The comparison of total energy and protein intake relative to estimated requirements in chronic spinal cord injury.

In chronic spinal cord injury (SCI), individuals experience dietary inadequacies complicated by an understudied research area. Our objectives were to assess (1) the agreement between methods of estimating energy requirement (EER) and estimated energy intake (EEI) and (2) whether dietary protein intake met SCI-specific protein guidelines. Persons with chronic SCI (n = 43) completed 3-day food records to assess EEI and dietary protein intake. EER was determined with the Long and Institute of Medicine (IOM) methods and the SCI-specific Farkas method. Protein requirements were calculated as 0·8-1·0 g/kg of body weight (BW)/d. Reporting accuracy and bias were calculated and correlated to body composition. Compared with IOM and Long methods (P < 0·05), the SCI-specific method did not overestimate the EEI (P = 0·200). Reporting accuracy and bias were best for SCI-specific (98·9 %, -1·12 %) compared with Long (94·8 %, -5·24 %) and IOM (64·1 %, -35·4 %) methods. BW (r = -0·403), BMI (r = -0·323) and total fat mass (r = -0·346) correlated with the IOM reporting bias (all, P < 0·05). BW correlated with the SCI-specific and Long reporting bias (r = -0·313, P = 0·041). Seven (16 %) participants met BW-specific protein guidelines. The regression of dietary protein intake on BW demonstrated no association between the variables (ß = 0·067, P = 0·730). In contrast, for every 1 kg increase in BW, the delta between total and required protein intake decreased by 0·833 g (P = 0·0001). The SCI-specific method for EER had the best agreement with the EEI. Protein intake decreased with increasing BW, contrary to protein requirements for chronic SCI.

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.

Sexuality, Intimacy, and Reproductive Health after Spinal Cord Injury.

Spinal cord injury (SCI) is a life-altering event often accompanied by a host of anxiety-provoking questions and concerns in the minds of affected individuals. Questions regarding the ability to resume sexual activity, partner's satisfaction as well as the ability to have biological children are just a few of the unknowns facing patients following the devastating reality that is SCI. As a result of advances in SCI research over the last few decades, providers now have the knowledge and tools to address many of these concerns in an evidence-based and patient-centered approach. SCI can impair multiple components involved in sexual function, including libido, achieving and maintaining an erection, ejaculation, and orgasm. Many safe and effective fertility treatments are available to couples affected by SCI. Finally, learning to redefine one's self-image, reinforce confidence and self-esteem, and feel comfortable communicating are equally as important as understanding functionality in regaining quality of life after SCI. Thus, this review aims to highlight the current state of SCI research relating to sexual function, reproductive health, and the search for meaning.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers.

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management.

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a traumatic spinal cord injury (SCI), supraspinal influences on the peripheral nervous system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, sympathetic blunting, and parasympathetic dominance, resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions, and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of the less reported nontraumatic SCI (NTSCI), its classification, its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue. Finally, management strategies for NTSCI will be provided.

Hemiballismus-hemichorea syndrome in an acute rehabilitation setting: two case reports.

BACKGROUND: We report two similar cases of patients diagnosed with hemiballismus-hemichorea syndrome secondary to uncontrolled hyperglycemia. Both patients were treated at an inpatient rehabilitation center and made a significant recovery in both function and activities of daily living. Although hemiballismus-hemichorea syndrome has known pharmacological treatments, little has been reported on the effectiveness of acute rehabilitation on managing and treating this syndrome. CASE PRESENTATION: The first case involves a 44-year-old Hispanic male with past medical history of type 2 diabetes mellitus, hypertension, anxiety, and depression who presented with continuous, uncontrollable, unilateral movements 1 month following a hospital admission for hyperglycemia. Magnetic resonance imaging findings showed lesions in the basal ganglia, confirming the diagnosis of hemiballismus-hemichorea syndrome. The patient was started on antipsychotic medications and antihyperglycemic medications controlling glucose levels, but continued to have hemiballismus symptoms. The second case involves a 78-year-old Haitian female with past medical history of type 2 diabetes mellitus and hypertension who presented with weakness and continuous, involuntary movements in her upper and lower extremities 1 month following a hospital admission for hyperglycemia and encephalopathy. Magnetic resonance imaging findings were positive for bilateral lesions in the basal ganglia, establishing a diagnosis of hemiballismus-hemichorea syndrome. After a 2-week stay at an acute rehabilitation center, both patients made a significant recovery in function and activities of daily living. CONCLUSION: The aim in presenting these cases is to elucidate the etiology and progression of a rare disease process known as hemiballismus-hemichorea syndrome and to provide evidence for the potential positive impact of acute rehabilitation on patients with unresolved hemiballismus-hemichorea following an episode of hyperglycemia.

Spinal cord stimulation for neuropathic pain following traumatic spinal cord injury: a case report.

INTRODUCTION: Neuropathic pain is a common complication of spinal cord injury (SCI), and is notoriously difficult to adequately treat. Gunshot wounds (GSW) near the spinal cord may cause intractable chronic pain through spinal/nerve root transection, or reactive tissue formation resulting in nerve root compression from retained bullet fragments (RBF). CASE PRESENTATION: This case report describes a 30-year-old man with a T12 AIS B incomplete spinal cord injury with paraplegia secondary to multiple GSW who presented with severe bilateral lower extremity dysesthesias and muscle spasms. Symptoms failed to improve with oral antispasmodic medications. After being diagnosed with Complex regional pain syndrome (CRPS) type I secondary to an SCI via GSW, he underwent a spinal cord stimulator (SCS) trial, which improved his symptoms by greater than 80%. DISCUSSION: Neuropathic pain refractory to conservative treatment may benefit from SCS. Effects of therapy go beyond gate-theory in SCI patients, and may benefit patients at the cellular and molecular level. Our case demonstrates the effectiveness of SCS treatment in a patient who developed CRPS type 1 after GSW resulting in SCI.

Fat to lean mass ratio in spinal cord injury: Possible interplay of components of body composition that may instigate systemic inflammation and metabolic syndrome.

OBJECTIVE: To investigate the relationships between percentage fat mass (%FM), percentage lean mass (%LM), and the ratio of %FM to %LM with pro-inflammatory adipokines and metabolic syndrome in individuals with chronic spinal cord injury (SCI). DESIGN: Observational, cross-sectional. Linear and logistic regression were used to examine the associations between the %FM, %LM, and the %FM to %LM ratio with inflammatory markers and metabolic syndrome, respectively. PARTICIPANTS: Seventy chronic SCI men and women. MAIN OUTCOME MEASURES: %FM, %LM, %FM to %LM ratio; fasting lipids, glucose, and tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and high-sensitivity c-reactive protein (hs-CRP); metabolic syndrome as determined by The International Diabetes Federation criteria. RESULTS: There were significant correlations between %FM, %LM and the %FM to %LM ratio with hs-CRP. The %LM beta coefficient value was negative and greater than the beta coefficient value for %FM. The %FM to %LM ratio had the strongest correlation with hs-CRP and showed the only significant relationship with IL-6. There were strong significant correlations between %FM, %LM and the %FM to %LM ratio with metabolic syndrome. However, the %FM to %LM ratio, again, showed the strongest relationship indicating that it may be the best predictor of metabolic syndrome. CONCLUSION: Both higher %FM and lower %LM affect cardiometabolic health and can be used as predictors for metabolic syndrome. However, the %FM to %LM ratio was the best predictor of systemic inflammation and cardiometabolic disorders in this group of SCI participants, suggesting that they both contribute to the statistical model.

The Diagnosis and Management of Cardiometabolic Risk and Cardiometabolic Syndrome after Spinal Cord Injury.

Individuals with spinal cord injuries (SCI) commonly present with component risk factors for cardiometabolic risk and combined risk factors for cardiometabolic syndrome (CMS). These primary risk factors include obesity, dyslipidemia, dysglycemia/insulin resistance, and hypertension. Commonly referred to as "silent killers", cardiometabolic risk and CMS increase the threat of cardiovascular disease, a leading cause of death after SCI. This narrative review will examine current data and the etiopathogenesis of cardiometabolic risk, CMS, and cardiovascular disease associated with SCI, focusing on pivotal research on cardiometabolic sequelae from the last five years. The review will also provide current diagnosis and surveillance criteria for cardiometabolic disorders after SCI, a novel obesity classification system based on percent total body fat, and lifestyle management strategies to improve cardiometabolic health.

Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review.

The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1-L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.

Concomitant Brain Injury and Spinal Cord Injury Management Strategies: A Narrative Review.

Spinal cord injury (SCI) is a catastrophic event with multiple comorbidities including spastic paralysis, sensory loss, autonomic dysfunction with sympathetic blunting, neurogenic orthostatic hypotension, neurogenic restrictive and obstructive lung disease, neuropathic pain, spasticity, neurogenic bladder, neurogenic bowel, immobilization hypercalcemia, osteopenia/osteoporosis, neurogenic obesity, and metabolic dysfunction. Cervical and thoracic SCI is all too often accompanied by traumatic brain injury (TBI), which carries its own set of comorbidities including headaches, seizures, paroxysmal sympathetic hyperactivity, aphasia, dysphagia, cognitive dysfunction, memory loss, agitation/anxiety, spasticity, bladder and bowel incontinence, and heterotopic ossification. This manuscript will review the etiology and epidemiology of dual diagnoses, assessment of both entities, and discuss some of the most common comorbidities and management strategies to optimize functional recovery.

Pressure Injuries and Management after Spinal Cord Injury.

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.

Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury.

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.

Neurogenic Bowel and Management after Spinal Cord Injury: A Narrative Review.

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

Psychosocial Consequences of Spinal Cord Injury: A Narrative Review.

Consequences of a spinal cord injury (SCI) entail much more than damage to the spinal cord. The lives of people with SCI, along with those around them, experience profound long-lasting changes in nearly every life domain. SCI is a physical (biological) injury that is inextricably combined with various psychological and social consequences. The objective of this review is to present psychosocial challenges following SCI through the biopsychosocial model, beginning with acknowledgement of the larger societal effects of ableism and stigma before addressing the many unique psychosocial aspects of living with SCI. Included in this review are qualitative studies and systematic reviews on current psychosocial outcomes and consequences. This paper attempts to structure this information by dividing it into the following sections: relationships and family; changes in finances and employment; issues related to the person's living situation; community reintegration; factors associated with mood and coping (e.g., depression, anxiety, substance use, and PTSD); self-harm behaviors (ranging from nonadherence to suicide); effects of traumatic brain injury; considerations regarding sexual health; aging with SCI; and concludes with a brief discussion about post-traumatic growth. Cultivating an understanding of the unique and interrelated psychosocial consequences of people living with SCI may help mitigate the psychosocial aftermath and serve as a reminder to providers to maintain a person-centered approach to care.

Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury.

Urinary incontinence is common after spinal cord injury (SCI) due to loss of supraspinal coordination and unabated reflexes in both autonomic and somatic nervous systems; if unchecked, these disturbances can become life-threatening. This manuscript will review normal anatomy and physiology of the urinary system and discuss pathophysiology secondary to SCI. This includes a discussion of autonomic dysreflexia, as well as its diagnosis and management. The kidneys and the ureters, representing the upper urinary tract system, can be at risk related to dyssynergy between the urethral sphincters and high pressures that lead to potential vesicoureteral reflux, urinary tract infections, and calculi associated with neurogenic lower urinary tract dysfunction (NLUTD). Recent guidelines for diagnosis, evaluation, treatment and follow up of the neurogenic bladder will be reviewed and options provided for risk stratification and management. Mechanical, pharmacological, neurolysis and surgical management will be discussed.

Pediatric Spina Bifida and Spinal Cord Injury.

Pediatric spina bifida (SB) and spinal cord injury (SCI) are unfortunately common in our society, and their unique findings and comorbidities warrant special consideration. This manuscript will discuss the epidemiology, pathophysiology, prevention, and management strategies for children growing and developing with these unique neuromuscular disorders. Growth and development of the maturing child places them at high risk of spinal cord tethering, syringomyelia, ascending paralysis, pressure injuries, and orthopedic abnormalities that must be addressed frequently and judiciously. Similarly, proper neurogenic bladder and neurogenic bowel management is essential not just for medical safety, but also for optimal psychosocial integration into the child's expanding social circle.

Spasticity Management after Spinal Cord Injury: The Here and Now.

Spasticity is a common comorbidity of spinal cord injury (SCI) that is characterized by velocity dependent tone and spasms manifested by uninhibited reflex activity of muscles below the level of injury. For some, spasticity can be beneficial and facilitate functional standing, transfers, and some activities of daily living. For others, it may be problematic, painful, and interfere with mobility and function. This manuscript will address the anatomy and physiology of neuromuscular reflexes as well as the pathophysiology that occurs after SCI. Spasticity assessment will be discussed in terms of clinical history and findings on physical examinations, including responses to passive and active movement, deep tendon reflexes, and other long tract signs of upper motor neuron injury, as well as gait and function. Management strategies will be discussed including stretch, modalities, pharmacotherapy, neurolysis, and surgical options.

Acute exercise improves glucose effectiveness but not insulin sensitivity in paraplegia.

PURPOSE: To determine the effect of a single session of arm crank ergometry (ACE) exercise on carbohydrate metabolism immediately and 24 h after the exercise bout in paraplegia and able-bodied controls (ABC). METHODS: Paraplegia (n = 11; 91% male; age 34.8 ± 11.4 years) and ABC (n = 6; 67% male; age 28.7 ± 11.9 years) underwent 45 min of ACE exercise at 75% VO2Peak. Glucose effectiveness (Sg) and insulin sensitivity (Si) were assessed. Data were analyzed with two-way mixed analysis of variance and Wilcoxon rank-sum or signed-rank post hoc test. RESULTS: VO2Peak was lower in paraplegia versus ABC (22.3 ± 3.99 vs. 30.8 ± 2.9 ml/kg/min, p = 0.003). Si was lower paraplegia vs. ABC immediately following exercise (3.28 ± 1.6 vs. 5.30 ± 1.2 min-1/[µU/mL-1]x10-4, p = 0.023). In paraplegia, Sg was higher immediately after exercise than baseline (B: 0.021 ± 0.01 vs. I: 0.026 ± 0.01 min-1, p = 0.037). Twenty-four hours after exercise, Sg was lower than immediately following exercise (I: 0.026 ± 0.01 vs. 24: 0.017 ± 0.01 min-1, p = 0.001), but not different than baseline in paraplegia (B: 0.021 ± 0.01 vs. 24: 0.017 ± 0.01 min-1, p = 0.216). In the ABC group, Sg was not different at all timepoints (p > 0.05). Si did not differ at all timepoints (p > 0.05). CONCLUSION: A single bout of ACE at 75% VO2Peak helped to acutely control glucose metabolism in those with paraplegia by increasing Sg by nearly 27%; however, this was not sustained past 24-hours. These data provide support for regular exercise engagement.Implications for RehabilitationDisorders of glucose metabolism have been reported at a greater prevalence in persons with spinal cord injury.A single bout of arm crank ergometry exercise at 75% VO2Peak helped to acutely control glucose metabolism persons with paraplegia; however, this was not sustained past 24 h.These data provide support for regular exercise engagement in persons with paraplegia.

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.