Background: Accurate estimation of energy needs is vital for effective nutritional management of individuals with spinal cord injury (SCI). Inappropriate energy prescription after SCI can compound the rates of malnutrition or obesity, increase the risk of complications and negatively influence outcomes. Energy requirements following SCI are not well understood, and there is currently no universally accepted method of estimating energy needs in clinical practice. Study design: This is a systematic literature review. Objectives: The objectives of this study were to investigate and compare the measured resting energy needs of adults with SCI across different phases of rehabilitation, and to identify appropriate energy prediction equations for use in SCI. Setting: This study was conducted in Australia. Methods: MEDLINE, EMBASE and CENTRAL databases were searched for studies published between 1975 and April 2015, identifying 298 articles. Full articles in English language of adults with SCI who were fasted for a minimum of 8 hours before undergoing indirect calorimetry to measure resting energy expenditure (REE) for at least 20 min were selected. On the basis of the inclusion criteria, 18 articles remained for data extraction. One author extracted information from all articles, and inter-rater reliability was tested in five articles. Results: REE across three phases of injury was assessed: acute, sub-acute and chronic. Few studies (n = 2) have investigated REE in the acute and sub-acute injury stages of SCI recovery. The factors influencing chronic energy needs in SCI patient populations are many and varied, and a valid predictive equation for use in SCI remains elusive. SCI is initially associated with catabolic conditions of trauma such as spinal shock and patients may be at risk of weight loss, malnutrition and pressure injuries. 1 In the long term, SCI results in marked body composition changes, specifically muscle atrophy below the level of injury and higher relative fat mass compared with people without SCI, 1-3 which may contribute to decreases in resting energy expenditure (REE). In an environment of reduced mobility, energy needs are further reduced, and there is an increased risk of weight gain and obesity-related chronic diseases. 4,5 To prescribe an appropriate daily energy intake, an individual's total daily energy expenditure (TDEE) must be determined. An individual's TDEE comprises three components, two of which may be considerably affected by SCI. Basal metabolic rate (BMR) is the minimum energy required for the basal processes of life, and it contributes the majority (~70%) of TDEE in a healthy person. 6 In the clinical literature, the term BMR is often used interchangeably with REE, and for the purpose of this review REE is defined as the energy expended in an awake, alert individual in a rested position following

Background: Certain dietary constituents may provoke symptoms of functional dyspepsia (FD); however, there is an absence of dietary trials testing specific dietary interventions. Empirically derived dietary strategies and the low FODMAP diet are frequently used in practice. This study aimed to compare the effectiveness of low FODMAP dietary advice with standard dietary advice for reducing epigastric and overall gastrointestinal symptoms in individuals with FD. Methods: Data were collected from 59 consecutive eligible individuals with FD attending an initial and review outpatient dietetic consultation at Princess Alexandra Hospital. Of these, 40 received low FODMAP advice and 19 received standard dietary advice. As part of usual care, the Structured Assessment of Gastrointestinal Symptom Scale (SAGIS) was used to assess epigastric (maximum score = 28) and overall gastrointestinal symptoms (maximum score = 88). Dietary adherence data were collected, and change in symptom score and proportion of responders (defined as a ≥30% reduction in score) for epigastric and total symptoms was calculated.Key Results: Most individuals (48/59, 81%) had FD and coexisting irritable bowel syndrome. There was a greater reduction in epigastric score in those receiving low FODMAP dietary advice compared with those receiving standard advice (est. marginal mean [95% CI]: −3.6 [−4.9, −2.2] vs. −0.9 [−2.9, 1.1], p = 0.032) and total symptom score (−9.4 [−12.4, −6.4] vs. −3.3 [−7.7, 1.1] p = 0.026). A greater proportion receiving low FODMAP dietary advice were responders versus those receiving standard advice (50% vs. 16%, p = 0.012). Dietary adherence did not differ between groups (p = 0.497). Conclusions & Inferences:The low FODMAP diet appears more effective for improving epigastric symptoms in people with FD compared with standard advice. A randomized controlled trial is required to substantiate these findings.

Summary Over a 19‐year period, 51 horses showing chronic lameness or gait abnormality that was not fully responsive to veterinary treatment at other referral clinics were referred to us for further treatment. All had either failed to have a diagnosis made, or treatment for the diagnosed conditions had shown only partial response. After further examination, we concluded that they showed abnormal function of the neck or back, but there was no obvious pathological cause. A diagnosis of ‘somatic dysfunction’ was made, characterised by altered muscle tone, tenderness or subtle changes in gait, similar to the condition recognised in human medicine. These cases subsequently underwent osteopathic treatment under sedation. Forty‐six cases (90.2%) responded to treatment in the short term (6 months after treatment). Seventeen (53.1%) were working at the same level or better than previously at least a year after treatment. Ten (31.2%) worked at a reduced level for between 1.5 and 10 years. Nineteen cases were lost to long‐term follow‐up. The findings of this study suggest that neck and back problems may be overlooked when investigating chronic lameness. When no pathology can be pinpointed as a cause of lameness, a diagnosis of somatic dysfunction as a primary problem should be considered. The presence of somatic dysfunction as a secondary complicating factor should not be overlooked. Stiffness and/or low grade pain in the spine of horses can result in persistent abnormal posture, gait, or behaviour, similar to ‘somatic dysfunction’ seen in the human patient. The cause is neuromuscular in origin, rather than resulting from tissue pathology. The diagnosis made clinically can be confirmed with thermography. This study confirms that osteopathic manipulation of the spine of horses can be a valuable treatment for cases of lameness that do not respond fully to standard veterinary treatments.

Effective management of spasticity with intrathecal Baclofen appears to be associated with weight gain but not REE. Without body composition and activity energy expenditure data, this observation is difficult to explain. Regardless, routine weight monitoring with appropriate dietary counselling should be considered in this patient group to help prevent unintentional weight gain.

Objective: To investigate the effectiveness of an intensive nutrition intervention or use of wound healing supplements compared with standard nutritional care in pressure ulcer (PU) healing in hospitalised patients. Method: Adult patients with a Stage II or greater PU and predicted length of stay (LOS) of at least seven days were eligible for inclusion in this pragmatic, multicentre, randomised controlled trial (RCT). Patients with a PU were randomised to receive either: standard nutritional care (n=46); intensive nutritional care delivered by a dietitian (n=42); or standard care plus provision of a wound healing nutritional formula (n=43). Relevant nutritional and PU parameters were collected at baseline and then weekly or until discharge. Results: Of the 546 patients screened, 131 were included in the study. Participant mean age was 66.1±16.9 years, 75 (57.2%) were male and 50 (38.5%) were malnourished at recruitment. Median length of stay was 14 (IQR: 7–25) days and 62 (46.7%) had ≥2 PUs at the time of recruitment. Median change from baseline to day 14 in PU area was –0.75cm2 (IQR: –2.9_–0.03) and mean overall change in Pressure Ulcer Scale for Healing (PUSH) score was –2.9 (SD 3.2). Being in the nutrition intervention group was not a predictor of change in PUSH score, when adjusted for PU stage or location on recruitment (p=0.28); it was not a predictor of PU area at day 14, when adjusted for PU stage or area on recruitment (p=0.89) or PU stage and PUSH score on recruitment (p=0.91), nor a predictor of time to heal. Conclusion: This study failed to confirm a significant positive impact on PU healing of use of an intensive nutrition intervention or wound healing supplements in hospitalised patients. Further research that focuses on practical mechanisms to meet protein and energy requirements is needed to guide practice.

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Background:In the absence of reliable predictive equations, indirect calorimetry (IC) remains the gold standard for assessing energy requirements after spinal cord injury (SCI), but it is typically confined to a research setting. The purpose of this study is to assess the feasibility and acceptability of implementing IC into routine clinical care in an Australian SCI rehabilitation facility. Methods: Bedside IC (canopy hood) was performed, and patients completed an IC acceptability questionnaire (open-ended; yes/no; 5-point Likert scale). Fasted resting energy expenditure (REE) steady-state criteria were applied to assess data quality, and adherence to a test ≥20 minutes was recorded. Staff were surveyed to assess impact of IC on usual care. Results: Of 35 eligible patients, 9 declined (7 reported claustrophobia). One patient could not be tested before discharge and 25 underwent IC (84% male, injury level C2-L2, AIS A-D). Anxiety prevented one patient from completing IC, while another failed to fast. The remaining 23 patients achieved a steady-state REE (≥5 consecutive minutes with ≤10% coefficient of variation for VO 2 and VCO 2 ). Test-retest (n = 5) showed <10% variation in REE. Patients deemed the procedure acceptable, with 88% reporting a willingness to repeat IC. Eighty percent of patients and 90% of staff agreed it was acceptable for IC to be integrated into usual care. Conclusion: This study found that IC is a feasible and acceptable addition to the routine clinical care of patients recovering from SCI and may serve to improve accuracy of nutrition interventions for this patient population.

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