Identification and Management of Cardiometabolic Risk after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers

This text is excerpted from the complete document, which includes the Consortium Member Organizations and Steering Committee Representatives, Acknowledgments, Reviewers, Glossary, and Appendix (Search Strategies).Administrative and financial support provided by Paralyzed Veterans of America.Reprinted with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines Consumer Guide: “Cardiometabolic Risk after Spinal Cord Injury: A Clinical Practice Guideline for Health Care Providers.” Washington, DC: © 2018 Paralyzed Veterans of America. Copies of the PVA's Guidelines are available at www.pva.org.These guidelines have been prepared based on scientific and professional information available in 2018. Users should periodically review this material to ensure that the advice herein is consistent with current reasonable clinical practice. The websites noted in this document were current at the time of publication; however, because web addresses and the information contained therein change frequently the reader is encouraged to stay apprised of the most current information.Cardiometabolic disease (CMD) can be thought of as a silent killer. The clinical manifestations of this secondary complication of spinal cord injury (SCI) may not be apparent until too late to intervene. Until now, CMD has been less of a focus of the SCI community as a whole, compared to the other major secondary conditions of neurogenic bowel and bladder, autonomic dysfunction, respiratory insufficiency, depression, sexual dysfunction, pressure injuries, and venous thromboembolism, which are overt in their presentation and have been addressed in previous guidelines.The recommendations of this Clinical Practice Guideline (CPG) regarding identifying and managing CMD risks are in line with current recommendations for identifying and managing CMD risks in people without SCI, which have also been recently updated. However, these recommendations also take into consideration the differences between the body composition and physiology of those with SCI and those without SCI, and the risks of certain interventions for persons with SCI, given the presence of other secondary conditions such as neurogenic bowel, and also acknowledge the challenges to implementing the recommendations within the SCI community.We were fortunate in the development and peer review of this CPG to have representation from all the various stakeholders and subspecialties impacted by these recommendations, including a range of experts in nutrition, exercise, cardiology, endocrinology, internal medicine, and rehabilitation. This wide-ranging representation will hopefully translate into uniform, quality practice through the widespread use of this CPG to guide CMD prevention and treatment in all settings, which can only result in the best outcomes and least amount of morbidity and mortality for those who experience SCI.On behalf of the consortium steering committee, I want first to acknowledge the leadership of the guideline panel, namely the Chair, Mark Nash, and Co-Chair Suzanne Groah, in guiding this panel through the ups and downs of a development process which spanned five years. The panel members themselves, who kept to task for so long, and the many reviewers who provided valuable feedback from all areas, are to be commended. Everyone, including the panel Chair and Co-Chair, volunteered their time to help produce this superb document. In addition, I wish to acknowledge the ongoing support of Paralyzed Veterans of America (Paralyzed Veterans), especially President David Zurfluh, Executive Director Carl Blake, and Director of Research and Education Cheryl Vines, as well as the rest of the leadership team, without whose support these guidelines would not exist.Thomas N. Bryce, MDChair, Steering CommitteeConsortium for Spinal Cord MedicineThe following Guideline is the first from the Consortium for Spinal Cord Medicine to address CMD after SCI. In doing so, it reports the emergence of all-cause cardiovascular diseases (CVD) and CVD-related risks as significant health hazards for persons with SCI and establishes a foundational standard for identification and management of cardiometabolic risks. The spinal cord community was first made aware of these risks in the early 1980s. Since then, hundreds of scholarly articles have examined antecedents, causes, personal and population characteristics, co-morbidities and treatments for these hazards. These studies have confirmed that persons with SCI are frequently sedentary, overweight, dyslipidemic and at elevated risk for insulin resistance, thus placing them in jeopardy of developing CMD. None of the health hazards imposed by the five archetypical CMD risk components foretells the long, active, productive, and healthy life we seek for persons with SCI. These conditions may also prohibit persons with SCI from undergoing, or ultimately benefiting from, the restorative therapies in clinical trials, or from using rehabilitation technologies that require a relatively lean and healthy body for their efficient use.Unlike some diseases and disorders addressed by other Consortium Guidelines, CMD typically develops slowly and without overt symptoms. Unless routinely surveilled in the SCI population, CMD may be irreversible once clinically detected. The panel seriously considered the possibility that CMD and its component risks, once identified, will be far more challenging to treat in persons with SCI than their non-disabled counterparts. For these reasons, this guideline will favor scheduled surveillance, early risk assessment, timely symptom recognition, and prudent interventional care. In arriving at these recommendations, the that and health and a will favor early and not doing so result in early morbidity and of this guideline health and stakeholders with will that its and may to persons with SCI at risk for a of CMD or its component risks than their non-disabled should be however, that all-cause and conditions are the most life and of hazards. In recommendations, the has also into consideration that health is less prepared to treat CMD in those with SCI than to these we it is to prevention as a In some the or clinical to the of recommendations that for CMD and management in the These guidelines standard in such have been or for the of the SCI for the population, we have also in of so that the foundational for CMD identification and management can more and the SCI the we for the and of David and with the of Cheryl Vines, Bryce, the Paralyzed Veterans CPG Steering and the Consortium who the of this and the to their Nash, of of Groah, of this guideline is to the of with spinal cord injury by guiding and with its The following recommendations use available and is experience and The based its on in which the focus of the was SCI. This information was using from trials, and contained in the scientific of are best made by these recommendations with clinical the based on risk for cardiometabolic the for and the of various within The to the of scientific the of the and the of panel with the Consortium of Spinal Cord Medicine is a of professional and with a in for with spinal cord The is to the development and of clinical practice guidelines and This is to the health and quality of life for persons with Consortium is and by Paralyzed Veterans of America (Paralyzed The Steering by Paralyzed Research and Education is made of from development of these guidelines the following major a of to be of to these of the quality of the of of recommendations, development of that the recommendations, and review and by panel The SCI CPG development process also review and a Veterans the and to and provided support for the members for their and all financial or other of through the of through Health and the of through using to spinal cord also for of to have in this the Appendix for complete to studies through of of studies and were into of studies was based on the in with Paralyzed reviewers and of through for using the articles of were and were for by were by only in were not because were available for quality of that information available in from or those that provided from were considered for with Paralyzed were to the of CMD and risk for for CMD and the of treatment for CMD in the SCI and regarding CMD guidelines were not of the information on guideline and are with or irreversible spinal cord injury or in with spinal was on population characteristics, for and outcomes for trials, and were was by and by a were by the internal of of trials, and based on These are based on the and the Health for and and the the internal of based on the for the of compared at to and the use of that a were at a risk of that all were at a risk of and the were at a risk of the risk of is studies with this in their and The of some studies risk of are to be are only A is by to of on the would be a with with the of or on were and were differences in studies were on to of and of and of were on the of review the of and use of and for of of the risk of of and of reviewers the quality of and differences were by quality of based on the to the quality of a body of this risk of and risk of and of the also other that may be for some such as a that would the the of of and the of that can be the quality of the body of to not to the or of for reviewers for and differences were by quality of the body of was for by the characteristics, quality and for all studies using a of the best is the focus of for population, and following addresses hazards for CMD and its risk components in persons with is a of health and is as a disease by the of the the the and the Health The and the of Health CMD as the of of the hazards in and a CMD is to the of developing and in the is at of the non-disabled and is with population The CMD a health risk to the of or is ultimately or by a between that is in of and and These risks are typically through with and The of CMD is insulin resistance, the body whose clinical is and and are not the guideline risks, are as or of the of CMD in with SCI from on the of risk in the on the this at least and the CMD for the population, which the the SCI community the risk that it guideline component risks for CMD insulin resistance, and The following addresses the hazards imposed by these risk components on the SCI is a disease by the of and and its are the of and in the development of insulin resistance, and by the scientific community as body in or in the of was to by the at the of the to more at risk for cardiovascular the five component risks, after SCI has been most challenging to and to in persons with SCI to in and body with and autonomic of the spinal The standard for of in persons with SCI, such that the of CMD the of CMD in persons with SCI in the studies have a of in persons 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and health for persons of all and health The of Medicine and and guidelines for health and in the population, which to the best of their are also for with These guidelines are in with the Guidelines for and and also the Guidelines for with SCI that were for SCI are also to the for for with Spinal Cord recommendations of the imposed on or by persons with SCI has as a population health a for a a that in persons with SCI to a of to many of it was that of with SCI and the for health This that of the with SCI in the are and in a considered to those with of and have far for and more are not more than persons with is not the five component risks of it is with and considered a major of insulin resistance, and however, to after SCI as a major to a CMD the SCI population was at the of the as a for a after SCI is a of which is in persons without to be and with of to are after SCI and may to or to exercise, of professional and financial SCI, body composition is by a significant of in and in a 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