Vitamin D deficiency in individuals with a spinal cord injury: a literature review

25-Hydroxyvitamin D Levels and Vitamin D3 Supplementation During Postacute Spinal Cord Injury Rehabilitation

Background

Insufficient 25-hydroxyvitamin D [25(OH)D] levels are associated with falls, fractures, and worse overall health outcomes. We evaluated 25(OH)D levels in individuals with spinal cord injury or disorder (SCI/D) during postacute rehabilitation who received vitamin D3 supplementation according to routine clinical practice. Associations with clinical outcomes were also assessed.

Methods

This prospective observational cohort study included individuals aged 18 to 85 years with newly acquired SCI/D admitted for inpatient rehabilitation to a specialized center. The following parameters were collected monthly from admission to discharge as part of the clinical routine: serum 25(OH)D, vitamin D3 supplementation, pressure injuries, bed rest, and falls. 25(OH)D levels were categorized as insufficient (≤75 nmol/L) or sufficient (>75 nmol/L). Descriptive statistics and group comparisons were performed.

Results

Eighty-seven patients (25 [29%] females, median age 53 [IQR 39-67] years) were included and followed for 186 (163-205) days. The proportion of patients with a sufficient 25(OH)D level increased from 8% (95% CI, 3-16) to 61% (95% CI, 50-71) (p < .001). Ninety-two percent of patients received vitamin D3 (1100 [1000-2000] IU/day). No differences in 25(OH)D levels or supplementation doses were found for the occurrence of pressure injuries, bed rest, or falls.

Conclusion

This is the first study to examine 25(OH)D levels and vitamin D3 supplementation during postacute SCI/D rehabilitation. Insufficient 25(OH)D levels were prevalent throughout rehabilitation. For some patients, the doses of vitamin D3 used in current clinical practice may be too low to achieve sufficient 25(OH)D levels. Regular monitoring of 25(OH)D levels and individualized supplementation strategies are warranted.

Evaluating initial screening practices for calcium dysregulation after acute traumatic spinal cord injury: a retrospective review

OBJECTIVES

The purpose of this study was to determine the frequency of which calcium homeostasis markers are obtained in the acute setting after an initial traumatic spinal cord injury (TSCI).

DESIGN

Retrospective chart review of a limited data set linking ICD 10 codes designating TSCI to corresponding calcium homeostasis markers for patients with an initial chart encounter for TSCI.

SETTING

A level 1 trauma center in Virginia, United States METHODS: The statistical software SPSS was used to calculate summary statistics including frequency, mean, and standard deviation for calcium homeostasis markers (basic metabolic panel, magnesium, spot urine calcium, testosterone panel, liver function tests, Vitamin D level, C-telopeptide, parathyroid hormone, celiac panel, DXA imaging report) as well as the mean and standard deviation for time to first check of the marker.

RESULTS

Most markers were not obtained besides calcium. Only 10 of 80 (12.5%) of subjects had a Vitamin D level (mean 28, SD 23) checked during acute admission (mean days to check 1.5, SD 1.6), with most other markers checked much less frequently.

CONCLUSIONS

Most calcium homeostasis markers were not checked on acute admission after TSCI. Future studies on implementing a standardized calcium homeostasis marker protocol for monitoring and potential medical intervention should be explored.

Comprehensive periodic health evaluations of 454 Norwegian Paralympic and Olympic athletes over 8 years: what did we learn?

OBJECTIVE

A periodic health evaluation (PHE) is a comprehensive and multidisciplinary investigation of athlete health widely used in elite sport, but its contents and benefits can be questioned. This study aimed to determine the prevalence of conditions identified by a PHE among Paralympic and Olympic athletes over four consecutive Games cycles from Rio de Janeiro 2016 to Beijing 2022 and to assess the benefits and potential pitfalls of a comprehensive PHE programme in detecting existing injuries, illnesses and other health issues.

METHODS

We collected extensive health history and clinical examination data on elite athletes: medical history, ECG, blood pressure, blood samples, spirometry, musculoskeletal health, cognitive function, mental health and compliance with public health programmes.

RESULTS

The final cohort included 87 Paralympic and 367 Olympic athletes, representing 565 PHE cycles. Musculoskeletal problems and unspecified pain, infections and allergies were the most frequent health issues. High blood pressure was the most prevalent cardiovascular finding, and vitamin D deficiency the most common laboratory abnormality. Most athletes complied with the public childhood vaccination programmes, but fewer with recommended cancer screening. Follow-up of health issues was variable.

CONCLUSION

Our PHE programme identified musculoskeletal problems, infections, allergies, elevated blood pressure and vitamin D deficiency as common health conditions. Longitudinal follow-up of health conditions identified during screening and improved compliance with public health and cancer screening programmes is needed to determine the true benefits of athlete care prompted by the PHE.

Prevalence and risk factors of low vitamin D levels in children and adolescents with familial hypokalemic periodic paralysis

Patients with familial hypokalemic periodic paralysis (HOKPP) experience episodes of reversible immobility and are at an increased risk of limited sunlight exposure, potentially leading to vitamin D deficiency. However, there is a lack of data on vitamin D levels in this population. We investigated serum vitamin D levels and their associated factors in children with HOKPP. This study included 170 genetically-confirmed children with HOKPP, aged 3-18 years, and 170 age-, sex-, and body mass index (BMI)-matched healthy controls from the Korean Channelopathy Study, a prospective controlled investigation. Anthropometric and clinical characteristics were recorded, and serum levels of calcium, ionized calcium, phosphorus, alkaline phosphatase, 25-hydroxyvitamin D, and intact parathyroid hormone (PTH) were analyzed. Vitamin D deficiency (< 20 ng/mL) was observed in 87.0% of the patients compared to 45.5% of the controls (P < 0.05) during the summer-fall season. During the winter-spring season, 91.7% of the patients and 73.4% of the controls were deficient (P < 0.05). A strong positive correlation was found between onset age of the first paralytic attack and vitamin D levels (r = 0.78, P < 0.01). Conversely, the frequency and duration of paralytic attacks were negatively correlated with vitamin D levels (r = -0.82 and r = -0.65, P < 0.01, respectively). Age, BMI, age at onset, frequency and duration of attacks, and PTH levels were independently associated with vitamin D levels (ß = -0.10, -0.12, 0.19, -0.27, -0.21, and -0.13, P < 0.05, respectively).

CONCLUSIONS

Vitamin D deficiency was highly prevalent in children with HOKPP, and vitamin D levels correlated with various disease characteristics. We recommend routine screening for vitamin D levels in these patients to address this prevalent deficiency. Considering the high prevalence of vitamin D deficiency observed, further research on other diseases characterized by reversible immobility is warranted.

WHAT IS KNOWN

• A correlation between immobility and low serum vitamin D levels has been established. However, the vitamin D status of patients with familial hypokalemic periodic paralysis (HOKPP) who experience periods of reversible immobility remains unknown.

WHAT IS NEW

• Vitamin D deficiency was highly prevalent in children with HOKPP, and vitamin D levels correlated with various disease characteristics.

Comorbidity in spinal cord injury in Iran: A narrative review

Spinal cord injury (SCI) is a severe medical condition that affects millions of people worldwide each year. In Iran, an estimated 9 out of every 100,000 individuals experience traumatic SCI occurrences. Long-term disabilities and comorbidities stemming from SCI often necessitate multiple therapeutic interventions. The aim of this study is to evaluate the morbidity in Iranian SCI patients. In this study, a four-step process was used to select, extract, analyze, and synthesize relevant literature. The search covered 750 records from five databases, resulting in 25 articles included in the review. These articles, published between 2000 and 2023, utilized cross-sectional, qualitative, or cohort designs. The findings explored the prevalence, risk factors, and consequences of comorbidities associated with SCI, categorized into four themes: physical, sexual, psychological, and metabolic morbidity. Physical morbidity refers to medical conditions or complications affecting body functions or structures in SCI patients. The most frequently reported cases include pressure ulcers, pain, osteoporosis, fractures, impaired pulmonary function, renal failure, and obesity. Metabolic morbidity includes conditions such as vitamin D deficiency and cardiometabolic risk factors. Psychological morbidity encompasses depression, anxiety, and adjustment disorders. Sexual morbidity refers to conditions or complications affecting the sexual function or satisfaction of SCI patients. This narrative literature review offers a comprehensive examination of various aspects of SCI in Iranian patients. The review identifies numerous challenges and difficulties faced by SCI patients while also highlighting protective factors that can improve their well-being. Additionally, the review acknowledges gaps and limitations within the current literature and suggests possible avenues for future research.

Basal Metabolic Rate Versus Dietary Vitamin D and Calcium Intakes and the Association With Body Composition and Bone Health After Chronic Spinal Cord Injury

We examined the association among basal metabolic rate (BMR) as well as dietary intakes of vitamin D (Vit D) and calcium on body composition and bone mineral density (BMD) after spinal cord injury (SCI). Cross-sectional design. Veterans Affairs Medical Center, Richmond, VA. About 33 individuals with chronic SCI who recorded their food consumption 3 days per week for 2 weeks. BMR was measured after 10 to 12 h of overnight fast. Average daily vit D and calcium intakes, and total caloric intake were recorded and analyzed using the Nutrition Data System for Research (NDSR) software. Fasting blood analysis for 25-hydroxyvitamin D (25[OH]D) status and Triiodothyronine (T3) status was performed (n = 10). Total and regional BMD, % fat mass (FM), and % lean mass (LM) were measured by dual X-ray absorptiometry scans. Participants consumed less than the Institute of Medicine (IOM) recommended daily allowances (RDA) for vit D (600-800 IU) and calcium (1000-1200 mg) for adults. BMR was positively related to total-lean mass (r = .62, P = .0001; n = 32) and leg-lean mass (r = .51, P = .003; n = 32). Adjusted BMR was negatively related to BMD of the left (r = -.38, P = .047; n = 28) and the right (r = -.41, P = .032; n = 28) proximal tibia. Vit D intake was negatively related to percentage total-FM (r = -.33, P = .07; n = 29) and legs-%FM (r = -.37, P = .047; n = 29). Multivariate regression models indicated that adjusted BMR explained the variance in leg fat mass (34%; P = .002) and percentage fat mass (44%; P < .0001). Persons with SCI are likely to consume less than the RDAs for vit D and calcium. BMR may explain the changes in body composition and bone metabolism. Dietary vit D should be considered as a prophylactic intervention in maintenance of bone health after SCI.

Bioactive role of vitamins as a key modulator of oxidative stress, cellular damage and comorbidities associated with spinal cord injury (SCI)

Introduction: Spinal cord injury (SCI) cause significant disability and impact the quality of life of those affected by it. The nutritional status and diet are fundamental to diminish the progression of complications; vitamins modulate the inflammatory response and oxidative stress, promote blood-spinal cord barrier preservation and the prompt recovery of homeostasis. A deep knowledge of the benefits achieved from vitamins in patients with SCI are summarized. Information of dosage, time, and effects of vitamins in these patients are also displayed. Vitamins have been extensively investigated; however, more clinical trials are needed to clarify the scope of vitamin supplementation.Objective: The objective of this review was to offer relevant therapeutic information based on vitamins supplementation for SCI patients.Methods: Basic and clinical studies that have implemented the use of vitamins in SCI were considered. They were selected from the year 2000-2022 from three databases: PubMed, Science Direct and Google Scholar.Results: Consistent benefits in clinical trials were shown in those who were supplemented with vitamin D (prevents osteoporosis and improves physical performance variables), B3 (improves lipid profile) and B12 (neurological prophylaxis of chronic SCI damage) mainly. On the other hand, improvement related to neuroprotection, damage modulation (vitamin A) and its prophylaxis were associated to B complex vitamins supplementation; the studies who reported positive results are displayed in this review.Discussion: Physicians should become familiar with relevant information that can support conventional treatment in patients with SCI, such as the use of vitamins, a viable option that can improve outcomes in patients with this condition.

Rehabilitation: Neurogenic Bone Loss after Spinal Cord Injury

Osteoporosis is a common skeletal disorder which can severely limit one's ability to complete daily tasks due to the increased risk of bone fractures, reducing quality of life. Spinal cord injury (SCI) can also result in osteoporosis and sarcopenia. Most individuals experience sarcopenia and osteoporosis due to advancing age; however, individuals with SCI experience more rapid and debilitating levels of muscle and bone loss due to neurogenic factors, musculoskeletal disuse, and cellular/molecular events. Thus, preserving and maintaining bone mass after SCI is crucial to decreasing the risk of fragility and fracture in vulnerable SCI populations. Recent studies have provided an improved understanding of the pathophysiology and risk factors related to musculoskeletal loss after SCI. Pharmacological and non-pharmacological therapies have also provided for the reduction in or elimination of neurogenic bone loss after SCI. This review article will discuss the pathophysiology and risk factors of muscle and bone loss after SCI, including the mechanisms that may lead to muscle and bone loss after SCI. This review will also focus on current and future pharmacological and non-pharmacological therapies for reducing or eliminating neurogenic bone loss following SCI.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

Effect of vitamin D deficiency on surgical outcomes of degenerative cervical myelopathy

Background

Due to its association with bone metabolic status and muscle strength/mass, vitamin D deficiency has the potential to affect neurological symptom recovery after surgery for degenerative cervical myelopathy (DCM). However, few studies have investigated the effects of vitamin D deficiency (serum 25(OH)D <20 ng/mL) on surgical outcomes in DCM patients. Herein, we investigated the prevalence of vitamin D deficiency in patients with DCM, and determined whether vitamin D deficiency affects surgical outcomes for DCM.

Methods

In this retrospective observational study we assessed the recovery rate 1 year after surgery in 91 patients diagnosed with DCM who underwent surgery. First, we analyzed the correlation between vitamin D levels and various background factors. Then, patients were divided into 2 groups according to vitamin D sufficiency, and univariate analysis was performed on vitamin D and surgical outcomes. Finally, Spearman correlation analyses were performed to identify factors correlated with recovery rate after surgery for DCM.

Results

The average Japanese Orthopedic Association score for the assessment of cervical myelopathy (C-JOA score) improved postoperatively. Age was positively correlated with vitamin D levels, and parathyroid hormone levels were negatively correlated with vitamin D levels. Among the 91 patients, 79.1% of patients were diagnosed with vitamin D deficiency. No significant differences in recovery rate were found between the vitamin D-deficient and vitamin D-sufficient groups. Finally, the Spearman correlation analysis showed a positive correlation between the preoperative C-JOA motor dysfunction score in the lower extremities and the recovery rate, while age demonstrated a negative correlation with recovery rate.

Conclusions

No association was found between vitamin D deficiency and clinical outcomes after surgery for DCM. The results of this study do not support the need to normalize vitamin D levels for achieving neurological improvements in patients with DCM.

Risk constellation of hospital acquired pressure injuries in patients with a spinal cord injury/ disorder - focus on time since spinal cord injury/ disorder and patients' age

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The aim of this study was to evaluate how time since spinal cord injury/disorder (SCI/D) and patients' age influence risk constellation for hospital acquired pressure injuries (HAPI) in patients with a SCI/D.

SETTING

Acute care and rehabilitation clinic specialized in SCI/D.

METHODS

We collected patients' characteristics and 85 risk factors for HAPI development in adults with SCI/D with at least one HAPI during their inpatient stay between August 2018 and December 2019. We analyzed patients' characteristics and HAPI risk factors using descriptive statistics according to time since SCI/D ( < 1 year, 1-15 years, > 15 years) and patients' age (18-35 years, 35-65 years, > 65 years).

RESULTS

We identified 182 HAPI in 96 patients. Comparing patients with SCI/D < 1 year with the other groups, autonomic dysreflexia (p < 0.001), abnormal body temperature (p = 0.001), hypertensive episode (p = 0.005), and pneumonia (p < 0.001) occurred more frequently; mean hemoglobin (p < 0.001), albumin (p = 0.002) and vitamin D levels (p = 0.013) were significantly lower, and patients with time since SCI/D < 1 year scored fewer points (10-12) on the Braden Scale (p < 0.001). Comparing groups per patients' age, only the SCIPUS score was higher in patients > 65 years compared to the other two groups (p = 0.002).

CONCLUSIONS

Different risk factor constellation seem to be underlying HAPI development with more differences in patients time since SCI/D than patients' age. Awareness of these differences in risk factor constellation depending on time since SCI/D in these patients might lead to different HAPI prevention strategies.

SPONSORSHIP

The study team didn't receive any additional sponsorship.

A comprehensive look at the psychoneuroimmunoendocrinology of spinal cord injury and its progression: mechanisms and clinical opportunities

Spinal cord injury (SCI) is a devastating and disabling medical condition generally caused by a traumatic event (primary injury). This initial trauma is accompanied by a set of biological mechanisms directed to ameliorate neural damage but also exacerbate initial damage (secondary injury). The alterations that occur in the spinal cord have not only local but also systemic consequences and virtually all organs and tissues of the body incur important changes after SCI, explaining the progression and detrimental consequences related to this condition. Psychoneuroimmunoendocrinology (PNIE) is a growing area of research aiming to integrate and explore the interactions among the different systems that compose the human organism, considering the mind and the body as a whole. The initial traumatic event and the consequent neurological disruption trigger immune, endocrine, and multisystem dysfunction, which in turn affect the patient's psyche and well-being. In the present review, we will explore the most important local and systemic consequences of SCI from a PNIE perspective, defining the changes occurring in each system and how all these mechanisms are interconnected. Finally, potential clinical approaches derived from this knowledge will also be collectively presented with the aim to develop integrative therapies to maximize the clinical management of these patients.

The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury

BACKGROUND

The prevention of lower extremity fractures and fracture-related morbidity and mortality is a critical component of health services for adults living with chronic spinal cord injury (SCI).

METHODS

Established best practices and guideline recommendations are articulated in recent international consensus documents from the International Society of Clinical Densitometry, the Paralyzed Veterans of America Consortium for Spinal Cord Medicine and the Orthopedic Trauma Association.

RESULTS

This review is a synthesis of the aforementioned consensus documents, which highlight the pathophysiology of lower extremity bone mineral density (BMD) decline after acute SCI. The role and actions treating clinicians should take to screen, diagnose and initiate the appropriate treatment of established low bone mass/osteoporosis of the hip, distal femur or proximal tibia regions associated with moderate or high fracture risk or diagnose and manage a lower extremity fracture among adults with chronic SCI are articulated. Guidance regarding the prescription of dietary calcium, vitamin D supplements, rehabilitation interventions (passive standing, functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)) to modify bone mass and/or anti-resorptive drug therapy (Alendronate, Denosumab, or Zoledronic Acid) is provided. In the event of lower extremity fracture, the need for timely orthopedic consultation for fracture diagnosis and interprofessional care following definitive fracture management to prevent health complications (venous thromboembolism, pressure injury, and autonomic dysreflexia) and rehabilitation interventions to return the individual to his/her pre-fracture functional abilities is emphasized.

CONCLUSIONS

Interprofessional care teams should use recent consensus publications to drive sustained practice change to mitigate fracture incidence and fracture-related morbidity and mortality among adults with chronic SCI.

Energy Availability and Nutritional Intake during Different Training Phases of Wheelchair Athletes

Optimizing nutritional intake and timing helps athletes to improve performance and long-term health. Different training phases can require varying nutritional needs. In this study, we conducted a descriptive assessment of dietary intake, energy availability (EA), and blood biochemical parameters in elite wheelchair athletes during distinct training phases. Data analyzed in this study were collected as part of a randomized controlled crossover trial exploring the feasibility of probiotics and prebiotic supplementation. Data were obtained from consecutive three-day diaries and blood samples, both collected at four different time points across four consecutive months. We included 14 athletes (mean (standard deviation) age 34 (9) years, eight females, and six males) active in different wheelchair sports. The mean daily nutritional intake (g/kg body mass) for females and males was 2.7 (0.9) and 4.0 (0.7) for carbohydrates, 1.1 (0.3) and 1.5 (0.3) for protein, and 0.8 (0.3) and 1.4 (0.2) for fat. EA did not change across the four time points in either female (p = 0.30) or male (p = 0.05) athletes. The mean EA was lower in female athletes compared to male athletes (p = 0.03). Low EA (≤30 kcal/ kg fat-free mass/day) was observed in female (58 (29) % of days) and male (34 (23) % of days) athletes. Iron deficiency with anemia was observed in two female athletes. Mean vitamin D levels were insufficient (<75 nmol/L). Macronutrient intake, EA, and blood biochemical parameters were suboptimal in this cohort of elite wheelchair athletes, especially in female athletes.

Prevalence of an insufficient vitamin D status at the onset of a spinal cord injury - a cross-sectional study

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

This study aimed to investigate the vitamin D status after acute spinal cord injury (SCI) onset.

SETTING

Specialized SCI rehabilitation center in Switzerland.

METHODS

Patients admitted to the center after an acute SCI onset were included. The prevalence of a deficient (25(OH)D ≤ 50 nmol/l), insufficient (50 < 25(OH)D ≤ 75 nmol/l) and sufficient (25(OH)D > 75 nmol/l) vitamin D status were determined after admission. Vitamin D status was compared between different patient groups based on demographic and SCI characteristics. The occurrence of bed rest, falls and pressure injuries were also assessed.

RESULTS

In total, 87 patients (median (interquartile range); 53 (39-67) years, 25 females, 66 traumatic SCI, 54 paraplegia) were included. Assessed a median of 15 (9-22) days after SCI onset, median vitamin D status was 41 (26-57) (range 8-155) nmol/l. The majority of patients had a deficient (67%, 95% confidence interval (95% CI) 0.56-0.76) or insufficient (25%, 95% CI 0.17-0.36) vitamin D status. A moderate negative correlation was found between vitamin D status and body mass index (p = 0.003). A moderate positive correlation was found between vitamin D and calcium status (p = 0.01).

CONCLUSION

A deficient or insufficient vitamin D status directly after SCI onset is highly prevalent. Vitamin D status should be carefully observed during acute SCI rehabilitation. We recommend that all patients with recent SCI onset should receive vitamin D supplementation with a dosage depending on their actual vitamin D status.

Prevalence of vitamin D deficiency in patients with spinal cord injury at admission: a single-centred study in the UK

Vitamin D deficiency is prevalent in patients with chronic spinal cord injury (SCI) and has been implicated as an aetiologic factor of osteoporosis and various skeletal and extra-skeletal issues in SCI patients. Few data were available regarding vitamin D status in patients with acute SCI or immediately assessed at hospital admission. This retrospective cross-sectional study evaluated vitamin D status in SCI patients at admission to a UK SCI centre in January-December 2017. A total of 196 eligible patients with serum 25(OH)D concentration records at admission were recruited. The results found that 24 % were vitamin D deficient (serum 25(OH)D < 25 nmol/l), 57 % of the patients had serum 25(OH)D < 50 nmol/l. The male patients, patients admitted in the winter-spring time (December-May), and patients with serum sodium < 135 mmol/l or with non-traumatic causes had a significant higher prevalence of vitamin D deficiency than their counterparts (28 % males v. 11⋅8 % females, P = 0⋅02; 30⋅2 % in winter-spring v. 12⋅9 % in summer-autumn, P = 0⋅007; 32⋅1 % non-traumatic v. 17⋅6 % traumatic SCI, P = 0⋅03; 38⋅9 % low serum sodium v. 18⋅8 % normal serum sodium, P = 0⋅010). There was a significant inverse association of serum 25(OH)D concentration with body mass index (BMI) (r = -0⋅311, P = 0⋅002), serum total cholesterol (r = -0⋅168, P = 0⋅04) and creatinine concentrations (r = -0⋅162, P = 0⋅02) that were also significant predictors of serum 25(OH)D concentration. Strategies for systematic screening and efficacy of vitamin D supplementation in SCI patients need to be implemented and further investigated to prevent the vitamin D deficiency-related chronic complications.

Endocrinological and inflammatory markers in individuals with spinal cord injury: A systematic review and meta-analysis

Spinal cord injury (SCI) can lead to dramatic physiological changes which can be a factor in developing secondary health conditions and might be reflected in biomarker changes in this elevated risk group. We focused specifically on the endocrine and inflammation profile differences between SCI and able-bodied individuals (ABI). Our aim was to determine the differences in inflammatory markers and endocrine profiles between SCI and ABI. We systematically searched 4 electronic databases for relevant studies. Human observational (cross-sectional, cohort, case-control) studies that compared biomarkers of interest between SCI and ABI population were included. Weighted mean difference between SCI and ABI was calculated using random-effects models. Heterogeneity was computed using I² statistic and chi-squared test. Study quality was evaluated through the Newcastle-Ottawa Scale. The search strategy yielded a total of 2,603 studies from which 256 articles were selected for full-text assessment. Sixty-two studies were included in the meta-analysis. SCI individuals had higher levels of pro-inflammatory C-reactive protein and IL-6 than ABI. Creatinine and 25-hydroxyvitamin D₃ levels were lower in SCI than ABI. Total testosterone levels and IGF-1 were also found to be lower, while cortisol and leptin levels were higher in SCI when compared to ABI. Accordingly, meta-regression, subgroup analysis, and leave-one-out analysis were performed, however, they were only able to partially explain the high levels of heterogeneity. Individuals with SCI show higher levels of inflammatory markers and present significant endocrinological changes when compared to ABI. Moreover, higher incidence of obesity, diabetes, osteoporosis, and hypogonadism in SCI individuals, together with decreased creatinine levels reflect some of the readily measurable aspects of the phenotype changes in the SCI group. These findings need to be considered in anticipating medically related complications and personalizing SCI medical care.

Vitamin D Promotes Remyelination by Suppressing c-Myc and Inducing Oligodendrocyte Precursor Cell Differentiation after Traumatic Spinal Cord Injury

Demyelination due to oligodendrocytes loss occurs after traumatic spinal cord injury (TSCI). Several studies have suggested the therapeutic potential of vitamin D (VitD) in demyelinating diseases. However, experimental evidence in the context of TSCI is limited, particularly in the presence of prior VitD-deficiency. In the present study, a contusion and a transection TSCI rat model were used, representing mild and severe injury, respectively. Motor recovery was assessed in rats with normal VitD level or with VitD-deficiency after 8 weeks' treatment post-TSCI (Cholecalciferol, 500 IU/kg/day). The impact on myelin integrity was examined by transmission electron microscopy and studied in vitro using primary culture of oligodendrocytes. We found that VitD treatment post-TSCI effectively improved hindlimb movement in rats with normal VitD level irrespective of injury severity. However, cord-transected rats with prior deficiency did not seem to benefit from VitD supplementation. Our data further suggested that having sufficient VitD was essential for persevering myelin integrity after injury. VitD rescued oligodendrocytes from apoptotic cell death in vitro and enhanced their myelinating ability towards dorsal root axons. Enhanced myelination was mediated by increased oligodendrocyte precursor cells (OPCs) differentiation into oligodendrocytes in concert with c-Myc downregulation and suppressed OPCs proliferation. Our study provides novel insights into the functioning of VitD as a regulator of OPCs differentiation as well as strong preclinical evidence supporting future clinical testing of VitD for TSCI.

Use and costs of non-prescription medications among people with spinal cord injury

OBJECTIVES

The study objectives were to assess the prevalence of, and factors associated with the use and costs of non-prescription medications among people with spinal cord injury.

DESIGN

Observational design; a cross-sectional online survey Setting: Community in Canada Participants: Individuals with spinal cord injury Interventions: Not applicable Main Outcome Measures: Not applicable Results: A total of 160 individuals participated in this study. Of all study participants, 83% reported that they used at least one non-prescription medication over the last 12 months. On an average, participants spent $52 per month on non-prescription medications. The average use and monthly expenditure did not differ significantly by age, sex, or injury parameters. Vitamins and minerals were most commonly used and constituted 62% of all non-prescription medications listed by the participants. Musculoskeletal issues were the most common health problems for which non-prescription medications were used.

CONCLUSION

Non-prescription medications are a common part of therapeutic drug regimens for people with spinal cord injuries and are purchased as an out-of-pocket expense. These products may or may not have established benefits. Knowledge about the use of non-prescription medications may help prescribers to improve drug safety, medication affordability, and quality of pharmacotherapy for their patients with spinal cord injury.

Vitamin D supplementation in chronic spinal cord injury (VitD-SCI): study protocol for a randomised controlled trial

INTRODUCTION

Vitamin D insufficiency, a vitamin D status or serum 25(OH)D concentration of ≤75 nmol/L, is highly prevalent in individuals with a spinal cord injury (SCI). Vitamin D is important for the functioning of the musculoskeletal, immune and respiratory systems, which are relevant determinants of secondary health conditions in SCI. An insufficiency should be treated with vitamin D supplementation. However, there is a lack of evidence regarding the optimal dosage and duration of vitamin D supplementation for individualised and long-term management of the vitamin D status in the context of SCI. This paper presents the protocol for the vitamin D supplementation in chronic spinal cord injury (VitD-SCI) trial that aims to investigate the effect of a 12-month intake of vitamin D supplementation on vitamin D status as well as on several secondary parameters among individuals with a chronic SCI.

METHODS AND ANALYSES

The VitD-SCI trial is a randomised, placebo-controlled, double-blinded, parallel-group, superiority trial, conducted at the Swiss Paraplegic Centre. A total of 45 participants living with an SCI for at least 3 years (chronic SCI) and a vitamin D insufficiency at the first study visit, will be randomly assigned to one of three intervention groups. Participants receive either a monthly dosage of 24 000 IU or 48 000 IU vitamin D or a placebo for 12 months. Measurements taking place every 3 months include the assessment of vitamin D status (primary outcome) as well as bone mineral density, handgrip strength, fatigue, mood, pain and pressure injuries (secondary outcomes). Safety and tolerance of vitamin D supplementation will also be evaluated.

ETHICS AND DISSEMINATION

The Swiss Ethics Committee for Northwest/Central Switzerland (EKNZ, 2020-01493) and the Swiss Agency for Therapeutic Products (Swissmedic, 2020DR3150) approved this study. Findings will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBERS

NCT04652544 and SNCTP000004032.

Nutritional Considerations for Para-Cycling Athletes: A Narrative Review

Para-cycling is a sport including athletes with different disabilities competing on the track and on the roads using bicycles, tandems, tricycles, and handbikes. Scientific literature in this special population is scarce, especially in the field of sports nutrition. This review summarizes the physiological aspects and demands of para-cycling. This information together with the existing literature on nutritional interventions in this population, helps to discuss the nutritional considerations. To date, only a limited amount of recommendations are available for this population. In most para-cycling athletes, a reduction in active muscle mass and consequently a reduction in resting energy expenditure occurs, except for visually impaired athletes. Furthermore, carbohydrate and protein intake and hydration, supplementation, heat, and weight loss need to be tailored to the disability-specific adaptations such as the reduced active muscle mass, neurogenic bladder, and bowel, a reduced metabolic cost during exercise, and a higher risk of micronutrient deficiency.

Ionic Hydrogels Based Wearable Sensors to Monitor the Solar Radiation Dose for Vitamin D Production and Sunburn Prevention

Wearable solar radiation sensors based on ionic hydrogels are facilely prepared to simultaneously monitor the radiation dose for the production of vitamin D and the prevention of sunburn. Tetramethylethylenediamine (TEMED) is neutralized with acrylic acid (AA) to obtain tetramethylethylenediamine acrylate (TEMEDA), which is further polymerized with acrylamide by a free radical reaction. By simply adding MB or NR during the polymerization, the final obtained ionic hydrogels can indicate solar radiation. Due to the extent of discoloration, the discoloration speed of MB and NR is correlated to the radiation dose. This wearable sensor can indicate the solar radiation dose required by the human body to synthesize vitamin D through the discoloration of the ionized hydrogel of MB, whereas those with NR are able to illustrate the threshold of radiation dose that causes potential skin hurt. Therefore, the benefit and drawback of solar radiation can be well balanced by optimizing the exposure time to solar irradiation. In addition, polyurethane cross-linked with a thermoresponsive coating is used as band for this wearable sensor. Due to the hydrophilicity below its transition temperature, the cross-linked band possesses the easy cleaning capability of stains after the daily wear. Such type of wearable sensor can be broadly used for monitoring the solar radiation, especially in outdoor activities.

Prevalence of Vitamin D Deficiency in a Young Adult With Acute Spinal Cord Injury

Introduction: Vitamin D deficiency has been implicated as an etiologic factor responsible for osteoporosis and various skeletal and extra-skeletal issues in spinal cord injury patients. There is a dearth of publications regarding the prevalence of vitamin D deficiency in acute spinal cord injury (ASCI) patients, thus it becomes imperative to study the status of vitamin D in ASCI cases to make an early diagnosis and start treatment for osteoporosis. Apart from this, we also planned to evaluate other factors associated with vitamin D deficiency in our subset of patients.

Material and methods: This cross-sectional cohort study included patients with acute thoracolumbar spinal cord injury patients admitted to a tertiary trauma centre between July 2019 and July 2020. Patients were assessed clinically and classified as per the American Spinal Cord Injury Association (ASIA) scale. Demographic details along with the mode of trauma and duration of injury were noted. Serum 25(OH) vitamin D3 levels were measured by chemiluminescence immunoassay. Depending upon serum 25(OH) vitamin D3 level, patients were classified into vitamin D deficient with serum level less than 20 ng/ml, vitamin D insufficient with serum level between 21-29 ng/ml and vitamin D sufficient with serum level greater than 30 ng/ml.

Results: Mean vitamin D level in 85 ASCI subjects (mean age 30.82 ± 6.77 years, 60 males) was 20.56 ± 11.22 ng/ml. Fifty subjects (58.82%) were vitamin D deficient, 15 subjects (17.64%) were vitamin D insufficient and the rest (n=20, 23.52%) were vitamin D sufficient. There was no significant difference in vitamin D levels as per gender, age, mode of trauma, type of injury and injury location. Patients admitted on the fifth day of injury had maximum vitamin D levels (mean 25.7143 ± 8.32 ng/ml), but it was also insignificant. The mean vitamin D level of subjects with samples taken during the summer season was significantly higher as compared to the winter season (p value <.05).

Conclusion: Vitamin D deficiency is widely prevalent in ASCI patients at admission to the trauma centre. Seventy-six percent of patients had vitamin D levels below 30 ng/ml in our study. Routine measurement of 25(OH) vitamin D3 levels at the time of admission is recommended for early diagnosis of vitamin D deficiency. Early treatment will be helpful in the prevention of osteoporosis and its long-term related consequences. 

Vitamin D, sport and health: a still unresolved clinical issue

Vitamin D metabolites have a pleiotropic role in human physiology, both in static and dynamic conditions, and a lot of vitamin D-related biological effects could influence physical and sport performances in athletes. Probably due to different factors (e.g., drugs, doping, nutrition, ultraviolet B radiation exposure), in athletes a very high prevalence of vitamin D inadequacy (i.e., deficiency or insufficiency) has been observed. Vitamin D inadequacy in athletes could be associated with specific health risks and to alterations of functional capacities, potentially influencing the fine adjustment of physical performances during training and sport competitions. When risk factors for vitamin D inadequacy exist, a preventive vitamin D supplementation is indicated, and if a vitamin D inadequacy is diagnosed, its supplementation is recommended. Unfortunately, on these issues many concerns remain unresolved. Indeed, it is not clear if athletes should be classified as a special population at increased risk for vitamin D inadequacy; moreover, in comparison to the non-athletic population, it is still not clear if athletes should have different reference ranges and different optimal target levels for serum vitamin D, if they have additional health risks, and if they need different type of supplementations (doses) for prevention and/or replacement therapy. Moreover, in athletes also the abuse of vitamin D supplements for ergogenic purposes raise different ethical and safety concerns. In this review, the main physio-pathological, functional and clinical issues that relate vitamin D to the world of athletes are described.

Spinal cord injury providers' perspectives on managing sublesional osteoporosis

Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI. Design: Telephone interviews with SCI providers. Setting: VA SCI centers and clinics. Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed. Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures. Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.

Association of Bisphosphonate Therapy With Incident of Lower Extremity Fractures in Persons With Spinal Cord Injuries or Disorders

OBJECTIVE

To investigate the association between prescriptions for bisphosphonates; calcium and vitamin D supplements; and receipt of dual-energy x-ray absorptiometry (DXA) screening, and incident fracture risk in men and women with a spinal cord injury (SCI) or disorder (SCID).

DESIGN

Propensity-matched case-control analyses.

SETTING

United States Veterans Affairs (VA) facilities.

PARTICIPANTS

A total of 7989 men and 849 women with an SCID included in VA administrative databases between October 1, 2005 and October 1, 2015 were identified (N=8838). Cases included 267 men and 59 women with a bisphosphonate prescription propensity matched with up to 4 controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incident lower extremity fractures.

RESULTS

There was no significant association between prescriptions for bisphosphonates and incident lower extremity fractures in men (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.62-1.77) or women (OR, 1.02; 95% CI, 0.28-3.75). In men, similar null associations were seen among those who were adherent to bisphosphonate therapy (OR, 1.25; 95% CI, 0.73-2.16), were concomitant users of vitamin D and calcium and a bisphosphonate (OR, 1.05; 95% CI, 0.57-1.96), had more than 1 fracture on different dates during the study period (OR, 0.13; 95% CI, 0.02-1.16) and in those who had undergone DXA testing prior to the date of the bisphosphonate prescription and incident fracture (OR, 1.26; 95% CI, 0.69-2.32).

CONCLUSIONS

In men with a traumatic SCI and women with a traumatic SCID, bisphosphonate therapies for osteoporosis do not appear to significantly affect fracture risk. Adequately powered randomized controlled trials are needed to definitively demonstrate efficacy of bisphosphonates for fracture prevention in this population. There is a compelling need to identify new medications to prevent fractures in this high-risk population.

Plasma vitamin D, past chest illness, and risk of future chest illness in chronic spinal cord injury (SCI): a longitudinal observational study

STUDY DESIGN

Observational study.

OBJECTIVE

Assess associations between vitamin D levels and other risk factors on future chest illness in a chronic spinal cord injury (SCI) cohort.

SETTING

Veterans Affairs Boston and the Boston, MA community.

METHODS

Between August 2009 and August 2017, 253 participants with chronic SCI were followed over a median of 3.2 years (up to 7.4 years) with two to four visits a median of 1.7 years apart. At each visit, plasma 25-hydroxyvitamin D level was obtained, spirometry performed, and a respiratory questionnaire assessing chest illnesses since last visit was completed. Repeated measures negative binomial regression was used to assess chest illness risk longitudinally.

RESULTS

At entry, 25% had deficient vitamin D levels (<20 nanograms/milliliter (ng/ml)), 52% were insufficient (20 to <30 ng/ml), and 23% were sufficient (≥30 ng/ml). Over 545 study visits, chest illnesses (n = 106) were reported by 60 participants. In multivariable models (including previous chest illness history), deficient vitamin D levels (compared with those with sufficient levels) were associated with future chest illness though with wide confidence limits (relative risk (RR) = 1.36, 95% confidence intervals (CI) = 0.74, 2.47). The strongest association with chest illness during the follow-up period was in persons who reported pneumonia/bronchitis after injury and a chest illness in the three years before study entry (RR = 7.62; 95% CI = 3.70, 15.71).

CONCLUSION

Assessed prospectively in chronic SCI, there was a suggestive association between deficient vitamin D levels and future chest illness. Past chest illness history was also strongly associated with future chest illness.

A Primary Care Provider's Guide to Bone Health in Spinal Cord-Related Paralysis

Individuals with spinal cord injury/disorder (SCI/D) are at high risk for developing secondary osteoporosis. Bone loss after neurologic injury is multifactorial and is dependent on the time from and extent of neurologic injury. Most bone loss occurs in the first year after complete motor paralysis, and fractures occur most commonly in the distal femur and proximal tibia (paraplegic fracture). The 2019 International Society for Clinical Densitometry Position Statement in SCI establishes that dual-energy X-ray absorptiometry (DXA) can be used to both diagnose osteoporosis and predict lower extremity fracture risk in individuals with SCI/D. Pharmacologic treatments used in primary osteoporosis have mixed results when used for SCI/D-related osteoporosis. Ambulation, standing, and electrical stimulation may be helpful at increasing bone mineral density (BMD) in individuals with SCI/D but do not necessarily correlate with fracture risk reduction. Clinicians caring for individuals with spinal cord-related paralysis must maintain a high index of suspicion for fragility fractures and consider referral for surgical evaluation and management.

Weight-Bearing Physical Activity Influences the Effect of Vitamin D on Bone Turnover Markers in Patients with Intellectual Disability

OBJECTIVES

Individuals with intellectual disabilities (IDs) are at increased risk for low bone mass and fragility fractures, and those who are nonambulatory may be at even higher risk. Patients with IDs often are vitamin D deficient, but there is little information concerning how vitamin D treatment of patients with IDs affects markers of bone formation and resorption.

METHODS

We performed a retrospective analysis of 23 institutionalized individuals with IDs who were the subject of a performance improvement continuing medical education project designed to reduce risk for fracture by optimizing serum vitamin D levels. Patients were divided into those with normal weight-bearing (NWB) physical activity (15 patients: 14 men, 1 woman) and those with low weight-bearing (LWB) physical activity (8 patients: 7 men, 1 woman). All of the subjects received 50,000 IU of vitamin D₃ weekly for 4 to 8 weeks, followed by a maintenance dose of 50,000 IU monthly for 3 to 6 months. Bone turnover markers (type 1 cross-linked C-telopeptide [CTX], type 1 N-terminal propeptide [P1NP], and parathyroid hormone [PTH]) and 25(OH)-vitamin D levels were measured before and after vitamin D supplementation.

RESULTS

At baseline, there were no significant differences in the serum levels of 25OH-D, PTH, P1NP, or CTX between the two groups (NWB and LWB). Vitamin D levels were increased to a higher value in LWB subjects than in NWB subjects (61 ± 4.1 vs 48.4 ± 2.2 ng/mL, P < 0.001). Vitamin D treatment suppressed PTH (20.5% ± 14.3% vs 31.4% ± 7.7%, P = not significant) and P1NP (33.0% ± 6.2% vs 29.4% ± 6.9%, P = not significant) similarly in both groups. Although CTX levels declined by 26.4% ± 5.3% (P = 0.0002) in NWB individuals (as anticipated), vitamin D supplementation resulted in an unexpected 25.8% ± 8% increase (P = 0.01) in CTX in LWB individuals, suggesting osteoclast activation.

CONCLUSIONS

Although high-dose vitamin D appeared to suppress osteoclast activity in NWB adults with IDs, the increase in serum CTX levels in those with LWB activity implies activation of osteoclasts that could exacerbate their unique low bone mass and increase fracture risk. The results support the use of a lower-dose vitamin D regimen in this patient group with LWB.

Carboxy terminal collagen crosslinks as a prognostic risk factor for fall-related fractures in individuals with established spinal cord injury

Study design

Prospective cohort study.

Objective

To study associations between specific bone turnover markers and fall-related fractures in individuals with spinal cord injury (SCI).

Setting

Rehabilitation Hospital.

Methods

Carboxy terminal collagen crosslinks (CTX), type-1 procollagen N-terminal (P1NP), albumin-corrected calcium (Ca²⁺), parathyroid hormone (PTH) and vitamin D were examined in a cohort of 106 participants with SCI at least 1 year post injury. The participants were followed for 1 year monitoring fall-related fractures.

Results

In total, 29 out of 106 reported having experienced a fall-related fracture post-injury at baseline, and 5 out of 100 had experienced a fall-related bone fracture during the 1 year follow-up. Our main findings were that high levels of serum CTX increased the odds of being in the fracture group, and that 25-hydroxy vitamin D (25 OHD) levels, Ca²⁺, PTH or P1NP were not associated with being in the fracture group.

Conclusions

We here present an association between high-CTX plasma levels at baseline and fall-related fractures reported during a 1-year follow-up among individuals with established SCI. We recommend studies with larger SCI populations before further clinical implications can be drawn.

Venous Thromboembolism is Associated With Lack of Vitamin D Supplementation in Patients With Spinal Cord Injury and Low Vitamin D Levels

BACKGROUND

The role of vitamin D in the pathogenesis of venous thromboembolism (VTE) and prevalence of low vitamin D (LVitD) in spinal cord injury (SCI) has motivated vitamin D testing and supplementation. This is an exploratory study of data collected at a time before the routine clinical practice of vitamin D supplementation, allowing for evaluation of the natural history of vitamin D levels in patients with SCI.

OBJECTIVE

To determine if vitamin D supplementation in persons with SCI and LVitD levels is associated with decreased prevalence of VTE.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation Center at a Level I Trauma Center.

PARTICIPANTS

Patients with SCI admitted to acute inpatient rehabilitation (N = 282).

MAIN OUTCOME MEASURES

VTE prevalence in patients with LVitD levels, grouped by presence or absence of vitamin D supplementation.

RESULTS

Of the acute inpatient SCI population, 80% (227/282) of patients demonstrated vitamin D levels <30 ng/mL (LVitD). Although the incidence of VTE was almost double in the LVitD group, 19% (43/227) of the patients in the LVitD group had VTE versus 9% (5/55) of patients with vitamin D levels ≥30 ng/mL (normal VitD [NVitD]); this difference was not statistically significant (P = .108, Cramer's V = .104). When the role of vitamin D supplementation was analyzed, individuals in the LVitD group who received no vitamin D supplementation (LVitDSuppNegative) had a higher incidence of VTE (statistically significant) compared to the LVitD group with vitamin D supplementation (LVitDSuppPositive) (24% [42/178] vs. 2% [1/49]) (P < .001, Cramer's V = .226). In post hoc exploratory analyses, the VTE rate of patients in the LVitDSuppNegative group was noted to be significantly higher than that in all other patient groups combined (P < .001, Cramer's V = .229). A binary logistic regression model incorporating clinical covariates also showed this grouping to be significant.

CONCLUSION

A significant association appears to exist between lack of vitamin D supplementation and VTE occurrence in persons with acute SCI and LVitD levels.

LEVEL OF EVIDENCE

III.

Vitamin D, diet, and lifestyle in a chronic SCI population

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Determine dietary, lifestyle, and clinical factors associated with plasma 25-hydroxyvitamin D [25(OH)D] levels in persons with chronic spinal cord injury (SCI).

SETTING

Veterans Affairs Medical Center in Boston, MA.

METHODS

174 participants completed food frequency and health questionnaires, provided a blood sample, and underwent dual x-ray absorptiometry (DXA) to assess %total body fat. Linear regression models were used to assess cross-sectional associations of personal, lifestyle, and nutritional factors with plasma 25(OH)D.

RESULTS

Independent factors positively associated with higher plasma 25(OH)D included vitamin D intake, age, hours of planned exercise, female sex, white race, wine consumption, and if a never or former smoker. The most important predictor of 25(OH)D was supplement intake. The majority of subjects (98.9% for vitamin D and 74.1% for calcium) did not meet the recommended daily allowance for adults from their diet alone. Level and completeness of SCI, injury duration, mobility, %total body fat, time outside, and comorbid diseases were not associated with plasma 25(OH)D.

CONCLUSIONS

Plasma 25(OH)D level in chronic SCI is not associated with clinical factors specific to SCI such as injury level and completeness, injury duration, and mobility mode, but related to supplement intake and other lifestyle factors.

Evaluation of Dietary Supplement Use in Wheelchair Rugby Athletes

Wheelchair rugby is a rapidly growing Paralympic sport; however, research remains predominantly in the realms of physiology and biomechanics. Currently, there is little investigation into nutrition and dietary supplement use among wheelchair rugby athletes (WRA). The aim of this study was to assess the types of dietary supplements (DS) used, the prevalence of usage, and the reasons for use among WRA. The secondary aim was to report utilized and preferred sources of nutritional information among this population. A valid, reliable Dietary Supplement Questionnaire was used to report supplement use and reasons for use. Male (n = 33) and female (n = 9) WRA were recruited at a national tournament and through emailing coaches of various Canadian teams. Dietary supplement usage was prevalent as 90.9% of males and 77.8% of females reported usage within the past three months with the most regularly used supplements being vitamin D (26.2%), electrolytes (19.5%), and protein powder (19.5%). The most common reason for usage was performance. The top sources of nutrition information were dietitian/nutritionist and the internet. Further investigation into DS use is needed to help create nutritional guidelines that are accessible to WRA and athletes with disabilities in general.

Key Nutritional Strategies to Optimize Performance in Para Athletes

Para athletes are a high-risk population for inadequate dietary intake leading to insufficiencies in nutrients important to athletic performance. This is partly due to minimal support and resources, especially in sport nutrition education, combined with limited prior nutrition knowledge and risks associated with different impairment types. Inadequate energy, carbohydrate, protein, iron, and vitamin D status are of particular concern in Para athletes. Assessment of these key nutrients, along with sport nutrition education, is needed to empower Para athletes with the knowledge to understand their individual nutrition needs and maximize athletic performance.

Energy and Nutrient Issues in Athletes with Spinal Cord Injury: Are They at Risk for Low Energy Availability?

Low energy availability (LEA) and nutrient intake have been well studied in able-bodied athletes, but there is a lack of research examining these issues amongst athletes with spinal cord injury (SCI). To date, there have been no studies that have examined energy availability (EA) amongst this population. Furthermore, athletes with SCI may experience unique challenges around nutrition that may increase their risk of LEA. This review will evaluate the literature and assess whether this population is at risk for LEA. Due to the limited research on this topic, sedentary individuals with SCI and para athletes were also included in this review. Review of the current literature suggests that athletes with SCI may be at an increased risk for LEA. While research examining EA and risk of LEA in athletes with SCI is lacking, the number of athletes with SCI continues to increase; therefore, further research is warranted to assess nutrient and energy needs and their risk to this population.

Bioinformatics analysis of the molecular mechanisms underlying traumatic spinal cord injury

Spinal cord injury (SCI) is a cause of disability. The present study aimed to investigate the molecular mechanisms involved in traumatic SCI. Transcriptome data under accession no. GSE5296, including 96 chips, were downloaded from the Gene Expression Omnibus database. The raw data were normalized and differentially expressed genes (DEGs) were identified. Furthermore, Kyoto Encyclopedia of Genes and Genomes pathway and Gene Ontology enrichment analysis of up‑ and downregulated DEGs was performed. Additionally, a protein‑protein interaction network was constructed and the expression patterns of different genes were determined. Compared with sham samples, there were 374, 707, 1,322, 1,475, 1,724 and 1,342 DEGs identified at 0.5, 4, 24 and 72 h, and 7 and 28 days post‑injury, respectively. At 24 and 72 h, and 7 days following injury, the upregulated DEGs were markedly enriched in 'inflammatory response' and 'immune process'. Downregulated DEGs were predominantly enriched in neuronal function‑associated pathways and 'steroid biosynthesis' process. Protein‑protein interaction network analysis demonstrated similar results. Trend charts further demonstrated that the inflammatory and neuronal functions were altered in a temporal and site‑specific manner. The present study provided an insight into the molecular mechanisms underlying traumatic SCI, which may benefit future SCI research and aid in therapy development.

Evaluation of Dietary Intakes and Supplement Use in Paralympic Athletes

Dietary intakes and supplement use in Paralympic athletes remains largely unexplored, and specialized recommendations are lacking. The aim of this study was to evaluate nutrient intakes and supplement use in high-performance athletes with physical disabilities using three-day food records and a validated dietary supplement use questionnaire. A secondary aim examined gender differences in nutrient and supplement intakes. Male (n = 18) and female (n = 22) athletes were recruited from nine Paralympic sports through sporting organizations, coaches, and social media. Athletes generally met able-bodied recommendations for macronutrients. Male and female athletes often failed to meet the Recommended Dietary Allowance (RDA) or Adequate Intake (AI) for vitamin D, vitamin E, pantothenic acid, magnesium, and potassium. On average, females did not meet the RDA for iron and calcium, whereas males did not meet the RDA for vitamin A and folate. Commonly consumed supplements were vitamin D, protein powder, sport bars, and sport drinks. Analysis of diet and supplement use within this population shows several micronutrient deficiencies and irregular use of specific supplements. Athlete support and education is required to optimize nutrition in Paralympic athletes.