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
RRTC Staff
Center Director
Suzanne Groah,
MD,MSPH
Emily
Ward, MS
Alexander
Libin, PhD
Miriam
Spungen, BS
Manon
Inger
Schladen
Ljungberg, MPH
(Lauderdale), MSE
Eric Larson
Jessica
Romella-Roman,
PhD, MSEE
Alison
Lichy, DPT
Mark
Nash, PhD
Brenda
Triyono, BS
Cynthia
Pineda, MD,
FAAPMR
Allen
Taylor, MD
Kurt
Johnson, PhD
Brenda
Gilmore, BFA
Mark Loeffler,
MA
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
Shannon
Minnick
Ms. Wheelchair
Maryland
ILRU Staff
Laurie Gerken Redd
Marj Elhardt
Summary of Proposed RRTC
• Research focus
– Cardiometabolic risk and cardiovascular disease
– Obesity
– Pressure ulcers
Summary of Proposed RRTC
• Training focus
– Consumers - focus on the underserved and nonEnglish speaking
– Health care professionals - including nonrehabilitationists
– State of the Science
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
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”
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)
Background
• Cardiometabolic
syndrome is
characterized by
risk clusters
• Risk clustering
present in >
33% young,
healthy
paraplegics
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
Objectives
1. Understand to what extent obesity, high blood
pressure, diabetes, pre-diabetes, cholesterol, and
inflammation lead to cardiovascular disease in
people with SCI
2. Understand if there are certain risk factors that have
greater importance in people with SCI
3. Develop an online cardiometabolic risk assessment
tool (RISK)
4. Develop an adjusted BMI table for people with SCI
R1 Methods
R1 Testing - Carotid IMT
• Shows atherosclerosis
in the blood vessels
leading to the brain
• Related to future heart
disease
• Associated with high
cholesterol levels
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
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
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 noncalcified plaques
CAC and CT Angiography
• Non-calcified
plaque most likely
lead to heart disease
• Calcified and noncalcified plaques
• 1/5 radiation
exposure
SOME EARLY RESULTS
Frequency of Risk Factors
Risk Clustering
Risk by BMI Category
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
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
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
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
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
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
Results – Blood Work
Subject 1
Total
Cholesterol
(mg/dL)
LDL (mg/dL)
118
64
Subject 2
206
136
Average Tetra*
Recommended Value
171.67
Less than 200 Good
200-239 Not Good
More than 240 Bad
108.71
Less than 100 Very Good
100-129 Good
130-159 Not Good
160-189 Bad
More or equal to 190 Very Bad
42.10
Less than 40 Bad
40-60 Ok
More than 60 Good
HDL (mg/dL)
46
49
Total
Cholesterol:
HDL
2.57
4.2
Less than 4.5 Good
More than 4.5 Bad
106
Less than 150 Good
150-199 Ok
200-499 Bad
More or equal to 500 Very Bad
TG (mg/dL)
38
94.92
* Groah SL, et al. Cardiometabolic risk in community-dwelling persons
with chronic spinal cord injury. JCRP. (in press).
Results – Blood Work Cont.
Subject 1
Fasting Blood
Sugar (mIU/mL)
78
Subject 2
80
Mean Tetra*
Recommended Value
87.29
<100 Normal
100-125 Impaired
≥126 Diabetic
2 hour Blood
Sugar (mIU/mL)
92
135
137.93
<140 Normal
140-199 Impaired
≥200 Diabetic
Fasting Insulin
(mIU/mL)
7.75
2.51
8.663
<20 Normal
2 hour Insulin
(mIU/mL)
45.07
23.94
94.36
HbA1C (%)
4.8
5.3
5.13
hsCRP (mg/L)
4.2
5.1
IL-6 (pg/mL)
4.4
4.3
* Groah SL, et al. Cardiometabolic risk in community-dwelling
persons with chronic spinal cord injury. JCRP. (in press).
4.4-6.4 Good
<1 Good
1-3 Normal
>3 Bad
Summary
Subject 1
BMI
Body Fat %
Blood lipids (fat) Inflammatory
Markers
24.6
50.4%
High
Normal
HsCRP: 4.2
High
37.3%
High
High Total
Cholesterol and
High LDLs
HsCRP: 5.1
High
Over
weight
Subject 2
19
Normal
weight
-Subjects have high body fat% regardless of body weight
-Both Normal and High blood lipids (fat) found
-Subjects have high levels of inflammatory markers
Results - Imaging
NRHR101
Right common
carotid arteryanterior
projection
13
Mean 0.627 mm
Max 0.738 mm
NRHR102
Right common
carotid arteryanterior
projection
Normal CIMT
Focal plaque
seen in carotid
artery
CAC score 0
NRHR101
Cardiac CT:
Coronary calcium
and CT
angiography
Plaque
quantitation:
Curved MPR
Thin cross
sections
RCA, thick MIP
Oblique MPR- No
plaque
NRHR102
Incidental finding of thickened pericardium (noncalcified)
History of pneumonia
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)
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
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.
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
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
Training* Overview
•
•
Overarching Objective: Translate findings of RRTC
research to practice for both consumers and health
care providers
Supporting Objectives:
1. Define and present the state of knowledge about
cardiovascular risk in people with SCI (systematic reviews)
2. Explore what knowledge and information formats and delivery
mechanisms are most useful and acceptable to our consumer
and clinician audiences
3. 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
“Tight” Relationship Between Our Research and
Training
•Components of web-based tools
•For both consumers and providers
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
Consumer-focused Objectives
• To translate the knowledge generated by Research
Projects R1, R2 in such a way as to help all persons
with SCI practically integrate that 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)
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
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?
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
“Follow Me”
• First stop: http://sci-health.org
• Second stop:
http://www.youtube.com/user/HealthyTomorrow
Current Activities:
Exploring How People Engage With
Information about SCI
• Specifically for Clinicians:
– What are the best approaches to teaching clinicians
how to serve people with SCI (both in terms of
applying best medical practice and in terms of
interpersonal communication)?
– What can we do to provide just-in-time information
about SCI best practice at the point of care?
Standardized Patients
•
Standardized patients (SPs): 3 flavors
1. Real people, simulate clinical symptoms, help clinicians train
for real practice
2. SCI SPs also real people, with real SCIs, provide clinicians with
more authentic training experiences
3. Virtual standardized patients (VPs), online, interactive
•
Currently exploring uses and limitations of SCI SPs
–
–
–
–
•
•
Resource intensive
Excellent for interpersonal learning
Good (not excellent) for clinical skills learning – promising for
teaching CVD risk assessment
Limitations (e.g. can’t really simulate clinical emergencies)
Experimentation with VPs to begin in fall 2010
Also exploring mannequin simulators
Efforts Involving Both Consumers and
From RRTC
Clinicians in Use of Knowledge
March 2010
Advisory Board
Meeting
Key point: The
centrality of the
person with SCI
What can we do to promote the application of
knowledge about CVD in SCI at the point of care?
• Under exploration: Use of Personally Controlled Health
Records (PCHRs) to bridge knowledge between people
with SCI and their health care providers
• What is a PCHR?
– An electronic medical record that is managed by the consumer
– Can include BOTH patient-specific and medical
knowledge/information
– May be “tethered” to a providers’ EMR or independent
– Has the potential to import information from a variety of health
sources
• Providers’ records, pharmacy, data from devices such as home BP
monitors
– Consumers can edit or annotate the record to assure information
is complete and correct
PHCRs
•
Utility and Advantages
– Can promote continuity of care
• Persons with chronic conditions, who see multiple providers may benefit the most
– Can be imported to a “smart card”, copied to a thumb drive or printed for sharing
– Can be accessed by health care providers if patient is unconscious
– Unlike EHRs, format is standardized and readable by browsers
•
Barriers
– Privacy
• Need to assure personal information remains confidential
– Credibility
• When is it appropriate for a provider to accept the assessment of another?
• How does a provider know that the knowledge (best practices) presented are reliable?
• To what degree is it good practice to allow consumers to control the information in their
health records?
• Can consumers actually be harmed by knowing certain information in their health
records?
– Accessibility
• What technology is required of both consumers and providers to access and annotate
the stored electronic records?
RRTC Training Project Contacts
• Director, consumer-focused projects
– Alex Libin, PhD
• Director, clinician-focused projects
– Cindi Pineda, MD FAARM
• Co-Director, both projects
– Manon Schladen, MSE PMP EdS
• Project Coordinator, both projects
– Inger Ljungberg, MPH