The prevalence of dyslipidemia in patients with spinal cord lesion in Thailand

Effects of walking training on risk markers of cardiovascular disease in individuals with chronic spinal cord injury

OBJECTIVE

To investigate the effects of an 8-week walking training program on glycemic control, lipid profile, and inflammatory markers in individuals with chronic spinal cord injury (SCI).

DESIGN

A pilot, single-group, pretest-posttest study.

SETTING

A neuromuscular research laboratory.

PARTICIPANTS

Eleven participants with chronic SCI.

INTERVENTION

An 8-week walking training program using a treadmill, a body weight-supported system, and an assistive gait training device.

OUTCOME MEASURES

Levels of glycated hemoglobin (HbA_1c), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), C-reactive protein (CRP), and interleukin-6 were assessed before and after the walking training.

RESULTS

Following the walking training, there was a statistically significant decrease in HbA_1c level (P<0.01) of uncertain clinical significance. The lipid profile improved after training, as shown by a statistically and clinically significant increase in HDL-C level (P<0.01) and a statistically significant decrease in LDL-C level (P<0.1) of no clinical significance. The ratio of LDL-C to HDL-C was significantly reduced (P<0.01). In regard to inflammatory markers, concentrations of IL-6 showed a significant reduction after training (P=0.05) of unknown clinical significance, while those of CRP trended to decrease (P=0.13).

CONCLUSION

The findings of this pilot study suggest that an 8-week walking training program may produce favorable changes in risk markers of cardiovascular disease in individuals with chronic SCI as shown by clinically meaningful improvements in HDL-C, and small changes in the right direction, but uncertain clinical significance, in HbA1c, LDL-C and IL-6. A randomized controlled trial is needed to compare the effects of walking training on these outcome measures with those of other exercise modalities suitable for this population, and to see if more prolonged exercise exposure leads to favorable parameters of significant size to justify the exercise modality.

The Potential Role of Inflammation in Modulating Endogenous Hippocampal Neurogenesis After Spinal Cord Injury

Currently there are approximately 291,000 people suffering from a spinal cord injury (SCI) in the United States. SCI is associated with traumatic changes in mobility and neuralgia, as well as many other long-term chronic health complications, including metabolic disorders, diabetes mellitus, non-alcoholic steatohepatitis, osteoporosis, and elevated inflammatory markers. Due to medical advances, patients with SCI survive much longer than previously. This increase in life expectancy exposes them to novel neurological complications such as memory loss, cognitive decline, depression, and Alzheimer's disease. In fact, these usually age-associated disorders are more prevalent in people living with SCI. A common factor of these disorders is the reduction in hippocampal neurogenesis. Inflammation, which is elevated after SCI, plays a major role in modulating hippocampal neurogenesis. While there is no clear consensus on the mechanism of the decline in hippocampal neurogenesis and cognition after SCI, we will examine in this review how SCI-induced inflammation could modulate hippocampal neurogenesis and provoke age-associated neurological disorders. Thereafter, we will discuss possible therapeutic options which may mitigate the influence of SCI associated complications on hippocampal neurogenesis.

Metabolic Dysfunction in Spinal Muscular Atrophy

Spinal muscular atrophy (SMA) is an autosomal recessive genetic disorder leading to paralysis, muscle atrophy, and death. Significant advances in antisense oligonucleotide treatment and gene therapy have made it possible for SMA patients to benefit from improvements in many aspects of the once devastating natural history of the disease. How the depletion of survival motor neuron (SMN) protein, the product of the gene implicated in the disease, leads to the consequent pathogenic changes remains unresolved. Over the past few years, evidence toward a potential contribution of gastrointestinal, metabolic, and endocrine defects to disease phenotype has surfaced. These findings ranged from disrupted body composition, gastrointestinal tract, fatty acid, glucose, amino acid, and hormonal regulation. Together, these changes could have a meaningful clinical impact on disease traits. However, it is currently unclear whether these findings are secondary to widespread denervation or unique to the SMA phenotype. This review provides an in-depth account of metabolism-related research available to date, with a discussion of unique features compared to other motor neuron and related disorders.

Dietetics After Spinal Cord Injury: Current Evidence and Future Perspectives

Following spinal cord injury (SCI), individuals are at high risk for obesity and several chronic cardiometabolic disorders due to a deterioration in body composition, hypometabolic rate, and endometabolic dysregulation. Countermeasures to the consequences of an SCI include adopting a healthy diet that provides adequate nutrition to maintain good body habitus and cardiometabolic health. A proper diet for individuals with SCI should distribute carbohydrates, protein, and fat to optimize a lower energy intake requirement and should stress foods with low caloric yet high nutrient density. The purpose of this article is to present available evidence on how nutritional status after SCI should advance future research to further develop SCI-specific guidelines for total energy intake, as it relates to percent carbohydrates, protein, fat, and all vitamins and minerals, that take into consideration the adaptations after SCI.

Hepatic dysfunction after spinal cord injury: A vicious cycle of central and peripheral pathology?

The liver is essential for numerous physiological processes, including filtering blood from the intestines, metabolizing fats, proteins, carbohydrates and drugs, and regulating iron storage and release. The liver is also an important immune organ and plays a critical role in response to infection and injury throughout the body. Liver functions are regulated by autonomic parasympathetic innervation from the brainstem and sympathetic innervation from the thoracic spinal cord. Thus, spinal cord injury (SCI) at or above thoracic levels disrupts major regulatory mechanisms for hepatic functions. Work in rodents and humans shows that SCI induces liver pathology, including hepatic inflammation and fat accumulation characteristic of a serious form of non-alcoholic fatty liver disease (NAFLD) called non-alcoholic steatohepatitis (NASH). This hepatic pathology is associated with and likely contributes to indices of metabolic dysfunction often noted in SCI individuals, such as insulin resistance and hyperlipidemia. These occur at greater rates in the SCI population and can negatively impact health and quality of life. In this review, we will: 1) Discuss acute and chronic changes in human and rodent liver pathology and function after SCI; 2) Describe how these hepatic changes affect systemic inflammation, iron regulation and metabolic dysfunction after SCI; 3) Describe how disruption of the hepatic autonomic nervous system may be a key culprit in post-injury chronic liver pathology; and 4) Preview ongoing and future research that aims to elucidate mechanisms driving liver and metabolic dysfunction after SCI.

Development of Cardiometabolic Health indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Context: Spinal cord injury or disease (SCI/D) leads to unchanged low-density lipoprotein and cholesterol, very low high-density lipoprotein a form of dyslipidemia and physical inactivity which combine to increase risk of morbidity and mortality from cardiometabolic disease. Herein, we describe the selection of structure, process and outcome indicators for adults in the first 18 months post-SCI/D rehabilitation admission. Methods: A Pan-Canadian Cardiometabolic Health Working Group was formed to develop a construct definition. Cardiometabolic risk factors were summarized in a Driver diagram. Release of the Paralyzed Veterans of America "Identification and Management of Cardiometabolic Risk after Spinal Cord Injury" and the International Scientific Exercise Guidelines: "Evidence-based scientific exercise guidelines for adults with spinal cord injury", informed the group's focus on prevention strategies to advance this Domain of rehabilitation admission. Results: The structure indicator identifies during rehabilitation the presence of appropriate time and resources for physical exercise prescription. Process indicators are lipid profile assessment at rehabilitation admission and documented exercise prescriptions prior to discharge. The outcome indicators track patient's knowledge retention regarding exercise prescription at discharge, current exercise adherence and lipid status 18 months after rehabilitation discharge. Conclusion: Routine national implementation of these indicators at the specified time points will enhance efforts to detect dyslipidemia and assure routine participation in endurance exercise. These indicators align with international initiatives to improve cardiometabolic health through interventions targeting modifiable risk factors specifically endurance exercising and optimal lipid profiles, crucial to augmenting cardiometabolic health after SCI/D.

Physical activity and sedentary behaviour research in Thailand: a systematic scoping review

BACKGROUND

The number of deaths per year attributed to non-communicable diseases is increasing in low- and middle-income countries, including Thailand. To facilitate the development of evidence-based public health programs and policies in Thailand, research on physical activity (PA) and sedentary behaviour (SB) is needed. The aims of this scoping review were to: (i) map all available evidence on PA and SB in Thailand; (ii) identify research gaps; and (iii) suggest directions for future research.

METHODS

A systematic literature search was conducted through 10 bibliographic databases. Additional articles were identified through secondary searches of reference lists, websites of relevant Thai health organisations, Google, and Google Scholar. Studies written in Thai or English were screened independently by two authors and included if they presented quantitative or qualitative data relevant to public health research on PA and/or SB.

RESULTS

Out of 25,007 screened articles, a total of 564 studies were included in the review. Most studies included PA only (80%), 6.7% included SB only, and 13.3% included both PA and SB. The most common research focus was correlates (58.9%), followed by outcomes of PA/SB (22.2%), prevalence of PA/SB (12.4%), and instrument validation (3.2%). Most PA/SB research was cross-sectional (69.3%), while interventions (19.7%) and longitudinal studies (2.8%) were less represented. Most studies (94%) used self-reports of PA/SB, and few (2.5%) used device-based measures. Both sexes were examined in most studies (82.5%). Adults were the main target population group (51.1%), followed by older adults (26.9%), adolescents (15.7%), and children (6.3%). Clinical populations were investigated in the context of PA/SB in a relatively large number of studies (15.3%), most frequently those with cardiovascular disease, diabetes, and hypertension (22%, 21%, and 21% respectively).

CONCLUSIONS

The number of Thai papers on PA published per year has been increasing, indicating a growing interest in this research area. More studies using population-representative samples are needed, particularly among children and adolescents, and investigating SB as a health risk factor. To provide stronger evidence on determinants and outcomes of PA/SB, longitudinal studies using standardised measures of PA and SB are required.

The analysis of serum lipid levels in patients with spinal cord injury

STUDY DESIGN

Retrospective study.

OBJECTIVES

The purposes of this investigation were to evaluate the serum lipid profile among a broad sample of patients with spinal cord injury (SCI), examining the impact of disease duration, lesion level, lesion grade and functional activity level on serum lipid levels of patients with SCI.

SETTING

Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Turkey.

METHODS

Serum lipid profiles of 269 participants with SCI were analyzed and correlated to disease duration, lesion level, lesion grade and ambulation status.

RESULTS

Total cholesterol (TC) was higher than normal in 21.2%, low density lipoprotein cholesterol in 24.4%, and triglycerides levels in 31% of the patients. The high density lipoprotein cholesterol (HDL-c) level was found to be lower than 40 mg/dl in 79.5% of the patients, TC/HDL-c ratio was 4.5 and above in 65.7% of the patients in our study. TC/HDL-c ratio was significantly higher in patients with SCI with a disease duration of 0-12 months than the group with a longer disease duration (P = 0.009). TC/HDL-c ratio was significantly higher in patients who could not be community ambulated than the patients who were community ambulated (P = 0.005). HDL-c levels in patients with motor complete SCI were significantly lower than patients with motor incomplete SCI (P = 0.028).

CONCLUSION

Dyslipidemia is observed in a large number of patients with SCI. The risk of dyslipidemia was seen to have increased in motor complete SCI patients, in patients who can not be community ambulated and whose disease duration is between 0 to 12 months.

Liver Adiposity and Metabolic Profile in Individuals with Chronic Spinal Cord Injury

PURPOSE

To quantify liver adiposity using magnetic resonance imaging (MRI) and to determine its association with metabolic profile in men with spinal cord injury (SCI).

MATERIALS AND METHODS

MRI analysis of liver adiposity by fat signal fraction (FSF) and visceral adipose tissue (VAT) was completed on twenty participants. Intravenous glucose tolerance test was conducted to measure glucose effectiveness (S_g) and insulin sensitivity (S_i). Lipid panel, fasting glucose, glycated hemoglobin (HbA1c), and inflammatory cytokines were also analyzed.

RESULTS

Average hepatic FSF was 3.7% ± 2.1. FSF was positively related to TG, non-HDL-C, fasting glucose, HbA1c, VAT, and tumor necrosis factor alpha (TNF-α). FSF was negatively related to S_i and testosterone. FSF was positively related to VAT (r = 0.48, p = 0.032) and TNF-α (r = 0.51, p = 0.016) independent of age, level of injury (LOI), and time since injury (TSI). The associations between FSF and metabolic profile were independent of VAT.

CONCLUSIONS

MRI noninvasively estimated hepatic adiposity in men with chronic SCI. FSF was associated with dysfunction in metabolic profile, central adiposity, and inflammation. Importantly, liver adiposity influenced metabolic profile independently of VAT. These findings highlight the significance of quantifying liver adiposity after SCI to attenuate the development of metabolic disorders.

Is the pattern of dietary amino acids intake associated with serum lipid profile and blood pressure among individuals with spinal cord injury?

OBJECTIVE

The probable effect of dietary amino acids intake pattern on serum lipid profile and blood pressure (BP) have not yet been described among individuals with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

People with SCI referred to Brain and Spinal Cord Injury Research Center between 2011 and 2014.

OUTCOME MEASURES

Dietary intakes were assessed by recording consumed foods by 24-hour dietary recall interviews using Nutritionist IV 3.5.3 modified for Iranian foods. Partial correlation test with adjustment for age, weight, body mass index, total energy intake, total fat, cholesterol and carbohydrate intake, and injury-related variables was used.

RESULTS

Dietary intake of lysine was positively related to levels of fasting plasma glucose (FPG), triglyceride (TG), systolic blood pressure (SBP) and diastolic blood pressure (DBP) (P < 0.0001, 0.046, 0.002 and 0.009, respectively). There was a positive significant relationship between the intake of cysteine and levels of TG and SBP as well (P : 0.027 and 0.048, respectively). Higher intakes of threonine and leucine had a negative relationship with TG level (P : 0.001 and 0.026, respectively). Furthermore, tyrosine, threonine and leucine were inversely correlated to blood pressure. Total cholesterol level was only related to intake of threonine and leucine (P : 0.004 and 0.012, respectively). FPG was positively associated with intake of all amino acids except for cysteine, glutamic acid, threonine, leucine and histidine.

CONCLUSION

In the present study, the pattern of relationships between dietary intake of amino acids and serum lipid profile and BP has been described among people with SCI.

Cardiovascular disease risk in people with spinal cord injury: is there a possible association between reduced lung function and increased risk of diabetes and hypertension?

STUDY DESIGN

Retrospective, descriptive study of medical files 253 patients with chronic traumatic spinal cord injury (SCI).

OBJECTIVES

To determine the frequency of cardiovascular disease (CVD) risk factors in SCI people, to estimate CVD risk in this population according to the Framingham Risk Score (FRS) and to determine whether reduced lung function parameters are significant predictors of diabetes mellitus (DM) and hypertension.

SETTING

Academic Rehabilitation Hospital.

METHODS

Demographic and clinical records of the patients and lung function parameters were obtained.

RESULTS

The FRS could not be calculated in 26 (10.3%) patients because this tool is designed for adults aged 20 years and older. According to the FRS guideline, ~6.7% of the SCI patients had high risk, 5.9% of them had intermediate risk and 77.1% of the study group had low risk for CVD. Regression analysis showed that impaired lung function parameters (FEV1, FVC and MVV) were significant predictors for the future development of hypertension (odds ratio (OR): 0.483 (0.258-0.903 95% confidence interval (CI)), OR: 0.549 (0.319-0.946 95% CI) and OR: 0.981 (0.965-0.998 95% CI), respectively) and DM (OR: 0.335 (0.140-0.801 95% CI), OR: 0.391 (0.183-0.839 95% CI) and OR: 0.970 (0.947-0.993 95% CI), respectively) in the SCI population.

CONCLUSION

This study showed that there might be a significant relationship between reduced lung function and the risk of DM and hypertension in people with SCI. Therefore, systematic measurement of these parameters should be performed in the routine clinical follow-up of SCI patients. Once reduced lung parameters are determined, the higher risk for developing hypertension and DM should be considered.

Regional neurovascular coupling and cognitive performance in those with low blood pressure secondary to high-level spinal cord injury: improved by alpha-1 agonist midodrine hydrochloride

Individuals with high-level spinal cord injury (SCI) experience low blood pressure (BP) and cognitive impairments. Such dysfunction may be mediated in part by impaired neurovascular coupling (NVC) (i.e., cerebral blood flow responses to neurologic demand). Ten individuals with SCI >T6 spinal segment, and 10 age- and sex-matched controls were assessed for beat-by-beat BP, as well as middle and posterior cerebral artery blood flow velocity (MCAv, PCAv) in response to a NVC test. Tests were repeated in SCI after 10 mg midodrine (alpha1-agonist). Verbal fluency was measured before and after midodrine in SCI, and in the control group as an index of cognitive function. At rest, mean BP was lower in SCI (70 ± 10 versus 92 ± 14 mm Hg; P<0.05); however, PCAv conductance was higher (0.56 ± 0.13 versus 0.39 ± 0.15 cm/second/mm Hg; P<0.05). Controls exhibited a 20% increase in PCAv during cognition; however, the response in SCI was completely absent (P<0.01). When BP was increased with midodrine, NVC was improved 70% in SCI, which was reflected by a 13% improved cognitive function (P<0.05). Improvements in BP were related to improved cognitive function in those with SCI (r(2)=0.52; P<0.05). Impaired NVC, secondary to low BP, may partially mediate reduced cognitive function in individuals with high-level SCI.

Regulation of cerebral blood flow after spinal cord injury

Significant cardiovascular and autonomic dysfunction occurs after era spinal cord injury (SCI). Two major conditions arising from autonomic dysfunction are orthostatic hypotension and autonomic dysreflexia (i.e., severe acute hypertension). Effective regulation of cerebral blood flow (CBF) is essential to offset these drastic changes in cerebral perfusion pressure. In the context of orthostatic hypotension and autonomic dysreflexia, the purpose of this review is to critically examine the mechanisms underlying effective CBF after an SCI and propose future avenues for research. Although only 16 studies have examined CBF control in those with high-level SCI (above the sixth thoracic spinal segment), it appears that CBF regulation is markedly altered in this population. Cerebrovascular function comprises three major mechanisms: (1) cerebral autoregulation, (i.e., ΔCBF/Δ blood pressure); (2) cerebrovascular reactivity to changes in PaCO2 (i.e. ΔCBF/arterial gas concentration); and (3) neurovascular coupling (i.e., ΔCBF/Δ metabolic demand). While static cerebral autoregulation appears to be well maintained in high-level SCI, dynamic cerebral autoregulation, cerebrovascular reactivity, and neurovascular coupling appear to be markedly altered. Several adverse complications after high-level SCI may mediate the changes in CBF regulation including: systemic endothelial dysfunction, sleep apnea, dyslipidemia, decentralization of sympathetic control, and dominant parasympathetic activity. Future studies are needed to describe whether altered CBF responses after SCI aid or impede orthostatic tolerance. Further, simultaneous evaluation of extracranial and intracranial CBF, combined with modern structural and functional imaging, would allow for a more comprehensive evaluation of CBF regulatory processes. We are only beginning to understand the functional effects of dysfunctional CBF regulation on brain function on persons with SCI, which are likely to include increased risk of transient ischemic attacks, stroke, and cognitive dysfunction.