Actionable Nuggets for SCI (2nd ed., 2013)
Cardiovascular disease (CVD) is the leading cause of death among people with SCI. As part of a pattern of premature aging, cardiovascular disease has an earlier onset with SCI. Symptoms of CVD are prevalent in 30-50% of the SCI population. Asymptomatic CVD (due to impaired sensation) may be prevalent in 60-70% of people with chronic SCI.
Screen for cardiovascular risk factors at least annually.
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, and 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. Results may be used to calculate the Framingham Risk Score, an estimate of the 10-year risk for developing CVD, although this 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|
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.
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.
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
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., 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.
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
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.
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.
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.
The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension. 2010 [cited 2010 April 28, 2010]. http://hypertension.ca/chep.
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
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.
D’Agostino, R.B., Sr., et al. (2008). General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation, 117(6): 743-53.
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
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.
Eichler, K., et al. (2007). Prediction of first coronary events with the Framingham score: a systematic review. American Heart Journal, 153(5): 722-31, 731 e1-8.
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.
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):711-6.
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.
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
Genest, J., et al. (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.
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.
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.
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.
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.
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
LaVela, S.L., Evans, C.T., Prohashka, 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.
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.
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
Myers, J. (2009). Cardiovascular disease after SCI: Prevalence, instigators, and risk clusters. Topics in Spinal Cord Injury Rehabilitation, 14(3): 1-14.
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.
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
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
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.
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.
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
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.
Stewart, B.G., et al. (2004). Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury. Muscle & Nerve, 30(1): 61-8.
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.
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.
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).
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.
Wahman, K., et al. (2010). Cardiovascular disease risk factors in persons with paraplegia: the Stockholm spinal cord injury study. Journal of Rehabilitation Medicine, 42(3): 272-8.
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.