The Essential Spinal Cord Injury Medicine Question Bank 3031077954, 9783031077951

Table of contents :
Preface
Contents
Contributors
1: Introduction
This Question Bank
The Examination
Purpose of Certification
Admissibility Requirements
Examination Format
Examination Outline with Approximate Target Weights
SCI Medicine Certificate
Maintenance of Certification (MOC) in SCI Medicine
Further Reading
2: Epidemiology, Risk Factors, and Prevention of Spinal Cord Injury
Epidemiology
3: Anatomy, Physiology and Imaging of the Spinal Cord
Questions
4: Assessment, Classification, and Prognosis in Spinal Cord Injuries
Questions
5: Acute Evaluation and Management of Spinal Cord Injuries
Questions
6: Cardiovascular Issues in Spinal Cord Injury
Questions
7: Pulmonary Changes After Spinal Cord Injury
Questions
8: Gastrointestinal Disorders in Spinal Cord Injury
Questions
9: Genitourinary Issues in Spinal Cord Injury
Questions
10: Sexuality and Reproductive Health After Spinal Cord Injury
Questions
11: Musculoskeletal Issues in Spinal Cord Injury
Questions
12: Neurological Complications of Spinal Cord Injury
Questions
13: Pressure Injuries
14: Pain and Spinal Cord Injury
Questions
15: Nutrition, Endocrine, and Immune Function
Questions
16: Psychological Disorders for Individuals with Spinal Cord Injuries
Questions
17: Rehabilitation of Spinal Cord Injuries
Questions
18: Non-Traumatic Spinal Cord Injury
Questions
19: Pediatric Spinal Cord Injury
Questions
20: System Based Practice and Ethical Considerations Related to Spinal Cord Injuries
Questions
21: Community Living with Spinal Cord Injuries
Questions
22: Methods and Basic Science Considerations in Spinal Cord Injury Research
Questions
Index

Citation preview

The Essential Spinal Cord Injury Medicine Question Bank Benjamin A. Abramoff Jing Wang Christine Krull Editors

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The Essential Spinal Cord Injury Medicine Question Bank

Benjamin A. Abramoff Jing Wang • Christine Krull Editors

The Essential Spinal Cord Injury Medicine Question Bank

Editors Benjamin A. Abramoff Department of Physical Medicine and Rehabilitation University of Pennsylvania - Perelman School of Medicine Philadelphia, PA, USA

Jing Wang Aiken Regional Medical Center Aiken, SC, USA

Christine Krull Spinal Cord Injury/Dysfunction Service VA St. Louis Health Care System St. Louis, MO, USA Department of Physical Medicine and Rehabilitation Baylor College of Medicine TIRR Memorial Hermann Houston, TX, USA

ISBN 978-3-031-07795-1    ISBN 978-3-031-07796-8 (eBook) https://doi.org/10.1007/978-3-031-07796-8 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Spinal cord injuries have wide ranging effects on the body and can impact every organ system. Therefore, the mastery of an extensive breadth of material is critical to building a foundation of knowledge to care for individuals who have had spinal cord injuries. One method familiar to those studying medicine to help gain and solidify this knowledge is high-yield question banks. For learners preparing for spinal cord injury board examinations, we felt that no such question bank existed for spinal cord injury medicine. This left us creating our own questions to test one another and improve our retention of material. Despite this, we felt future students would benefit from a more formal and structured question bank. From this background, The Essential Spinal Cord Injury Medicine Question Bank was created. We want to thank the chapter authors who have spent countless hours developing thought provoking, well-written, and fair questions. Generally, these questions require more than superficial familiarity to answer and test a true understanding of underlying concepts. The detailed explanations and references that the authors provided are as important as the questions and answers themselves. We encourage you to explore these references when you would like to learn more about the concepts addressed in the question. Although we hope that this question bank will help you gain significant knowledge and feel more comfortable with your upcoming examinations, we recognize that this is just one tool of many including textbooks, review courses, didactics, and most importantly the clinical experience of caring for individuals with spinal cord injury. While we have attempted to include the highest yield topics, we also fully recognize that this text is not exhaustive and lifelong learning is required to master the topics contained in this text. Our ultimate goal with this question bank is to help individuals feel more comfortable in their clinical care for patients with spinal cord injuries. By feeling comfortable with the clinical knowledge, we hope you have the opportunity to

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get to know your patients better as unique individuals. To those currently studying for your examinations, good luck! We look forward to collaborating with you in the future in our shared mission to improve the lives of those with spinal cord injuries. Philadelphia, PA, USA Aiken, SC, USA  Houston, TX, USA 

Benjamin A. Abramoff Jing Wang Christine Krull

Contents

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Introduction������������������������������������������������������������������������������������������������   1 David H. Quan, Gurtej S. Bajaj, and Benjamin A. Abramoff

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Epidemiology, Risk Factors, and Prevention of Spinal Cord Injury������������������������������������������������������������������������������������������������   9 John Lin, Wesley Chay, and Natasha Bhatia

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 Anatomy, Physiology and Imaging of the Spinal Cord��������������������������  25 Joanne M. Delgado-Lebron

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Assessment, Classification, and Prognosis in Spinal Cord Injuries����������������������������������������������������������������������������������������������  45 Donna Huang, James Doan, and Sameer Siddiqui

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 Acute Evaluation and Management of Spinal Cord Injuries����������������  75 Beverly Hon and Michelle M. Didesch

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 Cardiovascular Issues in Spinal Cord Injury������������������������������������������  91 Chloe McCloskey, D. Frank Distel, and Benjamin A. Abramoff

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 Pulmonary Changes After Spinal Cord Injury �������������������������������������� 109 Ellia Ciammaichella, Darby Cruz, and Christine Krull

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 Gastrointestinal Disorders in Spinal Cord Injury���������������������������������� 129 Lisa Wenzel and Christina Draganich

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 Genitourinary Issues in Spinal Cord Injury ������������������������������������������ 159 Karishma Gupta, Kyle A. Scarberry, Ryan P. Terlecki, and R. Caleb Kovell

10 Sexuality  and Reproductive Health After Spinal Cord Injury�������������� 187 Christine Krull, Aaron J. Lin, and Jennifer E. Mast 11 Musculoskeletal  Issues in Spinal Cord Injury���������������������������������������� 201 Allison Kessler, Vivian Roy, and Sushil Singla 12 Neurological  Complications of Spinal Cord Injury�������������������������������� 221 Peter Park and Katharine Tam

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13 Pressure Injuries���������������������������������������������������������������������������������������� 243 Gianna M. Rodriguez, Maryam Berri, and Michael Bush-Arnold 14 Pain  and Spinal Cord Injury�������������������������������������������������������������������� 263 Reuben Horace, Christopher Woolley, Danielle Zheng, and Joel Castellanos 15 Nutrition,  Endocrine, and Immune Function����������������������������������������� 279 Elisabeth K. Acker 16 Psychological  Disorders for Individuals with Spinal Cord Injuries���������������������������������������������������������������������������������������������� 301 Audrey Leung, Kendl Sankary, and Carolyn Campbell 17 Rehabilitation  of Spinal Cord Injuries���������������������������������������������������� 313 Shelly Hsieh, John Lopez, Jeremiah Nieves, and Steven Kirshblum 18 Non-Traumatic  Spinal Cord Injury �������������������������������������������������������� 355 Samir R. Belagaje 19 Pediatric  Spinal Cord Injury�������������������������������������������������������������������� 383 Lauren Fetsko, Simra Javaid, and Glendaliz Bosques 20 System  Based Practice and Ethical Considerations Related to Spinal Cord Injuries������������������������������������������������������������������������������ 407 Elizabeth Twist, David Leong, and James Wilson 21 Community  Living with Spinal Cord Injuries���������������������������������������� 421 Niña Carmela R. Tamayo, Heather Theobald, and Patricia L. Kiefer 22 Methods  and Basic Science Considerations in Spinal Cord Injury Research�������������������������������������������������������������������������������� 441 Felicia Skelton Index�������������������������������������������������������������������������������������������������������������������� 455

Contributors

Benjamin  A.  Abramoff  Department of Physical Medicine and Rehabilitation, University of Pennsylvania—Perelman School of Medicine, Philadelphia, PA, USA Elisabeth  K.  Acker  Spinal Cord Injury and Disorders Service, Central Virginia VA Health Care System, Richmond, VA, USA Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA Gurtej S. Bajaj  Department of Physical Medicine and Rehabilitation, University of Pennsylvania—Perelman School of Medicine, Philadelphia, PA, USA Samir R. Belagaje  Department of Neurology, Emory University, Atlanta, GA, USA Department of Rehabilitation Medicine, Emory University, Atlanta, GA, USA Maryam  Berri  Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA Natasha Bhatia  Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA Department of Physical Medicine and Rehabilitation, Shirley Ryan AbilityLab, Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Glendaliz Bosques  Department of Neurology, Dell Medical School at University of Texas, Austin, TX, USA Michael  Bush-Arnold  Spinal Cord Injury Unit, Rehabilitation Institute of Michigan, Detroit, MI, USA Carolyn  Campbell  Department of Physical Medicine and Rehabilitation, University of Washington Hospitals and Clinics, Harborview Medical Center, Seattle, WA, USA Joel Castellanos  Inpatient Rehabilitation, Department of Anesthesiology, UC San Diego Health, San Diego, CA, USA Wesley Chay  Department of Medical Staff, Shepherd Center, Atlanta, GA, USA

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Ellia  Ciammaichella  Department of Physical Medicine and Rehabilitation, Renown Regional Medical Center, Reno, NV, USA Darby  Cruz  Department of Respiratory Therapy, TIRR Memorial Hermann, Houston, TX, USA Joanne M. Delgado-Lebron  Department of Physical Medicine & Rehabilitation, Memorial Rehabilitation Institute at Memorial Healthcare System, Hollywood, FL, USA Michelle M. Didesch  Department of Neuro Rehab Physiatry, Confluence Health— Wenatchee Valley Medical Group, Wenatchee, WA, USA D. Frank Distel  Department of Physical Medicine & Rehabilitation, University of Pennsylvania, Philadelphia, PA, USA James  Doan  Spinal Cord Injury Division, VA Boston Healthcare System, Boston, MA, USA Department of Physical Medicine and Rehabilitation, Harvard Medical School/ Spaulding Rehabilitation Hospital, Boston, MA, USA Christina  Draganich  Physical Medicine and Rehabilitation Department, University of Colorado, Aurora, CO, USA Lauren Fetsko  Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, American Family Children’s Hospital, Madison, WI, USA Karishma  Gupta  Urology Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA Beverly Hon  Veteran Affairs New Jersey Health Care System, Spinal Cord Injury and Disorders Service, East Orange, NJ, USA Reuben Horace  New York Institute of Technology COM, Old Westbury, NY, USA Shelly  Hsieh, MD  Department of Physical Medicine and Rehabilitation, Albert Einstein College of Medicine, Bronx, NY, USA Burke Rehabilitation Hospital, Montefiore Health System, White Plains, NY, USA Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA Kessler Institute for Rehabilitation, West Orange, NJ, USA Donna  Huang  Spinal Cord Injury Care Line, Michael E.  DeBakey VA Medical Center, Houston, TX, USA H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA Simra  Javaid  Department of Physical Medicine and Rehabilitation, McGovern Medical School at UTHealth, Houston, TX, USA Patricia L. Kiefer, MSN, APRN, ACCNS-AG  Department of Medicine, Northeast Ohio Veteran Administration Healthcare System, Cleveland, OH, USA

Contributors

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Steven  Kirshblum, MD  Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA Kessler Institute for Rehabilitation, West Orange, NJ, USA R. Caleb Kovell  Perelman School of Medicine, University of Pennsylvania & The Children’s Hospital of Philadelphia, Philadelphia, PA, USA Christine  Krull  Spinal Cord Injury/Dysfunction Service, VA St. Louis Health Care System, St. Louis, MO, USA Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, TIRR Memorial Hermann, Houston, TX, USA David  Leong  Physical Medicine and Rehabilitation, MetroHealth Rehabilitation Institute, Cleveland, OH, USA Audrey Leung  Department of Physical Medicine and Rehabilitation, University of Washington Hospitals and Clinics, Harborview Medical Center, Seattle, WA, USA Aaron J. Lin  Department of Physical Medicine and Rehabilitation, University of Texas Medical School at Houston, Houston, TX, USA John Lin  Department of Medical Staff, Shepherd Center, Atlanta, GA, USA John  Lopez, DO  Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA Kessler Institute for Rehabilitation, West Orange, NJ, USA Jennifer E. Mast  Department of Physical Medicine and Rehabilitation, OhioHealth Neurological Physicians, Columbus, OH, USA Chloe McCloskey  Department of Physical Medicine & Rehabilitation, University of Pennsylvania, Philadelphia, PA, USA Jeremiah  Nieves, MD  Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA Kessler Institute for Rehabilitation, West Orange, NJ, USA Peter  Park  Division of Rehabilitation, Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA David H. Quan  Department of Physical Medicine and Rehabilitation, University of Pennsylvania—Perelman School of Medicine, Philadelphia, PA, USA Gianna  M.  Rodriguez  Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA Vivian  Roy  Division of Spinal Cord Injury Medicine, Shirley Ryan Abilitylab, Chicago, IL, USA Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA

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Contributors

Kendl Sankary  Department of Physical Medicine and Rehabilitation, University of Washington Hospitals and Clinics, Harborview Medical Center, Seattle, WA, USA Kyle  A.  Scarberry  Urology Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA Sameer Siddiqui  Spinal Cord Injury System of Care, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA Sushil Singla  Division of Spinal Cord Injury Medicine, Shirley Ryan Abilitylab, Chicago, IL, USA Felicia Skelton  H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA Niña Carmela R. Tamayo, DO, MS, MPH  Department of Physical Medicine and Rehabilitation, Cleveland Clinic Edwin Shaw Rehabilitation Hospital; Tamayo Physiatry, LLC, Cleveland, OH, USA Katharine Tam  Division of Rehabilitation, Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA Spinal Cord Injury and Disorders, Saint Louis VA Healthcare System, Saint Louis, MO, USA Ryan  P.  Terlecki  Wake Forest University Baptist Health System, Winston-­ Salem, NC, USA Heather  Theobald,  DO, MPH  Department of Physical Medicine and Rehabilitation, Mercy Medical Center, Catholic Health Services of Long Island, Rockville Centre, NY, USA Elizabeth Twist  Physical Medicine and Rehabilitation, MetroHealth Rehabilitation Institute, Cleveland, OH, USA Allison Kessler  Division of Spinal Cord Injury Medicine, Shirley Ryan Abilitylab, Chicago, IL, USA Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA Lisa Wenzel  H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, TIRR Memorial Hermann Hospital, Houston, TX, USA James Wilson  Physical Medicine and Rehabilitation, MetroHealth Rehabilitation Institute, Cleveland, OH, USA Christopher  Woolley  Pain Medicine, Department of Anesthesiology, UC San Diego, San Diego, CA, USA Danielle  Zheng  Pain Medicine, Department of Anesthesiology, UC San Diego, San Diego, CA, USA

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Introduction David H. Quan, Gurtej S. Bajaj, and Benjamin A. Abramoff

This Question Bank Spinal Cord Injury (SCI) Medicine is a field of medicine that addresses the prevention, diagnosis, and treatment of both traumatic and nontraumatic spinal cord injuries, as well as the management of their various sequelae. SCI medicine has been recognized as a subspecialty by the American Board of Medical Specialties (ABMS) since 1995. The purpose of this text is to serve as a high-yield resource for fellows and attending physicians preparing for subspeciality certification or recertification through the American Board of Physical Medicine and Rehabilitation (ABPMR) Spinal Cord Injury (SCI) Medicine examination. Medical students and residents may also find these questions useful while preparing for SCI rotations and, in the latter’s case, Part I of the ABPMR primary certification examination. In short, this question bank should be of use to anyone wishing to test and expand their knowledge of SCI medicine. The book is comprised of 22 chapters addressing the full scope of topics tested in the ABPMR SCI Medicine examination. The questions are written by leading experts in the field of SCI medicine and designed to be board-relevant in both content and style. Included with each question is a corresponding in-depth explanation as well as the pertinent citations for the supporting literature. The text has also been edited for clarity and conciseness.

D. H. Quan · G. S. Bajaj · B. A. Abramoff (*) Department of Physical Medicine and Rehabilitation, University of Pennsylvania—Perelman School of Medicine, Philadelphia, PA, USA e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. A. Abramoff et al. (eds.), The Essential Spinal Cord Injury Medicine Question Bank, https://doi.org/10.1007/978-3-031-07796-8_1

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The Examination This section provides an overview of the ABPMR SCI Medicine certification examination. The ABPMR is an independent, nonprofit organization that certifies doctors who meet specific educational, training, and professional requirements in this discipline. The ABPMR does not endorse any independent review courses, study guides or other study materials. Questions and items provided in any such materials may not be representative of actual questions on an ABPMR Board examination. For more information on ABPMR board certification and exams, please go to www. abpmr.org.

Purpose of Certification Currently, the ABPMR offers certification in seven subspecialities of PM&R. The ABPMR has offered certification in SCI Medicine since 1998. Subspecialty certification in SCI medicine both allows physiatrists to demonstrate their competency in the field and ensures the quality of care available to individuals with spinal cord injury. Examinations are administered simultaneously once a year at Pearson Professional Centers nationwide.

Admissibility Requirements In order to be considered eligible to sit for the examination, applicants must fulfill the following requirements: 1. ABMS Certification—Applicants must be diplomates in good standing of a member board of the ABMS. 2. Licensure—Applicants must have a current, valid, and unrestricted license to practice medicine in at least one jurisdiction in the United States, its territories, or Canada. Physicians must provide evidence of unrestricted licensure in the state or states they practice prior to issuance of the certificate. 3. Training—Applicants must • Successfully complete 12 months of an ACGME–accredited SCI Medicine fellowship following their residency, • Be evaluated annually by their program director with evaluations submitted directly to ABPMR • Be recommended for admissibility to the SCI Medicine Examination by their program director upon completion of their fellowship in SCI medicine. 4. Date of Training Completion—Applicants must complete their SCI Medicine fellowship on or before August 31 of the year of the scheduled examination.

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Examination Format The format of the SCI Medicine Examination should be familiar to candidates who have taken Part I of the ABPMR certification examination. It is a computer-based examination comprised of 280 multiple-choice questions divided into two 3.5-hour sections. All questions are multiple-choice with four options (A–D) with only one best answer. There is a 60-minute break between sections. There is also a tutorial at the beginning of the first section to allow the examinee to familiarize him or herself with the testing software. On the day of the exam, staff will ask candidates for two forms of identification (ID), including at least one government-issued ID with both their signature and a recent photograph. The other form of ID must also display their signature. Prior to the exam, candidates should ensure that the name listed on both their forms of ID match the name on file with the ABPMR. Exam results are typically released 6–8 weeks following exam administration. Candidates are notified by email when results become viewable electronically on the ABPMR website.

Examination Outline with Approximate Target Weights Class 1: Type of Myelopathy 1. Traumatic (55%) (a) Cervical (b) Thoracic, lumbosacral (c) Non-specified/multiple 2. Nontraumatic (25%) (a) Motor neuron disorder (b) Spondylotic (c) Infectious (e.g., epidural abscess, osteomyelitis, HIV, West Nile) (d) Immune, inflammatory not including MS (e.g., transverse myelitis) (e) Multiple sclerosis (f) Tumor (g) Vascular (e.g., ischemic myelopathy, arteriovenous malformation, radiation myelopathy) (h) Toxic/metabolic/nutritional (i) Hereditary and congenital (j) Poliomyelitis and post-polio syndrome 3. Myelopathy without specified etiology (20%) Class 2: Pathophysiology, Evaluation, and Management 1 . Prevention of SCI (1%) 2. Applied anatomy, physiology, and kinesiology (3%) 3. Epidemiology, risk factors, and genetics (3%) 4. Neurologic assessment/classification (4%)

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Acute evaluation and management (medical or surgical) (5%) Spinal orthosis (2%) Imaging of spine or spinal cord (3%) Prognosis/predicting outcome or function (4%) Ethics and professionalism (1%) Electrodiagnostic assessment (2%) Cardiovascular (5%) (a) Spinal shock (including neurogenic shock) (b) Orthostatic hypotension (c) Deep venous thrombosis (d) Pulmonary embolism (e) Autonomic dysreflexia (f) Other autonomic dysfunction (g) Other Pulmonary (6%) (a) Restrictive pulmonary disease/respiratory impairment (b) Invasive and noninvasive ventilation/MIE (c) Infection/aspiration/atelectasis (d) Sleep disorders (e) Other Gastrointestinal (5%) (a) Neurogenic bowel (b) Swallowing/dysphagia (c) Upper GI disorders (e.g., SMA, ileus) (d) Other (e.g., pancreatitis, hepatobiliary, appendicitis) Genitourinary (8%) (a) Neurogenic bladder (b) Infection (c) Lithiasis (d) Urodynamics (e) Renal impairment (f) Other Sexuality/reproductive (3%) (a) Sexual dysfunction (b) Fertility (c) Pregnancy (d) Other Musculoskeletal (6%) (a) Spinal fractures, dislocations, instability (b) Contractures/joint complications (c) Heterotopic ossification (d) Osteoporosis (e) Scoliosis and late spine complications (f) Overuse injuries (g) Fractures (extremities) (h) Other

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17. Neurological (5%) (a) Spasticity (b) Late central nervous system complications (hydro, syrinx, tethered cord) (c) Peripheral nerve dysfunction (d) Traumatic brain injury (e) Thermoregulation and sweating (f) Neuromodulatory and disease-­modifying agents (g) Other 18. Pressure injuries (4%) (a) Risk factors, prevention (b) Staging/assessment/site (c) Nonsurgical evaluation and management (d) Surgical management (e) Other 19. Nutrition, weight management, body composition (1%) 20. Endocrine/metabolic (2%) (a) Endocrine (b) Lipid metabolism (c) Hypercalcemia (d) Other metabolic (e.g., hyponatremia) 21. Infection/immune NOS (e.g., sepsis, latex allergy) (2%) 22. Pain (4%) (a) Musculoskeletal (b) Neuropathic (c) Other (e.g., CRPS, nonspecific) 23. Psychological (3%) (a) Depression/affective disorder (b) Substance disorder (c) Cognitive impairment (d) Conversion disorder (e) Other behavior 24. Healthcare maintenance (2%) (a) Immunization (b) Preventive health care (c) Aging 25. Functional assessment (2%) 26. Exercise and modalities (2%) (a) Therapeutic exercise (b) Functional electrical stimulation (c) Modalities (d) Nontraditional therapies 27. Mobility (3%) (a) Gait (b) Ambulation/lower extremity orthosis (c) Wheelchairs, other mobility devices (d) Transfers, positioning, and sitting balance

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28. Activities of daily living (2%) (a) Adaptive equipment/functional orthosis (b) Architectural adaptations (c) Tendon transfers (d) Environmental control technology 29. Speech and communication (1%) 30. Participation/living with SCI (2%) (a) Recreation and sports activities (b) Community access and driving (c) Vocational rehabilitation (d) Social issues 31. Healthcare systems (1%) (a) Rehabilitation team (b) Patient safety (c) Medico-legal issues, advocacy (d) Practice management 32. Clinical and basic science (3%) (a) Research and statistical methods (b) Neural injury/regeneration

SCI Medicine Certificate Upon approval of the application and the candidate’s successful completion of the examination, the ABPMR will grant a subspecialty certificate in SCI Medicine. Certificates are mailed approximately three months after notification of results. Note that the certificate is time-limited to a 10-year period, after which a maintenance of certification (MOC) will be necessary. The certificate expires on December 31 of the tenth year of the cycle.

Maintenance of Certification (MOC) in SCI Medicine To be considered eligible to participate in the SCI Medicine MOC Program, applicants must have a current, valid, and unrestricted license to practice medicine in at least one jurisdiction in the United States, its territories, or Canada. Applying physicians must provide evidence of unrestricted licensure in the state or states in which they practice prior to issuance of the certificate. MOC requires achieving a passing score on a computer-based, proctored SCI Medicine Examination prior to the certificate expiration date. Applicants may take the examination in years 7–10 of the SCI medicine MOC cycle. If the subspecialty certificate expires after the 10-year time limit, the physician has a maximum of three years to become recertified (i.e., meet the licensure requirement and pass the subspecialty MOC Examination). After this three-year period, the

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physician will be required to reapply and meet the application requirements in effect at the time of the new application (i.e., complete another ACGME–accredited SCI medicine fellowship).

Further Reading American Board of Physical Medicine and Rehabilitation. Subspeciality Certification. Available at: https://www.abpmr.org/Subspecialties. Accessed February 14, 2022. Sabharwal S, Chiodo AE, Raddatz MM.  Administration and performance on the Spinal Cord Injury Medicine Certification Examination over a 10-year period. J Spinal Cord Med. 2019;42(5):606–12. https://doi.org/10.1080/10790268.2018.1475995. Epub 2018 Jun 14

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Epidemiology, Risk Factors, and Prevention of Spinal Cord Injury John Lin, Wesley Chay, and Natasha Bhatia

Epidemiology 1. According to data collected from the National Spinal Cord Injury Database (NSCID), between 2005 and 2011, which of the following statements is true regarding the relationship between traumatic spinal cord injury (SCI) and an individual’s sex?

A. Traumatic SCI occurs equally among men and women B. Men are twice as likely to have a fall as the etiology of their SCI compared to women C. Men are twice as likely to have a gunshot wound as the etiology of their SCI compared to women D. Men are twice as likely to have an all-terrain vehicle (ATV) accident as the etiology of their SCI compared to women Answer: C. Overall, 78.3% of reported traumatic SCIs occurred in men. A gunshot wound as the etiology of SCI was twice as likely in men (11.7%) than in women (5.8%).

J. Lin (*) · W. Chay Department of Medical Staff, Shepherd Center, Atlanta, GA, USA e-mail: [email protected]; [email protected] N. Bhatia Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA Department of Physical Medicine and Rehabilitation, Shirley Ryan AbilityLab, Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. A. Abramoff et al. (eds.), The Essential Spinal Cord Injury Medicine Question Bank, https://doi.org/10.1007/978-3-031-07796-8_2

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Fall as the etiology of SCI was approximately equal between men (25.6%) and women (24.2%). ATV accidents as the etiology of SCI was approximately equal between men (1.8%) and women (1.6%). The most common etiology of traumatic SCI in both men and women was automobile accidents (27.9% of injuries in men, and 44.4% of injuries in women). Chen Y, Tang Y, Vogel LC, Devivo MJ.  Causes of spinal cord injury. Top Spinal Cord Inj Rehabil. 2013;19(1):1–8. https://doi.org/10.1310/sci1901-­1.

2. According to data collected from the National Spinal Cord Injury Database (NSCID), between 2005 and 2011, what is the most common cause of traumatic spinal cord injury among people older than 45 years in age?

A. Medical/surgical complications B. Automobile accidents C. Falls D. Gunshot wounds Answer: C. Automobile accidents are the leading cause of traumatic spinal cord injury among individuals until age 45 years. At older ages, falls become the leading cause of traumatic SCIs. Chen Y, Tang Y, Vogel LC, Devivo MJ.  Causes of spinal cord injury. Top Spinal Cord Inj Rehabil. 2013;19(1):1–8. https://doi.org/10.1310/sci1901-­1.

3. According to a 15-year population-based cohort study between 2002 and 2017, how has the incidence rate of SCI changed over time?

A. Incidence of SCI in women over age 65 increased significantly over study period B. Incidence of SCI in men over age 65 increased significantly over study period C. Incidence of SCI in women below age 65 increased significantly over study period D. Incidence of SCI in men below age 65 increased significantly over study period

the the the the

Answer: A. Between 2002 and 2017, the incidence of SCI in women in the older age cohort (>65 years) increased on average 4% per year. Incidence of SCI in women in the younger age cohort (140, with continued elevation of SBP >140 on re-check 10 min later C. An SBP 20 mmHg greater than athlete’s baseline that persists on re-check 10 min later D. A single reading of SBP >160 Answer: A. According to the 2016 IPC guidelines, a hazardous dysreflexic state is considered to be present when SBP is >160. An athlete with an SBP >160 mmHg is to be re-examined 10 min later. If the second examination remains with SBP >160, the person examining the athlete is to inform the technical delegate to withdraw the athlete from the event. International Paralymic Committee Handbook. Chapter 4.2 Position Statement on Autonomic Dysreflexia and Boosting. 2016. Available at: https://www.paralympic.org/ipc-handbook

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11. You are taking care of a patient who has been suffering from orthostatic hypotension. You recommend initiation of fludrocortisone. The patient asks what side effects to expect on the medication. You counsel them on all of the following common side effects except:

A. Fluid retention B. Electrolyte abnormalities C. Headaches D. Palpitations Answer: D. Fludrocortisone is a mineralocorticoid with vasopressor activity resulting from sodium retention and by increasing sensitivity of arterioles to norepinephrine. Fludrocortisone is typically started at a dose of 0.1 mg daily, with titration over intervals of 1–2 weeks. Patients should be advised to expect 5–8 pounds of weight gain from fluid retention. Electrolyte abnormalities also occur, primarily hypokalemia and hypomagnesemia requiring supplementation. Headaches are also common particularly in younger patients. Palpitations are not a common side effect of fludrocortisone but can be a side effect of ephedrine which is also used for management of orthostatic hypotension. Sabharwal S. Cardiovascular Dysfunction in Spinal Cord Injury. In: Kirshblum S, Lin VS, editors. Spinal cord medicine. 3rd ed. New  York City: Springer Publishing Company; 2019. pp. 63–76. https://doi.org/10.1891/9780826137753.0005

12. What is the most frequent cardiac dysrhythmia in the acute phase following spinal cord injury?

A. Atrial fibrillation B. Sinus tachycardia C. Bradycardia D. Supraventricular tachycardia Answer: C. The risk of cardiac dysrhythmia is higher in the acute phase and diminishes with time from injury. In the first few weeks, this can be life-threatening and patients should be monitored closely due to risk of cardiac arrest. In both the acute and chronic phase, ventricular bradyarrhythmias remain the most frequent cardiac arrhythmia, although atrial fibrillation can occur in the setting of autonomic dysreflexia. The frequency of bradycardia peaks at day 4 following injury, and gradually decreases thereafter. These events can be further triggered by vagal endotracheal suctioning, laryngoscopy, or even bowel movements due to unopposed vagal response. Grigorean VT, Sandu AM, Popescu M, Iacobini MA, Stoian R, Neascu C, Strambu V, Popa F. Cardiac dysfunctions following spinal cord injury. J Med Life. 2009;2(2):133–45.

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13. Following an episode of autonomic dysreflexia, how long is it recommended that the patient’s symptoms and blood pressure continue to be monitored?

A. 30 min B. 1 h C. 2 h D. 4 h Answer: C. According to expert opinion, patients should be monitored for recurrent symptoms for at least 2 h following an episode of AD. Patients should be advised to seek medical attention if the symptoms recur, and admission for close monitoring should be considered, particularly if the patient is pregnant or if the cause of the episode is unclear. It is advised that all episodes of AD be documented in the patient’s medical record. Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health-care facilities. J Spinal Cord Med. 2002;25(Suppl. 1):S67–88.

14. In children 6–12 years old, at what systolic blood pressure should you consider pharmacologic intervention in an episode of autonomic dysreflexia?

A. 110 B. 120 C. 130 D. 140 Answer: C. According to expert opinion, at age 6–12 pharmacologic intervention should be considered at a systolic blood pressure above 130 mmHg. For under 5 years old, it should be considered for SBP > 120 mmHg and for adolescents it should be considered >140 mmHg. It is always optimal to have the patient’s baseline blood pressure as a point of comparison, however these guidelines can be used if that information is unavailable. It is very important to ensure that you are using an appropriate size BP cuff when assessing for AD in a child, particularly because their ability to communicate symptoms accurately can be limited depending on their age. Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health-care facilities. J Spinal Cord Med. 2002;25(Suppl. 1):S67–88.

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15. For pregnant patients with SCIs, what is recommended to prevent episodes of autonomic dysreflexia during labor?

A. Vaginal delivery with epidural anesthesia B. Cesarean section under general anesthesia C. Vaginal delivery without anesthesia D. Vaginal delivery with intravenous analgesia Answer: A. Although studies are limited, epidural or spinal anesthesia is the recommended prevention of episodes of AD during labor for either vaginal or Cesarean delivery. Although some patients, depending on their level of injury, may not experience labor pains, they continue to be at risk for development of AD. AD or increased spasticity can sometimes be a prominent sign that a patient is in labor. It is essential that the patient has adequate analgesia through epidural or spinal anesthetic to prevent serious complications from uncontrolled hypertension in the setting of AD. Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009;90(4):682–95. https://doi.org/10.1016/j. apmr.2008.10.017.

16. Initiation of anti-hypertensive medications should be considered in most individuals with SCI and no other past medical history who have consistent blood pressure readings above what threshold?

A. 130/80 mmHg B. 140/90 mmHg C. 160/80 mmHg D. 160/100 mmHg Answer B. There is insufficient evidence that individuals with SCI should have a different threshold for treating hypertension than the general population. Current guidelines by most organizations recommend the initiation of pharmacologic agents when blood pressure is consistently above 140/90 in individuals with no other significant past medical history. Making the diagnosis of hypertension in individuals with SCI can be challenging as blood pressure can be highly variable as a result of postural influences and autonomic dysfunction. Blood pressure should be checked at every routine visit and at least annually. Elevated blood pressure should be confirmed on a subsequent visit prior to diagnosing hypertension. Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423. https://doi.org/10.1310/sci2404-­379.

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17. A patient with T4 AISA D SCI with a past medical history of diabetes mellitus should be initiated on anti-hypertensive medications when blood pressure readings are consistently above what threshold, despite lifestyle interventions?

A. 120/80 mmHg B. 130/80 mmHg C. 140/90 mmHg D. 160/100 mmHg Answer B. There is insufficient evidence that individuals with SCI should have a different threshold for treating hypertension than the general population. The Joint National Commission guidelines recommend a goal blood pressure of less than 130/80 mmHg for individuals with chronic kidney disease or diabetes mellitus. Current guidelines by most organizations recommend the initiation of pharmacologic agents when blood pressure is consistently above 140/90 in individuals with no past medical history. Armstrong C; Joint National Committee. JNC8 guidelines for the management of hypertension in adults. Am Fam Physician. 20141;90(7):503–4. Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423. https://doi.org/10.1310/ sci2404-­379.

18. Which of the following would NOT be recommend as first line pharmacologic intervention for treatment of hypertension in a 40-year-old male with history of a traumatic C5 ASIA D SCI and no other past medical history?

A. Calcium channel blocker B. Beta blocker C. Thiazide diuretic D. Angiotensin-converting enzyme inhibitor Answer B. There is insufficient data investigating antihypertensive agents in the SCI population. Recommendations for blood pressure management are based on guidelines for the general population. First line agents include calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and thiazide diuretics. Beta blockers are recommended as first line in individuals who have suffered a myocardial infarction but are not recommended as first line in this patient with no other significant past medical history. Individual factors must also be taken into account for each patient and the use

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of diuretics should be carefully considered in individuals with SCI who require intermittent bladder catheterization as these may change bladder volumes. Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423. https://doi.org/10.1310/ sci2404-­379.

19. How often should an adult with SCI and no other past medical history, who’s initial post-injury lipid panel was normal, be screened for hyperlipidemia?

A. Annually B. Every 6 months for the 1st year, and then if normal, annually C. Every 3 years D. Every 2 years Answer C. A patient with a normal post-injury lipid panel without other risk factors should be screened for hyperlipidemia every 3 years. If the patient has multiple risk factors for dyslipidemia, such as smoking, diabetes or obesity, a lipid panel should be checked annually. The decision to screen should always be based on clinical judgement. Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423. https://doi.org/10.1310/ sci2404-­379.

20. Clinicians should recommend their patients with SCI participate in at least how many minutes of physical exercise per week?

A. 200 min B. 150 min C. 120 min D. 60 min Answer B. Individuals with SCI should participate in at least 150 min of physical exercise per week in order to lower their risk of cardiometabolic disease and improve their general fitness. Exercise should begin as soon as possible following injury. Exercise can be broken up into 30–60 min sessions, 3–5 days per week. Exercise can also occur in three 10-min sessions, 5 days per week, in those unable to

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tolerate longer exercise durations. Anything above this (A) would be beneficial, but 150 min is the recommended minimum. Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423. https://doi.org/10.1310/ sci2404-­379.

21. At what level (and above) is transmission of angina less likely to be perceived by a patient with a SCI?

A. T5 B. T6 C. T7 D. T8 Answer A. Cardiac pain is transmitted in afferent sympathetic nerves through the first five thoracic segments. It is then carried through the spinal cord through the spinothalamic tract, to the thalamus, and then to the cortex. Individuals with injuries to T5 and above may fail to perceive cardiac chest pain due to interruption of this pathway. Malliani A, Lombardi F. Consideration of the fundamental mechanisms eliciting cardiac pain. Am Heart J. 1982;103(4 Pt 1):575–8. https://doi.org/10.1016/0002-­8703(82)90352-­0. Malliani A, Lombardi F, Pagani M.  Sensory innervation of the heart. Prog Brain Res. 1986;67:39–48. https://doi.org/10.1016/s0079-­6123(08)62755-­7.

22. Which anesthetic should be avoided for individuals with thoracolumbar SCI undergoing general anesthesia?

A. Rocuronium B. Propofol C. Vecuronium D. Succinylcholine Answer D. Rapid development of hyperkalemia in succinylcholine induced cardiac arrest in individuals with thoracolumbar SCI has been described in the literature. The presumed mechanism is that a larger potassium efflux will occur following depolarization due to changes in acetylcholine and succinylcholine sensitivity

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following denervation. Specifically, following denervation there is spread of the acetylcholine and succinylcholine sensitive area of the myoneural junction to a larger area of the muscle membrane, upregulation of acetylcholine receptors with spread of these receptors throughout the muscle membrane, and expression of acetylcholine receptor isomers. Patients with a thoracolumbar injury should receive alternatives to succinylcholine when undergoing anesthesia for surgical procedures. Brooke MM, Donovon WH, Stolov WC. Paraplegia: succinylcholine-induced hyperkalemia and cardiac arrest. Arch Phys Med Rehabil. 1978;59(7):306–9. Martyn JA, Richtsfeld M.  Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology. 2006;104(1):158–69. https://doi.org/10.1097/00000542-­200601000-­00022.

23. A 24-year-old male with a traumatic T4 ASIA B SCI presents to your clinic seeking advice regarding sexual function. He reports that he has been having trouble achieving an erection and is requesting a prescription for sildenafil. Which of the following comorbidities must this patient be screened for prior to prescribing this medication due to concerns related to polypharmacy?

A. Heterotopic ossification B. Autonomic dysreflexia C. Urinary retention D. Osteoporosis Answer B. Concomitant use of topical or intravenous nitrates with a phosphodiesterase-­5 inhibitor, such as sildenafil, can cause severe hypotension which could result in death. The two agents should not be prescribed together because of this serious interaction. Topical nitrates are often prescribed for individuals who suffer from autonomic dysreflexia. Individuals with injury at or above T6 are predisposed to autonomic dysreflexia and thus, should be screened for AD prior to prescribing a phosphodiesterase-5 inhibitor. Patients should be counseled about the serious risk of using these agents together. The other choices are not contraindications to the use of sildenafil. Sabharwal S. Cardiovascular Dysfunction in Spinal Cord Injury. In: Kirshblum S, Lin VS, editors. Spinal cord medicine. 3rd ed. New  York City: Springer Publishing Company; 2019. pp. 63–76. https://doi.org/10.1891/9780826137753.0005.

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24. Which of the following diagnostic components of cardiometabolic disease has not been validated in the SCI population?

A. Elevated blood pressure ≥ 130/80 mmHg B. Fasting glucose ≥ 100 mg/dL C. Waist circumference greater than 40” in men and 35” in women D. Reduced high-density lipoprotein (HDL) Answer C. All of the above are components of establishing the diagnosis of cardiometabolic disease. However, waist circumference has not been validated in the SCI population. It is instead recommended to use a BMI ≥ 22 kg/m2 or >22% body fat when using 3 or 4 compartment modeling to assess body composition. Nash MS, Groah SL, Gater DR Jr, Dyson-Hudson TA, Lieberman JA, Myers J, Sabharwal S, Taylor AJ; Consortium for Spinal Cord Medicine. Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423. https://doi.org/10.1310/ sci2404-­379. Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C; National Heart, Lung, and Blood Institute; American Heart Association. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Arterioscler Thromb Vasc Biol. 2004;24(2):e13–8. https://doi.org/10.1161/01.ATV.0000111245.75752.C6.

25. Which of the following statements regarding nutritional counseling in patients with SCI is FALSE?

A. Patients should undergo a caloric assessment using indirect calorimetry to estimate energy expenditure and establish caloric goals B. The Mediterranean or Dietary Approach to Stop Hypertension (DASH) diets should be adopted by individuals with SCI and cardiometabolic risk factors C. Saturated fats should be limited to 5–6% of total caloric intake D. Daily sodium intake should be limited to