Actionable Nuggets for SCI (3rd ed., 2016)
Screen for cardiovascular risk factors at least annually.
The Problem:
Cardiovascular disease (CVD) is the leading cause of death among people with SCI. Symptoms of CVD are prevalent in 30-50% of the SCI population, and asymptomatic CVD (due to impaired sensation) may be prevalent in 60-70% of people with chronic SCI. Cardiovascular disease may be part of a pattern of premature aging, with an earlier onset in patients with SCI.
Evidence-based Best Practice:
A number of key risk factors for CVD are exacerbated by SCI, such as dyslipidemia, blood pressure irregularities, abnormal glycemic control, chronic inflammation, autonomic nervous system dysfunction, obesity, and physical inactivity. Aggressive screening and preventive management are required in order that under-diagnosis and conservative treatment do not add to the burden of disability.
Blood pressure should be measured at every encounter — at least annually. Plasma lipid and hemoglobin A1C profiles should be assessed annually in men after 40 years of age, and in women who are at least 50 years of age or postmenopausal. The Framingham Risk Score (an estimate of the 10-year risk for developing CVD) may underestimate CVD risk in the SCI population. The National Cholesterol Education Program’s Adult Treatment Protocol III is recommended as a more accurate classification of lipid levels for the SCI population.
| Desirable | Borderline high risk | High risk | Very high risk | |
| Total cholesterol | < 5.2 | 5.2 – 6.2 | > 6.2 | |
| Low-density lipoprotein (LDL) | < 3.3 | 3.4 – 4.1 | 4.1 – 4.9 | > 4.9 |
| High-density lipoprotein (HDL) | > 1.5 | 1.0 – 1.3 (men) 1.3 – 1.5 (women) | < 1.0 (men) < 1.3 (women) | |
| Triglycerides | < 1.7 | 1.7 – 2.2 | 2.3 – 5.6 | > 5.6 |
Key Reference:
West, C. R., Mills, P., & Krassioukov, A. V. (2012). Influence of the neurological level of spinal cord injury on cardiovascular outcomes in humans: a meta-analysis. Spinal Cord, 50(7), 484–492. http://doi.org/10.1038/sc.2012.17
Additional References (chronological listing):
Chung, W.-S., Lin, C.-L., Chang, S.-N., Chung, H.-A., Sung, F.-C., & Kao, C.-H. (2014). Increased Risk of Deep Vein Thrombosis and Pulmonary Thromboembolism in Patients with Spinal Cord Injury: A Nationwide Cohort Prospective Study. Thrombosis Research, 133(4), 6–11. http://doi.org/10.1016/j.thromres.2014.01.008
Cragg, J. J., Noonan, V. K., Krassioukov, A., & Borisoff, J. (2013). Cardiovascular disease and spinal cord injury: Results from a national population health survey. Neurology, 81(8), 723-728. http://doi.org/10.1212/WNL.0b013e3182a1aa68
Canadian Task Force on Preventative Health Care. (2012). Recommendations on screening for type 2 diabetes in adults. Canadian Medical Association Journal, 184(15),1687-96.
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
Hagen, E. M., Rekand, T., Grønning, M., & Færestrand, S. (2012). Cardiovascular complications of spinal cord injury. Tidsskr Nor Legeforen, 132(9), 1115–1120.
LaVela, S. L., Evans, C. T., Prohaska, T. R., Miskevics, S., Ganesh, S. P., & Weaver, F. M. (2012). Males aging with a spinal cord injury: prevalence of cardiovascular and metabolic conditions. Archives of Physical Medicine and Rehabilitation, 93(1), 90–5. http://doi.org/10.1016/j.apmr.2011.07.201
Ragnarsson, K.T. (2012). Medical rehabilitation of people with spinal cord injury during 40 years of academic practice. American Journal of Physical Medicine and Rehabilitation, 91(3), 231-42.
Groah, S.L., Nash, M.S., Ward, E.A., Libin, A., Mendez, A.J., Burns, P., Elrod, M., et al. (2011). Cardiometabolic risk in community-dwelling persons with chronic spinal cord injury. Journal of Cardiopulmonary Rehabilitation and Prevention, 31(2), 73-80.
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.
Hackam, D. G., Khan, N. A., Hemmelgarn, B. R., Rabkin, S. W., Touyz, R. M., Campbell, N. R., … & Quinn, R. R. (2010). The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2–therapy. Canadian Journal of Cardiology, 26(5), 249-258. http://hypertension.ca/chep.
Teasell, R.W., Hsieh, J.T., Aubut, J.A.L., Eng, J.J., Krassioukov, A., & Tu., L. (2010). Venous thromboembolism after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 90(92), 193-200.
Wahman, K., Nash, M. S., Westgren, N., Lewis, J. E., Seiger, Å., & Levi, R. (2010). Cardiovascular disease risk factors in persons with paraplegia: the Stockholm spinal cord injury study. Journal of Rehabilitation Medicine, 42(3), 272-8. http://dx.doi.org/10.2340/16501977-0510
Buchholz, A.C., Martin Ginis, K.A., Bray, S.R., Craven, B.C., Hicks, A.L., Hayes, K.C., Latimer, A.E. 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 and Metabolism, 34(4), 640-7.
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.
Genest, J., McPherson, R., Frohlich, J., Anderson, T., Campbell, N., Carpentier, A., … & Grover, S. (2009). Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult – 2009 recommendations. Canadian Journal of Cardiology, 25(10), 567-79.
http://www.pulsus.com/journals/abstract.jsp?sCurrPg=abstract&jnlKy=1&atlKy=9081&isuKy=877&isArt=t&fromfold=
Hetz, S.P., Latimer, A.E., Buchholz, A.C., & Martin Ginis, K.A.; SHAPE-SCI Research Group (2009). Increased participation in activities of daily living is associated with lower cholesterol levels in people with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 90(10), 1755-9.
Myers, J. (2009). Cardiovascular disease after SCI: Prevalence, instigators, and risk clusters. Topics in Spinal Cord Injury Rehabilitation, 14(3), 1-14.
Svircev, J.N. (2009). Cardiovascular disease in persons with spinal cord dysfunction-An update on select topics. Physical Medicine and Rehabilitation Clinics of North America, 20(4), 737-747.
Waddimba, A.C., Jain, N.B., Stolzmann, K. Gagnon, D.R., Burgess, J.F., Jr., Kazis, L.E., et al. (2009). Predictors of cardiopulmonary hospitalization in chronic spinal cord injury. Archives of Physical Medicine and Rehabilitation, 90(2), 193-200.
Canadian Diabetes Association. (2008). Clinical practice guidelines for the prevention and management of diabetes in Canada. Canadian Journal of Diabetes, 32(Suppl 1), S1-S201.
http://www.diabetes.ca/for-professionals/resources/2008-cpg/
D’Agostino, R. B., Vasan, R. S., Pencina, M. J., Wolf, P. A., Cobain, M., Massaro, J. M., & Kannel, W. B. (2008). General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation, 117(6), 743-53. http://dx.doi.org/10.1161/CIRCULATIONAHA.107.699579
Finnie, A.K., Buchholz, A., & Martin Ginis, K.A.; SHAPE-SCI Research Group. (2008). Current coronary heart disease risk assessment tools may underestimate risk in community-dwelling persons with chronic spinal cord injury. Spinal Cord, 46(9), 608-15.
Gibson, A.E., Bushholz, A.C., & Martin Ginis, K.A., SHAPE-SCI Research Group. (2008). C-Reactive protein in adults with chronic spinal cord injury: Increased chronic inflammation in tetraplegia vs paraplegia. Spinal Cord, 46(9), 616-21.
Eichler, K., Puhan, M. A., Steurer, J., & Bachmann, L. M. (2007). Prediction of first coronary events with the Framingham score: a systematic review. American Heart Journal, 153(5), 722-731. http://dx.doi.org/10.1016/j.ahj.2007.02.027
Nash, M.S., & Mendez, A.J. (2007). A guideline-driven assessment of need for cardiovascular disease risk intervention in persons with chronic paraplegia. Archives of Physical Medicine & Rehabilitation, 88(6), 751-7. http://dx.doi.org/10.1016/j.apmr.2007.02.031
Chen, Y., et al. (2006). Obesity intervention in persons with spinal cord injury. Spinal Cord, 44(2), 82-91. http://dx.doi.org/10.1038/sj.sc.3101818
LaVela, S.L., et al. (2006). Diabetes mellitus in individuals with spinal cord injury or disorder. Journal of Spinal Cord Medicine, 29(4), 387-395. http://www.ncbi.nlm.nih.gov/pubmed/17044389
Lee, C.S., et al. (2006). Evaluating the prevalence of silent coronary artery disease in asymptomatic patients with spinal cord injury. International Heart Journal, 47(3), 325-330.
http://dx.doi.org/10.1536/ihj.47.325
Shah, P.K., Stevens, J.E., Gregory, C.M., Pathare, N.C., Jayaraman, A., Bickel, S.C., Bowden, M., et al. (2006). Lower-extremity muscle cross-sectional area after incomplete spinal cord injury. Archives of Physical Medicine & Rehabilitation, 87(6), 772-8.
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
Garshick, E., et al. (2005). A prospective assessment of mortality in chronic spinal cord injury. Spinal Cord, 43(7), 408-16. http://dx.doi.org/10.1038/sj.sc.3101729
Elder, C.P., Apple, D.F., Bickel, C.S., Meyer, R.A., & Dudley, G.A. (2004). Intramuscular fat and glucose tolerance after spinal cord injury-a cross-sectional study. Spinal Cord, 42(12), 711-716.
Stewart, B.G., et al. (2004). Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury. Muscle & Nerve, 30(1), 61-68. http://dx.doi.org/10.1002/mus.20048
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
Ozgurtas, T., et al. (2003). Do spinal cord injuries adversely affect serum lipoprotein profiles? Military Medicine, 168(7), 545-7. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12901464
Spungen, A.M., et al. (2003). Factors influencing body composition in persons with spinal cord injury: a cross-sectional study. Journal of Applied Physiology, 95(6), 2398-407.
http://jap.physiology.org/cgi/content/abstract/95/6/2398
Jeon, J.Y., et al. (2002). Improved glucose tolerance and insulin sensitivity after electrical stimulation-assisted cycling in people with spinal cord injury. Spinal Cord, 40(3), 110-7.
http://dx.doi.org/10.1038/sj.sc.3101260
Mohr, T., et al. (2001). Insulin action and long-term electrically induced training in individuals with spinal cord injuries. Medicine and Science in Sports and Exercise, 33(8), 1247-52.
http://dx.doi.org/10.1097/00005768-200108000-00001
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
Szlachcic, Y., et al. (2001). The effect of dietary intervention on lipid profiles in individuals with spinal cord injury. Journal of Spinal Cord Medicine, 24(1), 26-29.
http://www.ncbi.nlm.nih.gov/pubmed/11587431
Ayas, N.T., Garshick, E., Lieberman, S.L., Wien, M.F., Tun, C., & Brown, R. (1999). Breathlessness in spinal cord injury depends on injury level. Journal of Spinal Cord Medicine, 22(2), 97-101.
Chilibeck, P.D., et al. (1999). Functional electrical stimulation exercise increases GLUT-1 and GLUT-4 in paralyzed skeletal muscle. Metabolism, 48(11), 1409-13.
http://dx.doi.org/10.1016/S0026-0495(99)90151-8
Bauman, W.A., et al. (1998). The effect of residual neurological deficit on serum lipoproteins in individuals with chronic spinal cord injury. Spinal Cord, 36(1), 13-7. http://dx.doi.org/10.1038/sj.sc.3100513
Solomonow, M., et al. (1997). Reciprocating gait orthosis powered with electrical muscle stimulation (RGO II). Part II: Medical evaluation of 70 paraplegic patients. Orthopedics, 20(5), 411-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9172248
Bauman, W.A., et al. (1994). Cardiac stress testing with thallium-201 imaging reveals silent ischemia in individuals with paraplegia. Archives of Physical Medicine & Rehabilitation, 75(9), 946-50. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8085927
Bauman, W.A., & Spungen, A.M. (1994). Disorders of carbohydrate and lipid metabolism in veterans with paraplegia or quadriplegia: a model of premature aging. Metabolism, 43(6), 749-56. http://dx.doi.org/10.1016/0026-0495(94)90126-0
Bauman, W.A., et al. (1993). Tomographic thallium-201 myocardial perfusion imaging after intravenous dipyridamole in asymptomatic subjects with quadriplegia. Archives of Physical Medicine & Rehabilitation, 74(7), 740-4. http://dx.doi.org/10.1016/0003-9993(93)90036-A
DeVivo, M.J., Black, K.J., & Stover, S.L. (1993). Causes of death during the first 12 years after spinal cord injury. Archives of Physical Medicine & Rehabilitation, 74(3), 248-54.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8439250
Actionable Nuggets for Spinal Cord Injury 