FIST-SCI (ρ, .522; P<.05). FIST-SCI scores distinguished individuals requiring assistance to transfer from those who were independent (t=4.51; P<.05). Inter- and intra-rater reliability were excellent (intraclass correlation coefficient (2,k)=.985 and .983, respectively) and internal consistency was excellent (α=.94). A FIST-SCI cutoff score of 45 or greater was 92% sensitive and specific in characterizing transfer ability. Standard error of the measure (1.3) and minimal detectable change (3.5) were similar to previous work. CONCLUSIONS: Initial validity of the FIST-SCI is reported, but further assessment is required. Reliability is excellent in the cSCI population. FIST-SCI scores provide clinical insight into the seated functional ability of individuals with cSCI.

Differences in Acute Metabolic Responses to Bionic and Nonbionic Ambulation in Spinal Cord Injured Humans and Controls.

OBJECTIVES: To (1) compare energy expenditure during seated rest, standing, and prolonged bionic ambulation or bipedal ambulation in participants with spinal cord injury (SCI) and noninjured controls, respectively, and (2) test effects on postbionic ambulation glycemia in SCI. DESIGN: Two independent group comparison of SCI and controls. SETTING: Academic Medical Center. PARTICIPANTS: Ten participants with chronic SCI (C7-T1, American Spinal Injury Association Impairment Scale A-C) and 10 controls (N=20). INTERVENTIONS: A commercial bionic exoskeleton. MAIN OUTCOME MEASURES: Absolute and relative (to peak) oxygen consumption, perceived exertion, carbohydrate/fat oxidation, energy expenditure, and postbionic ambulation plasma glucose/insulin. RESULTS: Average work intensity accompanying 45 minutes of outdoor bionic ambulation was <40% peak oxygen consumption, with negligible drift after reaching steady state. Rating of perceived exertion (RPE) did not differ between groups and reflected low exertion. Absolute energy costs for bionic ambulation and nonbionic ambulation were not different between groups despite a 565% higher ambulation velocity in controls and 3.3× higher kilocalorie per meter in SCI. Fuel partitioning was similar between groups and the same within groups for carbohydrate and fat oxidation. Nonsignificant (9%) lowering of the area under a glucose tolerance curve following bionic ambulation required 20% less insulin than at rest. CONCLUSION: Work intensity during prolonged bionic ambulation for this bionic exoskeleton is below a threshold for cardiorespiratory conditioning but above seated rest and passive standing. Bionic ambulation metabolism is consistent with low RPE and unchanged fuel partitioning from seated rest. Bionic ambulation did not promote beneficial effects on glycemia in well-conditioned, euglycemic participants. These findings may differ in less fit individuals with SCI or those with impaired glucose tolerance. Observed trends favoring this benefit suggest they are worthy of testing.

Diagnostic accuracy of a two-stage model for detecting obstructive sleep apnoea in chronic tetraplegia.

BACKGROUND: Obstructive sleep apnoea (OSA) is highly prevalent in people with spinal cord injury (SCI). Polysomnography (PSG) is the gold-standard diagnostic test for OSA, however PSG is expensive and frequently inaccessible, especially in SCI. A two-stage model, incorporating a questionnaire followed by oximetry, has been found to accurately detect moderate to severe OSA (MS-OSA) in a non-disabled primary care population. This study investigated the accuracy of the two-stage model in chronic tetraplegia using both the original model and a modified version for tetraplegia. METHODS: An existing data set of 78 people with tetraplegia was used to modify the original two-stage model. Multivariable analysis identified significant risk factors for inclusion in a new tetraplegia-specific questionnaire. Receiver operating characteristic (ROC) curve analyses of the questionnaires and oximetry established thresholds for diagnosing MS-OSA. The accuracy of both models in diagnosing MS-OSA was prospectively evaluated in 100 participants with chronic tetraplegia across four international SCI units. RESULTS: Injury completeness, sleepiness, self-reported snoring and apnoeas were included in the modified questionnaire, which was highly predictive of MS-OSA (ROC area under the curve 0.87 (95% CI 0.79 to 0.95)). The 3% oxygen desaturation index was also highly predictive (0.93 (0.87-0.98)). The two-stage model with modified questionnaire had a sensitivity and specificity of 83% (66-93) and 88% (75-94) in the development group, and 77% (65-87) and 81% (68-90) in the validation group. Similar results were demonstrated with the original model. CONCLUSION: Implementation of this simple alternative to full PSG could substantially increase the detection of OSA in patients with tetraplegia and improve access to treatments. TRIAL REGISTRATION NUMBER: Results, ACTRN12615000896572 (The Australian and New Zealand Clinical Trials Registry) and pre-results, NCT02176928 (clinicaltrials.gov).

Model Programs to Address Obesity and Cardiometabolic Disease: Interventions for Suboptimal Nutrition and Sedentary Lifestyles.

Problems posed by obesity-related endocrine diseases embody a national health crisis. Caloric excess and sedentary lifestyle from which they develop also pose significant challenges for rehabilitation providers. Almost two thirds of the U.S. population are currently overweight or obese, a number that has increased by >10% within the last decade and is expected to grow. An overweight body habitus is strongly associated with clinical hazards, including cardiometabolic syndrome, diabetes hypertension, and coronary artery disease. The component health risks of the cardiometabolic syndrome include coalescing of risk factors that predict a health calamity unless effective interventions can be developed and widely adopted. Obesity by itself is now considered an American Diabetes Association-qualified disability, but it is also disturbingly prevalent in other physical disability groupings of adults and children. This monograph describes successes of the Diabetes Prevention Program (DPP), a National Institutes of Health multisite randomized controlled trial that reported significant weight reduction and a 58% decreased incidence of type-2 diabetes accompanying 1 year of structured lifestyle intervention. This treatment benefit (1) exceeded that of metformin pharmacotherapy, (2) was so powerful that the trial was closed before reaching endpoints, and (3) was judged cost-effective for the patient and society. The DPP roadmap incorporating physical activity, diet, and behavioral approaches has been widely adapted to specific community, faith, racial, ethnic, school, and national populations with excellent outcomes success. The lockstep physical activity approach, activity prescription, and long-term success of the program are described and compared with other programs to illustrate effective countermeasures for the pandemics of obesity and obesity-related cardioendocrine disease. We will illustrate adaptation of the DPP for a cohort of persons with disability from spinal cord injury and the benefits observed.

It Is Time to Invite Patients to the Physical Activity Party .

Physical activity is associated with a myriad of health benefits relevant to adults who commonly receive rehabilitation. Unfortunately, the prescription for exercise and overall activity still continues to be overlooked, which is a missed opportunity because those receiving rehabilitation are most likely to benefit from the effects of physical activity. The purpose of this supplement is to fill this knowledge gap by featuring articles that examine the efficacy of physical activity, and describe mechanisms underlying changes in physical activity and how physical activity in rehabilitation populations fits within broader medical and public health frameworks.

Cardiometabolic Syndrome in People With Spinal Cord Injury/Disease: Guideline-Derived and Nonguideline Risk Components in a Pooled Sample.

OBJECTIVE: To assess cardiometabolic syndrome (CMS) risk definitions in spinal cord injury/disease (SCI/D). DESIGN: Cross-sectional analysis of a pooled sample. SETTING: Two SCI/D academic medical and rehabilitation centers. PARTICIPANTS: Baseline data from subjects in 7 clinical studies were pooled; not all variables were collected in all studies; therefore, participant numbers varied from 119 to 389. The pooled sample included men (79%) and women (21%) with SCI/D >1 year at spinal cord levels spanning C3-T2 (American Spinal Injury Association Impairment Scale [AIS] grades A-D). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We computed the prevalence of CMS using the American Heart Association/National Heart, Lung, and Blood Institute guideline (CMS diagnosis as sum of risks ≥3 method) for the following risk components: overweight/obesity, insulin resistance, hypertension, and dyslipidemia. We compared this prevalence with the risk calculated from 2 routinely used nonguideline CMS risk assessments: (1) key cut scores identifying insulin resistance derived from the homeostatic model 2 (HOMA2) method or quantitative insulin sensitivity check index (QUICKI), and (2) a cardioendocrine risk ratio based on an inflammation (C-reactive protein [CRP])-adjusted total cholesterol/high-density lipoprotein cholesterol ratio. RESULTS: After adjustment for multiple comparisons, injury level and AIS grade were unrelated to CMS or risk factors. Of the participants, 13% and 32.1% had CMS when using the sum of risks or HOMA2/QUICKI model, respectively. Overweight/obesity and (pre)hypertension were highly prevalent (83% and 62.1%, respectively), with risk for overweight/obesity being significantly associated with CMS diagnosis (sum of risks, χ(2)=10.105; adjusted P=.008). Insulin resistance was significantly associated with CMS when using the HOMA2/QUICKI model (χ(2)2=21.23, adjusted P<.001). Of the subjects, 76.4% were at moderate to high risk from elevated CRP, which was significantly associated with CMS determination (both methods; sum of risks, χ(2)2=10.198; adjusted P=.048 and HOMA2/QUICKI, χ(2)2=10.532; adjusted P=.04). CONCLUSIONS: As expected, guideline-derived CMS risk factors were prevalent in individuals with SCI/D. Overweight/obesity, hypertension, and elevated CRP were common in SCI/D and, because they may compound risks associated with CMS, should be considered population-specific risk determinants. Heightened surveillance for risk, and adoption of healthy living recommendations specifically directed toward weight reduction, hypertension management, and inflammation control, should be incorporated as a priority for disease prevention and management.