Is Exercise Effective in Preventing Secondary Conditions in Persons with SCI

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Is Exercise Effective in Preventing Secondary
Conditions in Persons with SCI?

• Larry F. Hamm, PhD, FACSM
• National Rehabilitation Hospital
• Washington, DC

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Disclaimers

• Nothing to declare
• National Institute for Disability and
  Rehabilitation Research grant H133B03114

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Chicago
Minneapolis
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FAQ in Exercise Science

• What can I do with my baccalaureate or graduate
  degree?
• Cardiac rehabilitation
• Pulmonary rehabilitation
• Fitness and wellness
• Teach physical education
• College professor
• Other?

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RRTC on Spinal Cord Injury

• Promoting health and preventing complications
  through exercise
• 5-year, 4,000,000 grant
• Research 5 studies investigating the effects of
  exercise or physical activity on the health of
  persons with spinal cord injury (SCI)
• Training 4 studies
• Major conference for health care professionals

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What is SCI

• Injury to the spinal cord that disrupts nervous
  system communication from the brain to the
  periphery
• Affects muscular control and sensation
• Complete injury
• Incomplete injury

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From The CIBA Collection of Medical
Illustrations, Volume 8, Part I
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ASIA Exam

• American Spinal Injury Association (ASIA)
• ASIA sensory exam
• 28 sensory points (within dermatomes)
• 0, 1, 2 grading system to sensation of pin prick
• ASIA motor exam
• 10 key muscles (5 upper 5 lower extremeties)

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ASIA Exam (2)

• 6 point scale (0-5)
• 0 no active movement
• 1 muscle contraction
• 2 movement thru ROM w/o gravity
• 3 movement thru ROM against gravity
• 4 movement against some resistance
• 5 movement against full resistance

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From The CIBA Collection of Medical
Illustrations, Volume I, Part II
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Asia Impairment Scale

• A Complete No Sacral Motor / Sensory
• B Incomplete Sacral sensory sparing
• C Incomplete Motor Sparing (lt3)
• D Incomplete Motor Sparing (gt3)
• E Normal Motor Sensory

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SCI Classifications

• Level below which there is no sensory or motor
  function
• Tetraplegia SCI above T1 level
• High C1-C4
• Low C5-C8
• Paraplegia SCI at or below T1 level

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From Krusens Handbook of Physical Medicine
Rehabilitation, 4th Ed.
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From Krusens Handbook of Physical Medicine
Rehabilitation, 4th Ed.
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SCI Epidemiology

• Incidence
• 40 injuries/million population
• 11,000 new cases per year
• Does not include those who die at scene
• 4 deaths/million or 1,000 per year
• Prevalence
• 250,000 (225,000 288,000)

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SCI Epidemiology (2)

• Age at injury is increasing
• 37.6 years of age
• Increasing incidence in people 60 years of age
  at time of injury (10.6)
• 80 male
• Etiology
• 47 MVA, 23 falls, 14 violence, 9 sports, 7
  unknown
• MVA 1 cause if lt45 years
• Falls 1 cause if gt45 years

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SCI Epidemiology (3)

• Neurologic level
• Tetraplegia 52.9
• Paraplegia 40.6
• ASIA
• A 49.0
• B 10.3
• C 11.2
• D 29.1
• E 0.8

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SCI Epidemiology (3)

• Thoracic usually complete
• Lumbosacral usually A or D
• Cervical A-D

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SCI Secondary Conditions

• Osteopenia/osteoporosis
• Accelerated CVD/atherogenic lipid profile
• Decreased pulmonary function
• Hypokinetic lifestyle/low fitness
• Depression
• Poor diet
• Chronic pain
• Frequent infection

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Selected RRTC Research Studies
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R1 Cardiovascular Disease Risk Stratification
Across Injury Levels after Spinal Cord Injury
Assessment of Need for Intervention and its
Predictors
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R1 Research Questions

• To what extent do persons with different levels
  of SCI qualify for lifestyle and medical
  intervention when assessing their CVD risk by
  authoritative guidelines of the National
  Cholesterol Education Project Adult Treatment
  Panel III?
• Which specific CVD risks represent significant
  predictors of their need for intervention?

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Questions (2)

• What are expected responses to acute exercise for
  individuals with SCI based upon their unique
  levels and severities of injury, duration of
  injury, and age?
• Can peak fitness in persons with SCI be predicted
  by their resting physiology, unique physiological
  responses to exercise, and injury descriptive
  characteristics?

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R1 Inclusion Criteria

• Complete injury between C5 T12
• ASIA A or B
• SCI at least 12 months prior
• No history of cardiovascular disease
• 18 years of age
• Provide informed consent

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R1 Research Variables

• BMI
• Fasting
• Lipids
• Glucose
• HbA1c
• OGTT
• Smoking status
• ASIA assessment

• 4-day dietary record
• Arm ergometry exercise test
• ECG
• BP
• Gas analysis
• Calculation of NCEP-ATP III risk score

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Arm Ergometry
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R1 Interim Demographics (n82)

• Age 37.1 yr (18-73)
• Male 83
• AA 35 Caucasian 33 Hispanic 31
• ASIA A 64 B 36
• Level of SCI
• C5-C6 29 T1-T5 21
• C7-C8 6 T6-T12 44

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R1 Interim Demographics (2)

• Etiology
• MVA 34
• Violence 30
• Falls 11
• Sports 5
• Other 20

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R1 Interim Results-Ergometry
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NCEP-ATP III CVD Risk

• Age gender-specific
• Total cholesterol
• High-density lipoprotein cholesterol
• Smoking status
• Systolic blood pressure

• Point range
• Men lt 0 37
• Women lt 0 46
• Risk range
• lt 1 - ? 30

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R1 Interim Results-CVD Risk

• NCEP CVD 10-year CVD absolute risk estimate
• All subjects
• 4.6
• Tetraplegia
• 4.1
• Paraplegia
• 4.2

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R1 Interim Results-Dietary
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Motor Training to Facilitate Recovery in SCI
1. Animal studies 2.
Forced use (CIMT constraint induced movement
therapy) 3. Body weight supported
treadmill training (BWSTT) 4.
Robotics
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Robotic Technology

• Instrumented devices provide quantitative
  assessment measures for determining motor
  impairment and tracking functional progress.
• Accuracy reduces subjective evaluations made by
  clinicians.
• Can replicate existing therapies, making it
  possible for one therapist to work with more than
  one patient at a time.
• Active assistance allows weak and uncoordinated
  subjects to practice functional motor patterns.

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Robotics Lokomat
ManualBWSTT
Robotic BWSTT
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R3 Effect of robotic body-weight supported
treadmill training on bone mineral density and
selected secondary conditions in individuals with
spinal cord injury
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R3 Research Questions

• What is the effect of 6 months of RBWSTT on BMD?
• What is the effect of 6 months of RBWSTT on
  depression, pain, and overall quality of life?
• What is the effect of 6 months of RBWSTT on serum
  lipid, glucose, and insulin values?
• What is the effect of 6 months of RBWSTT on
  selected measures of aerobic fitness?

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Inclusion Criteria

• ASIA C or D motor incomplete
• Between 1 and 6 months post-SCI
• No contraindication for upright ambulation
• Initial BMD within 1 SD of age-related normal
• 18 years of age
• Provide informed consent

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R3 Research Variables

• BMD using DXA
• Depression-BDI II
• Multidimensional Pain Inventory
• MOS SF-36
• Fasting lipids, glucose, HbA1C
• Insulin sensitivity

• 4-day dietary record
• Fitness
• Decrease in VO2, HR, and RER at baseline exercise
  intensity
• Personal activity log

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Lokomat Exercise Testing
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R3 Interim Demographics (n9)

• Age 40.2 yr (19-59)
• Male 100
• AA 44 Caucasian 33 Hispanic 11
• ASIA C 100
• Level of SCI
• C5-C6 58 T10 14
• T1 14 L2 14

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R3 Interim Demographics (2)

• Etiology
• Gunshot/violence 44
• MVA 14
• Falls 14
• Sports 14
• Other 14

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R3 Interim Results-Exercise
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R3 Interim Results-SF 36
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R1 R3 Research Team

• NRH
• Suzanne Groah, MD
• Alison Lichy, PT
• Paula Karlin, MS and Emily Jadwin, BS
• University of Miami
• Mark Nash, PhD
• Edelle Field-Foté, PhD, PT

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What can I do with my baccalaureate or graduate
degree in Exercise Science?
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