RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI

1. RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI Suzanne Groah, MD, MSPH Mark Nash, PhD Alexander Libin, PhD Jessica Ramella-Roman, PhD Manon Lauderdale, ABD NSCIA and ILRU

2. RRTC Staff Center Director Suzanne Groah, MD,MSPH Alexander Libin, PhD Manon Schladen (Lauderdale), MSE Inger Ljungberg, MPH Alison Lichy, DPT Brenda Triyono, BS Emily Ward, MS Miriam Spungen, BS Eric Larson Jessica Romella-Roman, PhD, MSEE Mark Nash, PhD Cynthia Pineda, MD, FAAPMR

3. Allen Taylor, MD Kurt Johnson, PhD Brenda Gilmore, BFA Mark Loeffler, MA Shannon Minnick Ms. Wheelchair Maryland Other Staff (Picture not available) Nawar Shara, PhD Patricia Burns, MS Eleutevio Ballwis, BSN Jasmine Martinez, DO Armando Mendez, PhD Tom Burnett, MS Sydney Jacobs, MA Robert Marsteller Katherine Westie, PhD

4. ILRU Staff Laurie Gerken Redd Marj Elhardt

5. Summary of Proposed RRTC • Research focus • Cardiometabolic risk and cardiovascular disease • Obesity • Pressure ulcers

6. Summary of Proposed RRTC • Training focus • Consumers - focus on the underserved and non-English speaking • Health care professionals - including non-rehabilitationists • State of the Science

7. Importance of the Problem • Cardiovascular disease is a leading cause of death in long-term SCI • Overweight and obesity (especially around the abdomen) • Diabetes and pre-diabetes • High blood pressure • Abnormal cholesterol levels • Other – inflammation

8. Importance of the Problem • Pressure ulcers (PU) are the most common medical complication in people surviving at least 1-year post injury • Frequency may be on the increase • Turning and repositioning recommendations are NOT supported by evidence • When PU’s occur in the hospital, they are now considered a “Never Event”

9. Project R1:Cardiometabolic Risk, Obesity and Cardiovascular Disease in People with Spinal Cord Injury Principal Investigator (PI): Suzanne Groah, MD, MSPH Co-Principal Investigator (Co-PI) Mark Nash, PhD Project Coordinators: Emily Ward, MS (NRH) and Patricia Burns, MS (Miami)

10. Background • Cardiometabolic syndrome is characterized by risk clusters • Risk clustering present in > 33% young, healthy paraplegics

11. Background, con’t. • All of our knowledge of cardiovascular disease is from risk factors (cholesterol, etc) • But we don’t know whether obesity, abnormal cholesterol levels, diabetes or pre-diabetes actually leads to cardiovascular disease and “hard” endpoints • “Hard” endpoints for CVD include MI, cardiac death and stroke

12. Objectives • Understand to what extent obesity, high blood pressure, diabetes, pre-diabetes, cholesterol, and inflammation lead to cardiovascular disease in people with SCI • Understand if there are certain risk factors that have greater importance in people with SCI • Develop an online cardiometabolic risk assessment tool (RISK) • Develop an adjusted BMI table for people with SCI

13. R1 Methods

14. R1 Testing - Carotid IMT • Shows atherosclerosis in the blood vessels leading to the brain • Related to future heart disease • Associated with high cholesterol levels

15. R1 Testing - Carotid IMT • Associated with low good cholesterol (HDL-C) • Associated with diabetes and pre-diabetes • One study in people with SCI showed more atherosclerosis • Risk is underestimated by measurement of cholesterol levels

16. R1 Testing - Coronary Artery Calcium (CAC) Scores • Atherosclerosis often has calcium deposits • Any calcium in coronaries = atherosclerosis • CAC scores directly correlate with • Atherosclerosis • Heart disease

17. CAC and CT Angiography • But, CAC score alone may not fully reflect heart disease risk • Women and certain ethnic groups tend to not have calcium in heart • 1/10 with CAC score of 0 have non-calcified plaques

18. CAC and CT Angiography • Non-calcified plaque most likely lead to heart disease • Calcified and non-calcified plaques • 1/5 radiation exposure

19. SOME EARLY RESULTS

20. Frequency of Risk Factors

21. Risk Clustering

22. Risk by BMI Category

23. Subject 1 • Single 39yo African American Woman • Spinal Cord Injury: C6/C7 AIS B • Sense of touch maintained below neck • Loss of movement below neck • Due to car accident (9/1991) • Wheel Chair: Power

24. Subject 1 cont. • Health History: • Non-Smoker • Family Hx: Pre-diabetes (father) • Ht/Wt: 5 feet 10 inches, 171.3 pounds • Resting Heart Rate: 70bpm • Blood Pressure: 98/52 • Framingham Risk Score: <1% 10-year risk of heart attack or death

25. Subject 1 Body Fat • Body Fat Scan: • Total Body Fat: 50.4%; obese • Stomach Fat: 55.2% • Hip, Thigh, and Buttock Fat: 54.0% • BMI • 24.6 • “Normal” by general population tables • “Overweight” by SCI adjustment

26. Subject 2 • Married 48yo Caucasian Woman • Spinal Cord Injury: C2 Sensory, C6 Motor AIS A • Loss of feeling below upper neck • Loss of movement below lower neck • Due car accident (7/1999) • Wheel Chair: Power

27. Subject 2 cont. • Health History: • Non-Smoker • Muscle spasms/weakness, bed sores, under-active thyroid • Family Hx: heart disease, high blood pressure, high cholesterol, cancer • Surgical Hx: uterus removed (2006) • Ht/Wt: 5 feet 7 inches, 121.0 pounds • Resting Heart Rate: 62bpm • Blood Pressure: 78/51 • Framingham Risk Score: 1% 10-year risk of heart attack or death

28. Subject 2 Body Fat • Body Fat Scan: • Total Body Fat: 37.3%; obese • Stomach Fat : 43.0% • Hip, Thigh, and Buttock Fat: 42.1% • BMI • 19.0 • “Normal” by general population guidelines • “Normal” by SCI adjustment

29. Results – Blood Work * Groah SL, et al. Cardiometabolic risk in community-dwelling persons with chronic spinal cord injury. JCRP. (in press).

30. Results – Blood Work Cont. * Groah SL, et al. Cardiometabolic risk in community-dwelling persons with chronic spinal cord injury. JCRP. (in press).

31. Summary • Subjects have high body fat% regardless of body weight • Both Normal and High blood lipids (fat) found • Subjects have high levels of inflammatory markers

32. Results - Imaging

33. NRHR101 Right common carotid artery- anterior projection 13 Mean 0.627 mm Max 0.738 mm

34. NRHR102 Right common carotid artery- anterior projection Normal CIMT Focal plaque seen in carotid artery

35. CAC score 0 NRHR101 Cardiac CT: Coronary calcium and CT angiography RCA, thick MIP Oblique MPR- No plaque Plaque quantitation: Curved MPR Thin cross sections

36. NRHR102 Incidental finding of thickened pericardium (non-calcified) History of pneumonia

37. Project R2:Effect of an Omega-3 Supplement Intervention Program (OSIP) on Cardiometabolic Health in People with Spinal Cord Injury Principal Investigator (PI): Mark S Nash, PhD FACSM Co-Principal Investigator (Co-PI) Suzanne Groah, MD, MSPH Project Coordinators: Emily Ward, MS (NRH) and Patricia Burns, MS (Miami)

38. Benefits of ω-3 Poly-Unsaturated Fatty Acids • Reduced death due to heart disease • Improved cholesterol levels • Triglycerides • Low density lipoprotein cholesterol • Reduced irregular heartbeats • Reduced inflammation • Reduced body fat

40. Objectives • To determine whether ω-3 omega fatty acid supplementation can improve lipid (cholesterol) levels, inflammation, and body fat in people with chronic spinal cord injury (SCI) who have 2 or more cardiometabolic risk (CMR) factors.

41. Methods • Multi-center double-blind RCT • Participants: 34 individuals, 18-65, from Project R1 • Participants must have multiple (i.e., 2+) of the CMRs • Fasting TG> 150 mg/dL • HDL-C < 40 mg/dL for males or < 50 for females • hs-CRP > 3.0 • Body fat (by DXA) >25% for males and 33% for females

42. Methods • Procedures • Dietary Supplement and Placebo: • Ω-3 PUFA, 3.2 g EPA+DHA (EPA/DHA 3:1) vs. 4g Safflower seed oil • Blood Testing: • Administered at baseline (pre) and 3 months (post). • Testing for OGTT, lipid profile and inflammatory mediators as in R1 • Post-prandial Assessments (after a high fat meal) (0, 1,2,4,6 hrs): • Triglycerides • Inflammation • Whole body fat • Body Composition: DXA

43. Training* Overview • Overarching Objective: Translate findings of RRTC research to practice for both consumers and health care providers • Supporting Objectives: • Define and present the state of knowledge about cardiovascular risk in people with SCI (systematic reviews) • Explore what knowledge and information formats and delivery mechanisms are most useful and acceptable to our consumer and clinician audiences • Build capacity to support the health and well-being of persons with SCI (consumer living, clinical practice, research discovery) * What we mean by “training” • Activities that promote understanding and application of the knowledge our RRTC will produce

44. “Tight” Relationship Between Our Research and Training • Components of web-based tools • For both consumers and providers

45. Systematic Review • Definition: a systematic study of existing research in an area of focus • Goal: to produce a document that can be used by clinicians and consumers to change practice • Focus of our systematic review: What is the cardiovascular risk profile of people with SCI? • Collaboration with University of Washington, Knowledge Translation Center

46. Consumer-focused Objectives • To translatethe knowledge generated by Research Projects R1, R2 in such a way as to help all persons with SCI practically integratethat knowledge in to their self-management practices • Goal is application not passive understanding • To exercise particular sensitivity to the learning circumstances, in terms of language, literacy and culture, of the underserved. • Making information understandable by people with low literacy satisfies people with high literacy as well (Nielsen, 2005)

47. Clinician-focused Objectives Increase awareness and knowledge of the key SCI secondary conditions of cardiometabolic syndrome and obesity Promote primary (before disease occurs), secondary (screening to detect disease before it becomes symptomatic) and tertiary (reducing disability and restoring function due to disease) prevention

48. Current Activities:Exploring How People Engage With Information about SCI Specifically for Consumers: How do people find information about SCI? What contexts (interests, circumstances, concerns) motivate people to look for information? How do people like to get their information? In what formats? Through what mechanisms? How do people appraise the quality of the information they receive?

49. Consumers and SCI Information • Connecting through social media • YouTube, Facebook, Twitter • Website SCI-Health.org • Plain language, both English and Spanish • Interactive • Polls, information subscriptions, Help Desk

50. “Follow Me” • First stop: http://sci-health.org • Second stop: http://www.youtube.com/user/HealthyTomorrow