Actionable Nuggets for SCI (3rd ed., 2016)
Manage cardiovascular risk among patients with SCI as you would a high-risk ambulatory patient.
Forced immobility due to paralysis can result in obesity and profound de-conditioning, placing people with SCI at high risk for cardiovascular disease (CVD). In addition, SCI predisposes individuals to dyslipidemia, type 2 diabetes and hypertension. Recent studies suggest that cognitive deficits may result from hypotension (lesions above T1) and arterial stiffness (lesions below T7). This may be due to altered sympathetic tone related to the level of lesion.
Evidence-based Best Practice:
Aggressive treatment of dyslipidemia, obesity and diabetes are essential to minimize risk for cardiovascular disease. People with chronic SCI should receive pharmacological, dietary and lifestyle management of hyperlipidemia, hypertension and Type II diabetes, as you would for high risk patients in the ambulatory population.
Obesity has been estimated at 50-75% in the SCI population, and significant nutritional inadequacies have been found. Body mass index (BMI) cut-off scores must be adjusted to account for altered body composition with SCI. A cut-off of 22 is recommended (vs. 25 for the general population). Measures of waist circumference, waist-hip ratio and neck circumference have been shown to be a reasonable substitute for BMI, given difficulties in obtaining accurate weight and height measurements among wheelchair users.
Evidence-based physical activity guidelines for the SCI population recommend >20 minutes of moderate to vigorous aerobic activity twice a week, and resisted strength training twice a week for all major muscle groups. Regular physical activity has been associated with improved physical fitness, lipid profiles, glucose homeostasis, and reduced pain and depression. Popular modes of exercise include arm ergometry, wheelchair propulsion, wheelchair sports, swimming, circuit resistance training and electrically stimulated cycling. Prior to participation in physical activity, patients should be made aware of the potential for overuse injuries (see Nugget #7: Management of Musculoskeletal Pain), autonomic dysreflexia, thermal dysregulation (see Nugget #4: Autonomic Dysreflexia)
Cragg, J. J., Stone, J. A., & Krassioukov, A. V. (2012). Management of Cardiovascular Disease Risk Factors in Individuals with Chronic Spinal Cord Injury: An Evidence-Based Review. Journal of Neurotrauma, 29(11), 1999–2012. http://doi.org/10.1089/neu.2012.2313
Additional References (chronological listing):
Phillips, A. A., & Krassioukov, A. V. (2015). Contemporary Cardiovascular Concerns after Spinal Cord Injury: Mechanisms, Maladaptations & Management. Journal of neurotrauma, 32(24), 1927-1942. 150512042022004. http://doi.org/10.1089/neu.2015.3903
Driussi, C., Ius, A., Bizzarini, E., Antonini-Canterin, F., d’Andrea, A., Bossone, E., & Vriz, O. (2014). Structural and functional left ventricular impairment in subjects with chronic spinal cord injury and no overt cardiovascular disease. The Journal of Spinal Cord Medicine, 37(1), 85–92. http://doi.org/10.1179/2045772313Y.0000000161
Flank, P., Fahlström, M., Boström, C., Lewis, J. E., Levi, R., & Wahman, K. (2014). Self-reported physical activity and risk markers for cardiovascular disease after spinal cord injury. Journal of Rehabilitation Medicine, 46(9), 886–90. http://doi.org/10.2340/16501977-1857
Kressler, J., Cowan, R. E., Bigford, G. E., & Nash, M. S. (2014). Reducing Cardiometabolic Disease in Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America, 25(3), 573–604. http://doi.org/10.1016/j.pmr.2014.04.006
Lieberman, J., Goff, D. J., Hammond, F., Schreiner, P., Norton, H. J., Dulin, M., & Steffen, L. (2014). Dietary intake and adherence to the 2010 Dietary Guidelines for Americans among individuals with chronic spinal cord injury: a pilot study. The Journal of Spinal Cord Medicine, 37(6), 751–757. http://doi.org/10.1179/2045772313Y.0000000180
Arbour-Nicitopoulos, K. P., Martin Ginis, K. a, Latimer-Cheung, a E., Bourne, C., Campbell, D., Cappe, S., & Smith, K. (2013). Development of an evidence-informed leisure time physical activity resource for adults with spinal cord injury: the SCI Get Fit Toolkit. Spinal Cord, 51(6), 491–500. http://doi.org/10.1038/sc.2013.7
Smith, B., Papathomas, A., Martin Ginis, K. A., & Latimer-Cheung, A. E. (2013). Understanding physical activity in spinal cord injury rehabilitation: translating and communicating research through stories. Disability and Rehabilitation, 35(24), 1–10. http://doi.org/10.3109/09638288.2013.805821
Fraser, C., Teasell, R.W., Mehta, S. (2012). Nutrition issues following spinal cord injury. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver
Galea, M. P. (2012). Spinal cord injury and physical activity: preservation of the body. Spinal Cord, 50(5), 344–351. http://doi.org/10.1038/sc.2011.149
Myers, J., Gopalan, R., Shahoumian, T., & Kiratli, J. (2012). Effects of customized risk reduction program on cardiovascular risk in males with spinal cord injury. Journal of Rehabilitation Research & Development, 49(9), 1355–1364. http://doi.org/10.1682/JRRD.2011.11.0215
Nash, M.S., Cowan, R.E., & Kressler, J. (2012). Evidence-based and heuristic approaches for customization of care in cardiometabolic syndrome after spinal cord injury. Journal of Spinal Cord Medicine, 35(5), 278-92.
Ravensbergen, H.J.C., Keenleyside, M.C., Lear, S.A., & Claydon, V.E. (2012). What is the best marker for obesity in individuals with spinal cord injury? Clinical Autonomic Research Conference, 22(5), 245.
Tanhoffer, R.A., Tanhoffer, A.I., Raymond, J., Hills, A.P., & Davis, G.M. (2012). Comparison of methods to assess energy expenditure and physical activity in people with spinal cord injury. Journal of Spinal Cord Medicine, 35(1), 35-45.
Warburton, D.E.R., Sproule, S., Krassioukov, A., & Eng, J.J. (2012). Cardiovascular health and exercise following spinal cord injury. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. (Eds.). Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver.
Wolfe, D.L., Martin Ginis, K.A., Latimer, A.E., Foulon, B.L., Eng, J.J., Hicks, A.L., & Hsieh, J.T.C. (2012). Physical activity and SCI. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver.
Brurok, B., Helgerud, J., Karisen, T., Leivseth, G., & Hoff, J. (2011). Effect of aerobic high-intensity hybrid training on stroke volume and peak oxygen consumption in men with spinal cord injury. American Journal of Physical Medicine & Rehabilitation, 90(5), 407-414.
Chen, Y, Cao, Y., Allen, V., & Richards, J.S. (2011). Weight matters: Physical and psychosocial well being of persons with spinal cord injury in relation to body mass index. Archives of Physical Medicine & Rehabilitation, 92(3), 391-8.
Hicks, A.L., Martin Ginis, K.A., Pelletier, C.A., Ditor, D.S., Foulon, B., & Wolfe, D.L. (2011). The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: A systematic review. Spinal Cord, 49(11), 1103-1127.
Phillips, A.A., Cote, A.T., & Warburton, D.E.R. (2011). A systematic review of exercise as a therapeutic intervention to improve arterial function in persons living with spinal cord injury. Spinal Cord, 49(6), 702-714.
Rick Hansen Institute, & SCI Action Canada. (2011). Physical activity guidelines for adults with spinal cord injury. McMaster University, Hamilton, Ontario, Canada.
Stenson, K.W., Deutsch, A., Heinemann, A.W., & Chen, D. (2011). Obesity and inpatient rehabilitation outcomes for patients with traumatic spinal cord injury. Archives of Physical Medicine & Rehabilitation, 92(3), 384-90.
Taylor, J.A., Picard, G., & Widrick, J.J. (2011). Aerobic capacity with hybrid FES rowing in spinal cord injury: Comparison with arms-only exercise and preliminary findings with regular training. Physical Medicine and Rehabilitation, 3(9), 817-824.
Turiel, M., Sitia, S., Cicala, S., Magagnin, V., Bo, I., Porta, A., Caini, E., et al. (2011). Robotic treadmill training improves cardiovascular function in spinal cord injury patients. International Journal of Cardiology, 149(3), 323-329.
Wahman, K., Nash, M.S., Lewis, J.E., Seiger, A., & Levi, R. (2011). Cardiovascular disease risk and the need for prevention after paraplegia determined by conventional multifactorial risk models: The Stockholm spinal cord injury study. Rehabilitation Medicine, 43(3), 237-242.
Anneken, V., Hanssen-Doose, A., Hirschfeld, S., Scheuer, T., & Thietje, R. (2010). Influence of physical exercise on quality of life in individuals with spinal cord injury. Spinal Cord, 48(5), 393-399.
Ashe, M.C., Eng., J.J., Krassioukov, A.V., Warburton, D.E.R., Hung, C., & Tawashy, A. (2010). Response to functional electrical stimulation cycling in women with spinal cord injuries using dual-energy X-ray absorptiometry and peripheral quantitative computed tomography: A case series. Journal of Spinal Cord Medicine, 33(1), 68-72.
Frisbie, J.H. (2010). Anemia and hypoalbuminemia of chronic spinal cord injury: Prevalence and prognostic significance. Spinal Cord, 48(7), 566-569.
Hacker, C., Pandya, S., Sepahpanah, F., & Zaman, A.Y. (2010). Prevalence of diabetes mellitus in chronic spinal cord injury patients. PM and R conference: 71st Annual Assembly of the American Academy of Physical Medicine and Rehabilitation Seattle, WA.
Kahn, N.N., Feldman, S.P., & Beauman, W.A. (2010). Lower-extremity functional electrical stimulation decreases platelet aggregation and blood coagulation in persons with chronic spinal cord injury: A pilot study. Journal of Spinal Cord Medicine, 33(2), 150-158.
Kern, H., Carraro, U., Adami, N., Hofer, C., Loefler, S., Vogelauer, M., Mayr., W., et al. (2010). One year of home-based daily FES in complete lower motor neuron paraplegia: Recovery of tetanic contractility drives the structural improvements of denervated muscle. Neurology Research, 32(1), 5-12.
Martin Ginis, K.A., et al. (2010). Physical activity and subjective well-being among people with spinal cord injury: a meta-analysis. Spinal Cord, 48(1), 65-72. http://dx.doi.org/10.1038/sc.2009.87
Martin Ginis, K.A., Arbour-Nicitopoulos, K.P., Latimer, A.E., Buchholz, A.C., Bray, S.R., Craven, B.C., Hayes, K.C. et al. (2010). Leisure time physical activity in population-based sample of people with spinal cord injury part I: Demographic and injury-related correlates. Archives of Physical Medicine & Rehabilitation, 91(5), 722-728.
Martin Ginis, K.A., Arbour-Nicitopoulos, K.P., Latimer, A.E., Buchholz, A.C., Bray, S.R., Craven, B.C., Hayes, K.C. et al. (2010). Leisure time physical activity in population-based sample of people with spinal cord injury part II: Activity types, intensities, and durations. Archives of Physical Medicine & Rehabilitation, 91(5), 729-733.
Oleson, C.V., Patel, P.H., & Wuermser, L.A. (2010). Influence of season, ethnicity, and chronicity on vitamin D deficiency in traumatic spinal cord injury. Journal of Spinal Cord Medicine, 33(3), 202-213.
Opperman, E.A., Buchholz, A.C., Darlington, G.A., Martin Ginis, K.A., & SHAPE-SCI Research Group. (2010). Dietary supplement use in the spinal cord injury population. Spinal Cord, 48(1), 60-4.
Warburton, D.E.R., Charlesworth, S., Ivey, A., Nettlefold, L., & Bredin, S.S.D. (2010). A systematic review of the evidence for Canada’s Physical Activity Guidelines for Adults. International Journal of Behavioral Nutrition and Physical Activity, 7, article 39.
Arbour-Nicitopoulos, K.P., Ginis, K.A., & Latimer, A.E. (2009). Planning, leisure-time physical activity, and coping self-efficacy in persons with spinal cord injury: a randomized controlled trial. Archives of Physical Medicine & Rehabilitation, 90(12), 2003-11. http://dx.doi.org/10.1016/j.apmr.2009.06.019
Buchholz, A.C., et al. (2009). Greater daily leisure time physical activity is associated with lower chronic disease risk in adults with spinal cord injury. Applied Physiology, Nutrition, & Metabolism, 34(4), 640-7. http://dx.doi.org/10.1139/h09-050
Carvalho de Abreau, D.C., Cliquet, A., Rondina, M., & Cendes, F. (2009). Electrical stimulation during gait promotes increase in muscle cross-sectional area in quadriplegics: A preliminary study. Clinical Orthopaedics and Related Research, 467(2), 553-557.
Dyson-Hudson, T.A., & Nash, M.S. (2009). Guideline-driven assessment of cardiovascular disease and related risks after spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 14(3), 32-45.
Feasal, S., & Groah, S.L. (2009). The impact of diet on cardiovascular disease risk in individuals with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 14(3), 58-68.
Glinsky, J., Harvey, L., van Es, P., Chee, S., & Gandevia, S.C. (2009). The addition of electrical stimulation to progressive resistance training does not enhance the wrist strength of people with tetraplegia: A randomized controlled trial. Clinical Rehabilitation, 23(8), 696-704.
Goldberg, R.B. (2009). Guideline-driven intervention on SCI-associated dyslipidemia, metabolic syndrome, and glucose intolerance using pharmacological agents. Topics in Spinal Cord Injury Rehabilitation, 14(3), 46-47.
Griffen, L., Decker, M.J., Hwang, J.Y., Wang, B., Kitchen, K., Ding, Z., & Ivy, J.L. (2009). Functional electric stimulation cycling improves body composition, metabolic and neural factors in persons with spinal cord injury. Journal of Electromyography and Kinesiology, 19(4), 614-622.
Groah, S.L., Nash, M.S., Ljungberg, I.H., Libin, A., Hamm, L.F., Ward, E., Burns, P.A., & Enfield, G. (2009). Nutrient intake and body habitus after spinal cord injury: An analysis by sex and level of injury. Journal of Spinal Cord Medicine, 32(1), 25-33.
Groah, S.L., Spungen, M.I., & Bauman, W.A. (2009). Cardiovascular disease in individuals with spinal cord injury: Toward best practice. Topics in Spinal Cord Injury Rehabilitation, 14(3), 84-98.
Hetz, S.P., Latimer, A.E., & Martin Ginis, K.A. (2009). Activities of daily living performed by individuals with SCI: Relationships with physical fitness and leisure time physical activity. Spinal Cord, 47(7), 550-554.
Jack, L.P., Allan, D.B., & Hunt, K.J. (2009). Cardiopulmonary exercise testing during body weight supported treadmill exercise in incomplete spinal cord injury: A feasibility study. Technology and Health Care, 17(1), 13-23.
Jacobs, P.L. (2009). Effects of resistance and endurance training in persons with paraplegia. Medicine and Science in Sports and Medicine, 41(5), 992-997.
Kehn, M., & Kroll, T. (2009). Staying physically active after spinal cord injury: A qualitative exploration of barriers and facilitators to exercise participation. BMC Public Health, 9(168). http://dx.doi.org/10.1186/1471-2458-9-168
Laughton, G.E., Buchholz, A.C., Martin Ginis, K.A., Goy, R.E., & SHAPE Research Group. (2009). Lowering body mass index cutoffs better identifies obese persons with spinal cord injury. Spinal Cord, 47(10), 757-62.
McMahon, D., Tutt, M., & Cook, A.M. (2009). Pharmacological management of hemodynamic complications following spinal cord injury. Orthopedics, 32(35), 331.
Millar, P.J., Rakobowchuk, M., Adams, M.M., Hicks, A.L., McCartney, N., & MacDonald, M.J. (2009). Effects of short-term training on heart rate dynamics in individuals with spinal cord injury. Autonomic Neuroscience: Basic and Clinical, 150(1-2), 116-121.
Myers, J. (2009). Cardiovascular disease after SCI: Prevalence, instigators, and risk clusters. Topics in Spinal Cord Injury Rehabilitation, 14(3), 1-14.
Soyupek, F., Savas, S., Ozturk, O., Ilgun, E., Bircan, A., & Akkaya, A. (2009). Effects of body weight supported treadmill training on cardiac and pulmonary functions in the patients with incomplete spinal cord injury. Journal of Back and Musculoskeletal Rehabilitation, 22(4), 213-218.
Tawashy, A.E., Eng, J.J., Lin, K.H., Tang, P.F., & Hung, C. (2009). Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: A correlational study. Spinal Cord, 47(4), 301-306.
Walters, J.L., Buchholz, A.C., Martin Ginis, K.A.; SHAPE-SCI Research Group (2009). Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord, 47(4), 318-22.
Liang, H., Tomey, K., Chen, D., Saver, N.L., Rimmer, J.H., Braunscheig, C.L. (2008). Objective measures of neighborhood environment and self-reported physical activity in spinal cord injured men. Archives of Physical Medicine & Rehabilitation, 89(8), 1468-73.
van den Berg-Emons, R.J., et al. (2008). A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge. Archives of Physical Medicine & Rehabilitation, 89(11), 2094 101.http://dx.doi.org/10.1016/j.apmr.2008.04.024
Carpenter, C., Forwell, S.J., Jongbloed, L.E., & Backman, C.L. (2007). Community participation after spinal cord injury. Archives of Physical Medicine & Rehabilitation, 88(4), 427-33.
Martin Ginis, K.A., Latimer, A.E., Buchholz, A.C., Bray, S.R., Craven, B.C., Hayes, K.C., Hicks, A.L., et al. (2007). Establishing evidence-based physical activity guidelines: Methods for the Study of Health and Activity in People with Spinal Cord Injury (SHAPE SCI). Spinal Cord, 46(3), 216-21.
Nash, M.S., van Elk, N., & Johnson, B.M. (2007). Effects of circuit resistance training on fitness attributes and upper-extremity pain in middle-aged men with paraplegia. Archives of Physical Medicine & Rehabilitation, 88(1), 70-75. http://dx.doi.org/10.1016/j.apmr.2006.10.003
Bloeman-Vrencken, J.H., de Witte, L.P., Post, M.W., & van den Heuvel, W.J. (2006). Health behavior of persons with spinal cord injury. Spinal Cord, 45(3), 243-9.
Carison, M.J., & Krahn, G. (2006). Use of complementary and alternative medicine practitioners by people with physical disabilities: Estimates from a National US survey. Disability and Rehabilitation, 28(8), 505-13.
Latimer, A.E., Ginis, K.A.M., & Arbour, K.P. (2006). The efficacy of an implementation intention intervention for promoting physical activity among individuals with spinal cord injury: A randomized controlled trial. Rehabilitation Psychology, 51(4), 273-280. http://dx.doi.org/10.1037/0090-5518.104.22.1683
El-Sayed, M.S., & Younesian, A. (2005). Lipid profiles are influenced by arm cranking exercise and training in individuals with spinal cord injury. Spinal Cord, 43(5), 299-305. http://dx.doi.org/10.1038/sj.sc.3101698
Johnston, M.V., Diab, M.E., Chu, B.C., & Kirshblum, S. (2005). Preventative services and health behaviors among people with spinal cord injury. Journal of Spinal Cord Medicine, 28(1), 43-54.
Nash, M.S. (2005). Exercise as a health-promoting activity following spinal cord injury. Journal of Neurologic Physical Therapy, 29(2), 87-103. http://dx.doi.org/10.1097/01.NPT.0000282514.94093.c6
Scelza, W.M., et al. (2005). Perceived barriers to exercise in people with spinal cord injury. American Journal of Physical Medicine & Rehabilitation, 84(8), 576-83. http://dx.doi.org/10.1097/01.phm.0000171172.96290.67
Jacobs, P.L., & Nash, M.S. (2004). Exercise recommendations for individuals with spinal cord injury. Sports Medicine, 34(11), 727-51. http://dx.doi.org/10.2165/00007256-200434110-00003
Warms, C.A., et al. (2004). Lifestyle Physical Activity for Individuals with Spinal Cord Injury: A Pilot Study. American Journal of Health Promotion, 18(4), 288-291. http://www.ncbi.nlm.nih.gov/pubmed/15011927
Buchholz, A.C., McGillivray, C.F., & Pencharz, P.B. (2003). Physical activity levels are low in free-living adults with chronic paraplegia. Obesity Research, 11(4), 563-70. http://dx.doi.org/10.1038/oby.2003.79
de Groot, P.C., et al. (2003). Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord, 41(12), 673-9. http://dx.doi.org/10.1038/sj.sc.3101534
Hicks, A.L., et al. (2003). Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord, 41(1), 34-43. http://dx.doi.org/10.1038/sj.sc.3101389
Martin Ginis, K.A., et al. (2003). Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. Rehabilitation Psychology, 48(3), 157-164. http://dx.doi.org/10.1037/0090-5522.214.171.124
Nash, M.S., et al. (2001). Circuit resistance training improves the atherogenic lipid profiles of persons with chronic paraplegia. Journal of Spinal Cord Medicine, 24(1), 2-9. http://www.ncbi.nlm.nih.gov/pubmed/11587430
Kinne, S., Patrick, D.L., & Maher, E.J. (1999). Correlates of exercise maintenance among people with mobility impairments. Disability & Rehabilitation, 21(1), 15-22. http://dx.doi.org/10.1080/096382899298052
Janssen, T.W., et al. (1994). Relationship between physical strain during standardised ADL tasks and physical capacity in men with spinal cord injuries. Paraplegia, 32(12), 844-59. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7708424