The effect of level of injury on diabetes incidence and mortality after spinal cord injury - a longitudinal cohort study.

STUDY DESIGN: Retrospective longitudinal cohort study of veterans with SCI. OBJECTIVES: Spinal cord injury (SCI) is associated with an increased risk of developing diabetes mellitus (DM), likely due to body composition alterations and autonomic nervous system dysfunction. These factors are more pronounced in persons with tetraplegia (TP) versus paraplegia (PP). However, the effect of level of injury (LOI) on DM incidence is largely unknown. Therefore, the objective is to examine the effect of LOI on DM incidence in persons with SCI. SETTING: South Texas Veterans Health Care System. METHODS: We obtained electronic record data on age, sex, race/ethnicity, LOI and HbA1c concentration from January 1st 2001 through December 31st 2021. Cox proportional hazard regression analyses were used to assess the association between LOI, DM and all-cause mortality. RESULTS: Among 728 non-diabetic veterans with SCI (350 TP/ 378 PP, 52 ± 15 years, 690 male/38 female) 243 developed DM, of which 116 with TP and 127 with PP. Despite chronological variations between TP and PP, DM risk over the entire follow-up did not differ between the groups (hazard ratio (HR): 1.06, 95% CI: 0.82-1.38). Mortality was higher in TP versus PP (HR: 1.40, 95% CI: 1.09-1.78). However, developing DM did not increase the risk of death, regardless of LOI (HR: 1.07, 95% CI: 0.83-1.37). CONCLUSION: Despite chronological variations between both groups, the level of injury had minimal effect on long-term DM development in this cohort of veterans with SCI. Sponsorship NIH (DK105379; MS), RR&D SPiRE (I21RX003724-01A1; MT and SH).

Capsaicin 8% Patch for Spinal Cord Injury Focal Neuropathic Pain, a Randomized Controlled Trial.

BACKGROUND: Neuropathic pain (NP) after spinal cord injury (SCI) exacerbates disability, decreases quality of life (QOL), and is often refractory to available therapies. Patients report willingness to trade potential recovery of strength, bowel, bladder, or sexual function for pain relief. One proposed mechanism causing NP is up-regulation of transient receptor potential vanilloid 1 (TRPV 1) proteins in uninjured C fibers and dorsal root ganglia causing neuronal excitability. Recent studies have found up-regulation of TRPV 1 proteins after SCI. OBJECTIVE: We hypothesize the application of capsaicin 8% patch (C8P), FDA approved for NP in diabetic peripheral neuropathy and post-herpetic neuralgia, will improve pain, function and QOL in persons with SCI. METHODS: Randomized single-blind crossover design in which 11 persons with SCI and NP refractory to two oral pain medications received C8P or a control low dose Capsaicin 0.025% patch (CON) over two 12-week periods. Pain (VAS, MPI-SCI), quality of life (WHO-QOL), and functional status (SCIM) were measured at 2-4-week intervals. RESULTS: There was a main treatment effect of C8P over CON on VAS and MPI-SCI outcomes with pain reduction of 35% and 29% at weeks 2 and 4, respectively. C8P also demonstrated a main treatment effect over CON on the SCIM mobility subscale. WHO-QOL scores did not improve with C8P. CONCLUSIONS: C8P improves pain and mobility for patients with SCI and refractory NP. Larger studies should be performed to evaluate impact of repeat applications and QOL outcomes.

The effects of a heat acclimation protocol in persons with spinal cord injury.

Persons without spinal cord injury (SCI) physiologically acclimate between seven to fourteen consecutive days of exercise in the heat. Decreased resting and exercise core temperature, decreased heart rate, increased plasma volume and increased thermal comfort during exercise are changes consistent with heat acclimation. Autonomic dysfunction after SCI impairs heat dissipation through sweating and vasodilation. The purpose of this study is to determine if seven consecutive days of exercise in the heat would result in physiologic changes consistent with heat acclimation in persons with SCI. Ten persons with SCI divided into two groups: tetraplegia (n=5) and paraplegia (n=5) exercised in 35°C using an arm ergometer at 50% Wpeak for 30min followed by 15min rest. This protocol was repeated over seven consecutive days. Heart rate (HR), skin temperature, aural temperature (Taur), rate of perceived exertion (RPE), rate of perceived thermal strain (RPTS), and plasma volume (PV) were measured throughout the protocol. There were no significant differences in resting Taur exercise Taur, mean skin temperature, HR, PV, RPE or RPTS over the 7 days for either the tetraplegic or paraplegic group. Participants with SCI did not demonstrate the ability to dissipate heat more efficiently over 7 days of exercise at 35°C. The lack of heat acclimation seen in persons with SCI has implications for the athlete and non-athlete alike. For the SCI athlete, inability to acclimate will impair performance and endurance especially in warm environments, compared to the person without SCI. For the SCI non-athlete, there is a greater risk of heat-related illness in warm environments that can negatively affect participation in outdoor activities and thus quality of life.

Secondary adrenal insufficiency after glucocorticosteroid administration in acute spinal cord injury: a case report.

CONTEXT/BACKGROUND: A 61-year-old female with cervical stenosis underwent an elective cervical laminectomy with post-op worsening upper extremity weakness. Over the first 3 weeks post-op, she received two separate courses of intravenous steroids. Two days after cessation of steroids, she presented with non-specific symptoms of adrenal insufficiency (AI). Initial formal diagnostic tests of random cortisol level and 250 µg cosyntropin challenge were non-diagnostic; however, symptoms resolved with the initiation of empiric treatment with hydrocortisone. Ten days later, repeat cosyntropin (adrenocortocotropic hormone stimulation) test confirmed the diagnosis of AI. FINDINGS: AI is a potentially life-threatening complication of acute spinal cord injury (ASCI), especially in those receiving steroids acutely. Only three cases have been reported to date of AI occurring in ASCI after steroid treatment. The presenting symptoms can be non-specific (as in this patient) and easily confused with other common sequelae of ASCI such as orthostasis and diffuse weakness. The 250 µg cosyntropin simulation test may not the most sensitive test to diagnose AI in ASCI. CONCLUSION: The non-specific presentations and variability of diagnosis criteria make diagnosis more difficult. One microgram cosyntropin simulation test may be more sensitive than higher dose. Clinicians should be aware that AI can be a potential life-threatening complication of ASCI post-steroid treatment. Prompt diagnosis and treatment can reverse symptoms and minimize mortality.

Effect of a cooling vest on core temperature in athletes with and without spinal cord injury.

BACKGROUND: It is well accepted that persons with spinal cord injury (SCI) have impaired ability to regulate core temperature due to impaired vasomotor and sudomotor activity below their level of injury. Impaired heat dissipation puts SCI athletes at great risk of exercise-induced hyperthermia (EIH) (>37.8°C). There is minimal evidence for efficacy of any specific cooling method in SCI athletes in a thermoneutral sport-specific setting. OBJECTIVE: To evaluate the extent of EIH in persons with and without SCI and subsequently examine the effect of a cooling vest to attenuate rise in core body temperature (Tc). METHODS: SCI (n = 17) and able-bodied (AB; n = 19) athletes participated in a 60-minute intermittent sprinting exercise in a thermoneutral (21.1°C-23.9°C) environment. Participants were separated according to their level of injury: tetraplegia defined as above T1 (TP; n = 6), high paraplegia defined as T5 through T1 (HP; n = 5), low paraplegia defined as T6 and below (LP; n = 6), and AB (n = 19). Tc was recorded at 15-minute intervals using an ingestible thermometer pill. This protocol was completed with a cooling vest (V) and without a cooling vest (NV). RESULTS: All SCI and most AB athletes experienced EIH. After 60 minutes, Tc of TP athletes was significantly increased compared to HP (P = .03) and AB athletes (P = .007). There was no significant effect of the vest on Tc over time for any group. CONCLUSIONS: TP athletes have the highest risk of exercise-induced hyperthermia. The cooling vest does not significantly attenuate rise in Tc in SCI or AB athletes.

Mechanistic involvement of noradrenergic neuronal neurotransmitter release in cutaneous vasoconstriction during autonomic dysreflexia in persons with spinal cord injury.

INTRODUCTION: Autonomic dysreflexia (AD) is a potentially life-threatening consequence in high (above T6) spinal cord injury that involves multiple incompletely understood mechanisms. While peripheral arteriolar vasoconstriction, which controls systemic vascular resistance, is documented to be pronounced during AD, the pathophysiological neurovascular junction mechanisms of this vasoconstriction are undefined. One hypothesized mechanism is increased neuronal release of norepinephrine and co-transmitters. We tested this by examining the effects of blockade of pre-synaptic neural release of norepinephrine and co-transmitters on cutaneous vasoconstriction during AD, using a novel non-invasive technique; bretylium (BT) iontophoresis followed by skin blood flow measurements via laser doppler flowmetry (LDF). METHODS: Bretylium, a sympathetic neuronal blocking agent (blocks release of norepinephrine and co-transmitters) was applied iontophoretically to the skin of a sensate (arm) and insensate (leg) area in 8 males with motor complete tetraplegia. An nearby untreated site served as control (CON). Cutaneous vascular conductance (CVC) was measured (CVC = LDF/mean arterial pressure) at normotension before AD was elicited by bladder stimulation. The percent drop in CVC values from pre-AD vs. AD was compared among BT and CON sites in sensate and insensate areas. RESULTS: There was a significant effect of treatment but no significant effect of limb/sensation or interaction of limb x treatment on CVC. The percent drop in CVC between BT and CON treated sites was 25.7±1.75 vs. 39.4±0.87, respectively (P = 0.004). CONCLUSION: Bretylium attenuates, but does not fully abolish vasoconstriction during AD. This suggests release of norepinephrine and cotransmitters from cutaneous sympathetic nerves is involved in cutaneous vasoconstriction during AD.

Interaction between a smartphone and intrathecal baclofen pump case report.

INTRODUCTION: Intrathecal Baclofen (ITB) is used for the treatment of spasticity. Pump complications are most commonly related to surgical implantation or catheter dysfunction. Less common complications include catheter access port dysfunction, motor failure from excessive wear on motor gear shafts, or a complete stall of the motor. CASE PRESENTATION: 37-year-old with T9 motor complete paraplegia with ITB presented in baclofen withdrawal. Workup revealed that the pump's motor was not turning, requiring pump replacement. Questioning revealed that he had not undergone any MRI studies within the past six months, but that he recently purchased a new iPhone. The phone was 2-3 inches away from the pump for up to twelve hours a day, carried in a fanny pack around his waist. DISCUSSION: We present a case of motor pump failure from long term exposure to a magnetic field from a new iPhone. The ability of iPhones to overpower an ITB pump magnet is not widely known. In 2021, the Food and Drug Administration published a report regarding the effects of magnets in consumer electronics on implanted medical devices, recommending that such electronics should be kept at least 6 inches from the device. Providers should be aware of the ability of new models of commonly used electronic devices to stall the ITB motor to avoid life-threatening complications of baclofen withdrawal.

Elucidating mechanisms of attenuated skin vasodilation during passive heat stress in persons with spinal cord injury.

OBJECTIVE: Persons with spinal cord injury (SCI) are unable to efficiently dissipate heat via thermoregulatory vasodilation as efficiently as able-bodied persons during whole body passive heat stress (PHS). Skin blood flow (SkBF) is controlled by dual sympathetic vasomotor systems: noradrenergic vasoconstrictor (VC) nerves and cholinergic vasodilator (VD) nerves. Thus, impaired vasodilation could result from inappropriate increases in noradrenergic VC tone that compete with cholinergic vasodilation or diminished cholinergic tone. To address this issue, we used bretylium (BR) which selectively blocks neural release of norepinephrine, thereby reducing noradrenergic VC tone. If impaired vasodilation during PHS is due to inappropriate increase in VC tone, BR treatment will improve SkBF responses during PHS. DESIGN: Prospective interventional trial. SETTING: laboratory. PARTICIPANTS: 22 veterans with SCI. INTERVENTIONS: Skin surface areas with previously defined intact vs. impaired thermoregulatory vasodilation were treated with BR iontophoresis with a nearby untreated site serving as control/CON. Participants underwent PHS until core temperature rose 1°C. OUTCOME MEASURES: Laser doppler flowmeters measured SkBF over BR and CON sites in areas with impaired and intact thermoregulatory vasodilation. Cutaneous vascular conductance (CVC) was calculated for all sites. Peak-PHS CVC was normalized to baseline (BL): (CVC peak-PHS/CVC BL) to quantify SkBF change. RESULTS: CVC rise in BR sites was significantly less than CON sites in areas with intact (P = 0.03) and impaired (P = 0.04) thermoregulatory vasodilation. CONCLUSION: Cutaneous blockade of neural release of noradrenergic neurotransmitters affecting vasoconstriction did not enhance thermoregulatory vasodilation during PHS in persons with SCI; rather BR attenuated the response. Cutaneous blockade of neural release of noradrenergic neurotransmitters affecting vasoconstriction did not restore cutaneous active vasodilation during PHS in persons with SCI.

Impact of tetraplegia vs. paraplegia on venoarteriolar, myogenic and maximal cutaneous vasodilation responses of the microvasculature: Implications for cardiovascular disease.

Objective: Cardiovascular disease (CVD) is a leading cause of mortality in persons with SCI. While macrovascular remodeling and function after SCI is well documented, changes in the microvascular structure and function are comparably understudied, but importantly predict CVD risk. Specifically, the integrity of venoarteriolar (VAR), myogenic (MYO) and maximal vasodilation responses are largely unknown after SCI, especially in persons with tetraplegia (TP) at highest risk of CVD. This is the first to examine the differences in VAR (cuff inflation), MYO (limb dependency) and maximal vasodilation responses of the microvasculature between able bodied (AB) versus those with TP and paraplegia (PP).Design: Observational.Setting: Laboratory.Participants: Eight AB, 6 TP, and 8 PP persons.Interventions: One forearm and calf were treated topically with lidocaine 2.5%/prilocaine 2.5% while contralateral limb served as a control. Laser doppler flowmeters were applied over treated and control sites during limb dependency, cuff inflation and local skin heating (Tloc) up to 42°C.Outcome measures: Skin vascular resistance (SkVR) change with cuff inflation and limb dependency and maximal cutaneous vascular conductance (CVC) during local heating.Results: Change in SkVR was not significantly different between groups or extremity (upper vs. lower) during cuff inflation or limb dependency. However, CVC at Tloc 42°C was significantly different in the lower extremity (LE) of TP and PP (P = 0.007, 0.35) compared to AB.Conclusion: Increases in SkVR during cuff inflation (VAR) and limb dependency (VAR and MYO) are unaltered after SCI, however maximal vasodilation in the LE post-SCI is higher than AB persons.

Are Thermoregulatory Sweating and Active Vasodilation in Skin Controlled by Separate Nerves During Passive Heat Stress in Persons With Spinal Cord Injury?

Background: Sudomotor responses (SR) and active vasodilation (AVD) are the primary means of heat dissipation during passive heat stress (PHS). It is unknown if they are controlled by a single or separate set of nerves. Older qualitative studies suggest that persons with spinal cord injury (SCI) have discordant areas of sweating and vasodilation. Objectives: To test the hypothesis that neural control of SR and AVD is through separate nerves by measuring SR and vasodilation in persons with SCI to determine if these areas are concordant or discordant. Methods: Nine persons with tetraplegia, 13 with paraplegia, and nine able-bodied controls underwent PHS (core temperature rise 1°C) twice. Initially, the starch iodine test measured SR post-PHS in skin surface areas surrounding the level of injury. Subsequently, laser Doppler imagery scans measured vasodilation pre- and post-PHS in areas with and without SR. Percent change in red blood cell (RBC) flux was compared in areas with and without SR. Results: Persons with tetraplegia were anhidrotic on all areas; however, the same areas demonstrated minimal RBC flux change significantly less than equivalent able-bodied skin surface areas. In persons with paraplegia, areas of intact SR correlated with areas of RBC flux change quantitatively comparable to able-bodied persons. In anhidrotic areas, RBC flux change was significantly less than areas with SR and likely resulted from non-AVD mechanisms. Conclusion: In persons with SCI under PHS, areas with intact SR and AVD are concordant, suggesting these two aspects of thermoregulation are controlled by a single set of nerves.

Correlation of neurological level and sweating level of injury in persons with spinal cord injury.

Objective: Thermoregulatory dysfunction after spinal cord injury (SCI) impairs quality of life and predisposes persons to life-threatening sequela of heat-related illness (HRI) in conditions of high ambient temperature. SCI clinicians currently have no objective way to predict which persons are at greatest risk of HRI. Evaporative cooling via sweating is the body's most efficient mechanism of heat dissipation. The relationship between the neurological level of injury (NLOI) and the degree of sudomotor dysfunction is not well defined. This study examines the relationship between the NLOI and sweating level of injury (SwLOI). This information can assist SCI clinicians in identifying individuals with SCI who have most impaired sudomotor function and thus highest risk of HRI.Design: Observational.Setting: Human physiology laboratory.Participants: 10 persons with tetraplegia (TP), 14 with paraplegia (PP) and 10 able-bodied (AB).Intervention: Passive heat stress (1°C rise in core temperature) with sweat responses (SR) quantified with the starch iodine test.Outcome measures: The most caudal dermatomal level in which sweating was visualized was recorded as the SwLOI, which was compared to the NLOI. Minimum, maximum and median differences between NLOI and SwLOI were calculated.Results: Persons with tetraplegia demonstrated no SR. Persons with paraplegia demonstrated SR at a median of 1 level below NLOI. Able-bodied controls demonstrated sweating on all skin surface areas.Conclusions: Persons with motor complete tetraplegia lack evaporative cooling capacity through SR during passive heat stress predisposing them to HRI. Meanwhile, persons with paraplegia sweat on average 1 dermatomal level below their NLOI.

The treatment of neurogenic lower urinary tract dysfunction in persons with spinal cord injury: An open label, pilot study of anticholinergic agent vs. mirabegron to evaluate cognitive impact and efficacy.

STUDY DESIGN: Pre-post intervention. OBJECTIVES: 1. To test whether replacement of oral anticholinergic (AC) agents with mirabegron for neurogenic lower urinary tract dysfunction (NLUTD) yields improved cognitive function in older persons with spinal cord injury (SCI). 2. To test whether mirabegron is safe and as efficacious as AC. SETTING: USA. METHODS: Pilot study: Twenty older (>60 y/o) persons with SCI taking chronic (>6 months) AC medication for NLUTD were enrolled. All participants were first studied on AC at baseline then switched to mirabegron for 6 months. Primary outcomes were cognitive tests of (1) executive function (TEXAS, SDMT); (2) attention (SCWT); and (3) memory (SLUMS and WMS-IV Story A/B). Secondary outcomes assessed efficacy and safety including Neurogenic Bladder Symptom Score (NBSS), bladder diary, neurogenic bowel dysfunction (NBD) survey, heart rate (HR), electrocardiogram (EKG), and mean arterial pressure (MAP). RESULTS: When switching from AC to mirabegron for NLUTD, older persons with SCI exhibited statistically significant improvements in immediate Story A recall (p = 0.01), delayed story A and B recall (p = 0.01, 0.004), and in TEXAS (p = 0.04). Three subscores within NBSS significantly improved (p = 0.001) and the frequency of incontinence decreased (p = 0.03) on mirabegron. NBD, HR, MAP, and EKGs were unchanged. CONCLUSIONS: Older persons with SCI on AC for NLUTD demonstrated improved short-term and delayed memory (WMS-IV Story A/B) as well as executive function (TEXAS) when switched to mirabegron. Efficacy of mirabegron for NLUTD symptoms was superior to AC with no adverse effects on bowel or cardiovascular function. SPONSORSHIP: Claude D. Pepper Older Americans Independence Center.

Efficacy of Various Cooling Techniques During Exercise in Persons With Spinal Cord Injury: A Pilot Crossover Intervention Study.

Background: Decentralization of the sympathetic nervous system in persons with spinal cord injury (SCI) results in impaired vasomotor and sudomotor activity and, subsequently, impaired thermoregulatory capacity during exercise in the heat. Hyperthermia can be life-threatening and, as such, cooling interventions are needed to prevent this sequela. Objectives: To measure change in core temperature (ΔTC) over time during exercise in normothermic and high ambient heat conditions to compare thermoregulatory capacity in persons with varying degrees of intact vasomotor and sudomotor activity and to determine the efficacy of three cooling interventions in mitigating TC rise. Methods: Three persons participated: a 51-year-old with complete (AIS A) tetraplegia (TP), a 32-year-old with AIS A paraplegia (PP), and a 40-year-old without SCI (AB). Each exercised for 30 minutes on a wheelchair treadmill propelled at 30 revolutions per minute under five different conditions: (1) cool (C) = 75°F without cooling, (2) hot (H) = 90°F without cooling, (3) 90°F with cooling vest (CV), (4) 90°F with water spray (WS), and (5) 90°F with ice slurry ingestion (IS). ΔTC was compared for all conditions in all participants. Results: ΔTC in the C and H conditions was proportional to the neurological level of injury, with Tc rising highest in the TP followed by the PP then AB. WS was most efficacious at mitigating rise in TC followed by IS and CV in TP and PP. None of the cooling interventions provided an added TC cooling effect in AB. Conclusion: WS was most efficacious at mitigating rise in TC in TP>PP during exercise in the heat and should be studied in a larger SCI population.

Efficacy of water spray for evaporative cooling in athletes with spinal cord injury.

Study design: Interventional crossover study. Objective: Spinal cord injury (SCI) disrupts afferent input to the hypothalamus and impairs efferent vaso- and sudomotor output, especially in lesions above the sympathetic chain (T1-L2). In consequence, persons with SCI under heat stress experience impairment in the ability to dissipate heat proportional to the lesion level. Thermoregulatory dysfunction places an individual at high risk of hyperthermia, which can be life threatening, especially for athletes with SCI during exercise. Current evidence on therapeutic cooling techniques in athletes with SCI is limited, but basic physiologic and research data suggest water spray (WS) might be efficacious, particularly in athletes with tetraplegia (TP), who are most impaired in thermoregulation. The aim of this study was to evaluate the effect of WS on core temperature (Tc) during exercise in athletes with SCI. Setting: Texas, USA. Methods: Eleven individuals with SCI: seven with TP, four with paraplegia (PP); and sixteen able-bodied (AB) controls underwent a wheelchair intermittent sprint exercise for 90 min under two conditions: (1) WS application every 15 min and (2) control (C), without WS. Tc was measured every 15 min and was analyzed for the effect of group (TP, PP, and AB) and time. Change in Tc (ΔTc) was also compared between groups. Results: ΔTc was significantly higher in TP vs. PP (p < 0.0001) and TP vs. AB (p < 0.0001) groups under C treatment. WS significantly attenuated ΔTc in TP (p = 0.001), but did not change ΔTc in PP or AB. Conclusion: WS effectively attenuated Tc elevation during exercise in athletes with TP. Sponsorship: Texas chapter of the Paralyzed Veterans of America.

Impact of passive heat stress on persons with spinal cord injury: Implications for Olympic spectators.

Environmental heat stress can negatively impact health, work capacity, and athletic performance and potentially to lead to life-threatening consequences if not mitigated. With the upcoming Toyko Olympic games to be held during anticipated warm ambient temperatures (up to 29°C), and with spectators potentially spending long durations of time outdoors, certain populations of persons with impaired thermoregulatory capacity will be at higher risk of heat-related illness from passive heat stress. Persons with spinal cord injury (SCI) are one of these groups as a result of a decentralized sympathetic nervous system, which leaves them with impairment in convective and evaporative cooling via vasodilation and sweating, respectively. This review summarizes (1) thermoregulatory physiological responses of persons with SCI under passive heat stress: the effect of level and completeness of injury; (2) the impact of passive heat stress on quality of life (QOL), outdoor participation, behavioral thermoregulation, and cognition; (3) recommendations and education for clinicians providing health care for persons with SCI; and (4) suggestions of future directions for exploring the gaps in the literature on passive heat stress in persons with SCI. This article aims to equip consumers with SCI and health-care professionals with the most up-to-date knowledge on passive heat stress responses in persons with SCI, so that their attendance at the Olympic games can be done with maximal safety and enjoyment.

Thermoregulation following spinal cord injury.

Spinal cord injury results in physiologic adaptations affecting heat production (reduced muscle mass) and heat dissipation (blood redistribution and reduced sweating capacity below the level of lesion). However, it is the balance between these factors which determines whether heat balance is achieved. Core temperature estimates are generally consistent with those for the able-bodied, with cooler values reported in some instances. More notable differences are demonstrated through cooler lower-body skin temperatures at rest and a loss of anticipatory control during exposure to heat and cold when compared to the able-bodied. During exercise in cool conditions persons with paraplegia demonstrate similar body temperature responses as for the able-bodied but retain heat during recovery. Persons with tetraplegia demonstrate continual increases in core temperature and thus thermal imbalance along with greater heat retention. During exercise in the heat, athletes with paraplegia appear to be able to regulate body temperature to a similar extent as the able-bodied. Those with tetraplegia again show thermal imbalance but to a much greater extent than in the cold. Future work should focus upon specific sweating responses and adaptations following spinal cord injury, the effects of completeness of lesion, perceptual responses to environmental challenges, and how these translate to undertaking activities of daily living.

Effect of Wheelchair Stroke Pattern on Upper Extremity Muscle Fatigue.

BACKGROUND: Shoulder dysfunction is common in persons with spinal cord injury (SCI) with an incidence of up to 63%. Dysfunction is a result of muscle imbalances, specifically denervated rotator cuff muscles that are repetitively used during manual wheelchair propulsion. OBJECTIVE: To determine which arm stroke technique, pump (P) or semicircular (SC), is most energy efficient for long periods of propulsion. DESIGN: A randomized study with repeated measures observations. SETTING: The study was performed at an institutional gait analysis laboratory. PARTICIPANTS: 18 able-bodied (AB) male participants were studied and randomized into one of 2 conditions, SC or P. METHODS: Shoulder muscle fatigue was measured by changes in Borg CR10 Rate of Perceived Exertion (Borg RPE) and upper extremity strength via a handheld dynamometer. Participants were studied and assigned into one of 2 conditions of wheelchair arm propulsion patterns, SC or P group, and propelled on a wheelchair treadmill for 10 minutes. MAIN OUTCOME MEASURES: The primary outcomes included recordings of Borg RPE scale during continuous wheelchair propulsion and pre- and post-test dynamometer testing means for bilateral elbow and shoulder extension. Analysis of covariance, t-tests, and Kruskal-Wallis tests were used in analyzing data. RESULTS: Although not significant (P = .23), the Borg RPE scores for the SC condition were consistently higher than the scores for the P condition. In addition, the dynamometer pre- and post-test readings demonstrated a larger decrease for the SC condition participants than for the P condition participants, but were not statistically significant. CONCLUSIONS: These data demonstrate that the SC wheelchair propulsion pattern appears to be more fatiguing to shoulder muscles than the P propulsion pattern. However, more data would need to be collected to find a significant difference. LEVEL OF EVIDENCE: II.

Advanced Hip Osteoarthritis Causing Autonomic Dysreflexia and Severe Spasticity in a Patient With Spinal Cord Injury: A Case Report.

The life expectancy of persons with spinal cord injury (SCI) is increasing due to advances in medicine and technology. As a result, there is a higher incidence of age-associated illnesses in this population. Degenerative joint disease is a common age-associated illness that causes pain and thus, in persons with SCI above the T6 level, can serve as a noxious stimulus to trigger autonomic dysreflexia (AD). This is a case report of severe bilateral hip osteoarthritis (OA) causing unyielding AD in a person with tetraplegia leading to bilateral girdle stone surgeries. Hip OA as an etiology for AD has not previously been reported and is important to recognize as this population continues to age and to develop age-associated diseases. LEVEL OF EVIDENCE: V.

Thermodysregulation in persons with spinal cord injury: case series on use of the autonomic standards.

INTRODUCTION: The ability to maintain core body temperature (Tcore) within a narrow range (37 ± 0.6 °C), despite exposure to a wide range of ambient temperatures, is essential in order to provide an optimal environment for vital organs, the central nervous system (CNS), and cellular processes to function. High-level (above T6) spinal cord injury (SCI) interrupts the autonomic nervous system's ability to carry out hypothalamic regulation of thermoregulatory mechanisms for both heat dissipation and conservation. This interruption leaves persons with high-level SCI vulnerable to hyper and hypothermia even during exposure to relatively mild ambient temperatures. The goal of the Autonomic Standards is to enable the clinician to quickly identify those individuals with SCI who may be most at risk for thermoregulatory dysfunction. CASE PRESENTATION: Case 1: Heat Exhaustion, Case 2: Heat Stroke in absence of CNS symptoms, Case 3: Heat Exhaustion. DISCUSSION: The three cases demonstrate the signs and symptoms that may accompany hyperthermia in persons with SCI. The onset may be quite rapid and the condition persistent, despite ambient temperatures being much less intense than expected to be necessary to induce similar conditions in able-bodied (AB) persons. The responses of the persons in the case studies to the temperature regulation and autonomic control of sweating sections of the Autonomic Standards would identify them as being vulnerable and warrant providing appropriate exposure guidelines and precautions to them and their caregivers.

Does the CDC Definition of Fever Accurately Predict Inflammation and Infection in Persons With SCI?

Background: Pneumonia and septicemia have the greatest impact on reduced life expectancy in persons with spinal cord injury (SCI). Fever is often the first presenting symptom of infection or inflammation. Thermoregulatory dysfunction in persons with SCI may preclude a typical febrile response to infection or inflammation and thus delay diagnostic workup. Objective: To determine the core temperature of persons with SCI in the setting of infection or inflammation and the frequency with which it meets criteria for the CDC definition of fever (>100.4°F). Methods: Retrospective review of hospitalized SCI patients over 5 years with a diagnosis of infection or inflammation (DI), defined by serum leukocytosis. In this study, 458 persons with paraplegia (PP) and 483 persons with tetraplegia (TP) had 4,191 DI episodes. Aural temperatures (Tau) on the day of DI, 7 days prior, and 14 days afterwards were abstracted from medical records. Main outcome measures were average Tau at DI, frequency of temperatures >100.4°F at DI, and average baseline temperatures before and after DI. Results: Average Tau at DI was 98.2°F (±1.5) and 98.2°F (±1.4) in the TP and PP groups, respectively, with only 11.6% to 14% of DI resulting in Tau >100.4°F. Baseline temperatures ranged from 97.9°F (±0.7) to 98.0°F (±0.8). Conclusion: SCI persons with leukocytosis infrequently mount a fever as defined by the CDC, and baseline temperatures were subnormal (<98.6°F). Thermoregulatory dysfunction likely accounts for these findings. Tau >100.4°F is not a sensitive predictor of infection or inflammation in persons with SCI. Clinicians should be vigilant for alternative symptoms of infection and inflammation in these patients, so diagnostic workup is not delayed.