Cardiovascular disease prevention after spinal cord injury : a new challenge

Spinal cord injury (SCI) typically leads to permanent infralesional motor and sensory functional losses, pathophysiological aberrations in most organ systems and a lasting vulnerability for a variety of complicating conditions. Improvements in acute and rehabilitative management during the last decades have increased long term survival after SCI. Additionally, older persons now sustain and survive SCI. Thus, aging-related issues after SCI have arisen for the first time in history.

One such issue is cardiovascular disease (CVD), which now has emerged as a leading cause of morbidity and mortality in subjects with chronic SCI. However, it is not clear whether this reflects persons with SCI constituting a true high-risk population for CVD, or whether the epidemiological shifts merely reflect a normalization of the morbidity and mortality pattern due to the current increasingly effective management of previous SCI-specific causes of disease and death in this patient population. The overall aim of the thesis was to assess and explore the need for CVD prevention after SCI, and also to compare CVD risk in this population with that of the general population.

One hundred thirty-five participants (88 % of the total regional cohort), with traumatic wheelchair dependent paraplegia were assessed regarding CVD risk and was also compared with that of the general population (papers II-IV). Additionally, persons with paraplegia (n=8/16) and tetraplegia (n=8/16) were interviewed for the purpose of identifying facilitating factors for physical activity after SCI.

Wheelchair-dependent persons with traumatic paraplegia had an 8,5-fold increased prevalence of myocardial infarction as well as increased prevalence of dyslipidemia (83.1 %), hypertension (39.3%) and diabetes mellitus/impaired fasting glucose (10%). Further, 66-75% of subjects were overweight according adjusted BMI scores. An extensive clustering of cardiovascular risk factors according to authority guidelines was found. From a future intervention perspective, among others the following promoting factors to increase physical activity were identified; to gain and maintain independence, accepting assistance, finding environmental solutions, learning to live with narrower margins. Further, to have a role model and to be a role model was also important.

Conclusions: There is a high and increased CVD risk in persons with chronic wheelchair dependent paraplegia. Thus, regular CVD screening is indicated. CVD prevention including therapeutic lifestyle intervention needs to be developed, evaluated and then systematically implemented. Lifestyle interventions need to be tailored to the specific needs of this patient group.

List of scientific papers

I. Wahman K, Gabriele B, Richard L (2006). "What promotes physical activity after spinal cord injury? An interview study from a patient perspective." Disabil Rehabil 28(8): 481-8.
https://doi.org/10.1080/0963828050011932

II. Wahman K, Nash MS, Westgren N, Lewis JE, Seiger A, Levi R (2010). "Cardiovascular disease risk factors in persons with paraplegia: the Stockholm spinal cord injury study." J Rehabil Med 42(3): 272-8.
https://doi.org/10.2340/16501977-0510

III. Wahman K, Nash MS, Lewis JE, Seiger Å, Levi R (2010). "Increased cardiovascular disease risk in Swedish persons with paraplegia: The Stockholm Spinal Cord Injury Study." J Rehabil Med 42: 489 492. [Accepted]
https://doi.org/10.2340/16501977-0541

IV. Wahman K, Nash MS, Lewis JE, Seiger Å, Levi R (2010). "Need for cardiovascular disease intervention after paraplegia as assessed by multifactorial risk models: The Stockholm Spinal Cord Injury Study." J Rehabil Med. [Submitted]