Craig M. McDonald

Metabolic syndrome in adolescents with spinal cord dysfunction.

Abstract Objective: The purpose of this study was to determine the prevalence of components of the metabolic syndrome in adolescents with spinal cord injury (SCI) and spina bifida (SB), and their associations with obesity in subjects with and without SCI and SB. Methods: Fifty-four subjects (20 SCI and 34 SB) age 11 to 20 years with mobility impairments from lower extremity paraparesis were recruited from a hospital-based clinic. Sixty able-bodied subjects who were oversampled for obesity served as controls (CTRL). Subjects were categorized as obese if their percent trunk fat measured by dual x-ray absorptiometry (DXA) was>30.0> for males and>35 .0> for females. Ten SCI, 24 SB, and 19 CTRL subjects were classified as obese. Fasting serum samples were collected to determine serum glucose, insulin, and lipid concentrations. Metabolic syndrome was defined as having #x003D;3 of the following components: (a) obesity; (b) high-density lipoprotein (HDL) <45 mg/dl for males;<50 mg/dl for females; (c) triglycerides #x003D;100 mg/dl; (d) systolic or diastolic blood pressure95th percentile for age/ height/gender, and (e) insulin resistance determined by either fasting serum glucose 100-125 mg/dl; fasting insulin #x003D;20 μU /ml; or homeostasis model assessment of insulin resistance #x003D;4.0 . Results: Metabolic syndrome was identified in 32.4>of the SB group and 55> of the SCI group. Metabolic syndrome occurred at a significantly higher frequency in obese subjects (SB = 45 .8>, SCI = 100>, CTRL = 63.2>) than nonobese subjects (SB = 0>, SCI = 10>, CTRL = 2.4>). Conclusions: The prevalence of metabolic syndrome in adolescents with SB/ SCI is quite high, particularly in obese individuals. These findings have important implications due to the known risks of cardiovascular diseases and diabetes mellitus associated with metabolic syndrome in adults, particularly those with spinal cord dysfunction.

Effectiveness of an upper extremity exercise device integrated with computer gaming for aerobic training in adolescents with spinal cord dysfunction.

Abstract Background/Objective: To determine whether a new upper extremity exercise device integrated with a video game (GameCycle) requires sufficient metabolic demand and effort to induce an aerobic training effect and to explore the feasibility of using this system as an exercise modality in an exercise intervention. Design: Pre-post intervention. Setting: University-based research facility. Subject Population: A referred sample of 8 adolescent subjects with spina bifida (4 girls, 15.5 ± 0.6 years; 4 boys, 1 7.5 ± 0.9 years) was recruited to participate in the project. All subjects had some level of mobility impairment that did not allow them to participate in mainstream sports available to their nondisabled peers. Five subjects used a wheelchair full time, one used a wheelchair occasionally, but walked with forearm crutches, and 2 were fully ambulatory, but had impaired gait. Main Outcome Measures: Peak oxygen uptake, maximum work output, aerobic endurance, peak heart rate, rating of perceived exertion, and user satisfaction. Results: Six of the 8 subjects were able to reach a Vo2 of at least 50% of their Vo2 reserve while using the GameCycle. Seven of the 8 subjects reached a heart rate of at least 50% of their heart rate reserve. One subject did not reach either 50% of Vo2 reserve or 50% of heart rate reserve. Seven of the 8 subjects increased their maximum work capability after training with the GameCycle at least 3 times per week for 16 weeks. Conclusions: The data suggest that the GameCycle seems to be adequate as an exercise device to improve oxygen uptake and maximum work capability in adolescents with lower extremity disability caused by spinal cord dysfunction. The subjects in this study reported that the video game component was enjoyable and provided a motivation to exercise.

Body Mass Index and Body Composition Measures by Dual X-Ray Absorptiometry in Patients Aged 10 to 21 Years With Spinal Cord Injury

Abstract Background/Objective: To determine the body composition of adolescents with spinal cord injury (SCI) and to assess whether established cutoff values for obesity determined by body mass index (BMI) are valid for this population. Methods: Sixty patients, aged 10–21 years, with traumatic SCI (50 with paraplegia and 1 0 with tetraplegia) were compared with 60 gender–, age–, and BMI-matched controls (CTRL). Dual–energy x–ray absorptiometry was used to estimate regional and total bone mineral content, lean tissue mass, fat tissue mass, and body fat percentage. BMI was calculated from measured weight and stature (kg/m2) . Results: Total percent body fat was significantly higher in the paraplegia group (31.4%±1.2%; mean±SE) than in the tetraplegia and CTRL groups (25.7%±2.7% and 22.9%±1.1 %, respectively). This change in percent total body fat was associated with a reduction of lean tissue mass in the paraplegia (37.6±1.1 kg; mean±SE) and tetraplegia (32.8±2.5 kg) subjects as compared to the CTRL group (46.2±1.0 kg; P<0.001 ). Total fat mass was significantly greater in the paraplegia group (19.3±1.3 kg) than the CTRL and tetraplegia groups (14.9±1.2 kg and 11.7±3.0 kg, respectively). Regional measurements revealed thatthe greatest reduction of lean tissue mass in the SCI subjects occurred in the lower extremities, followed by the trunk. As a result of these changes in body composition, the optimal BMI for classifying obesity (trunk fat percen>0 in males and>35 in females) in subjects with SCI was 19 kg/m2 as compared to 25 kg/m2 in able–bodied subjects. Conclusions: Patients aged 10 to 21 years with SCI have significantly decreased lean tissue mass and bone mineral content, and increased fat mass. As a result, traditional BMI cutoff criteria significantly underestimate obesity in this population. New clinically applicable criteria to define obesity should be established for SCI children and adolescents with SCI.

Reliability of radiographic parameters in neuromuscular scoliosis.

Study Design. Retrospective review of radiographic data. Objectives. This study sought to define interoberserver and intraobserver variability to further delineate reliable means by which radiographs of patients with neuromuscular scoliosis can be examined. Summary of Background Data. Previous studies analyzed the use of Cobb angles in the measurement of idiopathic and congenital scoliosis, but no study until now describes a critical analysis of measurement in evaluating neuromuscular scoliosis. Methods. Forty-eight patients with neuromuscular scoliosis radiographs were reviewed. These were evaluated for Cobb angle, end vertebrae selection, Ferguson angle, apex of the curve, C7 balance, pelvic obliquity, Risser sign, status of the triradiate cartilage, kyphosis Cobb angle, endplate selection for kyphosis, and kyphotic index. Interclass and intraclass variability was examined with statistical analysis. Results. Cobb angle had an intraobserver variability was 5.7° and the interobserver variability was 14.8°. The intraobserver and interobserver variability for Ferguson angle was 6.8° and 20.6°, respectively. The kyphotic Cobb angle intraobserver variability was found to be 17.4°, and the interobserver variability was 24.01°. Conclusions. Neuromuscular scoliosis radiographs can be reliably analyzed with the use of Cobb angle. Other forms of analysis, such as Ferguson angle, are not as reliable. Pelvic obliquity should be measured from the horizontal, as other methods are not as reliable. Kyphosis is best evaluated with the use of the kyphotic Cobb angle. Finally, it is felt that a separate anteroposterior pelvis radiograph should be used to assess skeletal maturity, as scoliosis films often truncate the vital anatomy necessary to determine skeletal maturity.

Classification of the Gait Patterns of Boys With Duchenne Muscular Dystrophy and Their Relationship to Function

Corticosteroids have recently been shown to reduce expected loss of muscle strength in patients with Duchenne muscular dystrophy and extend the time they can walk. We evaluated 43 boys with the condition to determine whether taking corticosteroids is associated with differences in gait pattern, gross motor skills, energy efficiency, and timed motor performance. We used the gait deviation index to quantify the degree of gait pathology and a single measure of gait quality. There were minimal differences in gait pattern, gross motor skills, energy efficiency, or timed motor performance in boys who took corticosteroids compared with those who did not. Clustering by gait deviation index, however, revealed subtle differences between groups in gait patterns, gross motor skills, and energy efficiency. We conclude that, in boys with Duchenne muscular dystrophy, gait pattern deviations are related to function, which can provide further insight into the understanding of disease progression and treatment options to enhance function and maintain ambulation.

Behavioral Intervention, Exercise, and Nutrition Education to Improve Health and Fitness (BENEfit) in Adolescents With Mobility Impairment Due to Spinal Cord Dysfunction

Abstract Background/Objective: Determine the effects of a nutrition education and exercise intervention on the health and fitness of adolescents with mobility impairment due to spinal cord dysfunction from myelomeningocele and spinal cord injury. Subjects participated in a 16-week intervention consisting of a behavioral approach to lifestyle change, exercise, and nutrition education to improve fitness (BENEfit) program. Participants were given a schedule of aerobic and strengthening exercises and attended nutrition education and behavior modification sessions every other week along with their parent(s). Subjects: Twenty adolescents (aged 11–18 years, mean 15.4 ± 2.2 years) with spinal cord dysfunction. Methods: Subjects were tested immediately prior to starting and upon completion of the program. Aerobic fitness was measured using a ramp protocol with an arm ergometer. Heart rate and oxygen uptake were measured. Values at anaerobic threshold and maximum oxygen uptake were recorded. Peak isokinetic arm and shoulder strength were determined with a dynamometer. Body composition was estimated with dual–energy x–ray absorptiometry. Serum chemistry included measures of cholesterol, high–density lipoprotein, low-density lipoprotein, and triglycerides. Results: Fourteen individuals completed all testing sessions. There was no significant overall change in weight, body mass index, body mass index z–scores, or serum chemistry. Overall, there was a significant increase in whole body lean tissue without a concomitant increase in whole body fat. Fitness measures revealed a significant increase in maximum power output, work efficiency as measured by the amount of power output produced aerobically, and resting oxygen uptake. Strength measurements revealed a significant increase in shoulder extension strength and a trend towards increased shoulder flexion strength. There were no significant changes in high–density lipoprotein, low–density lipoprotein, total cholesterol, or triglycerides. Conclusions: The BENEfit program shows promise as a method for improving the health and fitness of adolescents with mobility impairments who are at high risk for obesity and obesity-related health conditions.

Depression in Adults Who Sustained Spinal Cord Injuries as Children or Adolescents

Abstract Study design: Interview survey. Objective: To assess depression in adults with pediatric–onset spinal cord injuries (SCI) and to determine demographic and injury–related factors, and outcomes associated with depression, and to determine which other outcomes are associated with depression. Methods: Subjects were adults with pediatric-onset SCI who sustained SCI at age =18 years and were interviewed at age =24 years. This is part of a longitudinal study for which there were 864 eligible participants; 353 (41%) were interviewed. Of these, 232 were assessed for depression. A telephone interview was conducted that included a structured questionnaire and standardized measures (Functional Independence Measure, Craig Handicap Assessment and Reporting Technique, Short-Form 12 measure of healthrelated quality of life, Satisfaction with Life Scale, and Patient Health Questionnaire–9 to screen for depression). Results: Twenty–seven percent reported depressive symptoms ranging from mild to severe, and 7% reported having suicidal thoughts within the last 2 weeks, and 3= reported symptoms consistent with probable major depressive disorder (MDD). Depression was not significantly associated with any demographic factors but it was associated with incomplete injury (P = 0.013). Depression was also associated with many participation outcomes, health–related quality of life, life satisfaction, and medical complications. Conclusions: Depression is a significant problem among adults with pediatric–onset SCI and is associated with poorer outcomes and lower quality of life. These findings should be addressed as clinicians prepare children and adolescents with SCI to transition to adulthood

Altered body composition affects resting energy expenditure and interpretation of body mass index in children with spinal cord injury.

Abstract Background: lndividuals with spinal cord injury (SCI) typically undergo changes in their body composition (reduction in lean body mass and an increase in fat mass) that can Iead to secondary complications associated with diminished physical activity and obesity. Methods: This study used dual energy X-ray absorptiometry (DXA) to estimate the totallean tissue mass (L TM), total body fat, and total bone mineral content (BMC) to assess the relationship between body mass index (BMI), body composition, and resting metabolic rate (RMR) in a group of children with SCI who were matched with able-bodied controls for age and sex. Body composition and RMR were measured in 18 boys and 9 girls (1 0-21 years of age) who had a SCI in the previous 1 to 3 years andin 27 age-and sex-matched controls. Results: Children with SCI had significantly lower mean LTM than control subjects (3 7.6 ± 9.6 kg and 46.7 ± 9.2 kg, respectively; P < 0.001) and higher percent body fat (26.4 ± 7.9% and 20.2 ± 8.5%, respectively; P < 0.02) as measured by DXA, despite their reduced BMI (1 8.9 ± 3.8 kg/m2 and 21.2 ± 2.9 kg/m2 , respectively; P < 0.01 ). Children with SCI had lower RMR than the controls subjects (1213 ± 334 kj/d and 1511 ± 257 kj/d, respectively), but there was no difference in RMR when adjusted for LTM. Conclusion: Children with SCI have lower RMRs that are associated with their reduced LTM. The reduction in LTM and RMR may predispose children with SCI to relative gains in body fat. BMI significantly underestimates body fat in children with SCI.

Development and pilot test of the shriners pediatric instrument for neuromuscular scoliosis (SPNS): A quality of life questionnaire for children with spinal cord injuries

Abstract Background/Objective: The purpose of this study is to report the results of rater agreement for the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory scores before and after training in the testing technique. Methods: Six raters performed sequential motor and sensory examinations on 5 adolescents with SCI according to the ISCSCI manual. After completion of the first examinations, all raters were provided with a half-day formal training session on testing techniques, after which the raters repeated the examinations. lntraclass correlation coefficients (ICCs) and 95% confidence intervals (Cis) were calculated to provide parameters for ICC interpretation: > 0.90 = high agreement; 0.75 to 0.90 = moderate agreement; < 0.75 = poor agreement. Results: After training, there was improvement in rater agreement of summed motor scores (MS) from ICC = 0.809 to 0.862 and discrimination scores from ICC = 0.786 to 0.892. There was moderate rater agreement for light touch scores (LTS) before and after training. After training, there was improvement in 95% Cis except for ICCs for LTS, but for all ICCs, the lower 95% Cl value remained less than 0.75. Conclusions: Training improved rater agreement on MS and discrimination, but 95% Cis remained unacceptably wide. The positive effect of training in motor and sensory testing techniques is supported by the study data. Unlike previous studies that have suggested the ISCSCI has acceptable reliability for clinical trials, the results of this study do not fully support the use of the ISCSCI for clinical trials without better standardization to establish a lower 95% Cl value of at least 0.75.

Impact of prophylactic thoracolumbosacral orthosis bracing on functional activities and activities of daily living in the pediatric spinal cord injury population.

Abstract Background/Objective: The purpose of this study is to assess the impact of a thoracolumbosacral orthosis (TLSO) on children with spinal cord injuries (SCI) in terms of functional independence and time requirements for performance of functional activities and to ascertain the childrens preference for TLSO use. Methods: Fourteen subjects with thoracic SCI, ages 6 to 14 years, were studied. All subjects had previously been prescribed and were using a TLSO to prevent the progression of scoliosis. Functional activities included in the Functional Independence Measure and 6 additional wheelchair and transfer skills were scored by level of assistance required. The timed motor test (TMT) included 6 activities involving dressing, transfers, and wheelchair propulsion. Subjects completed the activities of the functional activities scale (FAS) and TMT while wearing a TLSO and without a TLSO. Subjects were asked their preference for wearing or not wearing the TLSO during each of the activities. Results: For the TMT, subjects were slower with a TLSO when donning a shirt or pants, with even and uneven transfers and hallway propulsion (P < 0.05). The majority of subjects preferred not wearing the TLSO during the TMT activities. Lower functional activity scores were recorded while wearing a TLSO for upperextremity dressing (P < 0.05), lower-extremity dressing, bladder management, transferring to bed, and reaching for objects on the floor. Subjects preferred not wearing a TLSO for the following activities: lowerextremity dressing, bladder management, reaching for an object on the floor, and transfer from a supine to a sitting position. Conclusions: Wearing a TLSO adversely affected independence level and time requirements for selected functional activities. Subjects preferred not wearing a TLSO while performing the activities. Activities that required hip flexion, such as donning pants or transitioning from a supine to a sitting position were restricted by the TLSO. Future studies with larger sample sizes should explore the relationships between functioning with a TLSO as related to a patient’s age, level of injury, and TLSO design.