Marie Vazquez Morgan PT PhD Associate Professor LSU Health Shreveport

1. Marie Vazquez Morgan PT PhD Associate Professor LSU Health Shreveport Department of Rehabilitation Sciences Program in Physical Therapy Use of a Functional Electrical Stimulation (FES) Bike to Improve Cardiovascular Risk Factors in an Individual with Spinal Cord Injury in a Clinical Setting18th Annual Cardiologists ConferenceParis, France

2. Individuals with spinal cord injury (SCI) face health disparities and a number of challenges in maintaining cardiovascular health compared to the able bodied population. • The causes are multifactorial: • susceptibility to numerous medical conditions that impart a health hazard • illness behaviors leading to a disproportionate percentage of deaths as a result of preventable causes Introduction

3. Altered Body Composition • Less lean mass due to inactivity as well as paralysis (atrophy) of the muscles affected. • Less muscle mass can decrease resting metabolism • 50% compared to able bodied individuals. SCI Secondary Complications • Ashraf S. Gorgey, David R. Dolbow,James D. Dolbow,Refka K. Khalil,Camilo Castillo, and David R. Gater. Effects of spinal cord injury on body composition and metabolic profile – Part IJ Spinal Cord Med. November, 2014; 37(6): 693–702

4. Altered body composition and physical inactivity predispose individuals with SCI to metabolic syndrome (insulin resistance, dyslipidemia, hypertension, central obesity, pro-inflammatory and pre-thrombotic state, and further enhance CAD. (Cowan R, Nash M. “Cardiovascular disease, SCI and exercise: unique risks and focused countermeasures.” Disability & Rehabilitation. 32.26 (2010): 2228-2236. Web. 9 Jul. 2013. Fornusek, C., and G. Davis. "Cardiovascular and Metabolic Responses During Functional Electric Stimulation Cycling at Different Cadences." Archives of Physical Medicine and Rehabilitation. 89.4 (2008): 719-25. Web. 9 Jul. 2013. Gerrits, HL, A de Hann, AJ Sargeant , H van Langen, and MT Hopman. "Peripheral vascular changes after electrically stimulated cycle training in people with spinal cord injury." Archives of Physical Medicine and Rehabilitation . 82.6 (2001): 832-839. Web. 11 Jul. 2013.) SCI Secondary Complications

5. SCI Secondary Complications • Living longer • Sedentary lifestyles • Osteoporosis • UTI • Muscular atrophy • Fractures • Blood Pooling • DVT • Popa C., Popa, F., Grigorean, V.T., Onose, G., Sandu, A.M., Popescu, M., Burnei, G., Strambu, V., and Sinescu, C. “Vascular Dysfunctions Following Spinal Cord Injury.” JournalOf Medicine & Life. 3.3 (2010): 275-285 .

6. Unopposed PNS via vagal nerve • Limits cardiac output • Cardio acceleration • Shunting of blood from inactive to active muscle • Blunting of HR response to exercise due to no vagal withdrawal • 110 to 120 BPM Sympathetic Disturbances

7. Cardiovascular incidence most common cause of death with chronic SCI* • 60% increase in MI risk • Lack of sympathetic tone • Blunted aerobic response to exercise • Bradycardia • Dysrhythmias • Autonomic Dysreflexia Cardiovascular Disturbances Sonja de Groot,abJacinthe J. Adriaansen,cMargaTepper,dGovert J. Snoek,e Lucas H.V. van der Woude,bd Marcel W.M. Postcd Metabolic syndrome in people with a long-standing spinal cord injury: associations with physical activity and capacity Applied Physiology, Nutrition, and Metabolism, 2016, 41(11):

8. Elevated • Low density lipoprotein (LDL) • Triglycerides • Total cholesterol levels • Decreased • High density lipoprotein (HDL) levels • Gross overall decrease in aerobic fitness • Abnormal glucose homeostasis Cardiovascular Risk Factors

9. LE paralysis limits amount of muscle available for exercise-induced challenge to heart Small muscles of UE’s easily fatigued--limit exercise capacity before central cardiac system stressed Muscle Disturbances

10. In general, the higher the level of injury the more likely significant reduction in cardiorespiratory capacity

11. Proper prophylaxis, including non-pharmacologic and pharmacological strategies diminish occurrence of the cardiac dysfunction. • Improved work capacity & strength • Everyday activities less difficult • More energy reserves for greater independence • Increased ability to pursue more active lifestyle Value of Exercise Training • Warburton, D.J., Eng, J.J., Krassioukov, A., and Sproule, S. "Cardiovascular Health and Exercise Rehabilitation in Spinal Cord Injury." Top Spinal Cord Injury Rehabilitation. 13.1 (2007):

12. ACSM Exercise Management for Individuals with Chronic Disabilities • Modify & adapt • Training principles same • Overload- Progression • Specificity/Consistency Guidelines for Exercise Activities

13. FITTE Factors • FREQUENCY • 3 TO 5X/WK • Modify for adequate rest between sessions • INTENSITY • ACSM Guidelines • Borg’s Rate of Perceived Exertion (RPE) • TIME (DURATION) • 15-60 min • TYPE (MODE) • Largest MS Mass • FES+LCE (+ACE) • FES Bike • ENJOYMENT

14. In able-bodied individuals, physical activity can decrease the risk of T2DM and CAD. In the SCI population, physical exercise must be incorporated in a different form (FES cycling, body weight supported treadmill training (BWSTT), ambulation with FES assisted orthotic.) Barriers to Health

15. With SCI there are changes in the ability to exercise to maintain cardiac health. • Therefore, establishing and providing effective interventions for individuals with SCI is vital, • majority of rehabilitation research has been performed in research laboratories. Barriers to Health

16. Participant • An individual with diagnosis of chronic SCI • 10 years post injury • C5 AIS B • Inclusion: Medically stable with no change in medication/diet • Informed consent/IRB approval • Serve as their own control Methods

17. Frequency: 3x wk, 6 months • Duration: 30 min. (5/5) (Faghri 2014) • Parameters: • 6 stimulus channels • Waveform: Symmetrical biphasic • Amp: 0-140 milliamps constant current • Pulse Rate: 30-60 pps(Johnston 2013) Methods

18. Pre/Post Test Each Session • Glucose (A1c) • Cholesterol • HDL • LDL • vLDL • Total cholesterol/ratio • Serum Triglycerides • HR • BP • RPE (Borg) Methods

19. Train on FES bike Pre/Post Test Data Monitor each session Record Data Methods

20. Analysis

21. Analysis

22. Decreased • A1c • LDL cholesterol • Total cholesterol • Triglycerides • Increased • HDL cholesterol • Cholesterol ratio improved Findings

23. Abnormalities of the cardiovascular system are a concern for individual with SCI. Autonomic nervous system dysfunction underlies several cardiovascular irregularities that contribute to CAD, including heightened prevalence of a major CVD risk factors. Conclusion

24. Promotion of creative ways of increasing physical activity in this population is important to decrease incidence. Although statistical significance was not found, this single subject design study displayed that cardiovascular conditioning with an FES bike conducted in an outpatient setting, can reduce cardiovascular risk factors and facilitate health in individuals with chronic SCI. Conclusion

25. The findings from this study cannot be generalized to the SCI population, as this study was a single subject design where the participant acted as their own control. Limitations

26. Questions

27. Ashraf S. Gorgey, David R. Dolbow,James D. Dolbow,Refka K. Khalil,Camilo Castillo, and David R. Gater. Effects of spinal cord injury on body composition and metabolic profile – Part I J Spinal Cord Med. November, 2014; 37(6): 693–702 Faghri, P.D., Glaser, R.M., and Figoni, S.F. “Functional Electrical Stimulation Leg Cycle Ergometer Exercise; Training Effects on Cardiorespiratory Responses of Spinal Cord Injured Subjects at Rest and During Submaximal Exercise.” Archives of Physical Medicine and Rehabilitation. 73 (1992): 1085-1093. Web. 1 July 2014. Fornusek, C., & Davis, G. “Cardiovascular and Metabolic Responses During Functional Electric Stimulation Cycling at Different Cadences.” Archives of Physical Medicine and Rehabilitation. 89.4 (2008): 719-725. Web. 8 July 2014. Gerrits, H.L., de Hann, A., Sargeant, A.J., van Langen, H., and Hopman, H.T. "Peripheral Vascular Changes after Electrically Stimulated Cycle Training in People with Spinal Cord Injury.” Archives of Physical Medicine and Rehabilitation . 82.6 (2001): 832-839. Web. 3 July 2014. Hasnan, N., Ektas, N., Tanhoffer, A., Tanhoffer, R., Fornusek, C., Middleton, J., Husain, R., and Davis, G. “Exercise Responses during FES Cycling in Individuals with Spinal Cord Injury.” Medicine and Science in Sports and Exercise. (2012). Web. 7 July 2014. Hettinga, D.M. and Andrews, B.J. "Oxygen Consumption during Functional Electrical Stimulation-Assisted Exercise in Persons with Spinal Cord Injury - Springer." Sports Medicine 38.10 (2008): 825-38. Web. 31 June 2014. Johnston, T.E., Smith, B.T., Smith, M.S., Mulcahey, M.J., Betz, R. R., and Lauer, R.T. “A Randomized Controlled Trial on the Effects of Cycling with and without Electrical Stimulation on Cardiorespiratory and Vascular Health in Children with Spinal Cord Injury.” Archives of Physical Medicine and Rehabilitation. 90(2009): 1379-1388. Web. 25 June 2014. Popa C., Popa, F., Grigorean, V.T., Onose, G., Sandu, A.M., Popescu, M., Burnei, G., Strambu, V., and Sinescu, C. “Vascular Dysfunctions Following Spinal Cord Injury.” JournalOf Medicine & Life. 3.3 (2010): 275-285. Web. 9 Jul. 2014. Warburton, D.J., Eng, J.J., Krassioukov, A., and Sproule, S. "Cardiovascular Health and Exercise Rehabilitation in Spinal Cord Injury." Top Spinal Cord Injury Rehabilitation. 13.1 (2007): 98-122. Web. 1 Jul. 2014. References