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

Prolonged, uninterrupted sitting negatively impacts markers of peripheral vascular health, particularly, vasodilatory function of leg arteries. Whether sitting can similarly impact measures of central vascular health, as well as overall leg vasoreactivity (i.e., vaso-dilatory and vasoconstrictor function) remains unknown. To address this, measurements were made in relatively healthy participants (i.e., free of overt disease; n = 20, age = 26 § 7; body mass index = 30 § 7 kg/m2; 7 female) pre, during and post 3 hours of uninterrupted sitting. Measures of central vascular health included arterial wave reflection (augmentation index and Reflection Magnitude-RM%) and aortic vascular stiffness (aortic pulse wavevelocity). Local vasoreactivity of the distal, posterior tibialartery was measured using flow-mediated dilation-FMD, coupled with low-flow mediated constriction, and microvascular function was assessed through the total hyperemic blood velocity (area-under-curve) response during FMD. After sitting, there was a significant increase in aortic pulse wave velocity (pre sit = 5.7 § 0.3 vs post sit = 6.1 § 0.3 m/s; p=0.009, d = 0.36), whereas, augmentation index decreased (pre sit=13 § 3 vs post sit=3 § 1%; p < 0.001, d = 0.71). Albeit a moderate effect for decrease, RM % was not significantly altered during sitting (p = 0.13, d = 0.3). Vasodilatory (i.e., FMD pre sit = 0.5 § 0.04 vs post sit =0.3 § 0.04 mm; p = 0.014, d = 0.29) and micro vascular function (i.e., Microvascular area-under-curve: pre sit = 2,196 § 333 vs1, 157 §172 AU; p = 0.003, d = 0.31) decreased, but vasoconstrictor function (low-flow mediated constriction; p = 0.85, d = 0.005) was unaffected by sitting. In conclusion, these data demonstrate that a prolonged bout of uninterrupted sitting negatively impacts markers of peripheral and central vascular health in relatively healthy adults.

Diet and exercise are cornerstones in the management of obesity and associated metabolic complications, including insulin resistance, type 2 diabetes, and disturbances in the lipid profile. However, the role of exercise in managing body composition adaptations and metabolic disorders after spinal cord injury (SCI) is not well established. The current review summarizes evidence about the efficacy of using neuromuscular electrical stimulation or functional electrical stimulation in exercising the paralytic lower extremities to improve body composition and metabolic profile after SCI. There are a number of trials that investigated the effects on muscle cross-sectional area, fat-free mass, and glucose/lipid metabolism. The duration of the intervention in these trials varied from 6 weeks to 24 months. Training frequency ranged from 2 to 5 days/week. Most studies documented significant increases in muscle size but no noticeable changes in adipose tissue. While increases in skeletal muscle size after twice weekly training were greater than those trials that used 3 or 5 days/week, other factors such as differences in the training mode, i.e. resistance versus cycling exercise and pattern of muscle activation may be responsible for this observation. Loading to evoke muscle hypertrophy is a key component in neuromuscular training after SCI. The overall effects on lean mass were modest and did not exceed 10% and the effects of training on trunk or pelvic muscles remain unestablished. Most studies reported improvement in glucose metabolism with the enhancement of insulin sensitivity being the major factor following training. The effect on lipid profile is unclear and warrants further investigation.

Objective The aims of the study were to evaluate the influence of level of spinal cord injury (SCI) on caloric intake relative to total daily energy expenditure (TDEE) and body composition, and to develop a SCI–specific correction factor for the TDEE estimation. Design Individuals with paraplegia (PARA, n = 28) and tetraplegia (TETRA, n = 13) were analyzed. Daily caloric intake, basal metabolic rate, and TDEE were obtained using dietary recall, indirect calorimetry, and prediction equations, respectively. Caloric intake and TDEE were adjusted to bodyweight. Body composition was assessed using dual-energy x-ray absorptiometry. Results Total caloric (PARA 1516.4 ± 548.4, TETRA 1619.1 ± 564.3 kcal/d), fat (PARA 58.6 ± 27.4, TETRA 65.8 ± 29.7 g), and protein (PARA 62.7 ± 23.2, TETRA 71.5 ± 30.9 g) intake were significantly higher in TETRA versus PARA (P < 0.05) when adjusted for bodyweight. Adjusted and unadjusted TDEE (unadjusted: PARA 1851.0 ± 405.3, TETRA 1530.4 ± 640.4 kcal/d) and basal metabolic rate (unadjusted: PARA 1516.6 ± 398.0, TETRA 1223.6 ± 390.2 kcal/d) were significantly higher in PARA versus TETRA (P < 0.05). Bone mineral content (PARA 3.17 ± 0.6, TETRA 2.71 ± 0.5 g), lean body mass (PARA 50.0 ± 8.6, TETRA 40.96 ± 8.8 kg), and regional percent body fat (PARA 36.45 ± 8.0, TETRA 41.82 ± 9.1) were different between groups (P < 0.05). The SCI–specific correction factor was 1.15. Conclusions A dichotomy exists in caloric intake, TDEE, and body composition among TETRA and PARA. The SCI–specific correction factor of 1.15 is a promising tool to estimate TDEE in SCI. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Understand the influence of spinal cord level of injury on energy expenditure and body composition; (2) Appreciate that equations used to estimate total daily energy expenditure overestimate energy expenditure in individuals with spinal cord injury; and (3) Understand the importance of normalizing caloric intake to bodyweight after spinal cord injury. Level Advanced. Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Exercise training is accompanied with positive changes in body composition as well as compensatory decrease in BMR, that regressed back following 2.5 years of exercise cessation. Participation in an exercise trial is unlikely to confound the measurements of a follow-up trial.

This manuscript is a review of the theoretical and clinical concepts provided during an inter-institutional training program on Activity-Based Restorative Therapies (ABRT) and the perceptions of those in attendance. ABRT is a relatively recent high volume and intensity approach toward the restoration of neurological deficits and decreasing the risk of secondary conditions associated with paralysis after spinal cord injury (SCI). ABRT is guided by the principle of neuroplasticity and the belief that even those with chronic SCI can benefit from repeated activation of the spinal cord pathways located both above and below the level of injury. ABRT can be defined as repetitive-task specific training using weight-bearing and external facilitation of neuromuscular activation. The five key components of ABRT are weight-bearing activities, functional electrical stimulation, task-specific practice, massed practice and locomotor training which includes body weight supported treadmill walking and water treadmill training. The various components of ABRT have been shown to improve functional mobility, and reverse negative body composition changes after SCI leading to the reduction of cardiovascular and other metabolic disease risk factors. The consensus of those who received the ABRT training was that ABRT has much potential for enhancement of recovery of those with SCI. Although various institutions have their own strengths and challenges, each institution was able to initiate a modified ABRT program.

Exercise adherence rates were well above the reported 35% in the able-bodied population, which provides evidence for the feasibility of a home-based functional electrical stimulation lower extremity cycling program. Younger adults with a history of being physically active have the highest potential for exercise adherence.

Background: Functional electrical stimulation (FES) has been regularly used to offset several negative body composition and metabolic adaptations following spinal cord injury (SCI). However, the outcomes of many FES trials appear to be controversial and incoherent. Objective: To document the potential consequences of several factors (e.g. pain, spasms, stress and lack of dietary control) that may have attenuated the effects on body composition and metabolic profile despite participation in 21 weeks of FES training. Participant: A 29-year-old man with T6 complete SCI participated in 21 weeks of FES, 4 days per week. Methods: Prior to and following training, the participant performed arm-crank-graded exercise testing to measure peak VO 2 . Tests conducted included anthropometrics and dual energy X-ray absorptiometry body composition assessments, resting energy expenditure, plasma lipid profiles and intravenous glucose tolerance tests. Results: The participant frequently reported increasing pain, stress and poor eating habits. VO 2 peak decreased by 2.4 ml/kg/minute, body mass increased by 8.5 kg, and body mass index increased from 25 to 28 kg/m 2 . Waist and abdominal circumferences increased by 2-4 cm, while %fat mass increased by 5.5%. Absolute increases in fat mass and fat-free mass of 8.4 and 1 kg, respectively, were reported. Fasting and peak plasma glucose increased by 12 and 14.5%, while lipid panel profiles were negatively impacted. Conclusion: Failure to control for the listed negative emerging factors may obscure the expected body composition and metabolic profile adaptations anticipated from FES training.