Energy expenditure and metabolism during exercise in persons with a spinal cord injury

Energy Requirements of Paralympic Athletes: Insights from the Doubly Labeled Water Approach

PURPOSE

Advanced insight in energy requirements of Paralympic athletes is imperative for optimizing their nutritional counseling. Given the lack of accurate data on total daily energy expenditure (TDEE) of Paralympic athletes, this study aimed to assess energy expenditure and nutritional intake of a large cohort of Paralympic athletes, across different sports and disabilities.

METHODS

In this cross-sectional study, 48 Dutch and Norwegian Paralympic athletes (19 male/29 female) with various disabilities, competing in Para cycling, wheelchair tennis, wheelchair basketball, Para Nordic skiing, and alpine skiing participated. TDEE was assessed by the gold standard doubly labeled water method over a 14-d period, resting metabolic rate by ventilated hood indirect calorimetry, energy intake by three unannounced 24-h dietary recalls, body composition by dual-energy x-ray absorptiometry, and exercise training duration by a training log.

RESULTS

Mean TDEE was 2908 ± 797 kcal·d -1 , ranging from 2322 ± 340 kcal·d -1 for wheelchair basketball players to 3607 ± 1001 kcal·d -1 for Para cyclists. Regression analysis identified fat-free mass, exercise duration, and the presence of a spinal cord disorder as the primary predictors of TDEE, explaining up to 73% of the variance in TDEE. Athletes' energy intake (2363 ± 905 kcal·d -1 ) was below their TDEE, whereas their body mass remained constant, indicating underreporting. Carbohydrate intake (4.1 ± 1.9 g·kg -1 body mass) was low, even when considering underreporting, whereas protein intake (1.8 ± 0.6 g·kg -1 body mass) was relatively high.

CONCLUSIONS

Paralympic athletes display moderate- to high-energy expenditure, varying across sports and individuals. Much of the variation in TDEE can be attributed to individual differences in fat-free mass and exercise duration. This study establishes the benchmarks for energy requirements of Paralympic athletes, serving as the foundation for future dietary guidelines within this population.

Baseline Comparison of Exercisers and Nonexercisers With Spinal Cord Injury Enrolled in a Group Tele-Exercise Program

Background

Individuals with SCI are 1.5 times more likely to be sedentary compared to adults without disabilities or chronic health conditions. It is therefore imperative to develop and evaluate innovative facilitation strategies for physical activity behavior in this population.

Objectives

As an insightful step to creating and evaluating tailored physical activity interventions for individuals with SCI, we evaluated demographic, psychosocial, and physical characteristics of those who choose to engage in physical activity by enrolling in a group exercise study.

Design/Methods

We conducted a cross-sectional analysis detailing demographic features and baseline outcomes of those with SCI enrolled in a group tele-exercise study who were classified as regular exercisers versus nonregular exercisers per the American College of Sports Medicine exercise guidelines. Between-group differences for psychosocial and physical outcomes were assessed with chi-square and Mann-Whitney U tests (p < .05).

Results

Twenty-seven adult volunteers enrolled in the study (exercisers = 14, nonexercisers = 13). Groups were comparable for biological sex, gender identity, self-reported racial group(s), and current age. Exercisers demonstrated significantly shorter duration of injury compared to nonexercisers (p = .012). Exercisers exhibited significantly higher exercise self-efficacy (p = .017) and increased reported weekly minutes in vigorous intensity leisure time physical activity (p = .029).

Conclusion

Nonexercisers with SCI demonstrate increased injury duration and reduced exercise self-efficacy compared to active peers. These factors should be addressed in the design and delivery of SCI-specific physical activity interventions to increase the likelihood of this critical health behavior over time.

Intervention Design of High-Intensity Interval Training in Individuals With Spinal Cord Injury: Narrative Review and Future Perspectives

Background

Individuals with spinal cord injury (SCI) have lower levels of physical activity compared to the nondisabled population. Exercise guidelines recommend moderate or vigorous exercise to improve cardiovascular health and reduce cardiometabolic risk factors in persons with SCI. High-intensity interval training (HIIT) is a popular exercise choice and encompasses brief periods of vigorous exercise paired with intermittent periods of recovery.

Objectives

This review describes the available literature on HIIT for individuals with SCI, including differences in protocol design and suggested areas of further investigation.

Methods

Our institution's library system performed the comprehensive search. The primary keywords and phrases used to search included spinal cord injury, high-intensity interval training, tetraplegia, paraplegia, and several other related terms.

Results

Initially 62 records were screened, and 36 were deemed outside the scope of this review. Twenty-six studies published between 2001 and 2021 fulfilled the eligibility criteria and were divided among two researchers for review and analysis. All records required persons with SCI and a standardized HIIT intervention. Study design varied widely with respect to mode of exercise, prescribed intensity, duration of performance intervals, and session duration. This variability necessitates further investigation into the specifics of a HIIT prescription and the associated outcomes for persons with SCI.

Conclusion

Standardization of HIIT protocols may lead to more robust conclusions regarding its effects on cardiorespiratory fitness as well as mitigation of cardiometabolic risk factors. Meta-analyses will eventually be needed on proper dosing and session parameters to improve cardiorespiratory fitness and cardiometabolic risk factors.

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

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

Investigation of supplement use and knowledge among Japanese elite athletes for the Tokyo 2020 Olympic/Paralympic games and the Beijing 2022 winter Olympic/Paralympic games

Elite athletes frequently invest in the use of supplements to optimize their dietary regimens and enhance their athletic performance. However, unregulated and unplanned use of supplements can lead to adverse consequences, including anti-doping rule violations or health issues. Thus, athletes should verify their diets, consider scientific evidence, and take necessary precautions regarding supplements before use. To date, no study has explored whether athletes check these factors before using supplements. This study aimed to investigate supplement use using a questionnaire administered to 1,392 athletes (including candidate athletes) who participated in the Tokyo 2020 Olympic/Paralympic and Beijing 2022 Winter Olympic/Paralympic Games. Participants were categorized as follows: 1,040 participants in the Tokyo 2020 Olympic Games, 83 in the Tokyo 2020 Paralympic Games, 239 in the Beijing 2022 Winter Olympic Games, and 30 in the Beijing 2022 Winter Paralympic Games. We collected data on supplement use and gained further knowledge through interviews with the athletes. Approximately 70% of Tokyo 2020 Olympic/Paralympic and Beijing 2022 Winter Olympic athletes and approximately 50% of Beijing 2022 Winter Paralympians used supplements. Over 50% of athletes had not received a doctor's diagnosis or a dietitian's evaluation before supplement use. Moreover, only 50% of the athletes who used dietary supplements reviewed the scientific evidence for the dietary supplements before using them and justified their choice based on their own investigation, while those who did not use dietary supplements cited either a lack of need or fear of an anti-doping rule violation. Considering the holistic health and performance of athletes, as well as the risk associated with unregulated use, such as overdose and anti-doping rule violations, there is a need for nutritional education on supplement use for athletes and their entourages.

Multimodal Earable Sensing for Human Energy Expenditure Estimation

Energy Expenditure Estimation (EEE) is vital for maintaining weight, managing chronic diseases, achieving fitness goals, and improving overall health and well-being. Gold standard measurements for energy expenditure are expensive and time-consuming, hence limiting utility and adoption. Prior work has used wearable sensors for EEE as a workaround. Moreover, earables (ear-worn sensing devices such as earbuds) have recently emerged as a sub-category of wearables with unique characteristics (i.e., small form factor, high adoption) and positioning on the human body (i.e., robust to motion, high stability, facing thin skin), opening up a novel sensing opportunity. However, earables with multimodal sensors have rarely been used for EEE, with data collected in multiple activity types. Further, it is unknown how earable sensors perform compared to standard wearable sensors worn on other body positions. In this study, using a publicly available dataset gathered from 17 participants, we evaluate the EEE performance using multimodal sensors of earable devices to show that an MAE of 0.5 MET (RMSE = 0.67) can be achieved. Furthermore, we compare the EEE performance of three commercial wearable devices with the earable, demonstrating competitive performance of earables.Clinical Relevance - This study confirms that multimodal sensors in earables could be used for EEE with comparable performance to other commercial wearables.

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

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

Fat Oxidation during Exercise in People with Spinal Cord Injury, and Protocols Used: A Systematic Review

BACKGROUND

The aim of this study was to summarize evidence on energy metabolism through peak fat oxidation (PFO) and maximum fat oxidation (Fat_max), as well as to analyze the protocols used in people with spinal cord injury (SCI) and to examine the main factors related to fat oxidation ability (i.e., age, sex, level of physical activity, and level and degree of injury).

METHODS

Studies to determine PFO and Fat_max using indirect calorimetry with an arm exercise protocol for SCI patients were included after a systematic search. Other endpoints included study design, sample size, control group, demographic data, level of injury, physical condition, protocol, outcomes measured, and statistical findings.

RESULTS

Eight studies (n = 560) were included. The mean value of VO_2peak was 1.86 L∙min^-1 (range 0.75-2.60 L∙min^-1) (lowest value in the tetraplegic subjects). The PFO ranged between 0.06 and 0.30 g∙min^-1 (lowest rates: the non-trained subjects with cervical SCI; highest: the tetraplegic subjects). Two types of exercise protocol were found: arm cycle ergometer, and wheelchair propulsion with a computerized ergometer. Five studies used an incremental protocol (2-3 min/stage, different load increments); the rest performed tests of 20 min/stage at three intensities.

CONCLUSION

There are few existing studies measuring fat oxidation in SCI, many of which used small and heterogeneous samples. PFO was lower in SCI subjects when compared with non-injured people performing lower-limb exercise; however, comparing upper-limb exercise, people with SCI showed higher values.

The Role of Diets and Dietitians for Para-Athletes: A Pilot Study Based on Interviews

Efforts to provide nutrition support to para-athletes have not been established to date, and are far behind those established for athletes without disabilities. In the present study, we attempted to clarify the actual situation regarding dietary challenges of para-athletes. The aim of this study was to obtain clues to effective intervention methods that encourage the practice of sports nutrition. Six active elite para-athletes (30–70 years, four males) and a female physical therapist without physical disability participated in semi-structured interviews. All para-athletes had lower-limb disabilities and participated in the international wheelchair sports competitions (tennis, softball, and table tennis, with 2–26 years of player history). The interview items were on the ideal diet for improving competitive performance, evaluation of their typical diets, and the role of the dietitian as support. Responses obtained from participants were analyzed using quantitative content analysis by language analysis software. There are differences in the ideal diet based on the characteristics of the sport, but most participants believed that a nutritionally well-balanced diet with abundant vegetables was ideal for improving competitive performance. Para-athletes who use a wheelchair daily pay attention to their total calorie intake, because gaining weight is a critical issue for operating their wheelchairs and transferring themselves to and from their wheelchairs. Despite their world-class competition levels, none of them received routine dietary advice from dietitians. Some para-athletes did not even feel the need to engage with dietitians. Even for these para-athletes at a high level of competition, the “ideal diet” they considered was not always the optimal diet for improving their competitive performance. In addition, there are various barriers to practicing their optimal diet due to disability characteristics. Dietitians need to understand these barriers, their concerns and conflicts, and how to help them plan the optimal diet to improve their performance and maintain overall health.

Case Study: Improving Energy Status in a Wheelchair Athlete With Suppressed Resting Energy Expenditure

PURPOSE

Wheelchair athletes experience a reduction in fat-free mass due to the underlying condition and/or muscle disuse. This leads to a lower resting energy expenditure (REE), as well as a lower energy expenditure during exercise or daily activities. Traditional markers of low energy availability (LEA), including amenorrhea and low bone mineral density, are often inconclusive in wheelchair athletes. This case study provides data from a professional female wheelchair badminton player with multiple sclerosis who presented with a reduced measured-to-predicted REE ratio (REEratio), a common indicator of LEA in able-bodied athletes. Furthermore, a nutrition and exercise intervention was conducted to restore REE.

METHODS

REE and body composition were measured using indirect calorimetry and dual-energy X-ray absorptiometry, respectively. The predicted REE of the REEratio was calculated using 2 separate approaches. An REEratio <0.9 was considered an indicator for LEA. A nutrition and exercise intervention was implemented to normalize REE and induce weight loss through increased meal frequency, a 200- to 400-kcal/d increase in energy intake, and added endurance exercise.

RESULTS

The athlete (33 y, 78 kg, 154 cm) initiallly showed an REEratio of 0.65 to 0.70, which increased to 1.00 to 1.09 after 1 year. The athlete lost 11.8 kg, almost exclusively (11 kg) in the form of fat mass. The athlete reported reduced fatigue and higher perceived fitness.

CONCLUSION

The nutrition and exercise intervention successfully restored energy status, induced sustainable weight loss, and reduced fatigue in a wheelchair athlete with multiple sclerosis with presumed LEA. Methods to assess LEA in this population require further validation.

Adaptive Cycling: Injuries and Health Concerns

Para-cycling has high rates of acute injuries. The underlying medical conditions of para-athletes predispose these cyclists to injury patterns and sequelae different from those of their able-bodied counterparts. Such injuries include an increased incidence of upper-extremity and soft tissue injuries, along with predisposition for respiratory, skin, genitourinary, and heat-related illnesses. There are no validated sideline assessment tools or return-to-play protocols for sports-related concussion in wheelchair user para-athletes or those with balance deficits. Para-cyclists may be at increased risk for relative energy deficiency in sport due to competitive pressure to maintain certain weights and increased incidence of low bone mineral density.

Nutritional Considerations for Para-Cycling Athletes: A Narrative Review

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

Carbohydrate Considerations for Athletes with a Spinal Cord Injury

The Paralympic movement is growing in popularity, resulting in increased numbers of athletes with a spinal cord injury (SCI) competing in various sport disciplines. Athletes with an SCI require specialized recommendations to promote health and to maximize performance, as evidenced by their metabolic and physiological adaptations. Nutrition is a key factor for optimal performance; however, scientifically supported nutritional recommendations are limited. This review summarizes the current knowledge regarding the importance of carbohydrates (CHO) for health and performance in athletes with an SCI. Factors possibly affecting CHO needs, such as muscle atrophy, reduced energy expenditure, and secondary complications are analyzed comprehensively. Furthermore, a model calculation for CHO requirements during an endurance event is provided. Along with assessing the effectiveness of CHO supplementation in the athletic population with SCI, the evaluation of their CHO intake from the available research supplies background to current practices. Finally, future directions are identified. In conclusion, the direct transfer of CHO guidelines from able-bodied (AB) athletes to athletes with an SCI does not seem to be reasonable. Based on the critical role of CHOs in exercise performance, establishing recommendations for athletes with an SCI should be the overall objective for prospective research.

Aerobic fitness is a potential crucial factor in protecting paralympic athletes with locomotor impairments from atherosclerotic cardiovascular risk

Purpose

To test the hypothesis that aerobic fitness is inversely related to the risk of atherosclerotic cardiovascular disease (ACVD) in athletes with locomotor impairments deriving from health conditions, such as spinal cord injury (SCI), lower limb amputation, cerebral palsy, poliomyelitis, and other health conditions different from the previous ones.

Methods

A total of 68 male athletes who competed in either summer or winter Paralympic games were divided in two health conditions groups (35 with SCI, mean age 37.2 ± 8.0 years, and 33 with different health conditions, mean age 37.8 ± 9.9 years) and in four sport type groups (skill, power, intermittent—mixed metabolism—and endurance). They were evaluated through anthropometric and blood pressure measurements, laboratory blood tests, and graded cardiopulmonary maximal arm cranking exercise test, with oxygen uptake peak (VO2peak) measurement. Cardiovascular risk profile was assessed in each athlete.

Results

The prevalence of ACVD-risk factors in the overall population was 20.6% for hypertension; 47% and 55.9% for high values of total and LDL cholesterol, respectively; 22.1% for reduce glucose tolerance; and 8.8% for obesity. No difference was found between athletes with and without SCI, while the prevalence of obesity was significantly higher in those practicing skill sports (22.7%, p = 0.035), which was the sport type group with Paralympic athletes with the lowest VO2peak (22.5 ± 5.70 ml kg−1 min−1). VO2peak was lower in athletes with SCI than those with different health conditions (28.6 ± 10.0 vs 33.6 ± 8.9 ml kg−1 min−1p = 0.03), and in those with 3–4 risk factors (19.09 ± 5.34 ml kg−1 min−1) than those with 2 risk factors (27.1 ± 5.50 ml kg−1 min−1), 1 risk factor (31.6 ± 8.55 ml kg−1 min−1), or none (36.4 ± 8.76 ml kg−1 min−1) (p < 0.001).

Conclusions

The present study suggests that having higher VO2peak seems to offer greater protection against ACVD in individuals with a locomotor impairment. Prescribing physical exercise at an intensity similar to that of endurance and intermittent sports should become a fundamental tool to promote health among people with a locomotor impairment.

Protein Considerations for Athletes With a Spinal Cord Injury

Athlete participation in the Paralympic games is steadily increasing; prompting research focused on the unique needs of this population. While the Paralympic Games includes a diversity of athletes, athletes with a spinal cord injury (PARA-SCI) represent a subgroup that requires specialized recommendations. Nutritional guidelines designed to optimize performance, in the context of the neurological impairments, are required. This narrative review summarizes the current literature regarding the importance of dietary protein for optimal health and performance. Factors with the potential to affect protein needs in PARA-SCI including loss of active muscle mass, reduced energy expenditure, and secondary complications are examined in detail. Furthermore, we analyze protein intakes in PARA-SCI from the available research to provide context around current practices and trends. In conclusion, we make the case that protein recommendations for able-bodied athletes may not be directly transferable to PARA-SCI. Consequently, PARA-SCI need their own guidelines to maximize performance and ensure long-term health.

Comparison between the 10- and the 30-s-long Wingate Anaerobic Test in summer Paralympic athletes with a lower limb impairment

Background

The 30-s-long Wingate Anaerobic Test (WAnT_30s) has some limitations in high-level athletes. A shorter version might be helpful for both clinical applications and performance assessment. The comparison between the traditional WAnT_30s and a shorter version has never been carried out yet in Paralympic athletes.

Aim

To assess if a 10-s-long Wingate Anaerobic Test (WAnT_10s) could be used to accurately assess and predict the anaerobic components of physical fitness as an alternative to the traditional WAnT_30s in male Paralympic athletes.

Methods

Forty-four trained male Paralympic Athletes grouped by severity of locomotor impairment completed the WAnT_30s and the WAnT_10s with an arm cranking ergometer. Differences between mean and peak power achieved throughout both WAnTs were analysed using a mixed-design analysis of variance and predictivity was assessed by stepwise linear regression analysis.

Results

In the whole sample, peak power values were similar (P > 0.005) in the two tests and the WAnT_10s mean power was significantly higher than that in the WAnT_30s (P < 0.005). Finally, the mean power measured during WAnT_30s showed high level of predictability from mean power measured during WAnT_10s and the Functional class (adjusted R2 = 0.906; P < 0.001).

Conclusion

The WAnT_10s is accurate to assess peak power, is definitively appropriate to evaluate the alactic anaerobic metabolism and seems able to predict the mean power as traditionally evaluated through a WAnT_30s in male Paralympic Athletes. Thus, it can be used to assess the anaerobic components of physical fitness in this athletic population.

Recovery Off-Kinetics Following Exhaustive Upper Body Exercise in Spinal Cord Injury

Background

People with spinal cord injury (SCI) present with impaired autonomic control when the lesion is above T6. This could lead to delayed cardiorespiratory recovery following vigorous physical activity.

Objectives

To characterize and compare gas exchange off-kinetics following exhaustive exercise in individuals with SCI and an apparently healthy control group.

Methods

Participants were 19 individuals with SCI who presented with the inability to voluntarily lift their legs against gravity (age, 44.6 ± 14.2 years; AIS A, n = 5; AIS B, n = 7; AIS C, n = 7; paraplegia, n = 14; tetraplegia, n = 5) and 10 healthy comparisons (COM; age, 30.5 ± 5.3 years). All participants performed an arm ergometer cardiopulmonary exercise test (aCPET) to volitional exhaustion followed by a 10-minute passive recovery. O₂ uptake (V̇o₂ ) and CO₂ output (V̇co₂ ) off-kinetics was examined using a mono-exponential model in which tau off (τ_off ) and mean response time (MRT) were determined. The off-kinetics transition constant (Kt_off ) was calculated as ΔV̇o₂ /MRT. Student t tests were used to compare SCI versus COM group means.

Results

COM had a significantly higher relative peak V̇o₂ compared to SCI (1.70 ± 0.55 L/min vs 1.19 ± 0.51 L/min, p = .019). No difference was observed for τ_off between the groups, however Kt_off for both V̇o₂ and V̇co₂ was significantly lower in the SCI compared to the COM group.

Conclusion

A reduced Kt_off during recovery may suggest inefficiencies in replenishing muscle ATP stores and lactate clearance in these participants with SCI. These findings may contribute to the observed lower cardiorespiratory fitness and greater fatigability typically reported in individuals with SCI.

Influence of mid and low paraplegia on cardiorespiratory fitness and energy expenditure

STUDY DESIGN

Observational, Cross-sectional.

OBJECTIVE

Examine the influence of mid (MP) and low (LP) paraplegia on cardiorespiratory fitness (CRF), energy expenditure (EE), and physical activity levels (PAL), and compare these data to able-bodied (AB) individuals.

SETTING

Academic medical center.

METHODS

Persons with MP (n = 6, T6-T8, 83% male, age: 31 ± 11 y, BMI: 24 ± 7 kg/m²) and LP (n = 5; T10-L1, 100% male, age: 39 ± 11 y, BMI: 26 ± 5 kg/m²) and AB controls (n = 6; 67% male, age: 29 ± 12 y, BMI: 26 ± 5 kg/m²) participated. All participants underwent 45-min of arm-crank exercise where CRF and exercise EE were measured. Basal metabolic rate (BMR) was measured, and total daily EE (TDEE) and PAL were estimated.

RESULTS

Absolute VO_2Peak (MP: 1.6 ± 0.2, LP: 1.9 ± 0.1, AB: 2.5 ± 0.7 l/min), peak metabolic equivalents (MP: 6.8 ± 1.3, LP: 5.7 ± 0.7, AB: 8.8 ± 0.8 METs), peak power output (MP: 72.9 ± 11.5, LP: 86.8 ± 6.1, AB: 121.0 ± 34.8 Watts), and maximal heart rate (MP: 177.7 ± 9.8, LP: 157 ± 13.6, AB: 185.2 ± 8.5 bpm) were significantly different between the three groups (p < 0.05). BMR and TDEE did not significantly differ between the three groups (p > 0.05), whereas exercise EE (MP: 7.8 ± 1.2, LP: 9.5 ± 0.7, AB: 12.4 ± 3.5 kcal/min) and PAL (MP: 1.30 ± 0.04, LP: 1.32 ± 0.04, AB: 1.43 ± 0.06) significantly differed (p < 0.05). In the AB group, 33.3% and 66.7% were classified as sedentary or having low activity levels, respectively, while all persons with paraplegia were classified as sedentary according to PAL classifications.

CONCLUSION

Individuals with MP and LP have lower CRF, exercise EE, and PALs compared to AB individuals.

EMG median frequency shifts without change in muscle oxygenation following novel locomotor training in individuals with incomplete spinal cord injury

Objectives: To examine the effect of muscle fiber recruitment patterns on muscle oxygen utilization during treadmill walking in a group of individuals who have incomplete spinal cord injury.Methods: 5 participants with motor incomplete spinal cord injury (Age; 42.2 ± 18.8 years, Male; n = 4) completed an over ground locomotor training program. Muscle utilization/oxygenation and activation of the medial gastrocnemius were measured by near infrared spectroscopy and surface electromyography pre- and post-over ground locomotor training during two separate treadmill walking bouts at self-selected speeds. Outcomes were changes in deoxygenation hemoglobin/myoglobin concentrations, and the change in median power of the power spectrum of the electromyography after training.Results: A significant increase in median power of the power spectrum of the electromyography signal was observed during both bouts of treadmill walking, 6-minute walking bout and longer fatiguing bout (49% p = 0.047 and 48% p = 0.035, respectively) post-over ground locomotor training. There was no significant change in muscle utilization/oxygenation post-over ground locomotor training. There was no significant effect of median power of the power spectrum on deoxygenation hemoglobin/myoglobin during either of the walking bouts.Conclusions: The main finding of the current study was that median power of the power spectrum significantly increased following 12 weeks of over ground locomotor training, with no significant change in deoxygenation hemoglobin/myoglobin. The recruitment of more and/or larger motor units was seen in conjunction with no changes in muscle oxygen utilization for the same walking task.Implications for RehabilitationThe reduction of skeletal muscle innervation in Spinal Cord Injury may adversely affect the orderly recruitment of motor units, which could in turn blunt the oxidative metabolic response during physical activity.Over-ground locomotor could be a useful tool in the rehabilitative process following an incomplete spinal cord injury.

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.

Assessment of Exercise Stroke Volume and Its Prediction From Oxygen Pulse in Paralympic Athletes With Locomotor Impairments: Cardiac Long-Term Adaptations Are Possible

The determinants of cardiac output (CO) during exercise, i.e., stroke volume (SV) and heart rate (HR), could differ in Paralympic athletes (PAthl) with spinal cord injury (SCI) with respect to PAthl with locomotor impairments caused by different health conditions (HCs). The purposes of the present study were the comparisons of two groups of PAthl, one with SCI and the other with either amputation (AMP) or post poliomyelitis syndrome (PM), assessing the (1) peak cardiorespiratory responses and determinants (SV and HR) of CO during maximal and submaximal arm cranking exercise (ACE), respectively; (2) correlations between peak oxygen uptake (VO_2peak) and the highest SV obtained during submaximal exercise; and (3) correlations between oxygen pulse (O₂ pulse, ratio between VO₂ and HR) and both SV and O₂ arterio-venous difference [(a-v)O₂diff]. Each athlete (19 PAthl with SCI, 9 with AMP, and 5 with PM) completed a continuous incremental cardiopulmonary ACE test to volitional fatigue to assess peak responses. In a different session, CO was indirectly measured through carbon dioxide (CO₂) rebreathing method at sub-maximal exercise intensities approximating 30, 50, and 70% of the VO_2peak. There were no significant differences between the PAthl groups in age, anthropometry, and VO_2peak. However, peak HR was significantly lower, and peak O₂ pulse was significantly higher in PAthl with AMP/PM compared to those with SCI. During sub-maximal exercise, PAthl with AMP/PM displayed significantly higher SV values (154.8 ± 17.60 ml) than PAthl with SCI (117.1 ± 24.66 ml). SV correlated significantly with VO_2peak in both PAthl with SCI (R ² = 0.796) and AMP/PM (R ² = 0.824). O₂ pulse correlated significantly with SV in both PAthl with SCI (R ² = 0.888) and AMP/PM (R ² = 0.932) and in the overall sample (R ² = 0.896). No significant correlations were observed between O₂ pulse and (a-v)O₂diff. It was concluded that in PAthl with different HCs: (1) significant differences, as a consequence of the different HC, exist in the determinants of CO at maximal and submaximal ACE; (2) SV is a significant determinant of VO_2peak, suggesting cardiac adaptations possible also in PAthl with SCI; and (3) SV can be predicted from O₂ pulse measurements during submaximal exercise in both groups of PAthl.

Wearable Sensors in Ambulatory Individuals With a Spinal Cord Injury: From Energy Expenditure Estimation to Activity Recommendations

Inappropriate physical inactivity is a global health problem increasing the risk of cardiometabolic diseases. Wearable sensors show great potential to promote physical activity and thus a healthier lifestyle. While commercial activity trackers are available to estimate energy expenditure (EE) in non-disabled individuals, they are not designed for reliable assessments in individuals with an incomplete spinal cord injury (iSCI). Furthermore, activity recommendations for this population are currently rather vague and not tailored to their individual needs, and activity guidelines provided for the non-disabled population may not be easily translated for this population. However, especially in iSCI individuals with impaired abilities to stand and walk, the assessment of physical activities and appropriate recommendations for a healthy lifestyle are challenging. Therefore, the study aimed at developing an EE estimation model for iSCI individuals able to walk based on wearable sensor data. Additionally, the data collected within this study was used to translate common activity recommendations for the non-disabled population to easily understandable activity goals for ambulatory individuals with an iSCI. In total, 30 ambulatory individuals with an iSCI were equipped with wearable sensors while performing 12 different physical activities. EE was measured continuously and demographic and anthropometric variables, clinical assessment scores as well as wearable-sensor-derived features were used to develop different EE estimation models. The best EE estimation model comprised the estimation of resting EE using the updated Harris-Benedict equation, classifying activities using a k-nearest neighbor algorithm, and applying a multiple linear regression-based EE estimation model for each activity class. The mean absolute estimation error of this model was 15.2 ± 6.3% and the corresponding mean signed error was −3.4 ± 8.9%. Translating activity recommendations of global health institutions, we suggest a minimum of 2,000–3,000 steps per day for ambulatory individuals with an iSCI. If ambulatory individuals with an iSCI targeted the popular 10,000 steps a day recommendation for the non-disabled population, their equivalent would be around 8,000 steps a day. The combination of the presented dedicated EE estimation model for ambulatory individuals with an iSCI and the translated activity recommendations is an important step toward promoting an active lifestyle in this population.

Nutrition Considerations for Athletes with Physical Disabilities

Nutrition, which is an important factor that improves physical performance, has a major place in the lives of both disabled and nondisabled athletes. The main purpose of nutritional assessment of disabled athletes is to assess the individual's consumption to determine the insufficiencies and to suggest the necessary changes to design the most appropriate nutrition plan. Nutrition strategies play a key role in confirming the performance of disabled athletes. Considering the nature of the disability and the specific sports branch, it is important to determine the necessary nutrition solutions to ensure the best protection for the athletes concerned. The literature on the specific nutritional needs for the best sports performance of disabled athletes is insufficient and should be considered in light of current information on specific disability physiology.

Bone Health in Adaptive Sports Athletes

Adaptive sports athletes represent a growing population within the athletic community worldwide. Given potential cardiometabolic and psychosocial benefits of adaptive sports participation, the impact on bone health and injury risk in adaptive athletes is of increasing clinical interest. Impaired bone health as a result of low energy availability has been well described in able-bodied athletic women and, more recently, men as part of the female athlete triad and Relative Energy Deficiency in Sport (RED-S). However, the applicability of these models to adaptive athletes remains unclear given altered physiology and biomechanics compared with able-bodied counterparts. Thus, a literature review was completed to characterize the influence of adaptive sports participation and associated risk factors for impaired bone health in this unique population. To date, limited investigations demonstrate a consistent, positive effect of sports participation on bone health. Risk factors for impaired bone health include low energy availability and micronutrient deficiency.

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.

Low energy availability, menstrual dysfunction, and impaired bone health: A survey of elite para athletes

INTRODUCTION

The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population.

METHODS

Athletes were U.S. elite para athletes training to qualify for the 2016 or the 2018 Paralympic Games. Participants completed an online questionnaire characterizing nutrition, menstrual status (in females), bone health, and awareness of the Triad/RED-S.

RESULTS

The athletes were 260 elite para athletes (150 male, 110 female). While few reported prior eating disorder (3.1%), 32.4% had elevated Eating Disorder Examination Questionnaire (EDE-Q) pathologic behavior subscale scores. Most athletes (95 male, 65 female) were attempting to change their body composition or weight to improve performance. Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea. Bone stress injury was reported in 9.2% of athletes; of these, 54.5% (n = 12) had low BMD. Less than 10% of athletes reported awareness of the Triad/RED-S.

CONCLUSIONS

Factors associated with the Triad/RED-S are present in an elite para athlete population, regardless of sex or sport type. Awareness of the Triad/RED-S in para athletes is low. The consequences of LEA in para athlete populations are poorly understood. However, the high prevalence of factors observed suggests value in advancing screening tools and education efforts to optimize health in this population.

Evaluation of Dietary Supplement Use in Wheelchair Rugby Athletes

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

Low Energy Availability, Menstrual Dysfunction, and Low Bone Mineral Density in Individuals with a Disability: Implications for the Para Athlete Population

Low energy availability, functional hypothalamic amenorrhea, and low bone mineral density are three interrelated conditions described in athletic women. Although described as the female athlete triad (Triad), males experience similar health concerns. The literature suggests that individuals with a disability may experience altered physiology related to these three conditions when compared with the able-bodied population. The goal of this review is to describe the unique implications of low energy availability, low bone mineral density, and, in females, menstrual dysfunction in individuals with a disability and their potential impact on the para athlete population. A literature review was performed linking search terms related to the three conditions with six disability categories that are most represented in para sport. Few articles were found that directly pertained to athletes, therefore, the review additionally characterizes literature found in a non-athlete population. Review of the available literature in athletes suggests that both male and female athletes with spinal cord injury demonstrate risk factors for low energy availability. Bone mineral density may also show improvements for wheelchair athletes or athletes with hemiplegic cerebral palsy when compared with a disabled non-athlete population. However, the prevalence of the three conditions and implications on the health of para athletes is largely unknown and represents a key gap in the sports medicine literature. As participation in para sport continues to increase, further research is needed to understand the impact of these three interrelated health concerns for athletes with a disability, accompanied by educational initiatives targeting athletes, coaches, and health professionals.

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

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

Resting energy expenditure in male athletes with a spinal cord injury

OBJECTIVE

To investigate whether there are differences in the resting energy expenditure (REE) and body composition of athletes with a spinal cord injury (SCI) compared to active able-bodied controls.

DESIGN

In this cross sectional study, male athletes with a SCI were compared to active able-bodied controls matched for age, stretch stature and body mass. In addition, the accuracy of standard REE prediction equations in estimating REE was assessed.

PARTICIPANTS

Seven male wheelchair athletes with a SCI and six matched active able-bodied controls volunteered to participate.

OUTCOME MEASURES

REE was measured using indirect calorimetry and estimated using population-specific prediction equations. Body composition (lean tissue mass, fat mass and bone mineral content) was measured by dual energy X-ray absorptiometry (DXA).

RESULTS

While absolute and adjusted REE in the athletes with SCI was lower than controls, this difference was not significant (P = 0.259). When adjusted for lean tissue mass (LTM), REE was significantly higher (P = 0.038) in the athletes with SCI compared to the controls (146 ± 29kJ/kg LTM vs. 125 ± 8kJ/kg LTM). LTM was significantly lower in the athletes with SCI (44.35 ± 6.98 kg) compared to the able-bodied controls (56.02 ± 4.93 kg; P < 0.01). The differences between predicted and measured REE in the athletes with SCI were not statistically significant (except for the Owen equation), however there was no significant correlation between the measures.

CONCLUSION

This suggests that existing prediction equations used to estimate energy requirements may require modification for athletes with SCI.

Participation in moderate-to-vigorous leisure time physical activity is related to decreased visceral adipose tissue in adults with spinal cord injury

Increased visceral adiposity places individuals with chronic spinal cord injury (SCI) at increased risk of cardiometabolic disease. The purpose of this study was to identify if people with chronic SCI who participate in any moderate- to vigorous-intensity leisure time physical activity (LTPA) have lower visceral adipose tissue (VAT) area compared with those who report none. Participants included 136 adult men (n = 100) and women (n = 36) with chronic (mean (±SD) 15.6 ± 11.3 years post-injury) tetraplegia (n = 66) or paraplegia (n = 70) recruited from a tertiary rehabilitation hospital. VAT area was assessed via whole-body dual-energy X-ray absorptiometry using a Hologic densitometer and the manufacturer's body composition software. Moderate-to-vigorous LTPA was assessed using the Leisure Time Physical Activity Questionnaire for People with SCI (LTPAQ-SCI) or the Physical Activity Recall Assessment for People with SCI (PARA-SCI). Summary scores were dichotomized into any or no participation in moderate-to-vigorous LTPA to best represent the intensity described in current population-specific physical-activity guidelines. Data were analyzed using univariate and multiple regression analyses to identify the determinants of VAT. Overall, the model explained 67% of the variance in VAT area and included time post-injury, age-at-injury, android/gynoid ratio, waist circumference, and moderate-to-vigorous LTPA. Participation in any moderate-to-vigorous LTPA was significantly (95% confidence interval: -34.71 to -2.61, p = 0.02) associated with VAT after controlling for injury-related and body-composition correlates. Moderate-to-vigorous LTPA appears to be related to lower VAT area, suggesting potential for LTPA to reduce cardiometabolic disease risk among individuals with chronic SCI.

Thermoregulation following spinal cord injury

Spinal cord injury results in physiologic adaptations affecting heat production (reduced muscle mass) and heat dissipation (blood redistribution and reduced sweating capacity below the level of lesion). However, it is the balance between these factors which determines whether heat balance is achieved. Core temperature estimates are generally consistent with those for the able-bodied, with cooler values reported in some instances. More notable differences are demonstrated through cooler lower-body skin temperatures at rest and a loss of anticipatory control during exposure to heat and cold when compared to the able-bodied. During exercise in cool conditions persons with paraplegia demonstrate similar body temperature responses as for the able-bodied but retain heat during recovery. Persons with tetraplegia demonstrate continual increases in core temperature and thus thermal imbalance along with greater heat retention. During exercise in the heat, athletes with paraplegia appear to be able to regulate body temperature to a similar extent as the able-bodied. Those with tetraplegia again show thermal imbalance but to a much greater extent than in the cold. Future work should focus upon specific sweating responses and adaptations following spinal cord injury, the effects of completeness of lesion, perceptual responses to environmental challenges, and how these translate to undertaking activities of daily living.

Evaluation of Dietary Intakes and Supplement Use in Paralympic Athletes

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

The intensity and match load comparison between high spinal cord injury and non-spinal cord injury wheelchair basketball players: a case report

INTRODUCTION

This is a comparative case study between one high spinal cord injury (SCI) and two non-SCI players during an official wheelchair basketball (WB) match. The aim of the study was to calculate the differences in the absolute and relative HR responses and in the match load among one SCI and two non-SCI players in the same WB match.

CASE PRESENTATION

The study was conducted with first-division WB players in Vitoria-Gasteiz, Spain (2014). All of the participants had played the whole official WB match. Absolute heart rate (HR) in the test (10 m Yo-Yo Intermittent Recovery Test Level 1, YYIR1 10 m) as well as absolute and relative HR and match load (ML) were recorded for these three players in an official WB match.

DISCUSSION

The HRpeak and mean during the YYIR1 10 m test and the whole WB match were lower for the SCI player than the non-SCI players. However, as opposed to absolute HR values, relative HR values and ML reported very similar responses among SCI and non-SCI values. Moreover, in the high-intensity HR zone the values were similar among the three players but not in the low (<75% of HRpeak), moderate (75-85% of HRpeak) and maximal (>95% of HRpeak) HR zones. Although the absolute HR values were lower for the SCI player, the relative values and the ML were similar for all the players. Therefore, it could be necessary to use relative HR values to quantify the intensity of efforts in the WB matches.

Marginal Micronutrient Intake in High-Performance Male Wheelchair Basketball Players: A Dietary Evaluation and the Effects of Nutritional Advice

Wheelchair basketball has evolved into a high-performance sport over several years, and small variations in player performance can determine the difference between winning and losing. Therefore, adequate micronutrient intake may influence this difference if performance-promoting macronutrient intake and physical fitness are equal between teams. Seventeen elite male wheelchair basketball players belonging to the Spanish National Team participated in this study. Macro- and micronutrient intake were determined using a food-weighing diary over three consecutive days during three training camps in two consecutive years. Current Dietary Reference Intake levels were used to determine the adequacy of intake of seventeen micronutrients of particular interest for athletes. After categorizing the consumed foods into fourteen food groups according to the National Nutrient Database for Standard References (USDA) these groups were used to identify the best predictors of the adequacy of intake for each micronutrient. Total energy intake correlated positively with the adequacy of all micronutrient intake levels, except for vitamins A and E. Five B vitamins and phosphorus, selenium, and iron showed 100% adequacy. All other micronutrient intake levels were found to be inadequate, e.g., vitamin E (51% adequacy) and calcium (73%). The fruit, fish and cereal food groups were found to be predictors of adequate intake of most micronutrients. Together with energy intake (p = .009, η2 = 0.49), the intake of the fruit (p = .032, η2 = 0.39) and egg (p = .036, Kendall's W = 0.42) food groups increased significantly over time, along with improved iodine (p = .008, W = 0.61) and magnesium (p = .030, W = 0.44) adequacy levels. Because the adequacy of micronutrient intake correlates positively with energy intake (R = 0.64, p < .001), a varied diet that includes cereals, fish and fruits is especially important for players with low levels of energy intake. Supplements may be a possible solution if adequate micronutrient intake cannot be achieved through regular dietary intake alone. However, dietary analyses should be conducted on a regular basis throughout the year to improve the nutritional knowledge of the athletes and assure adequate micronutrient intake.

Documentation of weight management practices for individuals with spinal cord injuries and disorders

STUDY DESIGN

This cross-sectional chart review study included 100 US Veterans with spinal cord injuries/disorders (SCI/D) who received care at a Veterans Affairs (VA) SCI facility during a 12-month period. Progress notes were examined to extract need for weight management (WM), patient-provider discussions about risk due to overweight/obesity, recommended lifestyle changes and/or follow-up and WM education.

OBJECTIVES

To understand what WM services are offered to Veterans with SCI/D within the VA SCI System of Care during comprehensive preventive health evaluations (annual evaluations), inpatient stays and outpatient visits.

SETTING

VA SCI System of Care, Department of Veterans Affairs, United States.

RESULTS

Overall, 73% demonstrated a need for WM. Weight was most frequently addressed during the nutrition assessment of annual evaluations, but this assessment was most likely to be skipped. Nutrition histories were missing many key components. Over half received WM education; individuals who were described as overweight/obese by their provider were more likely to receive education. Most of the Veterans who were seen in an inpatient setting were weighed; weight was only discussed with 12%. Less than half of the Veterans with outpatient visits were weighed, and 23% received WM recommendations.

CONCLUSIONS

Weight was frequently discussed during nutrition assessments, but infrequently addressed during outpatient or inpatient encounters. Few Veterans received specific recommendations on caloric/nutrient requirements and nutrition histories were missing recommended elements. Additional work is needed to help providers to incorporate WM information into care.

The effect from maximal bench press strength training on work economy during wheelchair propulsion in men with spinal cord injury

OBJECTIVE

To assess the effect from maximal bench press strength training (MST) on wheelchair propulsion work economy (WE).

STUDY DESIGN

Pretest-posttest case-control group design.

SETTING

St Olavs Hospital, Trondheim, Norway.

METHODS

Seventeen male individuals with spinal cord injury (SCI) paraplegia were allocated to either MST bench press (n=11) or the control group (CG) (n=7). The MST group trained bench press three times per week, for 6 weeks, starting at 85-95% of their pretest bench press one-repetition maximum (1RM). For calculation of WE during wheelchair propulsion, oxygen uptake (VO₂) measurements were collected during wheelchair ergometry (WCE) at submaximal workload of 50 W. Similarly, peak oxygen uptake (VO_2peak) and peak power output (W) were measured during WCE.

RESULTS

Individuals in the MST regimen significantly improved WE compared with the CG by 17.3 % (mean between-group differences: 95% confidence interval) of 2.63 ml kg^-1 min^-1: (-4.34, -0.91) (P=0.007). Between pretest and posttest, the increase in bench press 1RM was by 17% higher in the MST group compared with the CG. At peak testing, the MST group generated significantly higher peak power compared with the CG. All other physiological variables were comparable within and between groups.

CONCLUSIONS

A 6-week MST bench press regimen significantly improved WE during wheelchair propulsion at 50 W workload. These preliminary data support a possible beneficial role for MST to reduce the energy cost of wheelchair propulsion for SCI individuals.

Comparison of therapeutic effects of anterior decompression and posterior decompression on thoracolumbar spine fracture complicated with spinal nerve injury

Objective:

To compare the clinical therapeutic effects of anterior decompression and posterior decompression on thoracolumbar spine fracture (TSF) complicated with spinal nerve injury (SNI).

Methods:

A total of 120 patients with TSF and SNI were selected and divided into a treatment group and a control group that were then treated by anterior decompression and posterior decompression respectively. The preoperative and postoperative motor scores, tactile scores, heights of injured vertebral body and Cobb’s angles, as well as surgical times and intraoperative blood losses were recorded and compared.

Results:

Before surgeries, the motor score, tactile score, height of injured vertebral body and Cobb’s angle of the treatment group were similar to those of the control group (P>0.05). After surgeries, the values of the treatment group were significantly different from those of the control group (P<0.05). The two groups also had significantly different intraoperative blood losses and surgical times (P<0.05).

Conclusion:

Compared with posterior decompression, anterior decompression improved spinal cord function better and relived spinal cord compression more effectively with a more reasonable mechanics of internal fixation. Although this protocol caused more blood loss, the overall therapeutic effects were more satisfactory.

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.

Changes in Body Composition and Physical Performance in Wheelchair Basketball Players During a Competitive Season

The present study analyzed the changes in body composition and physical performance in wheelchair basketball (WB) players during one competitive season. Players from a WB team competing in the first division of the Spanish League (n = 8, age: 26.5 ± 2.9 years, body mass: 79.8 ± 12.6 kg, sitting height: 91.4 ± 4.4 cm) participated in this research. The upper limbs showed a decrease in subcutaneous adipose tissue and there was an improvement in physical abilities such as sprinting with the ball (5 and 20 m), handgrip and aerobic capacity. However, the changes in physical fitness concerning sprinting without the ball and agility tests were low. It would be interesting to study the effects of implementing specific programs to improve physical performance in WB and to establish more test sessions to monitor the effects of the programs followed.

Health care provider practices, barriers, and facilitators for weight management for individuals with spinal cord injuries and disorders

BACKGROUND

Even though weight management is essential for the health of individuals with spinal cord injuries and disorders (SCI/D), little is known about current practices, barriers, and facilitators.

OBJECTIVE

To describe weight management delivery in the Veterans Affairs (VA) SCI/D System of Care, including barriers and facilitators experienced by health care providers.

METHODS

Qualitative focus groups were conducted in person at 4 geographically dispersed VA medical facilities delivering care to Veterans with SCI/D. Thirty-two employees involved in weight management efforts participated. Audio-recordings were transcribed and analyzed using qualitative content analysis techniques.

RESULTS

Participants at SCI centers reported that weight management treatment was delivered through the center by a multidisciplinary team using education (eg, written materials) and counseling/consults. Participants at SCI spoke facilities generally depended on facility-level programs (eg, MOVE!) to deliver treatment. Spoke facilities discussed barriers to delivering treatment through their SCI team, including staff shortages and resource and structural issues. MOVE! staff discussed barriers, including limited wheelchair space in classrooms. Staff participants across facilities noted that Veterans with SCI/D were hesitant to use facility-level programs, because of nonspecific SCI-relevant information and discomfort attending sessions with general Veterans. Other barriers, for both centers and spoke facilities, included necessary medications that increase weight, lack of evidence-based guidelines for weight management, safety concerns, and facility layout/accessibility. Facilitators included facility leadership support, provider involvement/prioritization, and community resources.

CONCLUSIONS

Weight management programs delivered through the SCI team, with peers and SCI-relevant content, are likely more acceptable and beneficial to individuals with SCI/D. Program classrooms should provide ample space for individuals with SCI/D.

Basal and resting metabolic rates of physically disabled adult subjects: a systematic review of controlled cross-sectional studies

AIM

To systematically review studies that investigated the basal metabolic rate (BMR) and resting metabolic rate (RMR) of physically disabled adult subjects.

METHODS

The studies were identified via MedLine, Science Direct, Science Search, Scientific Electronic Library Online, Wiley, Latin American and Caribbean Health Sciences Literature, Cochrane, Indice Bibliográfico Espanõl de Ciencias de la Salud, Scopus, ProQuest Dissertations & Theses Database and System for Information on Grey Literature in Europe. No restriction on publication date was imposed.

RESULTS

Data from 6 studies were included. The results showed that physically disabled adult subjects have a lower BMR and/or RMR compared to nondisabled subjects. However, the difference between the groups disappeared when the BMR and RMR were adjusted for fat-free mass. Due to the small number of studies on this subject and the limited types of physical disabilities evaluated in the literature, we could not make a definitive conclusion.

CONCLUSIONS

Disabled individuals seem to have a lower absolute BMR and/or RMR than able-bodied adults; however, this difference was not present or else it disappeared in half of the studies, after adjusting for body mass and/or fat-free mass.

Persistent polyuria in a rat spinal contusion model

Polyuria contributes to bladder overdistention, which confounds both lower and upper urinary tract management in individuals having a spinal cord injury (SCI). Bladder overdistention post-SCI is one of the most common triggers for autonomic dysreflexia, a potentially life-threatening condition. Post-SCI polyuria is thought to result from loss of vascular tone in the lower extremities, leading to edema and subsequent excess fluid, resulting in polyuria. Mild SCIs that have near complete recovery would therefore be expected to have little to no polyuria, while severe injuries resulting in flaccid limbs and lower extremity edema would be expected to exhibit severe polyuria. Since interventions that may decrease lower extremity edema are recommended to lessen the severity of polyuria, step training (which promotes vascular circulation) was evaluated as a therapy to reduce post-SCI polyuria. In the present study, polyuria was evaluated in mild, moderate, and severe contusive SCI in adult male rats. The animals were housed in metabolic cages for 24-hour periods pre- and post-SCI (to 6 weeks). Urine, feces, food, water, and body weights were collected. Other assessments included residual expressed urine volumes, locomotor scoring, in-cage activity, and lesion histology. SCI produced an immediate increase in 24-hour urine collection, as early as 3 days post-SCI. Approximately 2.6-fold increases in urine collection occurred from weeks 1-6 post-SCI for all injury severities. Even with substantial gains in locomotor and bladder function following a mild SCI, polyuria remained severe. Step training (30 min/day, 6 days/week) did not alleviate polyuria in the moderate SCI contusion group. These results indicate that (1) mild injuries retaining weight-bearing locomotion that should have mild, if any, edema/loss of vascular tone still exhibit severe polyuria, and (2) step training was unable to reduce post-SCI polyuria. Taken together, these results indicate that the current mechanistic hypothesis of post-SCI polyuria may be incomplete.

Effect of leg vascular occlusion on arm cycling peak oxygen uptake in spinal cord-injured individuals

STUDY DESIGN

Cross-sectional single-subject design.

OBJECTIVES

To determine whether leg vascular occlusion (LEVO) augment arm cycling (ACE) peak oxygen uptake in spinal cord-injured individuals.

SETTING

University Hospital, Norway.

METHODS

Fifteen individuals with C(4) to T(12) spinal cord injury (SCI) were recruited and divided into two groups: injury above (SCI-high, n=8) or below (SCI-low, n=7) the T(6) level. Peak oxygen uptake (VO(2peak)) was measured during (1) ACE combined with LEVO, (2) ACE alone and (3) ACE combined with functional electrical stimulation cycling (FES hybrid cycling).

RESULTS

In the SCI-high group, VO(2peak) and peak Watt during ACE with LEVO were higher than ACE alone: 20.0 (±5.0) versus 17.6 (±5.0) ml kg(-1) min(-1) (P=0.006), and 72.5(±32) versus 80.0 (±34) Watt (P=0.016), respectively. However, FES hybrid cycling VO(2peak) was significantly higher than ACE with LEVO: 24.4 (±4.1) versus 20.0 (±5.0) ml kg(-1) min(-1) (P=0.006). In the SCI-low group, there was no difference in VO(2peak) and related parameters between the three modalities.

CONCLUSIONS

For spinal cord-injured individuals with injury level above T(6) (high) in the present study, LEVO combined with ACE augment VO(2peak). However, this acute increase in VO(2peak) was lower than when FES cycling was combined with ACE. These findings may have future implications for exercise prescription for spinal cord-injured individuals.