Actionable Nuggets for Spinal Cord Injury

3. Management of Cardiovascular Risk in Patients with SCI

Actionable Nuggets for SCI (2nd ed., 2013)

Manage cardiovascular risk among patients with SCI as you would a high-risk ambulatory patient.

The Problem:

A sedentary lifestyle and a high prevalence of CVD risk factors such as dyslipidemia, type 2 diabetes, hypertension and obesity, place individuals with SCI at high risk for cardiovascular disease (CVD). Physical inactivity and dietary inadequacies result in obesity and profound de-conditioning, leading to activity limitations.

Evidence-based Best Practice:

Aggressive treatment of dyslipidemia, obesity and diabetes are essential to prevent excess cardiovascular disease risk. People with chronic SCI should receive guideline-level pharmacological management of cholesterol for high risk patients. Diabetes should be treated as for the general 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)

Key reference:

   Myers, J. (2009). Cardiovascular disease after SCI: Prevalence, instigators, and risk clusters. Topics in Spinal Cord Injury Rehabilitation, 14(3): 1-14.

Additional references:

    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.
    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
    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.
    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.
    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.
    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 = Physiologie Appliquee, Nutrition et Metabolisme, 34(4): 640-7.
http://dx.doi.org/10.1139/h09-050
    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
    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.
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    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.
    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.
    Cragg, J.J., Stone, J.A., & Lrassioukov, 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.
    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.
    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
    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.
    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
    Frisbie, J.H. (2010). Anemia and hypoalbuminemia of chronic spinal cord injury: Prevalence and prognostic significance. Spinal Cord, 48(7): 566-569.
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    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.
    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.
    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.
    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
    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.
    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.
    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
    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
   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.
   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.
   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
    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.
    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
    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/10.1037/0090-5550.51.4.273
    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.
    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.
    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/10.1037/0090-5550.48.3.157
    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.
    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.
    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.
    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
    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
    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.
    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
    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.
    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.
    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.
    Rick Hansen Institute, & SCI Action Canada (2011). Physical activity guidelines for adults with spinal cord injury. McMaster University, Hamilton, Ontario, Canada.
    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
     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.
     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.
    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.
    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.
    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.
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    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.
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http://www.ncbi.nlm.nih.gov/pubmed/15011927
    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