Health and Wellness after Spinal Cord InjuryLIZ DUNN, MS, RD, LDN

DAN MCCOY, ACE-PT

Liz Dunn

◦ Registered Dietitian

◦ Completed both Bachelor and Master degrees in nutrition at the University of Pittsburgh

◦ C6 Spinal Cord Injury

◦ Pittsburgh Steelwheelers wheelchair rugby player

◦ Sports Nutrition Intern at University of California, Los Angeles

◦ Current volunteer with University of Pittsburgh sports nutrition

◦ lizmdunnRD@gmail.com

Nutrition for SCIThings to consider:

◦ Injury specifics

◦ Ability to obtain and prepare food, feed self

◦ Elevated risk of cardiovascular disease1,2

◦ Neurogenic bowel/bladder

◦ Bone health

◦ Presence of pressure injuries

◦ BMI is not accurate in SCI1,3

◦ Lower BMI cutoffs have been suggested, DEXA is gold standard

Acute PhaseSpinal shock

◦ Is feeding appropriate/possible

Is the patient able to consume food orally?◦ Tube feeding

Presence of paralytic ileus◦ If prolonged, parenteral nutrition may be required

Initial weight loss from increased metabolism (?) and muscle catabolism2,4

◦ Negative nitrogen balance◦ Indirect calorimetry best

Indirect calorimetry is most accurate for measuring energy expenditure4

◦ Accuracy of predictive formulas is questionable

Increased protein needs

Chronic PhaseDue to increased cardiovascular disease risk, nutrition counseling is important2,5

◦ Increased odds of both heart disease and stroke

Many people with SCI struggle with weight issues

Predictive equations for calorie needs can overestimate as much as 30%, indirect calorimetry best4

◦ Equations all based on AB’s and modified for SCI

Ability to grocery shop/prepare foods

Encourage fruit and vegetable consumption to increase micronutrients◦ People with SCI consumed less whole grains, fruit/veg & dairy, but similar overall energy compared to

AB’s5

Protein is key for maintaining muscle mass and prevent pressure injury

Neurogenic Bowel & BladderInability to control bowel and bladder function due to nerve dysruption6

Adjust fiber and fluid as needed to maintain optimal stool consistency6

◦ Both constipation and loose stools may be a problem depending on level of injury

Fiber needs◦ Initial 15g/day, positive effects shown at 18g, but more than 30g is not recommended due to increased

intestinal transit time.7

Fluid for both UTI prevention and bowel function◦ 1ml/kcal +500ml or 40ml/kg + 500ml8

◦ This is higher than recommended needs for able-bodied individuals

Autonomic dysreflexia

Antibiotics for UTI◦ Keep in mind the effects on gut microbiome & how overtreating UTI’s can lead to antibiotic resistance8

Pressure InjuriesSCI at increased risk— reduced mobility

Malnutrition is risk – wounds can be prevented by adequate intake of protein, Vit E, zinc, and fluids to maintain skin integrity.9

Fluid needs may be increased due to wound drainage

Adequate energy, protein, arginine, Vit A, C, and zinc play important roles in wound healing9,10

◦ 30-35kcal/kg for adults at risk of pressure ulcer or have one & are at risk of malnutrition

◦ Stage 3 & 4 1.25-1.5g/kg pro supplement with protein + nutrients if necessary

Other Nutrition ConsiderationsIntermittent catheterization schedule (caffeine, hot liquids, alcohol, etc.)

◦ Certain fluids pass through the body faster and alter hydration status

GI disorders (IBS, lactose intolerance, celiac)◦ Either dx prior to injury or develop after

Colostomy/ostomies

Drug nutrient interactions

Just to name a few!

Sports Nutrition for Adaptive Athletes and Active IndividualsA few things to consider:

◦ Type of sport/activity

◦ Level of sport (recreational, club team, national team)

◦ Training schedule/exercise program

◦ Ability to regulate temperature◦ Particularly T6 & above (often completely unable to sweat)

◦ Appropriate pre/post activity snacks or meals

◦ Hydration and bladder management routine

Additional ResourcesAcademy of Nutrition and Dietetics

◦ www.eatright.org

Dietary Guidelines for Americans 2015-2020◦ https://health.gov/dietaryguidelines/2015/

National Pressure Ulcer Advisory Panel◦ www.npuap.org

Sports Nutrition for Paralympic Athletes◦ By Elizabeth Broad

References1 Eriks-Hoogland I, Hilfiker R, Baumberger M, et al. Clinical assessment of obesity in persons with spinal cord injury: validity of waist circumference, body mass index, and anthropometric index. J Spinal Cord Med. 2011;34(4):416-422

2 Cragg JJ, Noonan VK, Krassioukov A, Borisoff J. Cardiovascular disease and spinal cord injury Results from a national population health survey. Neurology. 2013;81:723–728

3 Yarar-Fisher C, Chen Y, Jackson AB, and Hunter GR. Body mass index underestimates adiposity in females with spinal cord injury. Obesity (Silver Spring). 2013;21(6): 1223–1225

4 Nevin AN, Steenson J, Vivanti A, and Hickman IJ.Investigation of measured and predicted resting energy needs in adults after spinal cord injury: a systematic review. Spinal Cord. 2016;54:248–253

5 Lieberman J, Goff D, Hammond F, et al. Dietary intake and adherence to the 2010 Dietary Guidelines for Americans among individuals with chronic spinal cord injury: A pilot study. J Spinal Cord Med. 2014;37(6):751-757

6 Coggrave M. Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions Initiated by the Multidisciplinary Association of Spinal Cord Injured Professionals. Sept 2012

7 Perret C, Stoffel-Kurt N. Comparison of nutritional intake between individuals with acute and chronic spinal cord injury. J Spinal Cord Med. 2011;34(6):569-575.

8 McColl MA, Gupta S, Smith K, McColl A. Promoting Long-Term Health among People with Spinal Cord Injury: What’s New? Int. J. Environ. Res. Public Health. 2017;14:1520

9 Saghaleini SH, Dehghan K, Shadvar K, et al. Pressure Ulcer and Nutrition. Indian J Crit Care Med 2018;22(4):283-289.

10 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: Quick reference guide. 2014.

Exercise for SCIDAN MCCOY, ACE-PT

STUDENT, MS – SPORTS SCIENCE

What is a Spinal Cord Injury?“A spinal cord injury usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae.” (www.ninds.nih.gov)

A bit more complicated than this…

Types of Spinal Cord InjuriesComplete/Incomplete

Congenital/Acute

Spina Bifida*

Spinal Cord Injury RehabilitationVaries person/person

◦ What age?

◦ Nature of injury?

◦ Level of injury?◦ Nerves associated

◦ Type/Severity?

E-Stim

PNF

Resistance Bands

Weights

Fitness Level Pre/Post InjuryAthlete?

◦ What level? Sport?

Sedentary?

Currently in Rehab?◦ Able to progress past?

Goal setting◦ SMART

◦ FITT

When to Start Post-InjuryProfessional guidance

◦ Evaluate physical/mental state

◦ Contraindications

Rate of healing◦ Diet?

◦ Wound care?◦ Pressure sores?

Individual must be ready to participate voluntarily

Considerations for ExerciseIncontinence

Contraindications

Pre/Post Nutrition & Supplementation

Pressure Sores

Hydration/Perspiration

Protein Intake◦ Other nutrition considerations

Grip strength, if applicable

Mobility needs◦ Spasticity

◦ Breathing difficulties

◦ Assistance

Type of Motivation◦ Extrinsic/Intrinsic

Mindset Shift…How?Disability can be a positive!

Friends/Family

New lease on life

Overcoming Odds

“Break Barriers, Build Confidence”

All about mental outlook on life and circumstance

Rep Ranges & Rest TimesBeginner (3 days/week)

◦ 15-20 reps, 3 sets, 1-2 min rest

◦ Cardio (5-10 min)

◦ Warm-up/Stretch

◦ 1 exercise/muscle group/workout

◦ “Full Body”

Intermediate (4-5 days/week)◦ 12-15 reps, 3-4 sets, 1-1.5 min rest

◦ Warm-up/Stretch

◦ Cardio (10-20 min, LISS, HIIT)

◦ Hit each muscle group 2x/week◦ “Split” can vary, Antagonistic, Push-Pull

Advanced (5-6 days/week)◦ 6-12 reps, 4-5 sets, 30sec-1 min rest

◦ Can be sport specific

◦ Upper/Lower, Antagonistic, Push-Pull, Endurance-Hypertrophy-Strength

Notable Muscles and Injuries AssociatedDeltoids*

◦ Dislocation◦ Tendonitis (Can present in Biceps)◦ Rotator cuff tear

Abs (If applicable)◦ Hernia

Wrists/Forearms◦ Carpal tunnel, Hyperextension

Traps/Neck◦ Pulled muscle/pinched nerve

Back◦ Pain radiating from legs (i.e. Hamstrings)◦ Herniated discs

Adaptive Sports ResourcesPittsburgh National

ReferencesAmerican Spinal Injury Association: International Standards to Document Remaining Autonomic Function after Spinal Cord Injury. Vol 2. 2nd ed. Atlanta, GA: Reprint; 2015.

American Spinal Injury Association: International Standards to Document Remaining Autonomic Function after Spinal Cord Injury. Vol 2. 2nd ed. Atlanta, GA: Reprint; 2015.

Intensive exercise program after spinal cord injury (SCIPA full-on): A randomized controlled trial. Egyptian Journal of Medical Human Genetics. https://www.sciencedirect.com/science/article/pii/S1877065718301684. Published July 13, 2018. Accessed August 31, 2018.

van JW, Martin KA, Ditor DS, et al. Effects of exercise on fitness and health of adults with spinal cord injury: A systematic review. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/28733344. Published August 15, 2017. Accessed August 31, 2018.

Spinal cord injury. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/symptoms-causes/syc-20377890. Published December 19, 2017. Accessed August 31, 2018.

Spina Bifida Fact Sheet. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Spina-Bifida-Fact-Sheet. Accessed August 31, 2018.

What You Need to Know About Spinal Cord Injuries. Johns Hopkins Medicine Health Library. https://www.hopkinsmedicine.org/healthlibrary/conditions/physical_medicine_and_rehabilitation/spinal_cord_injury_85,P01180. Accessed August 31, 2018.

Spinal Cord Injury Levels & Classification | Information. Spinal Cord Injury Zone! https://spinalcordinjuryzone.com/info/7333/spinal-cord-injury-levels-classification. Published October 1, 2011. Accessed August 31, 2018.

Martin KA, van JW, Latimer-Cheung AE, et al. Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/29070812. Published April 2018. Accessed August 31, 2018.