Effect of spinal cord injury on the heart and cardiovascular fitness

https://doi.org/10.1016/S0146-2806(98)80003-0Get rights and content

Summary

The use of various FES protocols to encourage increases in physical activity and to augment physical fitness and reduce heart disease risk is a relatively new, but growing field of investigation. The evidence so far supports its use in improving potential health benefits for patients with SCI. Such benefits may include more efficient and safer cardiac function; greater stimulus for metabolic, cardiovascular, and pulmonary training adaptations; and greater stimulus for skeletal muscle training adaptations. In addition, the availability of relatively inexpensive commercial FES units to elicit muscular contractions, the ease of use of gel-less, reusable electrodes, and the increasing popularity of home and commercial upper body exercise equipment mean that such benefits are likely to be more accessible to the SCI population through increased convenience and decreased cost.

The US Department of Health and Human Services has identified those with SCI as a ā€œspecial populationā€ whose health problems are accentuated, and so need to be specifically addressed. FES presents ā€œa clear opportunityā€¦. For health promotion and disease prevention efforts to improve the health prospects and functional independence of people with disabilities.ā€ As a corollary to this, the Centers for Disease Control and Prevention have recommended the development of techniques to prevent or ameliorate secondary disabilities in persons with a SCI.

  • ā€¢

    Patients with SCI have an increased susceptibility to cardiac morbidity and mortality in the acute and early stages of their injury. Most of these patients make an excellent adaptation except when confronted with infection or hypoxia.

  • ā€¢

    SCI by itself does not promote atherosclerosis; however, in association with multiple secondary conditions related to SCI, along with advancing age, patients with SCI are predisposed to relatively greater risk of heart disease. The epidemiologic significance of this is reflected in demographic studies that indicate an increasing number of SCI patients becoming aged.

  • ā€¢

    Currently 71,000 (40%) of the total 179,000 patients with SCI living in the United States are older than 40 years, and 45,000 have injuries sustained more than 20 years earlier. In addition, new injuries in the older population are increasing (currently 11% of all injuries), and some of these new patients with SCI already have pre-existing cardiac disease.

  • ā€¢

    Studies have demonstrated that improved lifestyle, physical activity, lipid management, and dietary restrictions can affect major risk factors for coronary artery disease. Therefore an aggressive cardiac prevention program is appropriate for patients with SCI as part of their rehabilitation.

  • ā€¢

    At a given submaximal workload, arm exercise is performed at a greater physiologic cost than is leg exercise. At maximal effort, however, physiologic responses are generally greater in leg exercise than arm exercise.

  • ā€¢

    Arm exercise is less efficient and less effective than lower body exercise in developing and maintaining both central and peripheral aspects of cardiovascular fitness. The situation is further compounded in SCI because of poor venous return as a result of lower-limb blood pooling, as a result of lack of sympathetic tone, and a diminished or absent venous ā€œmuscle pumpā€ in the legs. This latter mechanism perhaps contributes the greatest diminution in the potential for aerobic performance in the SCI population.

  • ā€¢

    Obtaining a cardiopulmonary training effect in individuals with SCI is quite possible. Current studies indicate decreases in submaximal HR, respiratory quotient, minute ventilation, and oxygen uptake, with increases in maximal power output, oxygen uptake, minute ventilation, and lactic acid. Individuals with SCI have been shown to benefit from lower limb functional electrical stimulation (FES)-induced exercise. Studies have consistently reported increases in lower limb strength and cycle endurance performance with these protocols, as well as improvements in metabolic and hemodynamic responses, body composition, and lipid profiles.

  • ā€¢

    The use of lower limb FES applied during concurrent aerobic arm exercise has been referred to as ā€œhybridā€ exercise. Hybrid exercise has consistently augmented acute cardiovascular and hemodynamic responses compared with arm exercise performed alone in SCI. Initial studies also show promise for augmented training effects using this protocol.

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      Additionally, 76% of people with SCI have dyslipidemia, while 50% of paraplegics and 62% of tetraplegics exhibit impaired glucose tolerance (Bauman and Spungen, 1994; Cragg et al., 2012; Manns et al., 2005; Nelson et al., 2007; Vichiansiri et al., 2012). Relationships between changes in carbohydrate and lipid metabolism and decreased muscle mass, increased core fat and increased inactivity also have been well documented in SCI individuals (Galea, 2012; Kocina, 1997; Lee et al., 2005; Manns et al., 2005; Maruyama et al., 2008; Myers et al., 2007; Phillips et al., 1998). NAFLD is closely linked to insulin resistance and type II diabetes.

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