Comparison of methods to assess energy expenditure and physical activity in people with spinal cord injury

Psychosocial Outcomes Associated With Types and Intensities of Physical Activity in People With Spinal Cord Injury: The Mediating Role of Self-Efficacy and Functionality

BACKGROUND

Low rates of participation and quality of life (QoL) and high rates of psychological distress are common in spinal cord injury (SCI) population. Research has supported the mediating role of self-efficacy and functionality in improving psychosocial outcomes. Furthermore, evidence supports the impact of physical activity (PA) on psychosocial variables, but little is known about the types and intensities of PA. The objective of this study was to determine whether functionality and/or general self-efficacy (GSE) mediate the relationships between the various types of PA: (1) lifestyle and (2) leisure-time physical activity (LTPA); and various intensities of PA: (1) mild, (2) moderate, and (3) heavy PA with participation, psychological distress, and perception of QoL.

METHODS

The Physical Activity Recall Assessment for SCI, and measures of functionality, GSE, participation, psychological distress, and perception of QoL were administered to 159 participants. Path analysis was performed using Jeffrey's Amazing Statistics Program.

RESULTS

GSE significantly mediated, and functionality partially significantly mediated, the relationship between LTPA and psychosocial outcomes. GSE and functionality did not mediate the relationship between lifestyle activity and psychosocial outcomes.

CONCLUSIONS

It is recommended that people with SCI perform LTPA on a regular basis to achieve psychosocial benefits. These programs should be accompanied by strategies to improve GSE.

Cross-Cultural Adaptation and Validation of the Arabic Version of the Physical Activity Scale for Individuals with Physical Disabilities in Saudi Arabia (PASIPD-AR)

This study aimed to cross-culturally adapt and validate the Arabic version of the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) with Saudi Arabian participants. The study encompassed four distinct stages: (i) translation and subsequent back-translation; (ii) a preliminary assessment aimed at evaluating the quality of the translated scale; (iii) an assessment of the reliability of the measures employed; and (iv) a comprehensive examination of the validity of the measures. A sample of Saudi Arabian participants with physical disabilities (N = 206) took part, ranging in age from 18 to 70 years old, with an average age of 39.56 years and a standard deviation of 12.16. The findings obtained from the reliability tests indicated a notable level of internal consistency and stability. Experts and confirmatory factor analysis were employed to establish the face, content, and construct validity. The findings of the assessment of the Arabic version of PASIPD demonstrated a satisfactory degree of reliability and validity, rendering it suitable for implementation within the Saudi Arabian setting.

Trends in measuring BMR and RMR after spinal cord injury: a comprehensive review

Studying factors that contribute to our understanding of maintaining normal energy balance are of paramount significance following spinal cord injury (SCI). Accurate determination of energy needs is crucial for providing nutritional guidance and managing the increasing prevalence of malnutrition or obesity after SCI. BMR represents 75-80 % of the total energy expenditure in persons with SCI. Accurately measuring BMR is an important component for calculating total energetic needs in this population. Indirect calorimetry is considered the gold-standard technique for measuring BMR. However, technical challenges may limit its applications in large cohort studies and alternatively rely on prediction equations. Previous work has shown that BMR changes in response to disuse and exercise in the range of 15-120 %. Factors including sex, level of injury and type of assistive devices may influence BMR after SCI. RMR is erroneously used interchangeably for BMR, which may result in overestimation of energetic intake when developing nutritional plans. To address this concern, we comprehensively reviewed studies that conducted BMR (n=15) and RMR (n=22) in persons with SCI. The results indicated that RMR is 9 % greater than BMR in persons with SCI. Furthermore, the SCI-specific prediction equations that incorporated measures of fat-free mass appeared to accurately predict BMR. Overall, the current findings highlighted the significance of measuring BMR as well as encouraging the research and clinical community to effectively establish countermeasures to combat obesity after SCI.

Reinventing the wheel for a manual wheelchair

PURPOSE

Standard manual wheelchairs (MWCs) are inefficient and pushrim propulsion may cause progressive damage and pain to the user's arms. We describe a wheel for a MWC with a novel propulsion mechanism.

METHODS

The wheel has two modes of operation called "Standard" mode and "Run" mode. In Run mode, the wheelchair is propelled forward by pushing a compliant handle forward and then pulling it back, both strokes contributing to forward propulsion. We report the propulsive force and preliminary testing on a rough outdoor circuit by three able-bodied participants.

RESULTS

In Run mode, the peak applied force is reduced to 30% and the maximum force gradient is reduced to 10% of that for standard pushrim propulsion, for the same work output. The travel time for the 1.06 km outdoor circuit is about 60% of that for a brisk walk and about 40% of that for pushrim propulsion. At a propulsion speed of 1 m/s, the cardiovascular effort in Run mode is 56% of that for pushrim propulsion. Automatic hill-hold in Run mode improves safety when ascending slopes. The mechanism has three gears so that it can be used by people with widely varying strength and fitness. Folding the handle away converts the operation to Standard mode with the conventional pushrim propulsion, supplemented by three gears.

CONCLUSIONS

Despite the increased weight, width and friction, the bimodal geared wheels facilitate wheelchair travel on challenging paths. This may bring significant improvement to the quality of life of MWC users.

Effects of behaviour change interventions on physical activity in people with spinal cord injury: A systematic review and meta-analysis

OBJECTIVES

This review investigated the effectiveness of behaviour-change interventions to improve physical activity (PA) participation in individuals with a spinal cord injury. Additionally, the review sought to analyse the change in PA behaviour that might be expected by utilising behaviour change in PA interventions and what specific intervention characteristics, application of behaviour change theories, and behaviour change techniques are most efficacious.

METHODS

The protocol was prospectively registered on PROSPERO: CRD42021252744, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed in this review. Eight databases were comprehensively searched using a well-defined strategy developed in collaboration with an academic liaison librarian. Randomised, non-randomised controlled, and non-controlled studies were included in this review; however, controlled and non-controlled studies were analysed separately. Studies were included if participants were older than 16 years and had an SCI of any cause, level or severity, regardless of the time since injury. The behaviour change technique taxonomy version 1 was used to code the intervention characteristics for behaviour modification. The combined effects across studies were pooled in a meta-analysis, and the risk of bias was assessed using the Cochrane Risk of Bias 2 tool.

RESULTS

The search retrieved 10,155 titles and abstracts. After duplicate removal and screening against the eligibility criteria, 23 studies were included. The overall effect estimate of the change in PA participation in the controlled trials post-intervention was medium (d = 0.50, 95% CI = 0.31-0.70) in favour of behaviour-targeted interventions. The mean difference in PA volume between pre- and post-intervention was an increase of 22 minutes per week (95% CI = 5.96-38.90). Interventions that provided practical support (d = 0.81, 95% CI = 0.46-1.16), which were individualised (d = 0.62, 95% CI = 0.34-0.90) and that utilised monitoring (d = 0.59, 95% CI = 0.34-0.83) had a greater effect on change to PA than those that were group-based and did not utilise those specific techniques.

CONCLUSIONS

Interventions that target behaviour change to increase PA in people with SCI appear effective. Utilising behaviour change frameworks and specific behaviour change techniques augments PA uptake and levels, and interventions aimed at improving PA in people with SCI should incorporate a behaviour modification component. More research is needed on the isolated effect of intervention structure parameters and specific behaviour change techniques.

Energy expenditure and nutrient intake after spinal cord injury: a comprehensive review and practical recommendations

Many persons with spinal cord injury (SCI) have one or more preventable chronic diseases related to excessive energetic intake and poor eating patterns. Appropriate nutrient consumption relative to need becomes a concern despite authoritative dietary recommendations from around the world. These recommendations were developed for the non-disabled population and do not account for the injury-induced changes in body composition, hypometabolic rate, hormonal dysregulation and nutrition status after SCI. Because evidence-based dietary reference intake values for SCI do not exist, ensuring appropriate consumption of macronutrient and micronutrients for their energy requirements becomes a challenge. In this compressive review, we briefly evaluate aspects of energy balance and appetite control relative to SCI. We report on the evidence regarding energy expenditure, nutrient intake and their relationship after SCI. We compare these data with several established nutritional guidelines from American Heart Association, Australian Dietary Guidelines, Dietary Guidelines for Americans, Institute of Medicine Dietary Reference Intake, Public Health England Government Dietary Recommendations, WHO Healthy Diet and the Paralyzed Veterans of America (PVA) Clinical Practice Guidelines. We also provide practical assessment and nutritional recommendations to facilitate a healthy dietary pattern after SCI. Because of a lack of strong SCI research, there are currently limited dietary recommendations outside of the PVA guidelines that capture the unique nutrient needs after SCI. Future multicentre clinical trials are needed to develop comprehensive, evidence-based dietary reference values specific for persons with SCI across the care continuum that rely on accurate, individual assessment of energy need.

mHealth Physical Activity Intervention for Individuals With Spinal Cord Injury: Planning and Development Processes

Background

Interventions to support physical activity participation among individuals with spinal cord injury (SCI) are required given this population’s low levels of physical activity and extensive barriers to quality physical activity experiences.

Objective

This study aimed to develop a mobile health intervention, called SCI Step Together, to improve the quantity and quality of physical activity among individuals with SCI who walk.

Methods

Our overarching methodological framework was the Person-Based approach. This included the following 4 steps: conduct primary and secondary research (step 1); design intervention objectives and features (step 2a); conduct behavioral analysis and theory (step 2b); create a logic model (step 3); and complete the SCI Step Together program content and integrated knowledge translation (IKT; step 4), which occurred throughout development. The partnership approach was informed by the SCI IKT Guiding Principles. Three end users pilot-tested the app and participated in the interviews.

Results

Step 1 identified issues to be addressed when designing intervention objectives and features (step 2a) and features were mapped onto the Behavior Change Wheel (step 2b) to determine the behavior change techniques (eg, action planning) to be included in the app. The logic model linked the mechanisms of action to self-determination theory (steps 2/3). Interviews with end users generated recommendations for the technology (eg, comparing physical activity levels with guidelines), trial (eg, emailing participants’ worksheets), and intervention content (eg, removing graded tasks; step 4).

Conclusions

Using the SCI IKT Guiding Principles to guide partner engagement and involvement ensured that design partners had shared decision-making power in intervention development. Equal decision-making power maximizes the meaningfulness of the app for end users. Future research will include testing the acceptability, feasibility, and engagement of the program. Partners will be involved throughout the research process.

Trial Registration

ClinicalTrials.gov: NCT05063617; https://clinicaltrials.gov/ct2/show/NCT05063617

Higher Physical Activity Level Improves Leptin Concentrations in Spinal Cord Injury Subjects

The present study was designed to compare the body composition and indicators of chronic inflammatory grade, such as leptin, adiponectin, and resistin concentrations in irregularly active and active SCI subjects. Thirty-two male subjects participated in this study. They were divided into three groups: able-bodied control irregularly active (control, n = 11), irregularly active with SCI (SCI-IA, n = 8), and physically active with SCI (SCI-PA, n = 13). The enzyme-linked immunosorbent assay (ELISA) assessed serum concentrations of leptin, adiponectin, and resistin. All volunteers performed the maximum oxygen uptake (VO_2max) test, 24 h total energy expenditure (TEE), and body composition by skinfold thicknesses. Leptin concentrations were higher in the SCI-IA group when compared to the other groups, while no significant differences were found between the SCI-PA and control cohorts. In addition, no significant differences were found among groups for serum adiponectin and resistin concentrations either. The SCI-PA group showed significantly higher values for TEE and VO_2max when compared to the other groups. Percentages of body fat and circumference were decreased in the control and SCI-PA groups when compared to the SCI-IA cohort. Associations between leptin and cardiorespiratory capacity and anthropometric markers were also observed. Our findings highlight that the lack of physical activity in the SCI subjects leads to poor general physical fitness and higher levels of body adiposity, which may induce hyperleptinemia, an essential marker for cardiometabolic disorders.

Cultural adaptation and Turkish version of Physical Activity Scale for Individuals with Physical Disabilities in individuals with spinal cord injury: a reliability and validity study

PURPOSE

To translate the "Physical Activity Scale for Individuals with Physical Disabilities (PASIPD)" into Turkish, to make a cultural adaptation, and to examine the psychometric properties including validity and reliability.

METHODS

During the translation period cross-cultural adaptation design proposed by guideline was used. Patients completed the Turkish version of the PASIPD and it was applied again a week later. To determine the reliability and internal consistency, Cronbach's alpha coefficient was calculated. Test-retest reliability was determined by using intraclass correlation coefficient (ICC) and Pearson's correlation analysis. Construct validity was examined with factor analysis. Convergent validity was examined by comparing PASIPD with Functional Independent Measurement (FIM), Nottingham Health Profile (NHP), and Craig Handicap Assessment and Reporting Technique Short (CHART-SF), and criterion validity was examined by comparing PASIPD with Manual wheelchair propulsion tests scores.

RESULTS

Cronbach's alpha coefficient was 0.725. The ICC coefficient for the test-retest reliability was 0.851. PASIPD was explained by three factors. The ratio of explaining the total variance of these 3 factors was determined as 51.66%. FIM (r = 0.307, p = 0.040) and CHART-SF were moderately positively correlated with PASIPD total score. The correlation between the total score of PASIPD and NHP was r = -0.443 (p = 0.002). 20 Meters Propulsion (r = -0.404, p = 0.005) and Slalom Tests (r = -0.305, p = 0.037) were highly negative and 6 min Push Propulsion (r = 0.456, p = 0.001) were moderately positive with PASIPD total score.

CONCLUSION

The Turkish version of the PASIPD is a valid and reliable scale in patients with spinal cord injury. IMPLICATIONS FOR REHABILITATIONThe Turkish and cross-culturally adapted version of PASIPD is a useful physical activity scale to evaluate the physical activity level of SCI.The Turkish version of the PASIPD is a valid and reliable scale and can be used in Turkish patients with SCI.PASIPD can be used to compare physical activity levels between disability types and groups with and without disabilities.PASIPD can be used to evaluate the effectiveness of attempts to increase physical activity in patients with SCI.

Comparison of total and activity energy expenditure estimates from physical activity questionnaires and doubly labelled water: a systematic review and meta-analysis

Physical activity questionnaires (PAQ) could be suitable tools in free-living people for measures of physical activity, total and activity energy expenditure (TEE and AEE). This meta-analysis was performed to determine valid PAQ for estimating TEE and AEE using doubly labelled water (DLW). We identified data from relevant studies by searching Google Scholar, PubMed and Scopus databases. This revealed thirty-eight studies that had validated PAQ with DLW and reported the mean differences between PAQ and DLW measures of TEE (TEEDLW - TEEPAQ) and AEE (AEEDLW - AEEPAQ). We assessed seventy-eight PAQ consisting of fifty-nine PAQ that assessed TEE and thirty-five PAQ that examined AEE. There was no significant difference between TEEPAQ and TEEDLW with a weighted mean difference of -243·3 and a range of -841·4 to 354·6 kJ/d, and a significant weighted mean difference of AEEDLW - AEE PAQ 414·6 and a range of 78·7-750·5. To determine whether any PAQ was a valid tool for estimating TEE and AEE, we carried out a subgroup analysis by type of PAQ. Only Active-Q, administered in two seasons, and 3-d PA diaries were correlated with TEE by DLW at the population level; however, these two PAQ did not demonstrate an acceptable limit of agreement at individual level. For AEE, no PAQ was correlated with DLW either at the population or at the individual levels. Active-Q and 3-d PA diaries were identified as the only valid PAQ for TEE estimation. Further well-designed studies are needed to verify this result and identify additional valid PAQ.

Physical activity recall assessment for people with spinal cord injury: Thai translation and cross-cultural adaptation

PURPOSE

This research sought to translate and culturally adapt the content of the original Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) into the Thai language and to assess its inter- and intra-rater reliability.

METHODS

This study was divided into two parts; (i) translation and cross-cultural adaptation, using a six-step guideline-based translation-validation process and (ii) reliability assessment of the translated survey tool using intraclass correlation coefficients (ICCs), Bland-Altman plots and one-way ANOVA analyses.

RESULTS

The Thai-PARA-SCI was successfully developed. The results revealed an excellent inter-rater reliability (ICC = 0.99, 95% CI range from 0.959-0.999) and the Bland-Altman plots showed little difference in times spent engaged physical activity. Intra-rater reliability results were affected inadvertently by testing across an unusual period, demonstrating poor to moderate scores (ICC ranged from 0.05-0.69, 95% CI ranged from -0.067-0.830) with the Bland-Altman plots showing very different ranges of time spent on physical activity.

CONCLUSION

This study achieved its aims of culturally and systematically translating the English PARA-SCI interview script into the Thai version with excellent scores for inter-rater reliability and was proven to be understandable by prospective users (Thai-PT) and participants (Thai-SCI).Implications for RehabilitationA robust cross-cultural translation and adaptation of the Physical Activity Recall Assessment for people with Spinal Cord Injury (PARA-SCI) into the Thai context has been undertaken, providing an effective exemplar for converting patient reported health outcome measures between languages of different root origins.When using the PARA-SCI as a pre- and post-intervention outcomes survey, clinicians should ensure that the timing of interview administration does not coincide with any unintended alterations in work-life balance, to ensure that the data are representative of the habitual physical activity levels performed by participants in their daily lives.Due to the possibility that physical activity levels could vary day-by-day or week-to-week, using the same day measurement findings may be a more reliable way to deploy the PARA-SCI than repeated assessments week(s) apart.

Energy Expenditure Following Spinal Cord Injury: A Delicate Balance

Following a spinal cord injury (SCI), neurogenic obesity results from changes in body composition, physical impairment, and endometabolic physiology and when dietary intake exceeds energy expenditure. Given the postinjury reductions in lean body mass, sympathetic nervous system dysfunction, and anabolic deficiencies, energy balance is no longer in balance, and thereby an obesogenic environment is created that instigates cardiometabolic dysfunction. Accurate determination of metabolic rate can prevent excess caloric intake while promoting positive body habitus and mitigating obesity-related comorbidities. Metabolic rate as determined by indirect calorimetry (IC) has not been adopted in routine clinical care for persons with SCI despite several studies indicating its importance. This article reviews current literature on measured and predicted metabolic rate and energy expenditure after SCI and stresses the importance of IC as standard of care for persons with SCI.

Factors associated with leisure-time physical activity participation among individuals with spinal cord injury who ambulate

PURPOSE

The purpose of this study was to employ the theoretical domains framework (TDF) to identify behaviour change factors related to leisure-time physical activity (LTPA) in spinal cord injury (SCI) ambulators.

METHODS

A cross-sectional design was employed. Among 43 SCI ambulators, the TDF behaviour change factors were assessed, along with the duration, types, and intensities of LTPA performed over the previous week.

RESULTS

The TDF behaviour change factors identified as barriers to LTPA included: knowledge, beliefs about capabilities, coping planning, and goal conflict. Approximately 71.81 mins/day (SD = 75.41) was spent doing LTPA. Participants reported aerobic and resistance training activities, along with several other types of LTPA (e.g., rock climbing). Coping planning, action planning, goal conflict, and skills explained significant variance in time spent on LTPA (R²_adjusted = 0.259, p < 0.01), but only action planning uniquely predicted LTPA.

CONCLUSIONS

Greater use of coping and action planning, lower levels of goal conflict and stronger skills were associated with greater participation in LTPA. These factors will be targeted for a future LTPA-enhancing intervention for SCI ambulators, informed by behaviour change theory. SCI ambulators participate in a surprisingly wide range of LTPA. Rehabilitation specialists can use this list to suggest activities for patients with SCI who ambulate.IMPLICATIONS FOR REHABILITATIONBarriers to leisure-time physical activity for individuals with spinal cord injury (SCI) who ambulate include lack of knowledge, weak beliefs about capabilities, lack of coping planning, and high goal conflict.Physical activity interventions for individuals with SCI who ambulate should include action and coping planning, goal conflict, and skills.Physical activity interventions should be created systematically using behaviour change theory and involvement of stakeholders throughout the development process.Practitioners can promote skills training in adapted activities like gardening, cycling, and rock-climbing for ambulators with SCI.

Construct validation of the leisure time physical activity questionnaire for people with SCI (LTPAQ-SCI)

STUDY DESIGN

Cross-sectional construct validation study.

OBJECTIVES

To test the construct validity of the Leisure Time Physical Activity Questionnaire for People with Spinal Cord Injury (LTPAQ-SCI) by examining associations between the scale responses and cardiorespiratory fitness (CRF) in a sample of adults living with spinal cord injury (SCI).

SETTING

Three university-based laboratories in Canada.

METHODS

Participants were 39 adults (74% male; M age: 42 ± 11 years) with SCI who completed the LTPAQ-SCI and a graded exercise test to volitional exhaustion using an arm-crank ergometer. One-tailed Pearson's correlation coefficients were computed to examine the association between the LTPAQ-SCI measures of mild-, moderate-, heavy-intensity and total minutes per week of LTPA and CRF (peak volume of oxygen consumption [V̇O_2peak] and peak power output [PO_peak]).

RESULTS

Minutes per week of mild-, moderate- and heavy-intensity LTPA and total LTPA were all positively correlated with V̇O_2peak. The correlation between minutes per week of mild intensity LTPA and V̇O_2peak was small-medium (r = 0.231, p = 0.079) while all other correlations were medium-large (rs ranged from 0.276 to 0.443, ps < 0.05). Correlations between the LTPAQ-SCI variables and PO_peak were also positive but small (rs ranged from 0.087 to 0.193, ps > 0.05), except for a medium-sized correlation between heavy-intensity LTPA and PO_peak (r = 0.294, p = 0.035).

CONCLUSIONS

People with SCI who report higher levels of LTPA on the LTPAQ-SCI also demonstrate greater levels of CRF, with stronger associations between moderate- and heavy-intensity LTPA and CRF than between mild-intensity LTPA and CRF. These results provide further support for the construct validity of the LTPAQ-SCI as a measure of LTPA among people with SCI.

Validation of the Severity of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome by Other Measures than History: Activity Bracelet, Cardiopulmonary Exercise Testing and a Validated Activity Questionnaire: SF-36

Introduction: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a severe and disabling chronic disease. Grading patient’s symptom and disease severity for comparison and therapeutic decision-making is necessary. Clinical grading that depends on patient self-report is subject to inter-individual variability. Having more objective measures to grade and confirm clinical grading would be desirable. Therefore, the aim of this study was to validate the clinical severity grading that has been proposed by the authors of the ME International Consensus Criteria (ICC) using more standardized measures like questionnaires, and objective measures such as physical activity tracking and cardiopulmonary exercise testing. Methods and results: The clinical database of a subspecialty ME/CFS clinic was searched for patients who had completed the SF 36 questionnaire, worn a Sensewear^TM armband for five days, and undergone a cardiopulmonary exercise test. Only patients who completed all three investigations within 3 months from each other—to improve the likelihood of stable disease—were included in the analysis. Two-hundred-eighty-nine patients were analyzed: 121 were graded as mild, 98 as moderate and 70 as having severe disease. The mean (SD) physical activity subscale of the SF-36 was 70 (11) for mild, 43 (8) for moderate and 15 (10) for severe ME/CFS patients. The mean (SD) number of steps per day was 8235 (1004) for mild, 5195 (1231) for moderate and 2031 (824) for severe disease. The mean (SD) percent predicted oxygen consumption at the ventilatory threshold was 47 (11)% for mild, 38 (7)% for moderate and 30 (7)% for severe disease. The percent peak oxygen consumption was 90 (14)% for mild, 64 (8)% for moderate and 48 (9)% for severe disease. All comparisons were p < 0.0001. Conclusion: This study confirms the validity of the ICC severity grading. Grading assigned by clinicians on the basis of patient self-report created groups that differed significantly on measures of activity using the SF-36 physical function subscale and objective measures of steps per day and exercise capacity. There was variability in function within severity grading groups, so grading based on self-report can be strengthened by the use of these supplementary measures.

Study protocol for a 9-month randomised controlled trial assessing the effects of almonds versus carbohydrate-rich snack foods on weight loss and weight maintenance

INTRODUCTION

Epidemiological studies indicate an inverse association between nut consumption and body mass index (BMI). However, clinical trials evaluating the effects of nut consumption compared with a nut-free diet on adiposity have reported mixed findings with some studies reporting greater weight loss and others reporting no weight change. This paper describes the rationale and detailed protocol for a randomised controlled trial assessing whether the inclusion of almonds or carbohydrate-rich snacks in an otherwise nut-free energy-restricted diet will promote weight loss during 3 months of energy restriction and limit weight regain during 6 months of weight maintenance.

METHODS AND ANALYSIS

One hundred and thirty-four adults aged 25-65 years with a BMI of 27.5-34.9 kg/m² will be recruited and randomly allocated to either the almond-enriched diet (AED) (15% energy from almonds) or a nut-free control diet (NFD) (15% energy from carbohydrate-rich snack foods). Study snack foods will be provided. Weight loss will be achieved through a 30% energy restriction over 3 months, and weight maintenance will be encouraged for 6 months by increasing overall energy intake by ~120-180 kcal/day (~500-750kJ/day) as required. Food will be self-selected, based on recommendations from the study dietitian. Body composition, resting energy expenditure, total daily energy expenditure (via doubly labelled water), physical activity, appetite regulation, cardiometabolic health, gut microbiome, liver health, inflammatory factors, eating behaviours, mood and personality, functional mobility and pain, quality of life and sleep patterns will be measured throughout the 9-month trial. The effects of intervention on the outcome measures over time will be analysed using random effects mixed models, with treatment (AED or NFD) and time (baseline, 3 months and 9 months) being the between and within factors, respectively in the analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of South Australia Human Research Ethics Committee (201436). Results from this trial will be disseminated through publication in peer-reviewed journals, national and international presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001861246).

Accelerometer assessment of physical activity in individuals with paraplegia who do and do not participate in physical exercise

OBJECTIVE

Our main goal was to measure physical activity (PA) in people with paraplegia. Secondarily, we aimed to establish the relationship between being engaged in physical exercise (PE) and reaching the recommended moderate-to-vigorous physical activity (MVPA) level. We further analyzed the effect of being engaged in PE on the PA levels.

DESIGN

Descriptive cross-sectional.

SETTING

Spanish associations for individuals with spinal cord injury.

PARTICIPANTS

Ninety-six manual wheelchair users with chronic paraplegia.

INTERVENTIONS

Participants wore a wrist accelerometer for one week.

OUTCOME MEASURES

Levels of PA and sedentary behavior. In addition, participants were classified into two groups, exercisers (EG) and non-exercisers (NEG) to analyze the effect of PE enrollment on the variables.

RESULTS

For all participants, a mean (SD) of 5,341.70 (966.4) minutes per week were spent engaged in sedentary behaviors, 2,188.99 (723.9) minutes were spent engaged in light activity, and 206.24 (180.0) minutes were spent engaged in MVPA. There was a significant relationship between PE and reaching the minimum levels of MVPA recommended [x2 (1) = 25.03, P < 0.01]. NEG showed a greater number of minutes per week for sedentary behavior [t (94) = 2.50, P < 0.05, r = 0.25]. The EG spent more than twice as much time doing MVPA than the NEG (263.8 min vs 114.3 min, respectively).

CONCLUSIONS

MVPA levels are low in manual wheelchair users who are not regular exercisers, but most of those who self-reported being regular exercisers reach the minimum levels recommended for health benefits. Sedentary behavior is a concern in this population.

A Systematic Review of the Accuracy of Estimated and Measured Resting Metabolic Rate in Chronic Spinal Cord Injury

The objective of this systematic review was to examine resting metabolic rate (RMR) measured through indirect calorimetry in adults with chronic spinal cord injury (SCI) and to evaluate the predication equations used for the estimation of RMR in this population. The authors additionally aimed to review the impact of sex and level of injury on RMR. A MEDLINE/PubMed, Google Scholar, Scopus, and Web of Science search was performed for studies published from the database inception to January 2018, identifying 326 articles. On the basis of the inclusion criteria, 22 studies remained for review. All articles that were identified were full-text, English language articles examining adults with chronic SCI who were fasted for a minimum of 8 hr before undergoing RMR through indirect calorimetry for at least 20 min. The measured RMR ranged from 1,256.0 to 1,854.0 kcal/day, whereas the estimated RMR ranged from 1,276.8 to 1,808.0 kcal/day in the chronic SCI population. Seven studies overestimated RMR from 4% to 15%, whereas two studies underestimated RMR from 2% to 17% using prediction equations established for the able-bodied population. Two studies produced SCI-specific equations to estimate RMR. With regard to sex and level of injury, RMR does not differ between individuals with tetraplegia and paraplegia, whereas sex-based differences remain inconclusive, given limited results. These data provide evidence for the use of indirect calorimetry to assess RMR and the need to validate SCI-specific prediction equations in the estimation of RMR.

Instruments Measuring Physical Activity in Individuals Who Use a Wheelchair: A Systematic Review of Measurement Properties

OBJECTIVE

To systematically review the evidence evaluating validity or reliability of self-reported and device-based instruments, to measure physical activity (PA) in individuals who use a wheelchair, and to make recommendations for the selection of PA outcomes tools.

DATA SOURCES

PubMed, Embase, and CINAHL were systematically searched.

STUDY SELECTION

Studies reporting measurement properties of instruments to assess PA in individuals who use a wheelchair.

DATA EXTRACTION

The Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist was used to assess the methodological quality of the included studies. The measurement properties of instruments assessing PA were examined.

DATA SYNTHESIS

The search yielded 5341 records, 61 were considered relevant, 21 articles were included. A best evidence synthesis was performed on 9 studies including 4 self-reported instruments and 13 studies including 8 device-based instruments. One study evaluated both self-reported and device-based instruments. The overall methodological quality of all studies ranged from poor to excellent. Variable levels of evidence were found for both the validity and reliability for self-reported instruments and for criterion validity for device-based instruments.

CONCLUSIONS

The Physical Activity Scale for Individuals with Disabilities (PASIPD) and The Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) seem the most promising self-reported instruments for measuring the intensity of PA. Device-based instruments that can be used for measuring both the intensity and type of PA are the GENEActiv, Actigraph GT3X+, Actiheart, or the Physical Activity Monitor System (PAMS), showing moderate evidence for a positive rating of criterion validity. For measuring the type of PA, the PAMS and VitaMove are suitable, showing both good evidence for a positive rating of criterion validity.

Utilizing a low-carbohydrate/high-protein diet to improve metabolic health in individuals with spinal cord injury (DISH): study protocol for a randomized controlled trial

Background

Metabolic disorders (e.g., impaired glucose tolerance, insulin resistance, and type 2 diabetes) are more prevalent in people with spinal cord injury (SCI) than able-bodied individuals. Dietary modification is a more cost-effective treatment option than pharmacological therapies for reducing the risk of metabolic dysfunction. Lowering carbohydrate, increasing protein, and maintaining a proper dietary fat intake are expected to induce favorable adaptations in glucose control, body fat distribution, and the composition of the gut microbiome. However, dietary modification has not been rigorously investigated in people with SCI. The purpose of this study is to determine if an 8-week low-carbohydrate/high-protein (LC/HP) dietary intervention will show improvements in clinically important metrics of metabolic function, body composition, the composition of gut bacteria, and quality of life.

Methods/design

We intend to recruit 100 participants with chronic traumatic SCI (3 years postinjury, C5–L2, American Spinal Injury Association impairment scale A–D, and aged 18–65 years) and insulin resistance, impaired glucose tolerance or untreated type 2 diabetes and randomly assign them to an 8-week LC/HP dietary intervention group or a control group. The daily LC/HP dietary intervention includes ~ 30% total energy as protein (1.6 g/kg per day) with a carbohydrate-to-protein ratio < 1.5 and fat intake set at ~ 30% of the total energy intake. The control group does not receive any dietary intervention and are continuing with their regular daily diets. Glucose tolerance, insulin sensitivity, β-cell function, body composition, gut microbiome composition, and quality of life measures are assessed at week 1, before starting the LC/HP dietary intervention, and at week 8, after completion of the LC/HP dietary intervention.

Discussion

New information derived from this project will result in the development of a low-cost, simple, self-administered LC/HP dietary intervention for improving metabolic function in individuals with chronic SCI, improved understanding of the composition of gut bacteria in SCI, and how a LC/HP dietary intervention alters gut bacteria composition. In addition, this project will improve our understanding of the relationship between metabolic function and quality of life in individuals with long-standing SCI.

Trial registration

ClinicalTrials.gov, NCT03207841. Registered on 5 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3520-3) contains supplementary material, which is available to authorized users.

Measuring Physical Activity in Spinal Cord Injury Using Wrist-Worn Accelerometers

OBJECTIVE

Our objective was to evaluate interunit agreement and construct validity of two activity monitors (Actiwatch Score and PRO-Diary) in people with and without spinal cord injury.

METHOD

Thirty-eight participants (19 with spinal cord injury; 19 age- and sex-matched controls; mean age = 49 yr) wore both monitors and completed tasks during one visit ranging in physical intensity. To compare activity by group and monitor, we conducted t tests. We assessed interunit agreement using intraclass correlations and Bland-Altman plots.

RESULTS

Both monitors demonstrated significantly different increasing physical activity levels with higher intensity tasks. Participants with spinal cord injury had similar activity counts within tasks compared with controls except for walking-wheeling. Agreement was high between monitors across tasks (interclass correlation coefficients = .78-.97).

CONCLUSION

Both monitors demonstrated good construct validity for measuring physical activity across activities and high agreement. Either monitor is appropriate to examine physical activity patterns in people with spinal cord injury.

Measured and predicted resting energy expenditure in wheelchair rugby athletes

Objective: Report measured resting energy expenditure (REE) in wheelchair rugby athletes and evaluate agreement between REE and the prediction models of Chun, Cunningham, Harris-Benedict, Mifflin, Nightingale and Gorgey, and Owen.Design: Cohort-based validation study.Setting. Paralympic team training camp.Participants: Fourteen internationally competitive athletes who play wheelchair rugby, 13 of whom had cervical spinal cord injuries (SCI).Outcome Measures: A portable metabolic analyzer was used to measure REE following an overnight fast and dual-energy X-ray absorptiometry (DXA) was used to assess lean body mass for the prediction equations.Results: REE in the current sample was 1735 ± 257 kcal × day^-1 ranging from 1324 to 2068 kcal × day^-1. Bland-Altman analyses revealed negative mean bias but similar limits of agreement between measured REE and scores predicted by Chun, Cunningham, Mifflin, Nightingale and Gorgey, and Owen models in elite athletes who play wheelchair rugby.Conclusion: Prediction models regressed on persons with and without SCI under-predicted REE of competitive wheelchair rugby athletes. This outcome may be explained by the higher REE/fat-free mass (FFM) ratio of current athletes compared to less active samples. Findings from the current study will help practitioners to determine nutrient intake needs on training days of varied intensity.

Malaysian adaptation of the physical activity scale for individuals with physical disabilities in individuals with spinal cord injury

Purpose: The Physical Activity Scale for Individuals with Physical Disabilities questionnaire provides an assessment of physical activity after spinal cord injury. This study sought to adapt, with cultural competence, the English questionnaire and translate it into Bahasa Malaysia, including evaluation of content and face validity, internal consistency and test-retest reliability, and completion of a factor analysis in order to validate the Malaysian version.Materials and methods: A total of 250 participants completed the questionnaire that was distributed via email, postal mail, the internet, physically and by word of mouth. Sixty-eight respondents were re-contacted to complete the questionnaire again.Results: The adapted PASIPD demonstrated adequate internal consistency Cronbach's α = 0.68 and acceptable test-retest reliability, intraclass correlation = 0.87. Factor analysis extracted four main dimensions for physical activity; factor 1 (heavy housework, home repair, lawn work and gardening), factor 2 (sports and recreation), factor 3 (light housework and caring for another person) and factor 4 (leisure and occupational activities) that accounted for 64% of the physical activities' total variance.Conclusion: The Malaysian-adapted English and translated Bahasa Malaysia versions of the questionnaires intended to measure physical activity levels in individuals with spinal cord injury, demonstrated good to acceptable validity and reliability. However, some individual items revealed weak reliability measures. Further work is needed to validate the questionnaire's criterion validity against other physical activity measures.Implications for rehabilitationThe Malaysian adaptation of the Physical Activity Scale for Individuals with Physical Disabilities questionnaire provided preliminary support for its use since it has demonstrated adequate construct validity and reliability.The Malaysian adaptation of the Physical Activity Scale for Individuals with Physical Disabilities questionnaire can quantify the physical activity level of community-dwelling individuals with spinal cord injury, whilst deriving descriptive information on their physical activities.Deploying the Physical Activity Scale for Individuals with Physical Disabilities questionnaire to a spinal cord injury population in Malaysia may provide the first data on activities of daily living in an Asian developing country.

Validity of activity monitors in wheelchair users: A systematic review

Assessing physical activity (PA) in manual wheelchair users (MWUs) is challenging because of their different movement patterns in comparison to the ambulatory population. The aim of this review was to investigate the validity of portable monitors in quantifying PA in MWUs. A systematic literature search was performed. The data source was full reports of validation and evaluation studies in peer-reviewed journals and conference proceedings. Eligible articles between January 1, 1999, and September 18, 2015, were identified in three databases: PubMed, Institute of Electrical and Electronics Engineers, and Scopus. A total of 164 articles (158 from the databases and 6 from the citation/reference tracking) were identified, and 29 met the eligibility criteria. Two investigators independently extracted the characteristics from each selected article following a predetermined protocol and completed seven summary tables describing the study characteristics and key outcomes. In the identified studies, the monitors were used to assess three types of PA measures: energy cost, user movement, and wheelchair movement. The customized algorithms/monitors did not estimate energy cost in MWUs as well as the commercial monitors did in the ambulatory population; however, they showed fair accuracy in measuring both wheelchair and user movements.

Measurement of Physical Activity and Energy Expenditure in Wheelchair Users: Methods, Considerations and Future Directions

Accurately measuring physical activity and energy expenditure in persons with chronic physical disabilities who use wheelchairs is a considerable and ongoing challenge. Quantifying various free-living lifestyle behaviours in this group is at present restricted by our understanding of appropriate measurement tools and analytical techniques. This review provides a detailed evaluation of the currently available measurement tools used to predict physical activity and energy expenditure in persons who use wheelchairs. It also outlines numerous considerations specific to this population and suggests suitable future directions for the field. Of the existing three self-report methods utilised in this population, the 3-day Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) telephone interview demonstrates the best reliability and validity. However, the complexity of interview administration and potential for recall bias are notable limitations. Objective measurement tools, which overcome such considerations, have been validated using controlled laboratory protocols. These have consistently demonstrated the arm or wrist as the most suitable anatomical location to wear accelerometers. Yet, more complex data analysis methodologies may be necessary to further improve energy expenditure prediction for more intricate movements or behaviours. Multi-sensor devices that incorporate physiological signals and acceleration have recently been adapted for persons who use wheelchairs. Population specific algorithms offer considerable improvements in energy expenditure prediction accuracy. This review highlights the progress in the field and aims to encourage the wider scientific community to develop innovative solutions to accurately quantify physical activity in this population.

Leisure time physical activity among older adults with long-term spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To describe participation in leisure time physical activity (LTPA) (amount, intensity and type) among older adults with long-term spinal cord injury (SCI), and to investigate the associations with sociodemographics, injury characteristics and secondary health conditions (SHCs).

SETTING

Home settings in southern Sweden.

METHODS

Data from the Swedish Aging with Spinal Cord Injury Study (SASCIS). The physical activity recall assessment for people with SCI was used to assess LTPA among 84 men and 35 women (mean age 63.5 years, mean time since injury 24 years, injury levels C1-L5, American Spinal Injury Association Impairment Scale A-D). Associations were analyzed statistically using hierarchical multivariable regression.

RESULTS

Twenty-nine percent reported no LTPA, whereas 53% performed moderate-to-heavy intensity LTPA. The mean minutes per day of total LTPA was 34.7 (±41.5, median 15, range 0-171.7) and of moderate-to-heavy LTPA 22.5 (±35.1, median 5.0, range 0-140.0). The most frequently performed activities were walking and wheeling. Sociodemographics, injury characteristics and SHCs (bowel-related and bladder-related problems, spasticity and pain) explained 10.6% and 13.4%, respectively, of the variance in total and moderate-to-heavy LTPA. Age and wheelchair use were significantly, negatively associated with total LTPA. Women, wheelchair users and employed participants performed significantly less moderate-to-heavy LTPA than men, those using walking devices/no mobility device and unemployed participants.

CONCLUSION

Many older adults with long-term SCI do not reach the amount or intensity of LTPA needed to achieve fitness benefits. Research is needed on how to increase LTPA and to identify modifiable factors that could enhance their participation.

The relationship between the implementation and effectiveness of a nationwide physical activity telephone counseling service for adults with spinal cord injury

PURPOSE

Get in Motion (GIM) is an evidence-based telephone counseling service that promotes leisure-time physical activity (LTPA) among Canadian adults with spinal cord injury (SCI). The first phase of GIM sustained intentions for, and increased participation in, LTPA; however, it is unclear how GIM led to these outcomes. The purpose of this study was to explore the implementation correlates of change in LTPA intentions and behavior in the second phase of GIM.

METHODS

The frequency, duration, and content of counseling sessions were tailored to meet clients' (N = 46; 50.0% male; 50.0% paraplegia; 51.46 (SD 12.36) years old) needs and preferences. Intervention dose and content were monitored using Counseling Session Checklists. Clients self-reported their intentions for and actual aerobic and strength-training LTPA participation at baseline, 2-, 4-, and 6-months, and their perceptions of service quality at 6-months.

RESULTS

The second phase of GIM effectively sustained LTPA intentions and increased time spent on moderate-to-vigorous strength-training and total LTPA. Increases in clients' moderate-to-vigorous aerobic LTPA were significantly positively related to intervention dose, intervention content (both informational and behavioral strategies), and clients' perceptions of service credibility.

CONCLUSIONS

This study identified intervention dose and content as key implementation variables for an LTPA telephone counseling service for adults with SCI. Implications for Rehabilitation An evidence- and theory-based telephone counseling service can effectively sustain LTPA intentions and increase LTPA behavior among adults with SCI. The first two months of the service are a critical period for enhancing LTPA participation and for minimizing dropouts. The provision of both informational and behavioral strategies is important for increasing aerobic LTPA levels among adults with SCI.

Differences in health, participation and life satisfaction outcomes in adults following paediatric- versus adult-sustained spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To compare differences in self-reported health status, participation and life satisfaction outcomes between adults with a spinal cord injury (SCI) sustained during paediatric (P) versus adulthood (A) years.

SETTING

Ontario, Canada.

METHODS

Secondary analysis of data from the Study of Health and Activity in People with SCI. Eighty-seven participants who sustained an SCI prior to age 19 (M±s.e.=25±1.5 years postinjury (YPI)) were matched for lesion level (C2-L5), severity (complete/incomplete), gender, age, education and ethnicity with 87 participants who sustained an SCI at ⩾age 19 years (M_YPI=12.8±1.1).

RESULTS

Those with a paediatric SCI reported significantly less pain, fewer visits to the physician in the past year, greater functional independence, social participation, occupational participation and minutes per day of moderate-to-vigorous physical activity than those who sustained an SCI in adulthood. No significant differences were found for the measures of depression, perceived health status or life satisfaction (P>0.05). With the exception of moderate-to-vigorous physical activity and visits to the physician in the past year, between-group differences were independent of YPI.

CONCLUSIONS

Regardless of time since injury, people who sustained a paediatric SCI reported better health and greater participation than those injured in adulthood. Nevertheless, both groups scored well below able-bodied normative values for all measures. The results highlight the importance of a comprehensive life-course approach to SCI rehabilitation, irrespective of age at the time of injury.

Type, intensity and duration of daily physical activities performed by adults with spinal cord injury

STUDY DESIGN

Secondary analysis of cross-sectional data.

OBJECTIVES

To describe and compare (1) self-reported intensities and durations of specific types of daily physical activities and (2) minutes per day spent on daily physical activities across key demographic groups.

SETTING

Community (Ontario, Canada).

METHODS

Participants were 695 adults with spinal cord injury (SCI; 76% male, M_age=46.81±13.41 years, M_{years post injury}=15.19±11.10 years). Daily activities were assessed over the telephone using the Physical Activity Recall Assessment for People with SCI. Multivariate analyses of variance (MANOVA) were computed to test for differences in intensities and durations of different daily activities (objective 1) and between-group differences in minutes per day of daily activities (objective 2).

RESULTS

Overall, participants reported 127.92±142.79 min per day of daily physical activities with significantly more time spent in mild intensity (78.93±104.62 min per day) than moderate- (40.23±68.71 min per day) or heavy-intensity activities (8.75±24.53 min per day). Four patterns emerged with respect to type, duration and intensity, with some activities being typically performed at lighter or heavier intensities than others. There were significant differences in minutes per day of activity intensity and duration between groups based on education, injury severity and mode of mobility (P<0.05).

CONCLUSION

Given that some groups were more likely to engage in moderate-heavy-intensity activities, and some activities were more likely to be performed at moderate-heavy intensities, interventions that target key groups to increase certain daily activities may be one strategy to enhance overall physical activity participation among people with SCI.

Quantification of Physical Activity and Sedentary Time in Adults with Cerebral Palsy

PURPOSE

The purpose of this study was to determine objective and subjective quantification of habitual physical activity (HPA) and sedentary time in ambulatory and nonambulatory adults with cerebral palsy (CP).

METHODS

We recruited a clinical sample of adults with CP (N = 42; 21 women; mean (SD) age, 33.5 (12.3) yr; Gross Motor Function Classification System (GMFCS) distribution: level I (n = 5), level II (n = 9), level III (n = 10), level IV (n = 11), and level V (n = 7). Objective measures of HPA and sedentary time were obtained by using ActiGraph GT3X accelerometers at both hip and wrist sites. Three previously established cut-point values distinguishing light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) were evaluated across GMFCS levels. The concurrent validity of the self-report Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) was assessed for LPA and MVPA intensities in GMFCS levels II-V.

RESULTS

Participants showed little reluctance to wearing accelerometers; one participant reported discomfort. Nonambulatory adults (GMFCS levels IV-V) differed from ambulatory adults (GMFCS levels I-III) for recorded activity counts (hip and wrist sites), minutes of MVPA with each cut-point value, and breaks from sedentary time (all P < 0.05). For the same measures, adults in GMFCS level III also differed from GMFCS level I (all P < 0.05). The PARA-SCI correlated significantly with accelerometer-derived minutes of MVPA per day (r = 0.396; P = 0.014) and per hour of monitoring time (r = 0.356; P = 0.027).

CONCLUSIONS

Our findings support the use of accelerometers to objectively measure HPA and sedentary behavior in adults with CP across the severity spectrum, regardless of cut-point implementation. The PARA-SCI is a valid tool to capture subjectively reported patterns of MVPA in adults with CP who are GMFCS levels II-V.

A description and estimate of very low-intensity activity and inactive awake time in community-dwelling adults with chronic spinal cord injury

STUDY DESIGN

Secondary analysis of cross-sectional data.

OBJECTIVES

To estimate the amount of very low-intensity activity (VLPA) or inactive daily awake time that people with spinal cord injury (SCI) engage in and to determine correlates of VLPA/inactivity in this population.

SETTING

Community (Ontario, Canada).

METHODS

Participants with SCI (n=695; Mage=47 years; Myears post-injury=15 years, 76% men) completed telephone interviews. Demographic details and injury-related characteristics were self-reported. Total daily physical activity (for example, mild, moderate and heavy intensity) was measured using the Physical Activity Recall Assessment for People with SCI (PARA-SCI). VLPA/inactivity was calculated by subtracting total daily physical activity time from daily awake time. Correlates of VLPA/inactivity were assessed using a hierarchical linear regression where demographic variables were entered on the first step and injury-related characteristics were entered second.

RESULTS

Participants reported VLPA/inactivity for approximately 768±169 min per day, or 84%, of their awake time. The regression model predicting VLPA/inactivity was not significant.

CONCLUSION

People with SCI spend the majority of their awake time in VLPA/inactivity. However, VLPA/inactivity did not differ as a function of demographic or injury-related variables, suggesting that all segments of the SCI population could benefit from strategies to reduce inactivity.

Investigation of measured and predicted resting energy needs in adults after spinal cord injury: a systematic review

BACKGROUND

Accurate estimation of energy needs is vital for effective nutritional management of individuals with spinal cord injury (SCI). Inappropriate energy prescription after SCI can compound the rates of malnutrition or obesity, increase the risk of complications and negatively influence outcomes. Energy requirements following SCI are not well understood, and there is currently no universally accepted method of estimating energy needs in clinical practice.

STUDY DESIGN

This is a systematic literature review.

OBJECTIVES

The objectives of this study were to investigate and compare the measured resting energy needs of adults with SCI across different phases of rehabilitation, and to identify appropriate energy prediction equations for use in SCI.

SETTING

This study was conducted in Australia.

METHODS

MEDLINE, EMBASE and CENTRAL databases were searched for studies published between 1975 and April 2015, identifying 298 articles. Full articles in English language of adults with SCI who were fasted for a minimum of 8 hours before undergoing indirect calorimetry to measure resting energy expenditure (REE) for at least 20 min were selected. On the basis of the inclusion criteria, 18 articles remained for data extraction. One author extracted information from all articles, and inter-rater reliability was tested in five articles.

RESULTS

REE across three phases of injury was assessed: acute, sub-acute and chronic. Few studies (n=2) have investigated REE in the acute and sub-acute injury stages of SCI recovery. The factors influencing chronic energy needs in SCI patient populations are many and varied, and a valid predictive equation for use in SCI remains elusive.

CONCLUSION

Indirect calorimetry remains the only accurate assessment of REE for health practitioners working with patients after SCI.

Do people with spinal cord injury meet the WHO recommendations on physical activity?

OBJECTIVES

To describe physical activity (PA) levels in persons with spinal cord injury (SCI) and to investigate associated factors.

METHODS

PA behavior of people with SCI in Switzerland was assessed in a community survey with four items from the Physical Activity Scale for individuals with physical disabilities (PA of light, moderate, and strenuous intensity and muscle-strengthening exercises). In addition to descriptive analyses, the odds of performing PA according to the WHO recommendations (at least 2.5 h/week of at least moderate intensity) were analyzed by multivariable logistic regression.

RESULTS

Participants (n = 485; aged 52.9 ± 14.8; 73.6 % male) carried out PA a total of 6.0 h/week (median). 18.6 % were physically inactive, 50.3 % carried out muscle-strengthening exercises, and 48.9 % fulfilled the WHO recommendations. Regression analyses showed that women, people aged 71+, and people with complete tetraplegia had significantly lower odds of fulfilling the WHO recommendations than participants in the respective reference category (men, ages 17-30, incomplete paraplegia).

CONCLUSIONS

PA levels of people with SCI in Switzerland are rather high. However, some subgroups need special consideration when planning interventions to increase PA levels.

Predicting physical activity energy expenditure in wheelchair users with a multisensor device

Aim

To assess the error in predicting physical activity energy expenditure (PAEE), using a multisensor device in wheelchair users, and to examine the efficacy of using an individual heart rate calibration (IC) method.

Methods

15 manual wheelchair users (36±10 years, 72±11 kg) completed 10 activities: resting, folding clothes, wheelchair propulsion on a 1% gradient (3456 and 7 km/h) and propulsion at 4 km/h (with an additional 8% of body mass, 2% and 3% gradient) on a motorised wheelchair treadmill. Criterion PAEE was measured using a computerised indirect calorimetry system. Participants wore a combined accelerometer and heart rate monitor (Actiheart). They also performed an incremental arm crank ergometry test to exhaustion which permitted retrospective individual calibration of the Actiheart for the activity protocol. Linear regression analysis was conducted between criterion (indirect calorimetry) and estimated PAEE from the Actiheart using the manufacturer's proprietary algorithms (group calibration, GC) or IC. Bland-Altman plots were used and mean absolute error was calculated to assess the agreement between criterion values and estimated PAEE.

Results

Predicted PAEE was significantly (p<0.01) correlated with criterion PAEE (GC, r=0.76 and IC, r=0.95). The absolute bias ±95% limits of agreement were 0.51±3.75 and −0.22±0.96 kcal/min for GC and IC, respectively. Mean absolute errors across the activity protocol were 51.4±38.9% using GC and 16.8±15.8% using IC.

Summary

PAEE can be accurately and precisely estimated using a combined accelerometer and heart rate monitor device, with integration of an IC. Interindividual variance in cardiovascular function and response to exercise is high in this population. Therefore, in manual wheelchair users, we advocate the use of an IC when using the Actiheart to predict PAEE.

Testosterone concentrations in female athletes and ballet dancers with menstrual disorders

Menstrual disorders are common among female athletes and ballet dancers. Endocrine changes, such as high testosterone (HT) levels and high luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratios, may suggest functional ovarian hyperandrogenism which may induce such dysfunction. The aim of this study was therefore to evaluate endocrine status in female athletes and ballet dancers with menstrual disorders. Their nutritional status and dietary habits were analysed in relation to the testosterone levels. In a cross-sectional approach, 31 female athletes (18.1 ± 2.6 years) and 21 ballerinas (17.1 ± 0.9) with menstrual disorders participated in the study. The levels of serum LH, FSH, progesterone (P), estradiol (E2), prolactin (PRL), thyroid-stimulating hormone, testosterone (T) and sex hormone-binding globulinwere measured to assess hormonal status. In addition, the free androgen index (FAI) was calculated. Nutritional status, total daily energy expenditure and nutritional habits were evaluated. Girls were assigned to one of the following groups: low testosterone (LT) level, normal testosterone level or HT level. There were significant differences between ballerinas and other female athletes in terms of testosterone levels, FAI, age at the beginning of training, length of training period and age at menarche. The PRL level was lowest in the LT group while the FAI index was highest in the HT group. Daily energy and carbohydrate intakes were significantly lower in the HT group. T levels in the study subjects were found to be associated with nutritional factors, energy availability, age at the beginning of training and frequency of training. This is the first report of HT levels being associated with the status of a female ballet dancer, the age of menarche and the length of the training history. Further research is necessary to confirm the results in a larger study group.

Reducing cardiometabolic disease in spinal cord injury

Accelerated cardiometabolic disease is a serious health hazard after spinal cord injuries (SCI). Lifestyle intervention with diet and exercise remains the cornerstone of effective cardiometabolic syndrome treatment. Behavioral approaches enhance compliance and benefits derived from both diet and exercise interventions and are necessary to assure that persons with SCI profit from intervention. Multitherapy strategies will likely be needed to control challenging component risks, such as gain in body mass, which has far reaching implications for maintenance of daily function as well as health.

Effects of spinal cord injury on body composition and metabolic profile - part I

Several body composition and metabolic-associated disorders such as glucose intolerance, insulin resistance, and lipid abnormalities occur prematurely after spinal cord injury (SCI) and at a higher prevalence compared to able-bodied populations. Within a few weeks to months of the injury, there is a significant decrease in total lean mass, particularly lower extremity muscle mass and an accompanying increase in fat mass. The infiltration of fat in intramuscular and visceral sites is associated with abnormal metabolic profiles. The current review will summarize the major changes in body composition and metabolic profiles that can lead to comorbidities such as type 2 diabetes mellitus and cardiovascular diseases after SCI. It is crucial for healthcare specialists to be aware of the magnitude of these changes. Such awareness may lead to earlier recognition and treatment of metabolic abnormalities that may reduce the co-morbidities seen over the lifetime of persons living with SCI.

Reliable assessment of physical activity in disease: an update on activity monitors

PURPOSE OF REVIEW

Physical activity is the main determinant of variability of individual energy expenditure. Reliable assessment of the activity level of an individual provides information on energy requirement and vital health. Here, evidence is presented on the validity of methods to assess physical activity as applied in health and disease.

RECENT FINDINGS

Improvement of technology has resulted in a growing number of physical activity monitors to evaluate the activity level of an individual. Outcome measures vary from raw data on body acceleration and posture to activity levels derived from proprietary algorithms based on body acceleration combined with sensor information on additional activity-induced physiological responses. Data interpretation is limited by evidence-based studies on the value of measured parameters for the assessment of physical activity.

SUMMARY

The optimal tool for reliable assessment of physical activity is an accelerometer providing a valid measure of body movement. Overall validity is derived from studies using doubly labelled water-assessed activity-induced energy as a reference. Thus, out of the large range of activity monitors, three came out with a better validity. The ultimate tool is a single unobtrusive device allowing valid and long-term monitoring of activity with regard to type and intensity.

Preliminary study for the assessment of physical activity using a triaxial accelerometer with a gyro sensor on the upper limbs of subjects with paraplegia driving a wheelchair on a treadmill

OBJECTIVE

This study aimed to examine whether, on the basis of the relationship between sensors attached on the upper limbs and energy expenditure (EE) at the time of wheelchair propulsion, there are differences in the measurement of EE depending on the sensor attachment site and whether addition of the angular velocity information to the acceleration value is advantageous. We also aimed to clarify the variables used to estimate EE as well as the estimated error.

SETTING

Laboratory of the National Hospital Organization Murayama Medical Center, Japan.

METHODS

Six male subjects with spinal cord injuries participated in the study. Each wore sensors at the wrist and the middle upper arm on both sides while driving a wheelchair on a treadmill at three levels: very, very light; very light; and fairly light. Triaxial acceleration, triaxial angular velocity and EE were measured during driving. We analyzed the correlation between EE and acceleration, angular velocity and synthesized values of acceleration and angular velocity at each location using regression, multiple regression and Bland-Altman analyses.

RESULTS

The determination coefficients between EE and the acceleration, angular velocity and synthesized values of acceleration and angular velocity varied from 0.68 to 0.87 at each location. The mean difference between the measured and estimated EE varied from 0.0028 (s.d., 0.0027) kcal min(-1) kg(-1) on the right upper arm.

CONCLUSION

These findings suggest that combining the synthesized values of angular velocity and acceleration of the motion sensors on the upper limbs might reflect EE during a wheelchair driving activity on a treadmill.

Avaliação da potência aeróbia de praticantes de Rugby em Cadeira de Rodas através de um teste de quadra

O presente estudo teve por finalidade estimar a potência aeróbia em atletas com LME praticantes de RCR, correlacionar os níveis de VO2máx com a classificação funcional (CF) dos atletas e analisar o comportamento da FC antes e pós-teste. A amostra foi composta por 10 atletas com LME, do sexo masculino e idade média de 29,6±6,5anos. Os atletas foram submetidos ao teste de corrida de 12 minutos e monitorados com o frequêncimetro cardíaco. A média do VO2máx foi de 18,3±8,1ml(kg.min)-1 e da FCmáx de 114,6±25,3bpm. Os valores de VO2máx obtidos no estudo são classificados como médio para a população com tetraplegia. Observou-se que existe correlação moderada (r=0,77) entre a CF e o VO2máx entre atletas praticantes de RCR e por fim, observou-se baixos valores de FC frente á um teste submáximo, fato que pode estar relacionado à diminuição da atuação simpática após LME.

Systematic framework to classify the status of research on spinal cord injury and physical activity

OBJECTIVES

To systematically classify the physical activity research for individuals with a spinal cord injury by using the behavioral epidemiologic framework; and to identify where the physical activity research for individuals with a spinal cord injury has focused between 2000 and 2012.

DESIGN

Relevant research was identified and then categorized into 1 of 5 phases by following the coding rules of the behavioral epidemiology framework. Phase 1 studies link physical activity and health outcomes, phase 2 studies validate or develop measures of physical activity, phase 3 studies identify factors that influence behavior or examine explanatory theories of behavior, phase 4 studies evaluate interventions, and phase 5 studies disseminate health promotion programs or policies and translate research into practice.

SETTING

Specific keywords were identified and then searched through EBSCOhost, PubMed, and Google Scholar.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

One hundred and thirteen articles met the criteria. Of the articles, 55% were categorized as phase 1, 12% as phase 2, 24% as phase 3, 5% as phase 4, and 4% as phase 5.

CONCLUSIONS

Most studies were categorized as phase 1, 2, or 3, which implies that this field is still in the early stages of development and research should focus on intervention development and dissemination.