Predictors of Subclinical Atherosclerosis in Women With Spinal Cord Injury

Background:

Chronic spinal cord injury (SCI) is associated with an increase in risk factors for cardiovascular disease (CVD). In the general population, atherosclerosis in women occurs later than in men and usually presents differently. Associations between risk factors and incidence of CVD have not been studied in women with SCI.

Objective:

To determine which risk factors for CVD are associated with increased carotid intima-media thickness (CIMT), a common indicator of atherosclerosis, in women with SCI.

Methods:

One hundred and twenty-two females older than 18 years with traumatic SCI at least 2 years prior to entering the study were evaluated. Participants were asymptomatic and without evidence of CVD. Exclusion criteria were acute illness, overt heart disease, diabetes, and treatment with cardiac drugs, lipid-lowering medication, or antidiabetic agents. Measures for all participants were age, race, smoking status, level and completeness of injury, duration of injury, body mass index, serum lipids, fasting glucose, hemoglobin A1c, and ultrasonographic measurements of CIMT. Hierarchical multiple linear regression was conducted to predict CIMT from demographic and physiologic variables.

Results:

Several variables were significantly correlated with CIMT during univariate analyses, including glucose, hemoglobin A1c, age, and race/ethnicity; but only age was significant in the hierarchical regression analysis.

Conclusions:

Our data indicate the importance of CVD in women with SCI.Key words: age, cardiovascular disease, carotid intima-media thickness, hemoglobin A1c, risk factors, smokingThe secondary conditions of metabolic syndrome and cardiovascular disease (CVD) resulting from spinal cord injury (SCI ) are not well understood. In particular, persons with SCI have an increase in metabolic risk factors for cardiovascular disease (CVD),^1–5 but researchers have not determined whether this increase is associated with an increased incidence of CVD. The association has not been shown in reports on mortality or prevalence rates for CVD in people with SCI^6–12 or in the few studies that have appraised CVD in people with SCI using physiologic assessments.^13–18 Either the question was not addressed, or the evidence is insufficient due to low sample sizes and a lack of objective, prospective epidemiological studies assessing this question. Nevertheless, studies consistently show that metabolic syndrome is prevalent among individuals with SCI.^1–5,12 Metabolic syndrome consists of multiple interrelated risk factors that increase the risk for atherosclerotic heart disease by 1.5- to 3-fold.^19,20Compounding the uncertainty about the association of metabolic risk factors with CVD in SCI are possible gender differences.^21–24 Findings from studies of men with SCI might not apply to women with SCI. For example, the correlation between physical activity and high-density lipoprotein (HDL) levels in men with SCI is not found for women with SCI.^25,26 Furthermore, able-bodied women develop atherosclerosis later than do able-bodied men, and they usually present differently.²⁷ Some studies indicate that abnormal glucose metabolism may play a particularly important role in CVD in women²⁷; data from our group suggest that this is the case in women with SCI as well.¹⁵ Although women constitute 18% to 20% of the SCI population, no studies have evaluated cardiovascular health in women with chronic SCI.Carotid intima-media thickness (CIMT) is the most robust, highly tested, and often used noninvasive endpoint for assessing the progression of subclinical atherosclerosis in men and women of all ages.^28–46 For people with SCI, CIMT is a reliable surrogate measure of asymptomatic CVD.^15,47 The incidence of asymptomatic CVD appears to increase with the duration of SCI,¹⁵ where duration of injury is a cardiac risk factor independent of age.¹⁷ Moreover, CIMT is greater in men with SCI than in matched able-bodied controls,⁴⁸ indicating a subclinical and atypical presentation of CVD. A variety of studies have confirmed the usefulness of high-resolution B-mode ultrasound measurement of CIMT for quantitation of subclinical atherosclerosis.⁴⁹To better discern the association of risk factors with measures of subclinical atherosclerotic disease in women with SCI, we performed blood tests and ultrasonographic measurements of CIMT on 122 females with chronic SCI who were free of overt CVD. We tested for the 3 metabolic risk factors that are consistently identified in the varied definitions of metabolic syndrome: abnormal carbohydrate metabolism, abnormally high triglycerides, and abnormally low HDL cholesterol. We also tested for 4 other CVD risk factors: high levels of low-density lipoprotein (LDL), high total cholesterol, high body mass index (BMI), and a history of smoking.     

Depression,Pain Intensity,and Interference in Acute Spinal Cord Injury

Background:

The high prevalence of pain and depression in persons with spinal cord injury (SCI) is well known. However the link between pain intensity, interference, and depression, particularly in the acute period of injury, has not received sufficient attention in the literature.

Objective:

To investigate the relationship of depression, pain intensity, and pain interference in individuals undergoing acute inpatient rehabilitation for traumatic SCI.

Methods:

Participants completed a survey that included measures of depression (PHQ-9), pain intensity (“right now”), and pain interference (Brief Pain Inventory: general activity, mood, mobility, relations with others, sleep, and enjoyment of life). Demographic and injury characteristics and information about current use of antidepressants and pre-injury binge drinking also were collected. Hierarchical multiple regression was used to test depression models in 3 steps: (1) age, gender, days since injury, injury level, antidepressant use, and pre-injury binge drinking (controlling variables); (2) pain intensity; and (3) pain interference (each tested separately).

Results:

With one exception, pain interference was the only statistically significant independent variable in each of the final models. Although pain intensity accounted for only 0.2% to 1.2% of the depression variance, pain interference accounted for 13% to 26% of the variance in depression.

Conclusion:

Our results suggest that pain intensity alone is insufficient for understanding the relationship of pain and depression in acute SCI. Instead, the ways in which pain interferes with daily life appear to have a much greater bearing on depression than pain intensity alone in the acute setting.Key words: depression, pain, spinal cord injuriesThe high incidence and prevalence of pain following spinal cord injury (SCI) is well established^1–6 and associated with numerous poor health outcomes and low quality of life (QOL).^1,7,8 Although much of the literature on pain in SCI focuses on pain intensity, there is emerging interest in the role of pain interference or the extent to which pain interferes with daily activities of life.^7,9 With prevalence as high as 77% in SCI, pain interference impacts life activities such as exercise, sleep, work, and household chores.^2,7,10–13 Pain interference also has been associated with disease management self-efficacy in SCI.¹⁴ There is a significant relationship between pain intensity and interference in persons with SCI.⁷ Like pain, the high prevalence of depression after SCI is well-established.^15–17 Depression and pain often co-occur,^18,19 and their overlap ranges from 30% to 60%.¹⁹ Pain is also associated with greater duration of depressed mood.²⁰ Pain and depression share common biological pathways and neurotransmitter mechanisms,¹⁹ and pain has been shown to attenuate the response to depression treatment.^21,22Despite the interest in pain and depression after SCI and implications for the treatment of depression, their co-occurrence has received far less attention in the literature.²³ Greater pain has been associated with higher levels of depression in persons with SCI,^16,24 although this is not a consistent finding.²⁵ Similarly, depression in persons with SCI who also have pain appears to be worse than for persons with non-SCI pain, suggesting that the link between pain and depression may be more intense in the context of SCI.²⁶ In one of the few studies of pain intensity and depression in an acute SCI rehabilitation setting, Cairns et al ²⁷ found a co-occurrence of pain and depression in 22% to 35% of patients. This work also suggested an evolution of the relationship between pain and depression over the course of the inpatient stay, such that they become associated by discharge. Craig et al²⁸ found that pain levels at discharge from acute rehabilitation predicted depression at 2-year follow-up. Pain interference also has been associated with emotional functioning and QOL in persons with SCI^1,7,29,30 and appears to mediate the relationship between ambulation and depression.³¹Studies of pain and depression in person with SCI are often limited methodologically to examine the independent contributions of pain intensity and interference to depression in an acute setting. For example, they include only pain intensity^{16,23,25,28,30}; classify subjects by either pain plus depression²³ or pain versus no pain^8,28,30; use pain intensity and interference as predictor and outcome, respectively¹; collapse pain interference domains into a single score¹; or use only univariate tests (eg, correlations).^7,8,25,30 In addition, the vast majority focus on the chronic period of injury. To fill a gap in knowledge, we examined the independent contributions of pain intensity and pain interference to depression, while accounting for injury and demographic characteristics, antidepressant treatment, and pre-injury binge drinking in a sample of persons with acute SCI. We hypothesized that when accounting for both pain intensity and interference in the model, interference would have an independent and significant relationship with depression, above and beyond pain intensity.     

Quality of Life in and After Spinal Cord Injury Rehabilitation: A Longitudinal Multicenter Study

Purpose:

To investigate the changes in quality of life (QOL) in persons with spinal cord injury (SCI) and their close persons during the first 2 years post injury.

Method:

Longitudinal multiple sample multiple wave panel design. Data included 292 patients recruited from Austrian British German Irish and Swiss specialist SCI rehabilitation centers and 55 of their close persons. Questionnaire booklets were administered at 6 weeks 12 weeks 1 year and 2 years after injury to both samples.

Results:

Study 1 investigated the WHOQOL-BREF domains in individuals with SCI and found differences mostly in the physical domain indicating that QOL increases for persons with SCI from onset. An effect of the culture was observed in the psychological and environmental domains with higher QOL scores in the German-speaking sample. Study 2 compared individuals with SCI to their close persons and found differences in the physical environmental and social domains over time. The scores on the psychological dimension did not significantly differ between the persons with SCI and their close persons over time.

Conclusion:

QOL measured by the WHOQOL-BREF shows that QOL changes during rehabilitation and after discharge. Apart from the physical dimension the persons with SCI and their close persons seem to experience a similar change in QOL. Further longitudinal research is suggested to clarify the mutual adjustment process of people with SCI and their close persons and to explore cultural differences in QOL between English-and German-speaking countries.Key words: close persons, quality of life, rehabilitation, spinal cord injuryAspinal cord injury (SCI) is a highly disruptive event in the life of an individual and requires a considerable coping process. Shortly after the injury, all attention is put into stabilizing the patient and from that moment the individual has to cope with challenges at physical, social, environmental, and psychological levels.The institutionalized context of the rehabilitation provides a largely standardized supportive setting that helps the person with SCI to become acquainted with the recently acquired disability. The health care professionals in collaboration with the patients and their close persons, that is, relatives or significant others, work together to prepare the transition back to everyday life.One expectation of rehabilitation is that the person with SCI will regain a satisfactory level of well-being and fulfill his or her aims in life. Many factors may facilitate the retrieval of a good quality of life (QOL). Some aspects of SCI are permanent or only susceptible to small changes (eg, the paralysis and other irrevocable neurological problems related to the injury), but many others (eg, psychological and social aspects) can be more or less actively influenced by the person with SCI.A number of recent studies regarding QOL in SCI emphasize that QOL is not strongly affected by physical variables.^1–4 Age ^3–7 and gender^1,2–4,7 are also weakly related to the QOL of the persons with SCI. Physical health aspects that can explain differences in QOL are pain^1,6,8–11 or secondary conditions such as pressure sores and dysreflexia. ^4,6,11Psychological resources are strong predictors of life satisfaction and well-being. Psychological resources are personal traits and characteristics that might influence the way a person perceives and manages challenges. Positive affect,^3,11 high self-efficacy,^1,6,9,11 optimism,⁶ hope,^3,11 and sense of coherence^11,12 have proven to be positively associated with better QOL. More dynamic psychological processes such as appraisals or coping strategies used by the persons with SCI have also significantly contributed to predicting QOL over time. ¹³Studies reporting on how the environment affects perceived QOL in persons with SCI are less frequent, despite a probable relation between mobility impairments and the advantages that a well-designed, obstacle-free, secure, and friendly environment might convey to persons with SCI. ^14–16A supportive familial environment⁶ and friends¹⁷ are important. Close persons of individuals with SCI have to adjust to the new situation, such as accepting a partner with altered needs with different degrees of daily care. Close persons of persons with SCI reported that becoming a caregiver is difficult and often dramatically life changing.¹⁸ Weitzenkamp¹⁹ reports high levels of depression in spousal caregivers, with sometimes higher rates of depression than partners with SCI. He also compared caregivers of persons with SCI with non-caregiving spouses, and found that caregivers showed higher levels of depression and emotional and physical stress.Familial caregivers hold a central position in the life of persons with SCI. Their health and QOL affects the health and well-being of the persons with SCI; life with SCI involves a systemic adjustment process. Ploypetch⁵ indicated that the participants’ perceived QOL was affected more if the caregiver was a member of the participants’ family rather than a health professional. Lucke ²⁰ showed that the level of QOL in persons with SCI and their caregiving spouses may vary significantly over time, with a drop at 3 months post injury and an increase in QOL in the following 6 months. As a consequence, QOL has to be seen as dynamic, reflecting the adjustment to changes occurring over time in individuals and their environment. Some longitudinal studies of persons with SCI and their QOL have been conducted,^21–23 but longitudinal studies involving the close persons of individuals with SCI remain scarce in the literature. ²⁰The present report shows the changes in QOL during the first 2 years post injury in individuals with SCI and their close persons from 5 European countries. The first aim is to describe the physical, social, environmental, and psychological QOL in persons with SCI in relation to injury and sociodemographic variables.

Hypothesis 1: It is expected that QOL in persons with SCI is quite high, especially after 2 years.

Second, the experienced QOL of the individuals with SCI and their close persons are compared at 6 weeks, 12 weeks, 1 year, and 2 years post injury.

Hypothesis 2: We expected that the scores of the physical QOL domain would be lower in the persons with SCI compared to the noninjured close persons. No significant differences were expected between the scores of the psychological domain.

     

Mental Health and Risk of Secondary Medical Complications in Adults With Pediatric-Onset Spinal Cord Injury

Objective:

To investigate mental health problems in adults with pediatric-onset spinal cord injury (SCI) and explore how these problems relate to the risk of negative outcomes over time.

Method:

The study included 466 adults who sustained an SCI prior to age 19 years and had been injured for at least 1 year. Participants were interviewed on an approximately annual basis using a study-specific questionnaire and standardized measures of depression, anxiety, substance use, and community involvement. Generalized estimating equations were used to assess the risk of negative outcomes across time as a function of depression, anxiety, and substance misuse.

Results:

Of the participants who reported on each domain of mental health, 26% reported misuse of alcohol or drugs (122/466), 21% reported problems with depression (78/360), and 29% reported problems with anxiety (49/168). Depression was associated with increased odds of pressure ulcers, urinary tract infections, hospitalizations, pain, and smoking and lower levels of economic independence and mobility. Anxiety was associated with increased odds of hospitalization, pain, and smoking. Substance misuse predicted an increased risk of pressure ulcers, pain, and smoking and decreased odds of occupational involvement. When examining the effect of mental health with time, results showed that depression accelerated the risk of urinary tract infections, respiratory complications, and hospitalizations and anxiety and depression accelerated risk for lower occupational independence.

Conclusions:

The added burden that mental health difficulties pose for medical and psychosocial outcomes highlight the importance of monitoring and treating mental health symptoms in pediatric-onset SCI.Key words: anxiety, depression, mental health, pediatric onset, spinal cord injury, substance useIndividuals with a spinal cord injury (SCI) face lifelong stressors, physical limitations, and medical complications that can be devastating at any age. Although many individuals adjust well to the challenges of an SCI and enjoy satisfying and meaningful lives after injury,^1,2 a significant minority are at heightened risks for developing mental health disorders such as anxiety, depressed mood, and substance abuse problems.³ Consequently, there is a real need to devote scientific attention to understanding the psychological impact of SCI and identifying indicators of risks related to the development of significant emotional distress.Rates of depression, in particular, tend to be higher for individuals with adult-onset SCI than is typically found in the general population. Estimates of depression range from 20% to 37% in the more acute stages of injury^4–10 and 11% to 48% at least 1 year post injury.^9–15 The course of anxiety symptoms following SCI has been studied less, but the prevalence of clinically significant anxiety symptoms for adult-onset SCI is estimated to be between 13% and 41%.^8,9,12,16 Compared to the adult-onset SCI population, individuals with pediatric-onset injury may adjust better than those injured as adults.^17,18 Estimates suggest that as many as 17% children will report elevated anxiety symptoms and 9% of children will report elevated symptoms of depression at least a year after injury.¹⁸ In a sample of adults with pediatric-onset SCI, only 3% reported symptoms consistent with probable major depressive disorder (MDD), but as many as 27% reported at least mild symptoms of depressed mood.¹⁷Alcohol and drug use are frequent contributors to injury onset, are highly comorbid with depression and anxiety, and are also utilized as a coping mechanism to deal with SCI-related stressors.¹⁹ Several studies have highlighted the importance of attending to substance use in the treatment of SCI due to the higher rates of problematic alcohol and drug use than in the general population.^19,20 Consequently, substance abuse is an important aspect of psychosocial adjustment to consider when looking at mental health symptoms for SCI survivors. Prevalence rates of substance use tend to vary widely depending on age and how it is defined (abuse/misuse vs use). In studies examining substance use in persons with SCI, rates vary from as high as 55% to 90% for alcohol use in young adults^21,22 and 60% for adults over 25²¹ to as low as 13% to 14% when distinguishing alcohol misuse from use.^20,23 Prevalence rates for illicit drug use, including marijuana, suggest a lower frequency of drug use among individuals with SCI compared to alcohol use, with an estimated 11% to 26% endorsing use of illegal drugs.^20,22–24An SCI, independent of any other factors, leads to a high degree of unique medical considerations and physical limitations, but the presence of mental health symptoms is typically associated with an increased incidence of secondary medical complications. Although highly comorbid with depression symptoms, less is known about specific risks associated with anxiety.²⁵ Elevated depression symptoms have been linked to several SCI-related health concerns, including increased pain and deterioration in health,^12,13,26 pressure ulcers,^17,27 longer rehabilitation,²⁸ and greater risk of mortality,²⁹ whereas anxiety has been associated with significant pain elevations.³⁰ Substance misuse in individuals with SCI has been associated with pressure ulcers,^20,31 pain,²⁰ urinary tract infections,³¹ lower overall perceived health,²⁴ and decreased life satisfaction.²⁰Taken together, these studies highlight the substantial psychological and emotional impact of SCI, as well as the potential physical and health consequences of emotional distress. Furthermore, it is important to consider that individuals who are injured at a young age may face challenges that those with adult-onset injuries may not. Unlike injuries that occur in adulthood, children with SCI must navigate the normal complexities of youth and identity development, while adjusting to a chronic health condition and physical disability. Additionally, as is the case with adult-onset injury, individuals with pediatric-onset SCI are susceptible to a number of secondary conditions; however, they have the added burden of spending their adult life vulnerable to these conditions. Consequently, the previously discussed cross-sectional designs may not account for the ways that mental health might relate to medical complications and adjustment over time.Given concerns noted in the literature regarding the ability of cross-sectional analyses to adequately capture changes in SCI-related complications,³² the purpose of this study was to (a) examine the presence of mental health problems in individuals with pediatric-onset SCI, (b) examine whether demographics or injury characteristics relate to mental health problems, and (c) explore longitudinal changes in the occurrence of medical complications and social adjustment as a function of mental health presentation.Based on the literature reviewed, we hypothesized that cross-sectional analyses may have underestimated previous estimates of mental health conditions in pediatric-onset SCI and that, when assessed longitudinally, rates of depression, anxiety, and substance misuse would be comparable to available estimates in the adult-onset SCI population as well as the general population. We also hypothesized that the prevalence of secondary health conditions would differ as a function of mental health difficulties and that individuals with mental health concerns would be at greater risk for increased SCI-associated medical complications and decreased participation and involvement.     

Muscle Density and Bone Quality of the Distal Lower Extremity Among Individuals with Chronic Spinal Cord Injury

Background:

Understanding the related fates of muscle density and bone quality after chronic spinal cord injury (SCI) is an important initial step in determining endocrine-metabolic risk.

Objective:

To examine the associations between muscle density and indices of bone quality at the distal lower extremity of adults with chronic SCI.

Methods:

A secondary data analysis was conducted in 70 adults with chronic SCI (C2-T12; American Spinal Injury Association Impairment Scale [AIS] A-D; ≥2 years post injury). Muscle density and cross-sectional area (CSA) and bone quality indices (trabecular bone mineral density [TbBMD] at the distal tibia [4% site] and cortical thickness [CtTh], cortical area [CtAr], cortical BMD [CtBMD], and polar moment of inertia [PMI] at the tibial shaft [66% site]) were measured using peripheral quantitative computed tomography. Calf lower extremity motor score (cLEMS) was used as a clinical measure of muscle function. Multivariable linear regression analyses were performed to determine the strength of the muscle-bone associations after adjusting for confounding variables (sex, impairment severity [AIS A/B vs AIS C/D], duration of injury, and wheelchair use).

Results:

Muscle density was positively associated with TbBMD (b = 0.85 [0.04, 1.66]), CtTh (b = 0.02 [0.001, 0.034]), and CtBMD (b = 1.70 [0.71, 2.69]) (P < .05). Muscle CSA was most strongly associated with CtAr (b = 2.50 [0.12, 4.88]) and PMI (b = 731.8 [161.7, 1301.9]) (P < .05), whereas cLEMS was most strongly associated with TbBMD (b = 7.69 [4.63, 10.76]) (P < .001).

Conclusion:

Muscle density and function were most strongly associated with TbBMD at the distal tibia in adults with chronic SCI, whereas muscle size was most strongly associated with bone size and geometry at the tibial shaft.Key words: bone mineral density, bone quality, muscle density, muscle size, osteoporosis, peripheral quantitative computed tomography, spinal cord injurySpinal cord injury (SCI) is associated with sublesional muscle atrophy,^1–3 changes in muscle fiber type,^4,5 reductions in hip and knee region bone mineral density (BMD),^6–8 and increased central and regional adiposity after injury.^9,10 Adverse changes in muscle and bone health in individuals with SCI contribute to an increased risk of osteoporosis,^11–13 fragility fractures,¹⁴ and endocrine-metabolic disease (eg, diabetes, dyslipidemia, heart disease).^15–17 Crosssectional studies have shown a higher prevalence of lower extremity fragility fractures among individuals with SCI ranging from 1% to 34%.^18–20 Fragility fractures are associated with negative health and functional outcomes, including an increased risk of morbidity and hospitalization,^21,22 mobility limitations,²³ and a reduced quality of life.²⁴ Notably, individuals with SCI have a normal life expectancy, yet fracture rates increase annually from 1% per year in the first year to 4.6% per year in individuals greater than 20 years post injury.^25,26Muscle and bone are thought to function as a muscle-bone unit, wherein muscle contractions impose loading forces on bone that produce changes in bone geometry and structure.^27,28 A growing body of evidence has shown that individuals with SCI (predominantly those with motor complete injury) exhibit similar patterns of decline in muscle cross-sectional area (CSA) and BMD in the acute and subacute stages following injury.^4,11,29 Prospective studies have exhibited a decrease in BMD of 1.1% to 47% per year^6,7,30 and up to 73% in the 2 to 7 years following SCI.^8,14,31,32 Decreases in muscle CSA have been well-documented following SCI, with greater disuse atrophy observed after complete SCI versus incomplete SCI, presumably due to the absence of voluntary muscle contractions and associated mobility limitations.^1,2,16 Muscle quality is also compromised early after SCI, resulting in sublesional accumulation of adipose tissue in the chronic stage of injury^3,33,34; the exact time course of this event has been poorly elucidated to date. Adipose tissue deposition within and between skeletal muscle is linked to an increase in noncontractile muscle tissue and a reduction in muscle force-generating capacity on bone.^35,36 Skeletal muscle fat infiltration is up to 4 times more likely to occur in individuals with SCI,^1,16,37 contributing to metabolic complications (eg, glucose intolerance),¹⁶ reduced muscle strength and function,³⁸ and mobility limitations³ – all factors that may be associated with a deterioration in bone quality after SCI.The association between lean tissue mass and bone size (eg, BMD and bone mineral content) in individuals with SCI has been wellestablished using dual energy x-ray absorptiometry (DXA).^9,10,29,34 However, DXA is unable to measure true volumetric BMD (vBMD), bone geometry, and bone structure. Peripheral quantitative computed tomography (pQCT) is an imaging technique that improves our capacity to measure indices of bone quality and muscle density and CSA at fracture-prone sites (eg, tibia).^3,39 Recent evidence from cross-sectional pQCT studies has shown that muscle CSA and calf lower extremity motor score (cLEMS) were associated with indices of bone quality at the tibia in individuals with SCI.^13,40 However, neither study measured muscle density (a surrogate of fatty infiltration when evaluating the functional muscle-bone unit). Fatty infiltration of muscle is common after SCI^1,16,37 and may affect muscle function or the muscle-bone unit, but the association between muscle density and bone quality indices at the tibia in individuals with chronic SCI is unclear. Muscle density measured using pQCT may be an acceptable surrogate of muscle quality when it is difficult to assess muscle strength due to paralysis.^3,39 Additionally, investigating which muscle outcome (muscle density, CSA, cLEMS) is most strongly associated with vBMD and bone structure may inform modifiable targets for improving bone quality and reducing fracture risk after chronic SCI.The primary objective of this secondary analysis was to examine the associations between pQCTderived calf muscle density and trabecular vBMD at the tibia among adults with chronic SCI. The secondary objective was to examine the associations between calf muscle density, CSA, and function and tibial vBMD, cortical CSA and thickness, and polar moment of inertia (PMI). First, we hypothesize that calf muscle density will be a positive correlate of trabecular and cortical vBMD, cortical CSA and thickness, and PMI at the tibia in individuals with chronic SCI. Second, we hypothesize that of the key muscle variables (cLEMS, CSA and density), calf muscle density and cLEMS will be most strongly associated with trabecular vBMD, whereas calf muscle CSA will be most strongly associated with cortical CSA and PMI.     

Restoring Voluntary Grasping Function in Individuals with Incomplete Chronic Spinal Cord Injury: Pilot Study

Background:

Functional electrical stimulation (FES) therapy has been shown to be one of the most promising approaches for improving voluntary grasping function in individuals with subacute cervical spinal cord injury (SCI).

Objective:

To determine the effectiveness of FES therapy, as compared to conventional occupational therapy (COT), in improving voluntary hand function in individuals with chronic (≥24 months post injury), incomplete (American Spinal Injury Association Impairment Scale [AIS] B-D), C4 to C7 SCI.

Methods:

Eight participants were randomized to the intervention group (FES therapy; n = 5) or the control group (COT; n = 3). Both groups received 39 hours of therapy over 13 to 16 weeks. The primary outcome measure was the Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT), and the secondary outcome measures were Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), Functional Independence Measure (FIM) self-care subscore, and Spinal Cord Independence Measure (SCIM) self-care subscore. Outcome assessments were performed at baseline, after 39 sessions of therapy, and at 6 months following the baseline assessment.

Results:

After 39 sessions of therapy, the intervention group improved by 5.8 points on the TRI-HFT’s Object Manipulation Task, whereas the control group changed by only 1.17 points. Similarly, after 39 sessions of therapy, the intervention group improved by 4.6 points on the FIM self-care subscore, whereas the control group did not change at all.

Conclusion:

The results of the pilot data justify a clinical trial to compare FES therapy and COT alone to improve voluntary hand function in individuals with chronic incomplete tetraplegia.Key words: chronic patients, functional electrical stimulation, grasping, therapy, upper limbIn the United States and Canada, there is a steady rate of incidence and an increasing rate of prevalence of individuals living with spinal cord injury (SCI). For individuals with tetraplegia, hand function is essential for achieving a high level of independence in activities of daily living.^1–5 For the majority of individuals with tetraplegia, the recovery of hand function has been rated as their highest priority.⁵Traditionally, functional electrical stimulation (FES) has been used as a permanent neuroprosthesis to achieve this goal.^6–14 More recently, researchers have worked toward development of surface FES technologies that are meant to be used as shortterm therapies rather than permanent prosthesis. This therapy is frequently called FES therapy or FET. Most of the studies published to date, where FES therapy was used to help improve upper limb function, have been done in both the subacute and chronic stroke populations^15–23 and 2 have been done in the subacute SCI population.^1–3 With respect to the chronic SCI population, there are no studies to date that have looked at use of FES therapy for retraining upper limb function. In a review by Kloosterman et al,²⁴ the authors have discussed studies that have used various combinations of therapies for improving upper extremity function in chronic SCI individuals; however, the authors found that the only study that showed significant improvements before and after was the study published by Needham-Shropshire et al.²⁵ This study examined the effectiveness of neuromuscular stimulation (NMS)–assisted arm ergometry for strengthening triceps brachii. In this study, electrical stimulation was used to facilitate arm ergometry, and it was not used in the context of retraining reaching, grasping, and/or object manipulation.Since 2002, our team has been investigating whether FES therapy has the capacity to improve voluntary hand function in complete and incomplete subacute cervical SCI patients who are less than 180 days post injury at the time of recruitment in the study.^1–3 In randomized controlled trials (RCTs) conducted by our team, we found that FES therapy is able to restore voluntary reaching and grasping functions in individuals with subacute C4 to C7 incomplete SCI.^1–3 The changes observed were transformational; individuals who were unable to grasp at all were able to do so after only 40 one-hour sessions of the FES therapy, whereas the control group showed significantly less improvement. Inspired by these results, we decided to conduct a pilot RCT with chronic (≥24 months following injury) C4 to C7 SCI patients (American Spinal Injury Association Impairment Scale [AIS] B-D), which is presented in this article. The purpose of this pilot study was to determine whether the FES therapy is able to restore voluntary hand function in chronic tetraplegic individuals. Based on the results of our prior phase I¹ and phase II^2,3 RCTs in the subacute SCI population, we hypothesized that individuals with chronic tetraplegia who underwent the FES therapy (intervention group) may have greater improvements in voluntary hand function, especially in their ability to grasp and manipulate objects, and perform activities of daily living when compared to individuals who receive similar volume and duration of conventional occupational therapy (COT: control group).     

Dietary Intake Relative to Cardiovascular Disease Risk Factors in Individuals With Chronic Spinal Cord Injury: A Pilot Study

Background:

The relationship between cardiovascular disease (CVD) risk factors and dietary intake is unknown among individuals with spinal cord injury (SCI).

Objective:

To investigate the relationship between consumption of selected food groups (dairy, whole grains, fruits, vegetables, and meat) and CVD risk factors in individuals with chronic SCI.

Methods:

A cross-sectional substudy of individuals with SCI to assess CVD risk factors and dietary intake in comparison with age-, gender-, and race-matched able-bodied individuals enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Dietary history, blood pressure, waist circumference (WC), fasting blood glucose, high-sensitivity C-reactive protein (hs-CRP), lipids, glucose, and insulin data were collected from 100 SCI participants who were 38 to 55 years old with SCI >1 year and compared to 100 matched control participants from the CARDIA study.

Results:

Statistically significant differences between SCI and CARDIA participants were identified in WC (39.2 vs 36.2 in.; P < .001) and high-density lipoprotein cholesterol (HDL-C; 39.2 vs 47.5 mg/dL; P < .001). Blood pressure, total cholesterol, triglycerides, glucose, insulin, and hs-CRP were similar between SCI and CARDIA participants. No significant relation between CVD risk factors and selected food groups was seen in the SCI participants.

Conclusion:

SCI participants had adverse WC and HDL-C compared to controls. This study did not identify a relationship between consumption of selected food groups and CVD risk factors.Key words: cardiovascular disease risk factors, dietary intake, spinal cord injuryCardiovascular disease (CVD) is a leading cause of death in individuals with chronic spinal cord injuries (SCIs).^1–5 This is partly because SCI is associated with several metabolic CVD risk factors, including dyslipidemia,^6–10 glucose intolerance,^6,11–14 and diabetes.^15–17 In addition, persons with SCI exhibit elevated markers of inflammation^18,19 and endothelial activation²⁰ that are correlated with higher CVD prevalence.^21–23 Obesity, and specifically central obesity, another CVD risk factor,^24–26 is also common in this population.^12,27–29Dietary patterns with higher amounts of whole grains and fiber have been shown to improve lipid abnormalities,³⁰ glucose intolerance, diabetes mellitus,^31–34 hypertension,³⁵ and markers of inflammation³⁶ in the general population. These dietary patterns are also associated with lower levels of adiposity.³¹ Ludwig et al reported that the strong inverse associations between dietary fiber and multiple CVD risk factors – excessive weight gain, central adiposity, elevated blood pressure, hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL-C), high low-density lipoprotein cholesterol (LDL-C), and high fibrinogen – were mediated, at least in part, by insulin levels.³⁷ Whole-grain food intake is also inversely associated with fasting insulin, insulin resistance, and the development of type 2 diabetes.^32,38,39Studies in the general population have also shown a positive association between the development of metabolic syndrome as well as heart disease and consumption of a Western diet, a diet characterized by high intake of processed and red meat and low intake of fruit, vegetables, whole grains, and dairy.^40,41 Red meat, which is high in saturated fat, has been shown to have an association with adverse levels of cholesterol and blood pressure and the development of obesity, metabolic syndrome, and diabetes.^40,42,43Numerous studies have shown that individuals with chronic SCI have poor diet quality.^44–49 A Canadian study found that only 26.7% of their sample was adherent to the recommendations about the consumption of fruit, vegetables, and grains from the “Eating Well with Canada’s Food Guide.”⁴⁴ Individuals with chronic SCI have also been found to have low fiber and high fat intakes when their diets were compared to dietary recommendations from the National Cholesterol Education Program,⁴⁶ the 2000 Dietary Guidelines for Americans,⁴⁹ and the recommended Dietary Reference Intakes and the Acceptable Macronutrient Distribution Range.^47,48However, unlike in the general population, the relationship between dietary intake and obesity and CVD risk factors is unknown in the chronic SCI population. If a dietary pattern consisting of higher intake of whole grains and dietary fiber is favorably associated with obesity and CVD risk factors in individuals with chronic SCI, then trials of increased intake of whole grains and fiber intake could be conducted to document health benefits and inform recommendations. The purpose of this pilot study is to investigate the association between selected food group intake and CVD risk factors in individuals with chronic SCI as compared to age-, gender-, and race-matched able-bodied individuals enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Data will also be used to plan future studies in the relatively understudied field of CVD and nutrition in individuals with SCI.     

Participation and Life Satisfaction in Aged People with Spinal Cord Injury: Does Age at Onset Make a Difference?

Background:

Few studies have reported on outcomes in samples of elderly people with SCI and the impact of the age at onset of SCI is unclear.

Objective:

To study levels of participation and life satisfaction in individuals with SCI aged 65 years or older and to analyze differences in participation and life satisfaction scores between individuals injured before or after 50 years of age.

Methods:

This cross-sectional survey included 128 individuals with SCI who were at least 65 years old. Age at onset was dichotomized as <50 or ≥50 years of age. Participation was measured with the Frequency scale of the Utrecht Scale for Evaluation-Participation, and life satisfaction was measured with 5 items of the World Health Organization Quality of Life abbreviated form.

Results:

Participants who were injured before 50 years of age showed similar levels of functional status and numbers of secondary health conditions but higher participation and life satisfaction scores compared to participants injured at older age. In the multiple regression analysis of participation, lower current age, higher education, and having paraplegia were significant independent determinants of increased participation (explained variance, 25.7%). In the regression analysis of life satisfaction, lower age at onset and higher education were significant independent determinants of higher life satisfaction (explained variance, 15.3%).

Conclusion:

Lower age at onset was associated with better participation and life satisfaction. This study did not reveal indications for worsening participation or life satisfaction due to an accelerated aging effect in this sample of persons with SCI.Key words: aged, aging, quality of life, rehabilitation outcome, spinal cord injuriesAging in the population of individuals with spinal cord injury (SCI) has 2 aspects: the average age at onset of SCI is increasing and people with SCI live on average longer than half a century ago. Age at onset of traumatic SCI has risen from 28.7 years in the 1970s to 40 years in the United States during the 2005-2009 period.¹ In other countries, a bimodal distribution of age at onset of traumatic SCI has emerged in recent years.² In the Netherlands, the median age at first admission to the acute hospital after traumatic SCI has increased to 62 years in 2010.³ People who are older at injury are more often victims of falls and have nontraumatic, incomplete, and cervical SCI more often than individuals who are injured at a younger age.³-⁵ They are more vulnerable than younger people and are at greater risk of death shortly after the onset of SCI.⁶ If they survive the acute phase, they are less often referred to specialized rehabilitation hospitals.³ If referred to a specialized center, elderly people with SCI may gain a similar rate of functional improvement⁷; but because older patients generally have lower functional scores at admission, they also show worse rehabilitation outcomes compared to people who are injured at a younger age.^4,8–10The life expectancy of the population with SCI has grown over the last 50 to 60 years.¹¹ Many people with a new SCI can expect to live another 30 to 40 years or more. However, this life expectancy has not grown in recent decades and is still clearly below that of the general population.¹¹ People with SCI are at risk of “accelerated aging” due to an inactive lifestyle and a greater risk of obesity, chronic inflammation, pressure ulcers, and pulmonary infections.^1,12Participation and quality of life in aged persons with SCI are influenced by a complex interaction of many factors associated with current chronologic age, age at injury, duration of injury, and age cohort effects. It has been suggested that increasing age and being of older age at onset of SCI are independently associated with worse outcomes and that longer time after SCI is associated with better adjustment, whereas the impact of age cohort effects on adjustment is unknown.^1,13–15 However, research into the impact of these health-related changes on participation and life satisfaction of aged people living with SCI is sparse, and associations with aging are often studied in samples that are well below retirement age.¹⁵Only 2 longitudinal projects in aging people with SCI are available. Krause and Bozard¹⁶ described 35-year longitudinal data of 64 individuals with SCI (mean age, 61.5 years; mean time since SCI, 41.4 years). The participants rated their overall adjustment significantly higher at follow-up than they did at the first assessment 35 years before (8.4 and 7.6 on a 0–10 scale, respectively). The participants, however, showed decreases in satisfaction with social life and participation indicators (visits with others, outings).¹⁶ Charlifue and Gerhart¹⁷ found in a large sample of people with long-standing SCI (mean age, 59 years; time since onset of SCI, 36 years at follow-up) a small but significant decline in community reintegration over a period of 10 years. Life satisfaction, however, remained stable over this time period.¹⁷It is still unclear how people aging with SCI differ from people who acquire SCI in later life.¹⁸ Given the same age, the accelerated aging hypothesis predicts that people injured at a younger age will be worse off. However, the reverse – higher age at injury is an independent predictor of worse functional outcomes – has also been shown.¹⁰ We therefore used data from earlier research with the following objectives: (a) to describe the levels of participation and life satisfaction in individuals with SCI aged 65 years or older, and (b) to analyze differences in participation and life satisfaction between individuals injured before 50 years of age or at or after 50 years of age.     

Identifying and Classifying Quality of Life Tools for Assessing Spasticity After Spinal Cord Injury

Objective:

To identify and classify tools for assessing the influence of spasticity on quality of life (QOL) after spinal cord injury (SCI).

Methods:

Electronic databases (MEDLINE/PubMed CINAHL and PsycInfo) were searched for studies published between 1975 and 2012. Dijkers’s theoretical framework on QOL was used to classify tools as either objective or subjective measures of QOL.

Results:

Sixteen studies met the inclusion criteria. Identified objective measures that were used to assess the influence of spasticity on QOL included the Short Form-36 (SF-36) the Sickness Impact Profile (SIP) and the Health Utilities Index-III (HUI-III). Subjective measures included the Quality of Life Index–SCI Version III (QLI-SCI) Life Situation Questionnaire–Revised (LSQ-R) Reciprocal Support Scale (RSS) Profile of Mood States (POMS) Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) and the Patient Reported Impact of Spasticity Measure (PRISM). A number of tools proved either to be insensitive to the presence of spasticity (QLI-SCI) or yielded mixed (SF-36) or weak (RSS LSQ-R) results. Tools that were sensitive to spasticity had limited psychometric data for use in the SCI population (HUI-III SIP POMS) although 2 were developed specifically for assessing spasticity on daily life post SCI (SCI-SET PRISM).

Conclusions:

Two condition-specific subjective measures the SCI-SET and PRISM emerged as the most promising tools for the assessment of spasticity impact on QOL after SCI. Further research should focus on establishing the psychometric properties of these measures for use in the SCI population.Key words: outcome measurement quality of life spasticity spinal cord injuryKey words: outcome, measurement, quality of life, spasticity, spinal cord injurySpasticity of the upper limbs, trunk, or lower limbs is typically experienced by individuals with an upper motor neuron spinal cord injury (SCI) following spinal shock, and the resulting spasms often negatively impact quality of life (QOL).¹ Although there is great variability in definitions of spasticity, the most commonly cited definition is by Lance^2(p485): “Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.” A wider definition of spasticity includes increased exteroceptive reflexes, as well as loss of motor function (ie, muscle power and coordination).³ The notion is that muscle weakness and impaired coordination are not part of the spasticity syndrome itself, but rather are associated with spasticity.^3–6 Spasticity following SCI is prevalent, with 65% to 78% of persons more than 1 year post injury reporting its occurence.^7,8The decision to treat spasticity largely depends on the frequency, severity, and impact of the spasms on a person’s daily life.^9,10 Treatment may include conservative physical therapy,¹¹ with a possible combination of other modalities,¹ including pharmacological treatments (eg, diazepam,^12,13 baclofen,¹⁴ clonidine,^14,15 tazanidine,^12,13,16 dantrolene sodium,^12,17 cyproheptadine,^14,18 and cannabis¹⁷). Persons who do not respond to oral administration of medications may be surgically implanted with a pump for intrathecal administration of baclofen^19–21 or receive injections of chemodenervation agents (phenol and ethanol²² or botulinum toxin^16,23). Severe recalcitrant cases require surgical intervention, including dorsal rhizotomy and cordotomy.²⁴ Continued improvements in the definition and management of spasticity are hampered by the development of valid and reliable tools for assessing spasticity impact.¹Relatedly, the valid and reliable assessment of QOL post SCI, which is an important outcome for understanding the additional burden of specific secondary health conditions that emerge post SCI and for gauging the success of rehabilitation interventions in minimizing their frequency and severity, is a challenge.²⁵ Symptoms of spasticity may have a profound influence on an individual’s QOL,^7,26 including lifestyle and sense of well-being,²⁷ by limiting workplace participation, adding to the cost of medication, and increasing attendant care requirements.^8,21,28 Despite these findings, there are problems with assessing the influence of spasticity on QOL that are related to the multidimensionality and breadth of spasticity definitions, the fluctuating nature of associated symptoms, and their clinical impact. It is therefore essential that health care professionals be made aware of available tools that are designed to assess the influence of spasticity on QOL after SCI.Furthermore, investigators should possess a broader understanding of the different conceptualizations of QOL and which tools correspond to each of these. This will help to ensure that the objectives of a study are well aligned with the selected QOL tool. Gaining prominence in the field is the notion that QOL can be measured from an objective or subjective perspective.²⁹ Objective measures are based on the assumption that there is widespread agreement about what constitutes QOL.²⁵ Such measures focus on external conditions and contain items that can be defined and quantified to reflect societal standards. Conversely, subjective measures are designed with the assumption that QOL can only be judged by the individuals experiencing it.³⁰ Although there are advantages and disadvantages inherent in each measurement type,²⁹ subjective measures give patients a means of providing health professionals with a greater understanding of QOL and its connection to their health and well-being following SCI, whereas objective measures can be used to inform decision makers on how to allocate funds and resources for various interventions.To date, no systematic reviews on the influence of spasticity on QOL, or on the appropriateness of QOL measures for assessing spasticity, have been conducted. Given the substantial influence spasticity has on QOL, there is a need to improve conceptual understandings of QOL to ensure that investigators employ appropriate research designs as well as suitable outcome measures to assess this prevalent secondary health condition. Hence, the purpose of this systematic literature review was to classify and evaluate outcome measures that are used to assess the influence of spasticity on QOL following SCI.     

Calorie and Protein Intake in Acute Rehabilitation Inpatients with Traumatic Spinal Cord Injury Versus Other Diagnoses

Background:

Obesity and its consequences affect patients with spinal cord injury (SCI). There is a paucity of data with regard to the dietary intake patterns of patients with SCI in the acute inpatient rehabilitation setting. Our hypothesis is that acute rehabilitation inpatients with SCI consume significantly more calories and protein than other inpatient rehabilitation diagnoses.

Objective:

To compare calorie and protein intake in patients with new SCI versus other diagnoses (new traumatic brain injury [TBI], new stroke, and Parkinson’s disease [PD]) in the acute inpatient rehabilitation setting.

Methods:

The intake of 78 acute rehabilitation inpatients was recorded by registered dieticians utilizing once-weekly calorie and protein intake calculations.

Results:

Mean ± SD calorie intake (kcal) for the SCI, TBI, stroke, and PD groups was 1,967.9 ± 611.6, 1,546.8 ± 352.3, 1,459.7 ± 443.2, and 1,459.4 ± 434.6, respectively. ANOVA revealed a significant overall group difference, F(3, 74) = 4.74, P = .004. Mean ± SD protein intake (g) for the SCI, TBI, stroke, and PD groups was 71.5 ± 25.0, 61.1 ± 12.8, 57.6 ± 16.6, and 55.1 ± 19.1, respectively. ANOVA did not reveal an overall group difference, F(3, 74) = 2.50, P = .066.

Conclusions:

Given the diet-related comorbidities and energy balance abnormalities associated with SCI, combined with the intake levels demonstrated in this study, education with regard to appropriate calorie intake in patients with SCI should be given in the acute inpatient rehabilitation setting.Key words: nutritional requirements, obesity, spinal cord injuriesIt is estimated that more than two-thirds of individuals with spinal cord injury (SCI) are obese.¹ Persons with SCI have been shown to be at increased risk of prematurely developing coronary heart disease and possess a higher prevalence of altered glucose metabolism compared to age-matched controls.^2–9 Additionally, obesity in this population is associated with increased likelihood of deep tissue injury¹⁰ and fatal pulmonary embolism,¹¹ higher rehospitalization rates and pain scores,¹² decreased lung volumes,¹³ and worse functional outcomes after rehabilitation.¹⁴ Given reports that cardiovascular disease is the leading cause of mortality in long-term SCI when excluding deaths during the first year after injury,¹⁵ obesity in this population demands attention.Total daily energy expenditure is the sum of basal metabolic rate, thermic effect of food digestion, and thermic effect of physical activity. Due to muscle atrophy and the subsequent reduction in fat-free lean body mass, SCI leads to drastic reductions in basal metabolic rate and thermic effect of physical activity.^1,2 This profoundly impacts energy balance and necessitates equivalent reductions in energy intake to prevent the accumulation of adipose tissue.¹ Given that total daily energy expenditure after SCI is reduced by 12% to 54% depending on level of injury, fat-free lean mass, and activity level,¹ coupled with the difficulties the SCI population faces with regard to physical activity participation,² an appropriate diet is of paramount importance in these individuals.The acute phase after SCI is unlike most trauma in that it is associated with a reduction in metabolic activity and an uncorrectable negative nitrogen balance.¹⁶Additionally, it has been reported that predicted energy expenditure is greater than actual energy expenditure in the first weeks after SCI and, as a result of this discrepancy, acute SCI patients have historically been overfed.¹⁷ As a result, there has been a call to develop specific nutritional treatment protocols for persons with acute SCI.¹⁶ Given that the initial decrease in metabolic rate continues into the chronic spine injury phase, there has also been a call to develop nutritional guidelines specific to subacute and chronic SCI.¹⁸There is a paucity of data with regard to dietary intake among individuals with SCI in the rehabilitation setting. This study attempts to characterize calorie and protein intake in patients with SCI in the acute inpatient rehabilitation setting and compare the intake of patients with SCI to other diagnoses commonly found in this setting. Understanding the dietary behavior of persons with SCI in the context of their immediate and chronic energy balance abnormalities and their long-term risk of obesity may lead to alterations in nutritional education provided to patients with new SCI undergoing rehabilitation. Additionally, comparing SCI intake to other diagnoses may serve to identify excessive dietary intake as a modifiable, SCI-specific medical problem.     

EMG Biofeedback and Exercise for Treatment of Cervical and Shoulder Pain in Individuals with a Spinal Cord Injury: A Pilot Study

Background:

Chronic or recurrent musculoskeletal pain in the cervical and shoulder region is a common secondary problem after spinal cord injury (SCI), reported by 30% to 70% of individuals.

Objective:

The purpose of this study was to investigate the effect of electromyographic (EMG) biofeedback training, in addition to a standard exercise program, on reducing shoulder pain in manual wheelchair users with SCI.

Methods:

Fifteen individuals with SCI, C6 or lower, who were manual wheelchair users with shoulder pain were randomly assigned to 1 of 2 interventions. The Exercise group (n = 7) received instruction on a standard home-based exercise program. The EMG Biofeedback plus Exercise group (n = 8) received identical exercise instruction plus EMG biofeedback training to improve muscle balance and muscle relaxation during wheelchair propulsion. Shoulder pain was assessed by the Wheelchair Users Shoulder Pain Index (WUSPI) at baseline, at posttest 10 weeks after the start of intervention, and at follow-up 16 weeks after posttest.

Results:

The number of participants per group allowed only within-group comparisons; however, the findings indicated a beneficial effect from EMG biofeedback training. Shoulder pain, as measured by WUSPI, decreased 64% from baseline to posttest for the EMG Biofeedback plus Exercise group (P = .02). Shoulder pain for the Exercise group decreased a nonsignificant 27%. At follow-up, both groups showed continued improvement, yet the benefit of EMG biofeedback training was still discernible. The EMG Biofeedback plus Exercise group had an 82% reduction in shoulder pain from baseline to follow-up (P = .004), while the Exercise group showed a 63% reduction (P = .03) over the same time period.

Conclusions:

This study provides preliminary evidence that EMG biofeedback has value when added to an exercise intervention to reduce shoulder pain in manual wheelchair users with SCI. These findings indicate that EMG biofeedback may be valuable in remediating musculoskeletal pain as a secondary condition in SCI. This preliminary conclusion will need to be studied and verified through future work.Key words: biofeedback, exercise, pain, spinal cord injuryChronic or recurrent musculoskeletal pain in the cervical and shoulder region is a common secondary problem after spinal cord injury (SCI) that interferes with daily activities and reduces quality of life (QOL).¹ Reported prevalence ranges from 30% to 70%.^2–9 Both incidence and intensity increase with duration of injury and become an added concern for SCI individuals as they age.^8,10,11 For manual wheelchair users, who rely on their upper extremities for mobility (wheelchair propulsion), 35% report shoulder pain. Shoulder pain increases to 60% for wheelchair athletes.^12,13Muscle imbalance plays a role in the development of musculoskeletal pain in manual wheelchair users, as muscles used for the forceful push phase strengthen relative to muscles used for the recovery phase.^13,14 Recent studies have reported effective use of exercise programs designed to address this problem.^15–18 Two of these studies were randomized trials that included an untreated control group to rule out spontaneous recovery.^17,18 As a result of this research, exercise has become a standard intervention for reducing shoulder pain in manual wheelchair users with SCI.In addition to muscle imbalance, muscle fatigue likely plays a significant role. Research on work-related musculoskeletal pain (WRMP) has demonstrated that disruption of normal work/rest cycles can promote localized muscle fatigue and pain.^19–21 Electromyographic studies have found that repetitive tasks consist of alternating periods of muscle contraction and muscle relaxation; a muscle that is slow to relax – bypassing the rest portion of work/rest cycles – is at risk of developing WRMP.^22–24 Clinical studies have reported slow and incomplete relaxation of the upper trapezius muscle during repetitive tasks, compared to pain-free controls, in musicians with occupational upper extremity pain²⁵ and individuals with cervical pain and headache.^{19, 24} Manual wheelchair propulsion, with its highly repetitive muscle activity, puts the wheelchair user at risk of muscle fatigue and eventually pain.This research suggests that EMG biofeedback interventions designed to improve work/ rest cycling may be an effective addition to rehabilitation programs for cervical and shoulder pain in manual wheelchair users with SCI. At present, EMG biofeedback procedures are widely used for muscle training in rehabilitation, athletics, and the workplace and have been effective in training overactive muscles to relax quickly during functional activities.^20,26–30 In the present study, EMG biofeedback training is designed to improve both muscle balance and work/rest cycles during functional wheelchair propulsion. The purpose of this study was to determine the extent to which EMG biofeedback training is associated with a reduction in shoulder pain, above and beyond the effects of a standard exercise program.     

Allostatic Load and Spinal Cord Injury: Review of Existing Research and Preliminary Data

Objective:

To introduce allostatic load (AL) as a framework for measuring stress-related outcomes after spinal cord injury (SCI) by identifying the number and nature of biomarkers investigated in existing studies and by generating preliminary data on AL in 30 persons with traumatic SCI.

Methods:

This systematic review and pilot study were conducted at a medical university in the southeastern United States. A review of literature published between 1993 and 2012 identified studies using 2 or more of 5 classes of AL biomarkers. We then collected data on 11 biomarkers (n = 30) from self-selected participants using physical exams and blood and urine specimen collection. These included waist to hip ratio, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, dihydroepiandrosterone, glycosylated hemoglobin, C-reactive protein, interleukin-6, and cortisol, norepinephrine, and epinephrine normalized by 12-hour creatinine.

Results:

We were unable to identify any studies investigating AL biomarkers from each of the 5 areas or any studies specifically proposing to investigate AL. AL scores were relatively low, with metabolic indicators being the most elevated and neuroendocrine the least elevated.

Conclusions:

AL is a promising, yet underutilized, construct that may be feasibly assessed after SCI.Key words: allostasis, allostatic load, spinal cord injury, stressTraumatic spinal cord injury (SCI) typically results in permanent disability and increased risk of health complications and early mortality. In the United States, the primary causes of SCI are motor vehicle crashes, falls, acts of violence, sports, and other unknown etiology.¹ After traumatic SCI, individuals face significant physiological and psychological adjustments.^2,3 Their response to these and other stressors is influenced greatly by the condition of their body (ie, severity of injury, physical conditioning, presence of comorbidities or risk factors for disease, etc) and how they perceive and interpret the situation (ie, coping styles).⁴The traumatic, sudden nature of SCI and the resulting long-term increased vulnerability to secondary health conditions⁵ suggest the appropriateness of evaluating both physiological and psychological stress paradigms among persons with SCI. Some research has suggested that SCI is associated with posttraumatic stress disorder (PTSD),^6–9 although other research has suggested that PTSD rarely occurs in the absence of a depressive disorder.¹⁰ A number of studies have examined psychological adjustment to SCI,^2,3,11 but further research regarding physiological responses to injury and stressors is warranted.Two concepts, allostasis and allostatic load (AL), relate to the physiological adaptation to stress and associated costs on the body and brain.⁴ Allostasis refers to the dynamic regulatory process by which stability is maintained through changes in physiologic systems including autonomic, central nervous, neuroendocrine, cardiovascular, metabolic, and immune systems.¹² AL is a measure of the “wear and tear” experienced after chronic allostatic responses to stressful situations; it is the price of adaptation.¹³ AL may result from recurrent stress and subsequent activation of allostatic systems, failure to shut down the allostatic activity following a stressor, or an inadequate response of an allostatic system ultimately leading to elevated activity of another system.⁴ The AL model,¹⁴ a biologic theory of stress, proposes that the stress response is influenced by a number of factors, including life experiences, genetics, and behavior. Over time, the accumulation of AL can have systemwide adverse effects, contributing to morbidity and mortality.^14–17Measurement of AL was initially operation-alized to reflect levels of physiologic activity across the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system, the cardiovascular system, and metabolic processes through a set of 10 biomarkers, each having been previously linked to increased risk for pathology.^4,15 A more diverse and expanded set of biomarkers have since been grouped by (1) anthropometric measures and (2) cardiovascular and respiratory, (3) metabolic, (4) neuroendocrine, and (5) immune system biomarkers.¹⁸ In the original index, immune biomarkers were not assessed. A review by Juster et al¹⁸ lists 25 biomarkers commonly assessed in AL studies. The number of markers measured in any particular study ranges from 4 to 17.¹⁸ Numerous algorithms, formulas, and statistical techniques have been implemented to quantify, or score, AL based on the biomarkers collected. Each biomarker contributes to an overall risk score defined by a critical threshold or cutoff point, whereas the biomarker only counts for the overall score if it is outside the critical threshold.It is possible that specific stressors associated with long-term injury, in combination with daily life stressors, may make persons with SCI more susceptible to high levels of AL. In studies assessing biomarkers in persons with SCI, there has not been consistency in which biomarkers were assessed or in the cutpoints for some biomarkers. As persons with SCI are at increased risk of secondary conditions and early mortality due to their injury, increased AL is an important concept that could result in even further negative health consequences due to the cumulative wear and tear on body systems and secondary health conditions.     

Depression and Depression Treatment in Women With Spinal Cord Injury

Background:

Research has documented high rates of depression in people with spinal cord injury (SCI); however, most SCI research is conducted with predominantly male study participants. Additional research is needed on depression and depression treatment among women with SCI.

Objective:

Study objectives were to examine depression, correlates of depression, and depression treatment in a sample of women with SCI.

Methods:

The sample included 51 ethnically and racially diverse women with SCI who participated in a larger study on secondary conditions of women with diverse physical disabilities. Recruited through health clinics and community organizations in a large metropolitan area, participants completed structured interviews that included demographic and disability characteristics and measures of health and health care utilization.

Results:

Scores on the Beck Depression Inventory–II (BDI-II) indicated that 41% of the women had depressive symptomatology in the mild to severe range. BDI-II scores were significantly related to more severe secondary conditions, greater pain, and poorer health perceptions but not to demographic or disability variables. Nearly a third (n = 16) of the women had scores exceeding the standard cutoff for significant clinical depressive symptomatology, yet only 5 of those had received any treatment for depression in the past 3 months and only 1 had received counseling or psychotherapy. Lifelong depression treatment showed a similar pattern of predominantly pharmacologic treatment.

Conclusion:

Depression is a common problem for women with SCI, and many do not receive treatment, particularly psychological treatment. Disability-sensitive and affordable depression treatment must be made available to women with SCI.Key words: depression, depression treatment, spinal cord injury, womenThere is a large body of literature documenting the high prevalence of depression, psychological distress, and psychological morbidity after spinal cord injury (SCI).^1–6 In a recent study of community-residing people with traumatic SCI, the rate of probable major depression was found to be 3 times that of the general population.³ Women represent about 19% of people with SCI⁷; therefore, most research on psychosocial health after SCI has been based on samples consisting predominantly of men with SCI. There is very little research examining rates of depression or severity of depressive symptoms specifically in women with SCI or comparing rates and severity of depression by gender. As a result, recent reviews on psychological health after SCI have been completely silent with regard to gender differences.^1,6 Early studies seemed to confirm assumptions drawn from the literature on the general population that rates of depression were higher among women with SCI^5,8; however, more recent findings have been mixed, with some studies reporting greater depression and poorer mental health among women^3,9–11 and others finding no differences between men and women.^12,13Although the prevalence of depression after SCI has received a great deal of attention in the literature, a number of researchers have argued that more research needs to be directed toward the development and evaluation of effective depression treatments for people with SCI.^2–6,14,15 There is little known about the treatment that people with SCI receive for depression. Noting this lack of research about treatment, particularly the application of standard treatment guidelines for depression among people with SCI,¹⁶ Fann and colleagues³ examined depression treatment utilization of people with SCI. They found low rates of mental health treatment for people with SCI who had probable major depression. Among those classified as depressed in their sample, only 29% were receiving antidepressant medication and far fewer were receiving medication at an appropriate guideline-level dosage and duration. Only 11% had received any psychotherapy for depression in the past 3 months, and only half of these had received appropriate guideline-level psychotherapy in the past 3 months. To our knowledge, this is the only study in the literature examining and documenting lower rates of depression treatment among people with SCI. Gender and gender differences received little attention in the article, but an examination of the tables revealed that a higher percentage of women than men had elevated depression scores. The authors did note that results not included in the article revealed a trend toward women receiving more guideline-level treatment than men. No such gender differences were noted with regard to whether participants received any treatment for depression.Given the paucity of data on depression treatment among women with SCI, the purpose of this study was to examine depression and its treatment in a sample of women with SCI. Using a self-report interview survey, the study examined depressive symptomatology and recent as well as lifetime treatment for depression. In addition, demographic, disability, and health-related variables were examined as potential correlates of depression in an effort to identify important factors for clinicians to consider in screening for and treating depression in women with SCI.