David R. Gater

Prevalence of obesity and high blood pressure in veterans with spinal cord injuries and disorders: a retrospective review.

Weaver FM, Collins EG, Kurichi J, Miskevics S, Smith B, Rajan S, Gater D: Prevalence of obesity and high blood pressure in veterans with spinal cord injuries and disorders: a retrospective review. Am J Phys Med Rehabil 2007;86:22–29. Objective:A frequent cause of mortality in spinal cord injuries and disorders (SCI&D) is cardiovascular disease (CVD). Obesity and high blood pressure (BP) are modifiable risk factors for CVD. Design:Retrospective review of clinical and administrative data for 7959 veterans with SCI&D. Data elements included height, weight, blood pressure, demographics, and level of injury. Analyses included descriptive statistics and generalized logistic regressions. Results:Twenty percent of veterans were obese according to their body mass index (BMI), and 33% were overweight; 22% had high BP (≥140/90 mm Hg). Because BMI underestimates obesity in SCI&D, adjusted BMIs for overweight (23–27 kg/m2) and obesity (28+ kg/m2) indicate that those overweight increased to 37%, and 31% were obese. Veterans ages 50–64 or who had paraplegia were more likely to be overweight and obese than others; being white or age 65+ was associated with a higher likelihood of being overweight. Veterans who were overweight or obese, black, older (age 50+), and paraplegic were more likely to have higher blood pressure. Conclusions:Obesity and high BP rates were lower for veterans with SCI&D than the general population. However, because BMI underestimates body adiposity in SCI&D, obesity is likely a much more prevalent problem in this population and warrants attention.

Effects of Resistance Training on Adiposity and Metabolism after Spinal Cord Injury

PURPOSE This pilot work was conducted to evaluate the effects of neuromuscular electrical stimulation resistance training (RT) of the paralyzed knee extensor muscle groups on skeletal muscle and intramuscular fat (IMF) cross-sectional areas, trunk visceral adipose tissue (VAT), carbohydrate, and lipid profiles in men with spinal cord injury. METHODS Nine individuals with motor complete spinal cord injury were randomly assigned to an RT + diet group (n = 5) or a diet group (n = 4). The RT + diet underwent 12 wk of progressive RT, twice weekly, to the knee extensor muscle groups using neuromuscular electrical stimulation and ankle weights. Weekly feedback was provided to both groups to maintain a standard diet. Magnetic resonance imaging and a whole-body dual-energy x-ray absorptiometric images were obtained before and 1 wk after interventions. Participants underwent a metabolic study after a 12-h overnight fast to measure fasting and postchallenge plasma glucose, insulin, and lipid profiles. RESULTS Skeletal muscle hypertrophy was detected in the whole thigh, knee extensors, and flexors in the RT + diet group compared with the diet group. VAT cross-sectional area, VAT/subcutaneous adipose tissue ratio at L5-S3, and percent IMF decreased significantly in the RT + diet group. Plasma insulin area under the curve decreased in the RT + diet group but not in the diet group. Fasting triglycerides and cholesterol/HDL decreased in the RT + diet group. CONCLUSIONS Twice-weekly evoked RT to the paralyzed lower extremities resulted in significant skeletal muscle hypertrophy that was associated with reduction in VAT, VAT/subcutaneous adipose tissue ratio, and percent IMF. Significant improvements in insulin profile and lipid metabolism were noted in the RT + diet when compared with diet alone.

Clinical Applications of Electrical Stimulation After Spinal Cord Injury

Abstract Summary: During the last one-half century, electrical stimulation has become dinically significant for improving health and restoring useful function afterspinal cord injury. Short-term stimulation can be provided by electrodes on the skin or percutaneous fine wires, but implanted systems are preferable for long-term use. Electrical stimulation of intact lower motor neurons can exercise paralyzed musdes and reverse wasting; improve strength, endurance, and cardiovascular fitness; and may reduce the progression of osteoporosis. Other potential therapeutic uses being investigated indude reduction of spasticity, prevention of deep vein thrombosis, and improvement of tissue health. Pacing of intact phrenic nerves in high tetraplegia can produce effective respiration without mechanical ventilation, allowing improved speech, increased mobility, and increased sense of well-being. lmprovement of cough has also been demonstrated. Stimulation of intact sacral ne.rves can produce effective micturition and reduce urinary tract infection; it can also improve bowel function and erection. lt is usually combined with posterior sacral rhizotomy to improve continence and bladder capacity, and the combination has been shown to reduce costs of care. Electroejaculation can now produce semen in most men with spinal cord injury. Significant achievements have also been made in restoring limb function . Useful hand grasp can be provided in CS and C6 tetraplegia, reducing dependence on adapted equipment and assistants. Standing, assistance with transfers, and walking for short distances can be provided to selected persons with paraplegia, improving their access to objects, places, and opportunities that are inaccessible from a wheelchair. This review summarizes the current state of therapeutic and neuroprosthetic applications of electrical stimulation afterspinal cord injury and identifies some future directions of research and dinical and commercial development.

Diabetes mellitus in individuals with spinal cord injury or disorder

Abstract Background/Objective: To examine diabetes prevalence, care, complications, and characteristics of veterans with a spinal cord injury or disorder (SCI/D). Methods: A national survey of veterans with an SCI/D was conducted using Behavioral Risk Factor Surveillance System (BRFSS) survey questions. Data were compared with national Centers for Disease Control and Prevention BRFSS data for veteran and nonveteran general populations. Results: Overall prevalence of diabetes in individuals with an SCI/D was 20% (3 times higher than in the general population). Veterans with an SCI/D and veterans, in general, had a higher prevalence of diabetes across all age groups; however, those with an SCI/D who were 45 to 59 years of age had a higher prevalence than other veterans. One fourth of the persons with an SCI/D and diabetes reported that diabetes affected their eyes or that they had retinopathy (25%), and 41 % had foot sores that took more than 4 weeks to heal. More veterans, both with (63%) and without an SCI/D (60%), took a class on how to manage their diabetes than the general population (50%). Veterans with an SCI/D and diabetes were more likely to report other chronic conditions and poorer quality of life than those without diabetes. Conclusions: Diabetes prevalence is greater among veterans with an SCI/D compared with the civilian population, but is similar to that of other veterans, although it may occur at a younger age in those with an SCI/D. Veterans with an SCI/D and diabetes reported more comorbidities, more slow-healing foot sores, and poorer quality of life than those without diabetes. Efforts to prevent diabetes and to provide early intervention in persons with SCI/D are needed.

Energy cost of physical activities in persons with spinal cord injury.

INTRODUCTION The objectives of this descriptive study were (a) to determine the energy expenditure of activities commonly performed by individuals with a spinal cord injury (SCI) and summarize this information and (b) to measure resting energy expenditure and establish the value of 1 MET for individuals with SCI. METHODS One-hundred seventy adults with SCI were partitioned by gender, anatomical level of SCI, and American Spinal Injury Association designations for motor function. Twenty-seven physical activities, 12 recreational/sport and 15 daily living, were performed, while energy expenditure was measured continuously via a COSMED K4b portable metabolic system. In addition, 66 adult males with SCI completed 30 min of supine resting energy testing in a quiet environment. RESULTS Results for the 27 measured activities are reported in kilocalories per minute (kcal·min(-1)) and VO2 (mL·min(-1) and mL·kg(-1)·min(-1)). One MET for a person with SCI should be adjusted using 2.7 mL·kg(-1)·min(-1). Using 2.7 mL·kg(-1)·min(-1), the MET range for persons in the motor incomplete SCI group was 1.17 (supported standing) to 6.22 (wheeling on grass), and 2.26 (billiards) to 16.25 (hand cycling) for activities of daily living and fitness/recreation, respectively. The MET range for activities of daily living for persons in the group with motor complete SCI was 1.27 (dusting) to 4.96 (wheeling on grass) and 1.47 (bait casting) to 7.74 (basketball game) for fitness/recreation. CONCLUSIONS The foundation for a compendium of energy expenditure for physical activities for persons with SCI has been created with the completion of this study. In the future, others will update and expand the content of this compendium as has been the case with the original compendium for the able-bodied.

Effects of spinal cord injury on body composition and metabolic profile – Part I

Abstract Several body composition and metabolic-associated disorders such as glucose intolerance, insulin resistance, and lipid abnormalities occur prematurely after spinal cord injury (SCI) and at a higher prevalence compared to able-bodied populations. Within a few weeks to months of the injury, there is a significant decrease in total lean mass, particularly lower extremity muscle mass and an accompanying increase in fat mass. The infiltration of fat in intramuscular and visceral sites is associated with abnormal metabolic profiles. The current review will summarize the major changes in body composition and metabolic profiles that can lead to comorbidities such as type 2 diabetes mellitus and cardiovascular diseases after SCI. It is crucial for healthcare specialists to be aware of the magnitude of these changes. Such awareness may lead to earlier recognition and treatment of metabolic abnormalities that may reduce the co-morbidities seen over the lifetime of persons living with SCI.

Central adiposity associations to carbohydrate and lipid metabolism in individuals with complete motor spinal cord injury.

Altered body composition has been suggested as a major factor for the high prevalence of impaired glucose tolerance, insulin resistance, and dyslipidemia in individuals with spinal cord injury (SCI). The contributions of visceral adipose tissue (VAT), trunk subcutaneous adipose tissue (SAT), and the VAT/SAT ratio to these metabolic derangements in SCI are poorly defined. Thirteen individuals with traumatic motor complete SCI underwent a metabolic study after overnight fasting to measure plasma glucose, insulin, and lipid concentrations. Fast spin echo magnetic resonance imaging was used to quantify the average cross-sectional area (CSA), volumes, and percentages of VAT and SAT across multiaxial slices. Dual-energy x-ray absorptiometry was performed to measure whole-body fat-free mass and fat mass. Visceral adipose tissue CSA was positively related to fasting plasma glucose (r = 0.77, P = .002) and to the ratio of cholesterol to high-density lipoproteins (HDL-C) (r = 0.71, P = .006). Visceral adipose tissue volume was related to total cholesterol (r = 0.57, P = .043) and to low-density lipoproteins (r = 0.59, P = .032). Trunk %SAT was negatively related to glucose concentration and area under the curve (both, r = -0.61, P = .026). Fasting plasma insulin was negatively related to the VAT CSA and VAT/SAT ratio (both, r = -0.57, P = .043). Partial correlations showed a negative association between trunk %SAT and glucose area under the curve (r = -0.61, P = .02) and a positive association with HDL-C (r = 0.64, P = .033). The findings suggest that an increase in VAT, SAT, and VAT/SAT is associated with the adverse metabolic profile commonly seen in individuals with SCI. Trunk %SAT is associated with a reduced risk of glucose intolerance and an increased HDL-C.

Relationship of spasticity to soft tissue body composition and the metabolic profile in persons with chronic motor complete spinal cord injury.

Abstract Background/Objective: To determine the effects of spasticity on anthropometrics, body composition (fat mass [FM] and fat-free mass [FFM]), and metabolic profile (energy expenditure, plasma glucose, insulin concentration, and lipid panel) in individuals with motor complete spinal cord injury (SCI). Methods: Ten individuals with chronic motor complete SCI (age, 33 ± 7 years; BMI, 24 ± 4 kg/m2; level of injury, C6—T11; American Spinal Injury Association A and B) underwent waist and abdominal circumferences to measure trunk adiposity. After the first visit, the participants were admitted to the general clinical research center for body composition (FFM and FM) assessment using dual energy x-ray absorptiometry. After overnight fasting, resting metabolic rate (RMR) and metabolic profile (plasma glucose, insulin, and lipid profile) were measured. Spasticity of the hip, knee, and ankle flexors and extensors was measured at 6 time points over 24 hours using the Modified Ashworth Scale. Results: Knee extensor spasticity was negatively correlated to abdominal circumferences (r = -0.66, P = 0.038). After accounting for leg or total FFM, spasticity was negatively related to abdominal circumference (r = -0.67, P = 0.03). Knee extensor spasticity was associated with greater total %FFM (r = 0.64; P = 0.048), lower %FM (r = -0.66; P = 0.03), and lower FM to FFM ratio. Increased FFM (kg) was associated with higher RMR (r = 0.89; P = 0.0001). Finally, spasticity may indirectly influence glucose homeostasis and lipid profile by maintaining FFM (r = -0.5 to -0.8, P < 0.001). Conclusion: Significant relationships were noted between spasticity and variables of body composition and metabolic profile in persons with chronic motor complete SCI, suggesting that spasticity may play a role in the defense against deterioration in these variables years after injury. The exact mechanism is yet to be determined.

Functional electrical stimulation therapies after spinal cord injury.

The use of electricity for therapeutic purposes dates back to 15 AD, when Scribonius Largus, a court physician to the Roman emperor Claudius began using electric shocks from the torpedo ray fish to treat gout pain and headaches [1]. Although the phenomenon of electricity had been used for centuries the actual word “electricity” was not in use until the 1600’s, when William Gilbert, an English physician, coined the new Latin word “electricus” meaning like amber. The Creek word amber refers to the property of attracting small objects after being rubbed [2]. In 1780, Luigi Galvani, an Italian physician and physicist showed that impulses from nerve cells pass to muscles by demonstrating the electrical stimulation of a frog’s leg muscles [3]. Italian physicist and nephew of Luigi Galvani, Giovanni Aldini, carried on the work of his uncle by demonstrating the ability to stimulate brain tissue by applying electrical stimulation to the heads of decapitated prisoners [4]. In 1874, physician Robert Bartholow, stimulated muscle contractions while working on the cancerous brain of a live woman [5]. Research into the uses of electricity continued through the 19th and 20th centuries allowing the development of numerous inventions i.e. galvanometer, micro-electrodes, cathode ray oscilloscope, pacemakers and defibrillators [6,7]. These and other advances

Relationship between regional bone density measurements and the time since injury in adults with spinal cord injuries

OBJECTIVES To determine the bone mineral density (BMD) of the legs, arms, and trunk region of a group of adults with spinal cord injury (SCI) and to determine the relationship between regional BMD values and the time since injury. DESIGN BMD measurements were determined by total-body, dual-energy x-ray absorptiometry scans and percentage values (percentage-matched BMD), based on manufacturer-supplied normative data for age, sex, body weight, and ethnic group. The relationship between percentage-matched BMD values and time since injury was determined by linear regression analyses. SETTING Research laboratories in a university setting. PARTICIPANTS Twenty-nine subjects (21 men, 8 women; mean age, 38.5 y) who had sustained an SCI a mean of 10.6 years earlier (range, 0.6-35.3 y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The relationship between percentage-matched BMD values and the time since injury. RESULTS There was a significant inverse relationship between percentage-matched BMD leg (r2 = -.76), arm (r2 = -.45), and trunk (r2 = -.38) values and the log of time since injury. CONCLUSION Despite the varying levels of SCI and other relevant BMD contributing factors, the regional percentage-matched BMD values were significantly inversely related to the log of time since injury.