Recovering from Spinal Cord Injury: What Research Says | Pro-SCI
Ceren Yarar-Fisher, PhD
Spinal Cord Injury (SCI) research has made significant strides in recent years, shedding light on critical aspects of recovery and rehabilitation that were previously overlooked. From the gut microbiome's role in recovery to the impact of blood sugar levels, these advancements are paving the way for better outcomes and enhanced quality of life for those affected by SCI.
In this interview, Ceren Yarar-Fisher, PhD and the PRO-SCI team address five key questions that delve into the latest findings and their implications for diet, exercise, and overall care in SCI.
5 Questions with the PRO-SCI Team
1. Talk about the role of the gut microbiome and how this relates to recovery from injuries such as SCI (Spinal Cord Injury).
In animals (mice), traumatic SCI causes profound gut dysbiosis (loss of commensal bacteria and increase in pathogenic bacteria) that persists for at least 4 weeks after injury. However, even longer durations are expected in humans because neurogenic bladder/bowel and gastrointestinal dysfunction are chronic complications of mammalian SCI.
A causal role for gut dysbiosis in the secondary pathophysiology of SCI was proved. Specifically, an antibiotic cocktail was used to induce gut dysbiosis before SCI. When mice given antibiotics in this study, intraspinal pathology and inflammation were exacerbated, and recovery of locomotor function was significantly impaired relative to normal SCI mice. Importantly, the effects of SCI dysbiosis were time-dependent and could be blocked by treating mice with probiotics after SCI.
These data highlight a previously unappreciated role for the gut–CNS–immune axis in regulating recovery after SCI, providing a new level of enlightenment and information in the field.
2. High blood sugar levels at the time of hospital admission have been linked to poorer motor outcomes in SCI patients. Could you explain the connection between high blood sugar and these adverse outcomes?
Emerging evidence suggests that acute-phase hyperglycemia is a critical factor in the poor functional outcomes of SCI. The presence of hyperglycemia (≥126 mg/dl) on hospital admission (irrespective of past diabetes mellitus history) was found to be strongly associated with a lower probability of improvement in motor and sensory function. Results of preclinical studies have indicated that hyperglycemia exacerbates inflammatory cytokine production, neural cell apoptosis, and demyelination during acute SCI in rodents. These findings have shed light on the importance of achieving tight glycemic control in acute human SCI to obtain better neurological outcomes. Surprisingly, enteral and solid diets in SCI acute care have traditionally promoted high carbohydrate nutritional content (carbohydrate: 45%, fat: 30%, and protein: 25%). In contrast, the ability of a ketogenic diet (KD) to ameliorate the diabetic state and help stabilize hyperglycemia has been repeatedly shown in human studies.
Consistent with the published effects of a KD in rat models of SCI and in humans with hyperglycemia, we recently showed, for the first time, that compared with a standard hospital diet (SD), 5 weeks of KD significantly improved upper extremity motor function in patients with acute SCI. These effects are likely mediated, at least in part, by the observed reduction in serum levels of the proinflammatory protein fibrinogen (results are shown in Preliminary studies). Moreover, patients who received the KD experienced a reduction in fasting glucose (-24 mg/dL) and insulin (-0.18 µU/mL) levels, while the patients who received an SD had an increase in both parameters (fasting glucose, +0.7 mg/dL; insulin, +11 µU/mL). Based on the results of these studies, we believe that KD may be optimal for maintaining a normal glycemic state after SCI.
Kobayakawa, K., Kumamaru, H., Saiwai, H., Kubota, K., Ohkawa, Y., Kishimoto, J., Yokota, K., Ideta, R., Shiba, K., Tozaki-Saitoh, H., Inoue, K., Iwamoto, Y. and Okada, S. (2014). Acute hyperglycemia impairs functional improvement after spinal cord injury in mice and humans. Sci Transl Med 6, 256ra137.
Sala, F., Menna, G., Bricolo, A. and Young, W. (1999). Role of glycemia in acute spinal cord injury. Data from a rat experimental model and clinical experience. Ann N Y Acad Sci 890, 133-154.
Yarar-Fisher C*, Kulkarni A, Li J, Farley P, Renfro C, Aslam H, Bosarge P, Wilson L, and Barnes S. Evaluation of a Ketogenic Diet for Improvement of Neurological Recovery in Individuals with Acute Spinal Cord Injury: A Pilot, Randomized Safety and Feasibility Trial. Spinal Cord Cases and Series. 2018; 4: 1-8.
3. What does current research say about the optimal diet for improving health outcomes in those with spinal cord injuries?
While research specifically focused on the optimal diet for individuals with spinal cord injury (SCI) is limited, we do have extensive knowledge about the health challenges they face and the best dietary strategies for managing these conditions—thanks to studies conducted in broader populations. Individuals with SCI often encounter issues such as muscle atrophy, increased adiposity (body fat), poor blood sugar control, pressure injuries, and neuropathic pain. Fortunately, making thoughtful dietary changes can play a vital role in preventing and managing these health concerns. Here, we’ll dive into some of the most common health challenges faced by individuals with SCI and explore how dietary adjustments can help manage these conditions effectively.
It’s important to remember that these are general recommendations. Each person’s needs are unique, and it’s crucial to adapt slowly to any dietary changes. Additionally, dietary modifications can impact bowel movements, so it’s essential to adjust your bowel program accordingly.
Anti-inflammatory Foods: Incorporating plenty of fruits, vegetables, whole grains, nuts, seeds, and fatty fish (like salmon and sardines) into your diet can significantly reduce inflammation. These foods are packed with omega-3 fatty acids, antioxidants, and fiber, all of which are powerful allies in fighting chronic inflammation. This is especially important for those with SCI, as inflammation can worsen complications like pressure injuries and neuropathic pain.
Muscle Health: Keeping your muscles strong is key, especially when mobility is limited. Adequate protein intake is crucial not only for maintaining muscle mass but also for preventing and healing pressure injuries. Lean protein sources—such as poultry, fish, eggs, low-fat dairy, legumes, and plant-based proteins—are your best bet for supporting muscle health and overall recovery.
Adiposity Management: After an SCI, many people experience weight gain due to a slower metabolism, reduced physical activity, and hormonal changes. Managing your weight effectively starts with a balanced diet rich in portion-controlled, nutrient-dense, and low-energy-dense foods, like vegetables and fruits, lean proteins, and healthy fats. Cutting back on added sugars, saturated fats, and refined carbohydrates is also essential to prevent excessive body fat accumulation and its associated risks.
Glucose Tolerance: Individuals with SCI are at a higher risk of developing insulin resistance and type 2 diabetes. To keep blood sugar levels in check, focus on a diet low in refined sugars and simple carbohydrates. Prioritize whole grains, legumes, and non-starchy vegetables to stabilize glucose levels. Adding lean protein and healthy fats to each meal can also slow down carbohydrate digestion and absorption, helping to maintain more consistent blood sugar levels. Opting for smaller, more frequent meals and snacks can further support glucose management.
Pressure Injury Prevention: Nutrition plays a crucial role in both the prevention and healing of pressure injuries—a common complication for those with SCI due to prolonged immobility. Ensuring sufficient intake of protein, vitamins C and A, zinc, and fluids is essential for maintaining skin integrity and promoting wound healing. A diet rich in high-quality protein, combined with adequate hydration, is key to supporting skin health and preventing tissue breakdown that can lead to pressure injuries.
In summary, a well-balanced diet for individuals with SCI should be nutrient-dense, anti-inflammatory, and customized to support muscle maintenance, weight management, glucose control, and skin health. By making these dietary adjustments, individuals with SCI can take proactive steps toward improving their overall health and quality of life.
4. What other conditions would benefit from this type of diet?
This diet may be applicable to any neurological or developmental conditions resulting in extreme muscle atrophy and cardiovascular deconditioning. In addition, individuals with cardiometabolic dysfunction may benefit from these general recommendations.
5. Based on the latest research, if you experienced a spinal cord injury, what would your acute and chronic regimen look like?
Acute (~2 weeks)/Subacute (~4-5 weeks)
Personal experience
Focus is going to be on tolerance to upright positions (BP control), getting appropriately fitted for a wheelchair, and then once medically stable progressing independence in function through physical mobility skills as well as training using adaptive equipment – bed mobility, transfers, wheelchair skills, locomotor training if applicable
Establish bowel program and bladder care technique (internal catheterization), stabilize other autonomics
Family training is essential, ordering adaptive equipment (wheelchair, transfer voard, lifts, hospital bed, etc.), education on home modifications etc. to allow for safe discharge to home environment
Multidisciplinary team includes: physician (PMR, neuro/ortho surgery), nursing, occupational therapists, physical therapists, social work, at times speech and respiratory therapists
Literature
Needs to be a multi-disciplinary approach to address and prevent: pressure ulcers (through positioning and pressure breaks), UTIs, autonomic dysreflexia (AD), pulm/cardiovascular problems, contractures, preventing muscle and bone density loss, respiratory, bowel bladder care (Nas 2015)
Initiate ABT (activity-based therapy) to promote neuroplasticity – optimal “window” has not been established
Mobility training, self-care skills, overground vs BWSTT (Body Weight Support Treadmill Training) locomotion, unsupported sitting, task-specific training, strengthening, stretching/ROM (range of motion), FES (Functional Electrical Stimulation), according to Burns et al.
Chronic/outpatient
Personal experience
Progressing physical function skills to further increase independence
Focus on community/back to life (work, social, sports) re-integration and independence. Social work is key here
Independence on bowel/bladder care, addressing sexual function
Therapies include gait training (current debate about the use of body weight support treadmill training but this was long utilized for all levels/severities of injuries for a while), electrical stimulation (such as FES), use of exoskeletons, sitting balance, progressing/preserving current strength, cardiovascular training (UE ergometer), big push for high-intensity training currently – recent shift from focusing on walking however.
Introducing assistive technology for increased independence – wheelchairs, “smart homes”, driving
Progress neuromodulation/neuroplasticity therapies
Educate/train on a home exercise program (HEP)
The multidisciplinary team expands to rehab psychology, therapeutic recreation
Literature
Clinical Practice Guidelines (CPG): For ambulatory individuals: Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality–based training to ambulatory individuals greater than 6 months following acute onset CNS injury to improve walking speed or distance. (Hornby 2020)
Activity-based therapies (ABT) that promote neuroplasticity (transcranial magnetic stimulation, FES, robotic-assisted training) (Duan 2021)
Most frequent types of therapy/ABT are: treadmill training (59%), muscle strengthening (36%), and overground walking (33%). Electrical stimulation (50%) and virtual reality (6%) were used in combination with an ABT exercise (Kaiser 2022).
Here’s a good resource in general for rehabilitation: https://msktc.org/sci/factsheets/understanding-spinal-cord-injury-part-2-recovery-and-rehabilitation
Burns AS, Marino RJ, Kalsi-Ryan S, Middleton JW, Tetreault LA, Dettori JR, Mihalovich KE, Fehlings MG. Type and Timing of Rehabilitation Following Acute and Subacute Spinal Cord Injury: A Systematic Review. Global Spine J. 2017 Sep;7(3 Suppl):175S-194S.
Duan Ruimeng, Qu Mingjia, Yuan Yashuai, Lin Miaoman, Liu Tao, Huang Wei, Gao Junxiao, Zhang Meng, Yu Xiaobing. Clinical Benefit of Rehabilitation Training in Spinal Cord Injury: A Systematic Review and Meta-Analysis. SPINE 46(6):p E398-E410, March 15, 2021.
Hornby TG, Reisman DS, Ward IG, Scheets PL, Miller A, Haddad D, Fox EJ, Fritz NE, Hawkins K, Henderson CE, Hendron KL, Holleran CL, Lynskey JE, Walter A; and the Locomotor CPG Appraisal Team. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. J Neurol Phys Ther. 2020 Jan;44(1):49-100.
Jones ML, Harness E, Denison P, Tefertiller C, Evans N, Larson CA. Activity-based Therapies in Spinal Cord Injury:: Clinical Focus and Empirical Evidence in Three Independent Programs. Top Spinal Cord Inj Rehabil. 2012 Winter;18(1):34-42.
Kaiser A, Chan K, Pakosh M, McCullum S, Rice C, Zariffa J, Musselman KE. A Scoping Review of the Characteristics of Activity-based Therapy Interventions Across the Continuum of Care for People Living With Spinal Cord Injury or Disease. Arch Rehabil Res Clin Transl. 2022 Jul 26;4(4):100218.
Nas K, Yazmalar L, Şah V, Aydın A, Öneş K. Rehabilitation of spinal cord injuries. World J Orthop. 2015 Jan 18;6(1):8-16.
Diet and Exercise Guidelines for SCI
Dietary Guidelines (Acute SCI)
Protein intake: If the patient with spinal cord injury is in the acute phase, the registered dietitian should calculate protein needs at 2.0g per kg of ideal body weight per day to lessen the obligatory negative nitrogen balance that occurs during the acute phase. (A.N.D., 2016)
Dietary Guidelines (Chronic SCI)
Protein intake: If the person with spinal cord injury is in the rehabilitation phase or community living phase, then the registered dietitian should calculate protein needs at 0.8g to 1.0g per kg of body weight per day for maintenance of protein status in the absence of pressure ulcers or infection. (A.N.D., 2016)
Exercise (Acute SCI)
Standard guidelines specific to acute SCI are not available, however, most individuals enter inpatient physical and occupational therapy soon after injury. The therapists can facilitate and provide exercise regimens appropriate to the patient’s ability and health.
Exercise (Chronic SCI)
Cardiorespiratory fitness and muscle strength: ≥20 min of moderate to vigorous intensity aerobic exercise 2x per week & 3 sets of strength exercises for each major functioning muscle group at a moderate to vigorous intensity 2x per week (Martin Ginis et al., 2018)
Cardiometabolic health: ≥30 min of moderate to vigorous intensity aerobic exercise 3x per week (Martin Ginis et al., 2018)
Exercise examples: arm cycle, hybrid arm-leg cycle, recumbent elliptical, body weight- support treadmill (only useful at higher intensities), adapted rowing machine, electrical stimulated cycling (Pelletier, 2023)
SCI Guidelines (UBC) - https://sciguidelines.ubc.ca/
Starting level (The starting level is the minimum level of activity needed to achieve fitness benefits.)
20 minutes of moderate to vigorous intensity 2x/week
Strength training: 2 sets of 10 reps 2x/week for each major muscle group
Advanced level (The advanced level will give you additional fitness and health benefits, such as lowering your risk of developing Type 2 diabetes and heart disease.)
30 minutes of moderate to vigorous intensity 3x/week
Strength training: 3 sets of 10 reps 2x/week for each major muscle group
Moderate intensity: working somewhat hard, but should feel like you can keep going for a long time. Should be able to talk during these activities, but not sing.
Vigorous intensity: working really hard, can only continue for short time before getting tired
Social Participation
In general, social participation improves both life satisfaction and mental health. Social participation may come in the form of interactions with family and friends or engaging with the community. Examples of social participation in the community include attending a public gym and employment. (Halvorsen et al., 2021)
Barriers: Sociodemographic characteristics such as race, income, and living situation, can prevent individuals with SCI from social participation. The SCI Model Systems has resources for individuals to become involved with the community through fitness programs, sports groups, and employment (https://msktc.org/SCI). Many of these groups are available for further contact to facilitate individuals’ needs. Additionally, physicians and therapists may have more locally relevant resources.
https://www.andeal.org/vault/pq89.pdf A.N.D., A. o. N. a. D. (2016). SCI: Assessment of Protein Needs 2009.
Halvorsen, A., Pape, K., Post, M. W. M., Biering-Sørensen, F., Mikalsen, S., Hansen, A. N., & Steinsbekk, A. (2021). Participation and quality of life in persons living with spinal cord injury in Norway. J Rehabil Med, 53(7), jrm00217. https://doi.org/10.2340/16501977-2858
Hoekstra, F., McBride, C.B., Borisoff, J. et al. Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource. Spinal Cord 58, 647–657 (2020).
Martin Ginis, K. A., van der Scheer, J. W., Latimer-Cheung, A. E., Barrow, A., Bourne, C., Carruthers, P., Bernardi, M., Ditor, D. S., Gaudet, S., de Groot, S., Hayes, K. C., Hicks, A. L., Leicht, C. A., Lexell, J., Macaluso, S., Manns, P. J., McBride, C. B., Noonan, V. K., Pomerleau, P., . . . Goosey-Tolfrey, V. L. (2018). Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord, 56(4), 308-321. https://doi.org/10.1038/s41393-017-0017-3
Pelletier, C. (2023). Exercise prescription for persons with spinal cord injury: a review of physiological considerations and evidence-based guidelines. Applied Physiology, Nutrition, and Metabolism, 48(12), 882-895. https://doi.org/10.1139/apnm-2023-0227
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