causing nutritional problems [75].

Finally the effect of drugs such as analgesics and barbiturates is crucial. Drugs that are frequently administered to acute paraplegic patients may themselves increase skeletal-muscle breakdown (corticosteroids), decrease splanchnic blood flow (pressor agents), or increase urinary loss of electrolytes, minerals, and water-soluble vitamins (diuretics). Infection, operative trauma, and other stresses may increase energy expenditure and protein and micronutrient needs [71-74]. The average daily dietary needs are modified because of the altered physiology of each body system and psychological integrity of a patient susceptible to an injury, potentially at any age, which cannot exclude the possibility of a pre-existing disease

Moreover, the frequent coexistence of injuries from other systems, such as brain injury, maxillofacial injuries, fractures, etc., disturbs the normal physiology further. Studies in malnourished patients stated that malnutrition before a spine stabilization surgery is leading to postoperative complications, hyperthermia, which increases the caloric needs of the patient, and denervation, leading to atrophy and paralysis, which supply amino acids for gluconeo‐

genesis, which, in turn, supplies glucose to meet caloric needs [1].

excretion of nitrogen which starts about a week after the injury [67].

138 Topics in Paraplegia

During aging with paraplegia other complications are added in the physiopathological context of "malnourished paraplegics".

A neglected factor is muscle tonus: hypotonia (low muscle tone, floppiness) results in a lower resistance to muscle movement. The lower the resistance, the fewer calories burned during movement. Furthermore, hypertonia (high muscle tone, spasticity) is limiting muscle move‐ ment and reduces caloric needs. Lack of movement results in muscle atrophy and a lower lean body mass, which in turn reduces the number of calories burned even at rest [79].

In spinal cord injured subjects is mainly central or abdominal obesity leading to metabolic, cardiovascular issues etc. There is conflicting evidence about the contribution of visceral and subcutaneous adipose tissue to different metabolic disorders after SCI. Moreover subjects with longstanding disabilities (i.e. spinal cord injury) are at increased risk for cardiovascular disease and cardiopulmonary disease because of extensive fat intake and limiting activities. In generally, subjects with disabilities are prone to developing vitamin D deficiency. Earlier work by Bauman et al suggested that approximately 32% of veterans with spinal cord injury (SCI) were absolutely deficient in vitamin D (25 hydroxyvitamin D [25(OH)D]). Most subjects have a high incidence of vitamin D deficiency as defined by levels of 25(OH)D<20 ng/mL. The reasons might be due to a combination of low dietary vitamin D intake and avoiding sun exposure because of depression or sensitivity in drugs i.e. dantrolene [80]. The low intake of vitamin D, which is supplied by food either in vitamin D2 (ergocalciferol, activated ergosterol), found in yeast, or vitamin D3 (cholecalciferol), found in fish, can be bypassed through supplements [81].

Moreover, reduced mobility and immobilization for long period cause pressure ulcers of the skin and the wound but can be prevented by adequate intake of quantity of protein, vitamin E, zinc, and fluids to maintain skin integrity [82].

Pneumonia and paralysis of respiratory muscles through malnutrition may further weaken the respiratory muscles. On the other site excessive feeding may lead to increased oxidation of glucose and production of carbon dioxide to be eliminated and further stress on the respiratory system. The fluid overload or aggressive implementation of parenteral support can lead to pulmonary edema. The reduced hydration can lead to reduced drainage of secretions, atelectasis, and pneumonia. Abdominal distension due to unabsorbed food by mouth or enteral feeding or swallowing air during feeding can lead to compromise the functioning of the diaphragm and predisposes to hypoventilation or aspiration [83]. Neuro‐ genic bowel requires the right amount of food, fiber and fluids in order to be successful retraining of the bowel, and prevent constipation, diarrhea, incontinence, and autonomic dysreflexia as a result of fecal impaction. Bowel function may be compromised by hyperos‐ molar feeding through a tube, lactose intolerance or pseudomembranous colitis, prolonged treatment with antibiotics, which can cause diarrhea and require parenteral nutritional support. For neurogenic bladder vitamin C and other supplements are necessary for the acidification of urine and prevention of infection of the urinary tract.

#### **7. The nutritional support**

The provision of a nutritional supplement is definitely not a frontline management technique for poor oral intake. Supplements when administered correctly to patients can easily optimize nutrition and should be an adjunctive to nutrition.

Per os feeding is recommended for patients who are weaned from tracheal tubes, which are awakened, may follow commands and have good swallowing and intestinal function. Patients with central nervous system (CNS) acute diseases are frequently in coma or have their swallowing reflexes impaired and need parenteral nutrition or enteral tube feeding [84, 85]. Enteral nutrition (EN) is recommended for patients who are tubed, not able to swallow or to receive adequate diet orally but have good bowel function.

Early nutrition support through the enteral route has been shown to blunt catabolism, reduce complications and reduce length of stay in a number of patient populations, including both surgical and non-surgical neuro patients [86, 87]. However, nutrition support must be initiated within the 48-to 72-hour period immediately following injury or surgical insult to achieve these benefits. Clinicians are often hesitant to feed critically ill neuro patients too soon. However, studies indicate patients with severe neurological deficits and clinically silent abdomens can tolerate low-rate jejunal feedings within 36 hours of injury with a gradual increase in feeding rate to meet initial caloric goals within two to four days [88, 89]. If jejunal feedings are initiated prior to induction of pentobarbital infusion, even patients in pentobarbital coma can be fed enterally [90].

where enteral feeding is expected to be required for longer than 2–4 weeks, for example in patients with acute stroke [91]. Although complications of PEG tube feeding are rare in stable patients, they become increasingly common in critically ill and debilitated patients. One of most feared complication of enteral feeding: aspiration hypoxia/ pneumonia. Clinically, gastric residual volume (GRV) measurement was frequently used as marker to predict aspiration & pneumonia. Elevated GRV: associated with comorbidities such as vasopressor use, sedation sepsis, vomiting. GRV: no significance between GRV> 200ml and GRV> 400ml, low sensitivity

**Figure 2.** The enteral feeding pump type COMPAT (unpublished photo courtesy of Dionyssiotis Y). The system is a rel‐ atively simple, lightweight, easy to use for managing all types of enteral feeding. Have an audible and visual alarm that alerts you when each of the following conditions: empty container feeding, low battery, change the dose, or the existence of j free flow out of the system (waste). The memory of the pump retains infusion rate, volume delivered, dose limit even after turning it off. It is designed to provide precision dosing. Start enteral feeding schedule and prog‐

Malnutrition in Paraplegia http://dx.doi.org/10.5772/58382 141

With increasing frequency, nasogastric feeding tubes are replaced by PEG to provide semilong-term enteral nutrition because of various advantages of a PEG in daily use [93-95]. In contrast to a nasogastric feeding tube, PEG does not interfere with the swallowing mechanism, which reduces the possibility of choking, especially when oral feeding is initiated during

as a marker of aspiration [92].

ress.

Νasogastric or nasoenteric feeding tubes should not be used for periods longer than 4 weeks because of discomfort and the risk of nasal injury and sinusitis. Placement of a percutaneous endoscopic gastrostomy (PEG) tube should be considered for patients who continue to require enteral feeding beyond 4 weeks[90]. PeG is also indicated as firstline intervention in conditions

Pneumonia and paralysis of respiratory muscles through malnutrition may further weaken the respiratory muscles. On the other site excessive feeding may lead to increased oxidation of glucose and production of carbon dioxide to be eliminated and further stress on the respiratory system. The fluid overload or aggressive implementation of parenteral support can lead to pulmonary edema. The reduced hydration can lead to reduced drainage of secretions, atelectasis, and pneumonia. Abdominal distension due to unabsorbed food by mouth or enteral feeding or swallowing air during feeding can lead to compromise the functioning of the diaphragm and predisposes to hypoventilation or aspiration [83]. Neuro‐ genic bowel requires the right amount of food, fiber and fluids in order to be successful retraining of the bowel, and prevent constipation, diarrhea, incontinence, and autonomic dysreflexia as a result of fecal impaction. Bowel function may be compromised by hyperos‐ molar feeding through a tube, lactose intolerance or pseudomembranous colitis, prolonged treatment with antibiotics, which can cause diarrhea and require parenteral nutritional support. For neurogenic bladder vitamin C and other supplements are necessary for the

The provision of a nutritional supplement is definitely not a frontline management technique for poor oral intake. Supplements when administered correctly to patients can easily optimize

Per os feeding is recommended for patients who are weaned from tracheal tubes, which are awakened, may follow commands and have good swallowing and intestinal function. Patients with central nervous system (CNS) acute diseases are frequently in coma or have their swallowing reflexes impaired and need parenteral nutrition or enteral tube feeding [84, 85]. Enteral nutrition (EN) is recommended for patients who are tubed, not able to swallow or to

Early nutrition support through the enteral route has been shown to blunt catabolism, reduce complications and reduce length of stay in a number of patient populations, including both surgical and non-surgical neuro patients [86, 87]. However, nutrition support must be initiated within the 48-to 72-hour period immediately following injury or surgical insult to achieve these benefits. Clinicians are often hesitant to feed critically ill neuro patients too soon. However, studies indicate patients with severe neurological deficits and clinically silent abdomens can tolerate low-rate jejunal feedings within 36 hours of injury with a gradual increase in feeding rate to meet initial caloric goals within two to four days [88, 89]. If jejunal feedings are initiated prior to induction of pentobarbital infusion, even patients in pentobarbital coma can be fed

Νasogastric or nasoenteric feeding tubes should not be used for periods longer than 4 weeks because of discomfort and the risk of nasal injury and sinusitis. Placement of a percutaneous endoscopic gastrostomy (PEG) tube should be considered for patients who continue to require enteral feeding beyond 4 weeks[90]. PeG is also indicated as firstline intervention in conditions

acidification of urine and prevention of infection of the urinary tract.

**7. The nutritional support**

140 Topics in Paraplegia

enterally [90].

nutrition and should be an adjunctive to nutrition.

receive adequate diet orally but have good bowel function.

**Figure 2.** The enteral feeding pump type COMPAT (unpublished photo courtesy of Dionyssiotis Y). The system is a rel‐ atively simple, lightweight, easy to use for managing all types of enteral feeding. Have an audible and visual alarm that alerts you when each of the following conditions: empty container feeding, low battery, change the dose, or the existence of j free flow out of the system (waste). The memory of the pump retains infusion rate, volume delivered, dose limit even after turning it off. It is designed to provide precision dosing. Start enteral feeding schedule and prog‐ ress.

where enteral feeding is expected to be required for longer than 2–4 weeks, for example in patients with acute stroke [91]. Although complications of PEG tube feeding are rare in stable patients, they become increasingly common in critically ill and debilitated patients. One of most feared complication of enteral feeding: aspiration hypoxia/ pneumonia. Clinically, gastric residual volume (GRV) measurement was frequently used as marker to predict aspiration & pneumonia. Elevated GRV: associated with comorbidities such as vasopressor use, sedation sepsis, vomiting. GRV: no significance between GRV> 200ml and GRV> 400ml, low sensitivity as a marker of aspiration [92].

With increasing frequency, nasogastric feeding tubes are replaced by PEG to provide semilong-term enteral nutrition because of various advantages of a PEG in daily use [93-95]. In contrast to a nasogastric feeding tube, PEG does not interfere with the swallowing mechanism, which reduces the possibility of choking, especially when oral feeding is initiated during neurological recovery. The cosmetic advantage of a PEG, which can be worn invisibly underneath the patients' clothes, may play a psychological role during recovery. PEG place‐ ment is associated with a mortality rate of 1-3 per cent, major complication rates of 3-9 per cent and minor complication rates of 5-45 per cent. The risk of aspiration, frequently associated with nasogastric feeding tubes, has not been eliminated with PEG placement [96-100].

hyperglycemia, an increased risk of infectious complications and increased mortality rates in

Malabsorption and maldigestion must be recognized early in the decision making process in the use of enteral nutrition. Weight loss, signs of macronutrient (i.e., decreased visceral protein status, hypoglycemia, and steatorrhea) and micronutrient (electrolytes, trace elements, and vitamins) abnormalities suggest that the intestine may not be optimally functioning [107].

The European Society for Clinical Nutrition and Metabolism guidelines recommends that: "All patients receiving less than their targeted enteral feeding after 2 days should be considered for

Despite considerable controversy in this field, physicians generally agree on two key aspects: firstly, the enteral route is preferable whenever possible, and secondly, if possible, enteral nutritional support should be started early (within 24–48 h after admission) [101, 108, 109].

The American Society for Parenteral and Enteral Nutrition (ASPEN) and Society of Critical Care Medicine (SCCM) guidelines recommend that parenteral nutrition be initiated after 1 week, unless the patient is severely malnourished. By contrast, the European Society of Enteral and Parenteral (ESPEN) guidelines recommend consideration of a combination of enteral and parenteral nutrition after only 2–3 days in the ICU if enteral nutrition alone is insufficient at

In the early phase of rehabilitation enteral feeding solutions with low osmolarity (<300 mOsm/ l) to prevent hyperosmolar diarrhea (appeared in case of long time left unfeeded intestine, and

> **Nutricia Pre-nutrison 500ml**

**g/100ml** 2, 5 30% 1, 95 35% 0, 2 2% 1, 5 13, 3% **Fibers** 0, 5 0 0 0 **Osmolarity** 250 140 N.A. 269

**Energy Kcal/ml** 0, 75 0, 5 0, 5 1 **Protein g/100ml** 5 27% 2 16% 8, 5 68% 5, 2 20, 8% **Gluamine g/100ml** 1 N.A. 6 1, 4

**Fresenius Intestamin 500ml**

8 43% 6, 1 49% 17, 7 54% 16, 4 64, 9%

**Abbott Osmolite HP**

Malnutrition in Paraplegia http://dx.doi.org/10.5772/58382 143

**8. Transition from parenteral to enteral feeding and vice versa**

critically ill patients [104, 105].

supplementary parenteral nutrition" [108].

low calorie <1Kcal/ml) are usually used (Table 3).

**Novartis Novasource start 500ml**

that time [108, 110].

**Products**

**Carbohydrates g/100ml**

**Fat**

**Table 3.** Starters for enteral nutrition

Another interesting issue is early compared with late introduction of the feed. With data limited to ICU patients there was no overall difference in mortality rates with either EN or PN with no apparent difference in mortality rates across groups receiving EN or PN (RR 1.08; 95% CI 0.70 to 1.65). As suggested compared with PN, EN was associated with a significant reduction in infectious complications (RR 0.61; 95% CI 0.44 to 0.84; p=0.003). The early compared with late introduction of enteral feed only suggested that early EN was associated with a trend toward a reduction in mortality (RR 0.52; 95% CI 0.25 to 1.08; p=0.08) when compared with delayed nutrient intake and infection risk was not different [101]. The compi‐ lation of 11 high quality studies comparing enteral and parenteral nutrition revealed a significant effect in favor of parenteral nutrition [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.27–0.97]. A subgroup analysis of trials comparing parenteral nutrition with early or late enteral feeding showed that there was no survival benefit in parenteral nutrition when enteral nutrition was provided early. The benefit of parenteral nutrition was confined to trials comparing it with late enteral nutrition. Therefore, this metaanalysis confirms at least a finding already reported in earlier metaanalyses: there is no increased mortality risk with parenteral nutrition! [102].

A major concern with EN is the discrepancy between prescribed and delivered amount of nutrient, the major causes of which are diarrhea, vomiting or gastric stasis. Furthermore, enteral nutrient delivery is gradually increased in critically ill patients in order to avoid the possibility of gastrointestinal intolerance, so that a few days are required to achieve the caloric target. Administering the total nutritional requirement of mechanically ventilated medical patients starting on day 1 was associated with greater infectious complications and prolonged length of hospital stay compared to patients in whom a gradual approach was implemented [103]. Despite the caloric deficiency, EN is still superior to PN so that nonenergetic effects of EN, such as immune modulation or protection of the intestinal mucos‐ al barrier, seem to be of greater value in the critically ill than the mere energetic supply. The issue of the better enteral access (gastric vs. post-pyloric route) is not yet settled. However, available evidence does not support the routine insertion of post-pyloric tubes as long as the gastric route is effective [104, 105, 106].

Aside from the potential problems associated with receiving in adequate or excessive nutrition or medication therapy, additional injury to the patient may result from using the gut that is at risk for bacterial or candidal translocation. Therefore, enteral nutrition should be started only if the potential benefits outweigh the risks [107, 108].

However, nutritional support is not without adverse effects and risks. Early EN may be associated with high gastric residuals, bacterial colonization of the stomach, and increased risk of aspiration pneumonia. PN has been associated with gut mucosal atrophy, overfeeding, hyperglycemia, an increased risk of infectious complications and increased mortality rates in critically ill patients [104, 105].

#### **8. Transition from parenteral to enteral feeding and vice versa**

Malabsorption and maldigestion must be recognized early in the decision making process in the use of enteral nutrition. Weight loss, signs of macronutrient (i.e., decreased visceral protein status, hypoglycemia, and steatorrhea) and micronutrient (electrolytes, trace elements, and vitamins) abnormalities suggest that the intestine may not be optimally functioning [107].

The European Society for Clinical Nutrition and Metabolism guidelines recommends that: "All patients receiving less than their targeted enteral feeding after 2 days should be considered for supplementary parenteral nutrition" [108].

Despite considerable controversy in this field, physicians generally agree on two key aspects: firstly, the enteral route is preferable whenever possible, and secondly, if possible, enteral nutritional support should be started early (within 24–48 h after admission) [101, 108, 109].

The American Society for Parenteral and Enteral Nutrition (ASPEN) and Society of Critical Care Medicine (SCCM) guidelines recommend that parenteral nutrition be initiated after 1 week, unless the patient is severely malnourished. By contrast, the European Society of Enteral and Parenteral (ESPEN) guidelines recommend consideration of a combination of enteral and parenteral nutrition after only 2–3 days in the ICU if enteral nutrition alone is insufficient at that time [108, 110].

In the early phase of rehabilitation enteral feeding solutions with low osmolarity (<300 mOsm/ l) to prevent hyperosmolar diarrhea (appeared in case of long time left unfeeded intestine, and low calorie <1Kcal/ml) are usually used (Table 3).

**Table 3.** Starters for enteral nutrition

neurological recovery. The cosmetic advantage of a PEG, which can be worn invisibly underneath the patients' clothes, may play a psychological role during recovery. PEG place‐ ment is associated with a mortality rate of 1-3 per cent, major complication rates of 3-9 per cent and minor complication rates of 5-45 per cent. The risk of aspiration, frequently associated with nasogastric feeding tubes, has not been eliminated with PEG placement [96-100].

Another interesting issue is early compared with late introduction of the feed. With data limited to ICU patients there was no overall difference in mortality rates with either EN or PN with no apparent difference in mortality rates across groups receiving EN or PN (RR 1.08; 95% CI 0.70 to 1.65). As suggested compared with PN, EN was associated with a significant reduction in infectious complications (RR 0.61; 95% CI 0.44 to 0.84; p=0.003). The early compared with late introduction of enteral feed only suggested that early EN was associated with a trend toward a reduction in mortality (RR 0.52; 95% CI 0.25 to 1.08; p=0.08) when compared with delayed nutrient intake and infection risk was not different [101]. The compi‐ lation of 11 high quality studies comparing enteral and parenteral nutrition revealed a significant effect in favor of parenteral nutrition [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.27–0.97]. A subgroup analysis of trials comparing parenteral nutrition with early or late enteral feeding showed that there was no survival benefit in parenteral nutrition when enteral nutrition was provided early. The benefit of parenteral nutrition was confined to trials comparing it with late enteral nutrition. Therefore, this metaanalysis confirms at least a finding already reported in earlier metaanalyses: there is no increased mortality risk with parenteral

A major concern with EN is the discrepancy between prescribed and delivered amount of nutrient, the major causes of which are diarrhea, vomiting or gastric stasis. Furthermore, enteral nutrient delivery is gradually increased in critically ill patients in order to avoid the possibility of gastrointestinal intolerance, so that a few days are required to achieve the caloric target. Administering the total nutritional requirement of mechanically ventilated medical patients starting on day 1 was associated with greater infectious complications and prolonged length of hospital stay compared to patients in whom a gradual approach was implemented [103]. Despite the caloric deficiency, EN is still superior to PN so that nonenergetic effects of EN, such as immune modulation or protection of the intestinal mucos‐ al barrier, seem to be of greater value in the critically ill than the mere energetic supply. The issue of the better enteral access (gastric vs. post-pyloric route) is not yet settled. However, available evidence does not support the routine insertion of post-pyloric tubes

Aside from the potential problems associated with receiving in adequate or excessive nutrition or medication therapy, additional injury to the patient may result from using the gut that is at risk for bacterial or candidal translocation. Therefore, enteral nutrition should be started only

However, nutritional support is not without adverse effects and risks. Early EN may be associated with high gastric residuals, bacterial colonization of the stomach, and increased risk of aspiration pneumonia. PN has been associated with gut mucosal atrophy, overfeeding,

as long as the gastric route is effective [104, 105, 106].

if the potential benefits outweigh the risks [107, 108].

nutrition! [102].

142 Topics in Paraplegia

The rate of early products' infusion is shown in the Table 4. Moreover, Table 5 depicts most used enteral products according to categories and their characteristics.

**Categories Products Characteristics** Novasource Forte (Novartis) Nutrison Energy (Nutricia) Nutridrink (Nutricia)

The goal of rehabilitation is to return through a gradual transition from the feeding tube back in swallowing if possible. The steps for neurocognitive and neuromuscular patients are based

The initial (preparatory) phase focuses on physiologic readiness for oral nutrition and incorporates medical and nutrition stability (normal swallowing function and nutrition values in normal range), and includes implementation of intermittent tube feeding, and swallowing assessment. The second (weaning) phase is described as a graduated increase in oral feeding, with corresponding decreases in tube feeding. In a patient able to consume more than 75% of his nutrition requirements consistently by mouth for 3 days, all tube feedings are discontinued. Subjects during weaning phase are being continuously evaluated for specific clinical param‐ eters including weight, hydration, and swallowing ability, focusing on respiratory complica‐

1 Rehabilitation Center "Aghios Loukas o Iatros", Trikala Thessaly, Greece

ting. http://emedicine.medscape.com/article/318180-overview

2 University of Athens, 1st Department of Orthopaedics, General University Hospital Attikon,

[1] Dawodu TS, Scott DD, Chase M. Nutritional management in the rehabilitation set‐

Perative (Abbott) 1, 31 kcal/ml

Malnutrition in Paraplegia http://dx.doi.org/10.5772/58382 145

Fresubin HP Energy (Fresenius) 1, 5 kcal/ml Intestamin (Fresenius) 0.5 kcal/ml) Infatrini (Nutricia 1 kcal/ml

**Hyperprotein**

tions [111, 112].

**Author details**

Athens, Greece

**References**

Yannis Dionyssiotis1,2\*

**Table 5.** Most used enteral solution products per company

in a clinical algorithm proposed by Buchholz [111].

**Table 4.** Starting enteral nutrition rate

**Table 5.** Most used enteral solution products per company

The goal of rehabilitation is to return through a gradual transition from the feeding tube back in swallowing if possible. The steps for neurocognitive and neuromuscular patients are based in a clinical algorithm proposed by Buchholz [111].

The initial (preparatory) phase focuses on physiologic readiness for oral nutrition and incorporates medical and nutrition stability (normal swallowing function and nutrition values in normal range), and includes implementation of intermittent tube feeding, and swallowing assessment. The second (weaning) phase is described as a graduated increase in oral feeding, with corresponding decreases in tube feeding. In a patient able to consume more than 75% of his nutrition requirements consistently by mouth for 3 days, all tube feedings are discontinued. Subjects during weaning phase are being continuously evaluated for specific clinical param‐ eters including weight, hydration, and swallowing ability, focusing on respiratory complica‐ tions [111, 112].

#### **Author details**

The rate of early products' infusion is shown in the Table 4. Moreover, Table 5 depicts most

**1** 30ml/h 10 max 500ml **2** 40ml/h 10 max 1000ml **3** 60ml/h 20 max 1500ml

**<sup>4</sup>** 90ml/h <sup>30</sup> max

**<sup>5</sup>** 100ml/h <sup>30</sup> max

**Categories Products Characteristics**

Jevity FOS (Abbott) 1 kcal/ml Fresubin Energy Fibre (Fresenius) 1, 5 kcal/ml Fresubin Original Fibre (Fresenius) 1 kcal/ml Novasource Forte (Novartis) 1, 5 kcal/ml Novasource Gl Control (Novartis) 1, 1 kcal/ml Cubison (Nutricia) 1 kcal/ml

Stresson Multi Fibre (Nutricia) 1 kcal/ml

Fresubin Energy (Fresenius) 1, 5 kcal/ml

Osmolite HN (Abbott)

Pediasure (Abbott) Frebini (Fresenius) Fresubin Original (Fresenius) Isosource Standard (Novartis) Nutrison Standard (Nutricia) Nutrini Standard (Nutricia) Tetrini Standard (Nutricia)

Nutrison Multifibre (Nutricia)

Ensure Plus (Abbott)

Fresubin HP Energy (Fresenius)

**per minute (20 drops=1ml)**

**Total Volume**

2000ml

2000ml

1 kcal/ml

used enteral products according to categories and their characteristics.

**Day Rate Drops**

**Table 4.** Starting enteral nutrition rate

144 Topics in Paraplegia

**Isotonic**

**Enriched with fibers**

**Hypercaloric**

Yannis Dionyssiotis1,2\*

1 Rehabilitation Center "Aghios Loukas o Iatros", Trikala Thessaly, Greece

2 University of Athens, 1st Department of Orthopaedics, General University Hospital Attikon, Athens, Greece

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**Chapter 7**

**Body Composition in Paraplegia**

Additional information is available at the end of the chapter

of aging, and muscle-wasting diseases [8, 9].

spinal cord injury (SCI) [14].

ambulatory subjects with paraplegia.

Paraplegia leads to immobilisation associated with profound changes in body composition. The potential risks involved with these changes i.e. loss of lean tissue mass (LM) and bone mineral density (BMD) vs. gain in fat mass (FM) in body composition have implications for the health of the disabled individuals [1]. Body fat has been identified as a significant predictor of mortality in humans making body composition measurement to quantify nutritional and health status an important issue for human health [2-4]. Moreover, some disorders such as carbohydrate intolerance, insulin resistance, lipid abnormalities, and heart disease occur prematurely and at a higher prevalence in disabled populations may be related to adverse changes in body composition that result from immobilization and skeletal muscle denervation [5]. To standardize or index physiological variables, such as resting metabolic rate and power fat free mass (FFM) is usually used [4]. Skeletal muscle represents 50% of the non fat component in the total body [6, 7] and exact quantification of the amount of skeletal muscle is important to assess nutritional status, disease risk, danger of illnesses, physical function, atrophic effects

A paraplegic subject could be wheelchair bound, may have an alternated walking gait pattern but may also be unable to walk at all [10, 11]. In addition to these differences and according to osteoporosis the role of factors which do not change, such as race or gender of patients has not been yet clarified, although there are few studies in women debating that bone mass in women with paraplegia is more affected than men [12, 13]. Similar findings of reduced muscle mass and increased intramuscular fat have been also published in individuals with incomplete

Therefore, the purpose of this chapter was to present the bone-mineral density, bone-mineral content, and bone-mineral-free lean and fat tissue mass alterations of ambulatory and non-

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Yannis Dionyssiotis

**1. Introduction**

http://dx.doi.org/10.5772/58539

#### **Chapter 7**

### **Body Composition in Paraplegia**

Yannis Dionyssiotis

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/58539

#### **1. Introduction**

Paraplegia leads to immobilisation associated with profound changes in body composition. The potential risks involved with these changes i.e. loss of lean tissue mass (LM) and bone mineral density (BMD) vs. gain in fat mass (FM) in body composition have implications for the health of the disabled individuals [1]. Body fat has been identified as a significant predictor of mortality in humans making body composition measurement to quantify nutritional and health status an important issue for human health [2-4]. Moreover, some disorders such as carbohydrate intolerance, insulin resistance, lipid abnormalities, and heart disease occur prematurely and at a higher prevalence in disabled populations may be related to adverse changes in body composition that result from immobilization and skeletal muscle denervation [5]. To standardize or index physiological variables, such as resting metabolic rate and power fat free mass (FFM) is usually used [4]. Skeletal muscle represents 50% of the non fat component in the total body [6, 7] and exact quantification of the amount of skeletal muscle is important to assess nutritional status, disease risk, danger of illnesses, physical function, atrophic effects of aging, and muscle-wasting diseases [8, 9].

A paraplegic subject could be wheelchair bound, may have an alternated walking gait pattern but may also be unable to walk at all [10, 11]. In addition to these differences and according to osteoporosis the role of factors which do not change, such as race or gender of patients has not been yet clarified, although there are few studies in women debating that bone mass in women with paraplegia is more affected than men [12, 13]. Similar findings of reduced muscle mass and increased intramuscular fat have been also published in individuals with incomplete spinal cord injury (SCI) [14].

Therefore, the purpose of this chapter was to present the bone-mineral density, bone-mineral content, and bone-mineral-free lean and fat tissue mass alterations of ambulatory and nonambulatory subjects with paraplegia.

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **2. Body composition measurements**

#### **2.1. Anthropometric and various techniques of body composition measurements**

Similar body mass indices were found between paraplegics and controls; although there were significant decreases in the lean muscle mass of the paraplegics (16% less).  Furthermore, where authors performed a research in the usage of the body mass index (BMI) in anthropometric measure‐ ments, the conclusion was that BMI, widely used as an obesity measurement tool, is not capable of distinguishing the weight components among people so that the fat percentage is degraded in the population of paraplegic in comparison to the control group [16].

BMI of the male paraplegic group was slightly greater than that of the male tetraplegic group

with SCI and that observed in men in the US general population. Distribution of BMI by level of injury was similar with 37.5% and 40.5% of the male tetraplegic and male paraplegic groups, respectively, falling into the recommended BMI range. Approximately 50% in each male group were overweight by BMI, and 12.5% and 10.8%, respectively, were classified as obese. Overall, when compared with the general population-observed distribution by BMI, a greater propor‐ tion of men with SCI fell into the desirable BMI range and fewer fell into the obese category [26].

No differences were found in BMI between paraplegics in the acute phase of injury and controls, which is a finding in accordance with other studies reported in chronic paraplegic patients and controls, in which despite the same BMI the body composition and the distribu‐ tion of fat and fat free mass were alterated in patients with spinal cord damage, with the fat free mass being statistically significantly lower in paraplegic patients in total body composition and in the lower, but not the upper limbs. As far as the fat mass is concerned, it was statistically significantly higher (kilograms and %) in the total body composition in the upper and lower

These findings show that using the BMI does not contribute substantially in determining the body composition of paraplegics and lowers the percentage of fat in this population, finding that agrees with other studies and shows that the anthropometric measurement with BMI in paraplegics, underestimates fat in body composition when measurements are compared with

Changes in body composition in spinal cord injured subjects can be assessed with various techniques including isotope-labelled water [1] total body potassium counting (Lussier et al 1983; Spungen et al 1992) anthropometric measures [16] hydrodensitometry [28] dual photon absorptiometry (DPA) [29] and dual energy X-ray absorptiometry (DXA) [1]. However, some

The hydrodensitometric model was regarded as the "gold standard" for body composition assessment. This model partitions the body into two compartments of constant densities [fat

components [water, protein, protein, bone mineral (BM), and non-BM] are fixed [4]. Hydro‐ densitometry is clearly inappropriate for individuals who deviate from these fixed and/or assumed values (e.g., children, elderly, blacks, obese), and its application is, therefore,

Bioelectrical impedance analysis has been used to measure cerebral palsy subjects. However, the inclusion of weight in the BIA predictive equation may reduce its accuracy in determining change in lean body mass. The inability of BIA to accurately predict percentage body fat in the sample may be related to several factors. In the BIA method where the impedance of a geometrical system (i.e., the human body) is dependent on the length of the conductor (height) and its configuration, it is almost impossible to measure accurately height in subjects with CP because of their muscle contractures. An over-or underestimation of height by 2.5 cm can result in a l.0-L error in the estimation of TBW, producing a small error in the estimation of percentage

] and assumes that the relative amounts of the FFM

of these methods are not particularly suitable for use in the SCI population.

; p<0.01). Proportion of overweight or obese was comparable between men

Body Composition in Paraplegia http://dx.doi.org/10.5772/58539 157

(25.2 vs. 24.7 kg/ m2

limbs [27].

healthy subjects [1].

mass: 0.9007 g/cm3 and FFM: 1.100 g/cm3

somewhat limited [30, 31].

In a study which investigated a chronic paraplegic population the values of BMI did not present statistical significance in relation to the controls, which is a finding in line with the literature [17, 18, 19]. Moreover, the values of BMI in both paraplegics and controls were below values consider to signify obesity (BMI>27.8) [19, 20, 21]. This finding could be acceptable for the population of the controls, but raises questions regarding the paraplegics. It is known from literature that paraplegics are obese [22]. Nevertheless, there are studies which demonstrate the usefulness of BMI as an indicator of obesity, in body composition in people with spinal cord injury [23]. These studies, however, included in their sample both tetraplegics and middle-aged people unlike the Greek one which included relatively young individuals [19]. Whether the criteria of BMI may assess obesity in people with spinal cord injury the latest studies show the opposite [24].

Similarly to the healthy population values of BMI are positively correlated with obesity. This emerged from a study, conducted by whole body DXA Norland X-36, only when the findings of total fat in paraplegics were correlated with BMI. Employing whole body DXA Norland XR-36 it was found that the total fat mass was statistically significantly higher for any given BMI value in paraplegics compared with controls [19], finding that strongly supports the studies held by the whole body DXA Hologic QDR-2000 method [5, 25].

The studies illustrated statistically significantly higher total fat mass and fat percentages for any given unit of body mass index in paraplegics in comparison to controls. Increased fat per body mass index unit was found in a study of monozygotic twins, one with SCI compared with a non-SCI co-twin by the above authors also [25]. Adjustments in classifications of normal, overweight, obese, and morbid obesity by BMI are needed for persons with SCI [26].

In addition, by analysis between paraplegics with high and low neurological level injuries not statistically significant differences in BMI were highlighted. However, when data from the analysis undertaken in areas measured by the method of whole body DEXA were compared in the same patients there were differences between paraplegics with high and low neurolog‐ ical level of injury. This finding is new and reinforces those views on the inability of BMI usage in the analysis of body composition of paraplegics [19].

BMI of the male paraplegic group was slightly greater than that of the male tetraplegic group (25.2 vs. 24.7 kg/ m2 ; p<0.01). Proportion of overweight or obese was comparable between men with SCI and that observed in men in the US general population. Distribution of BMI by level of injury was similar with 37.5% and 40.5% of the male tetraplegic and male paraplegic groups, respectively, falling into the recommended BMI range. Approximately 50% in each male group were overweight by BMI, and 12.5% and 10.8%, respectively, were classified as obese. Overall, when compared with the general population-observed distribution by BMI, a greater propor‐ tion of men with SCI fell into the desirable BMI range and fewer fell into the obese category [26].

**2. Body composition measurements**

156 Topics in Paraplegia

studies show the opposite [24].

**2.1. Anthropometric and various techniques of body composition measurements**

in the population of paraplegic in comparison to the control group [16].

studies held by the whole body DXA Hologic QDR-2000 method [5, 25].

in the analysis of body composition of paraplegics [19].

Similar body mass indices were found between paraplegics and controls; although there were significant decreases in the lean muscle mass of the paraplegics (16% less).  Furthermore, where authors performed a research in the usage of the body mass index (BMI) in anthropometric measure‐ ments, the conclusion was that BMI, widely used as an obesity measurement tool, is not capable of distinguishing the weight components among people so that the fat percentage is degraded

In a study which investigated a chronic paraplegic population the values of BMI did not present statistical significance in relation to the controls, which is a finding in line with the literature [17, 18, 19]. Moreover, the values of BMI in both paraplegics and controls were below values consider to signify obesity (BMI>27.8) [19, 20, 21]. This finding could be acceptable for the population of the controls, but raises questions regarding the paraplegics. It is known from literature that paraplegics are obese [22]. Nevertheless, there are studies which demonstrate the usefulness of BMI as an indicator of obesity, in body composition in people with spinal cord injury [23]. These studies, however, included in their sample both tetraplegics and middle-aged people unlike the Greek one which included relatively young individuals [19]. Whether the criteria of BMI may assess obesity in people with spinal cord injury the latest

Similarly to the healthy population values of BMI are positively correlated with obesity. This emerged from a study, conducted by whole body DXA Norland X-36, only when the findings of total fat in paraplegics were correlated with BMI. Employing whole body DXA Norland XR-36 it was found that the total fat mass was statistically significantly higher for any given BMI value in paraplegics compared with controls [19], finding that strongly supports the

The studies illustrated statistically significantly higher total fat mass and fat percentages for any given unit of body mass index in paraplegics in comparison to controls. Increased fat per body mass index unit was found in a study of monozygotic twins, one with SCI compared with a non-SCI co-twin by the above authors also [25]. Adjustments in classifications of normal,

In addition, by analysis between paraplegics with high and low neurological level injuries not statistically significant differences in BMI were highlighted. However, when data from the analysis undertaken in areas measured by the method of whole body DEXA were compared in the same patients there were differences between paraplegics with high and low neurolog‐ ical level of injury. This finding is new and reinforces those views on the inability of BMI usage

overweight, obese, and morbid obesity by BMI are needed for persons with SCI [26].

No differences were found in BMI between paraplegics in the acute phase of injury and controls, which is a finding in accordance with other studies reported in chronic paraplegic patients and controls, in which despite the same BMI the body composition and the distribu‐ tion of fat and fat free mass were alterated in patients with spinal cord damage, with the fat free mass being statistically significantly lower in paraplegic patients in total body composition and in the lower, but not the upper limbs. As far as the fat mass is concerned, it was statistically significantly higher (kilograms and %) in the total body composition in the upper and lower limbs [27].

These findings show that using the BMI does not contribute substantially in determining the body composition of paraplegics and lowers the percentage of fat in this population, finding that agrees with other studies and shows that the anthropometric measurement with BMI in paraplegics, underestimates fat in body composition when measurements are compared with healthy subjects [1].

Changes in body composition in spinal cord injured subjects can be assessed with various techniques including isotope-labelled water [1] total body potassium counting (Lussier et al 1983; Spungen et al 1992) anthropometric measures [16] hydrodensitometry [28] dual photon absorptiometry (DPA) [29] and dual energy X-ray absorptiometry (DXA) [1]. However, some of these methods are not particularly suitable for use in the SCI population.

The hydrodensitometric model was regarded as the "gold standard" for body composition assessment. This model partitions the body into two compartments of constant densities [fat mass: 0.9007 g/cm3 and FFM: 1.100 g/cm3 ] and assumes that the relative amounts of the FFM components [water, protein, protein, bone mineral (BM), and non-BM] are fixed [4]. Hydro‐ densitometry is clearly inappropriate for individuals who deviate from these fixed and/or assumed values (e.g., children, elderly, blacks, obese), and its application is, therefore, somewhat limited [30, 31].

Bioelectrical impedance analysis has been used to measure cerebral palsy subjects. However, the inclusion of weight in the BIA predictive equation may reduce its accuracy in determining change in lean body mass. The inability of BIA to accurately predict percentage body fat in the sample may be related to several factors. In the BIA method where the impedance of a geometrical system (i.e., the human body) is dependent on the length of the conductor (height) and its configuration, it is almost impossible to measure accurately height in subjects with CP because of their muscle contractures. An over-or underestimation of height by 2.5 cm can result in a l.0-L error in the estimation of TBW, producing a small error in the estimation of percentage body fat (< 5%). The second major problem is body asymmetry which renders the assumption of a symmetrical configuration of the human body invalid in this case [20, 32].

Isotope dilution measures the water compartment of the whole body rather than a single area assumed to mimic the composition of the whole body. Thus, the use of a stable isotope to measure body composition is ideal for people with CP because it is non-invasive, does not require the subject to remain still for the measurement, and is independent of height and body symmetry. However, the prohibitive cost of the isotopes and the need for a mass spectrometry facility and highly trained technicians make this method impractical for routine clinical use [32].

To determine whether bioelectrical impedance analysis (BIA) and anthropometry can be used to determine body composition for clinical and research purposes in children with cerebral palsy 8 individuals (two female, mean age=10 years, mean gross motor function classifica‐ tion=4.6 [severe motor impairment]) recruited from an outpatient tertiary care setting under‐ went measurement of fat mass, fat-free mass, and percentage body fat using BIA, anthropometry (two and four skinfold equations), and dual-energy x-ray absorptiometry. Correlation were excellent for determination of fat-free mass for all methods (i.e., all were above 0.9) and moderate for determination of fat mass and percent body fat (range=0.4 to 0.8). Moreover, skinfolds were better predictors of percent body fat, while bioelectrical impedance was a better predictor for fat mass [33]. On the contrary another study investigated the pattern of body composition in 136 subjects with spastic quadriplegic cerebral palsy, 2 to 12 years of age, by anthropometric measures, or by anthropometric and total body water (TBW) measures (n=28), compared with 39 control subjects. Body composition and nutritional status indicators were significantly reduced.

Figure 1. Whole body and regional distribution of fat mass, lean mass, bone mineral content (BMC) and bone mineral density (BMD) from paraplegic subject thoracic 6 (left picture) using whole body DXA (Norland X-36, Fort Atkinson, Wisconsin, USA) and values of measured parameters. Modified and translated with permission from: Dionyssiotis Y. (2008a). Doctoral Dissertation, Laboratory for Research of the Musculoskeletal System,

Body Composition in Paraplegia http://dx.doi.org/10.5772/58539 159

**Figure 1.** Whole body and regional distribution of fat mass, lean mass, bone mineral content (BMC) and bone mineral density (BMD) from paraplegic subject thoracic 6 using whole body DXA (Norland X-36, Fort Atkinson, Wisconsin, USA) and values of measured parameters. Modified and translated with permission from Dionyssiotis Y, Doctoral Dis‐

DXA analyzes differently the dense pixels in body composition. Soft tissue pixels are analyzed for two materials: fat and fat-free tissue mass. Variations in the fat mass/fat free tissue mass composition of the soft tissue produce differences in the respective attenua‐ tion coefficients at both energy levels. The ratio at the two main energy peaks is automat‐ ically calculated of the X-ray attenuation providing separation of the soft tissue compartment into fat mass and fat-free tissue mass (lean mass) [40, 41]. A bone-contain‐ ing pixel is analyzed for "bone mass" (bone mineral content, BMC) and soft tissue as the two materials. Thus, the fat mass/fat free tissue mass of the soft tissue component of the

The important issue on this the investigation of distribution of bone mineral, fat and mass throughout the body. These changes induce the risk for diseases such as diabetes, coronary heart disease, dyslipidaimias and osteoporosis [22, 43, 44, 45]. There is a need to quantify the alterations in body composition to prevent these diseases and their complications. Studies also reported that bone density measurements at one site cannot usefully predict the bone density elsewhere [46] because different skeletal regions, even with similar quantities of trabecular or

In disabled conditions the accuracy of skeletal muscle measured by DXA may be compro‐ mised when muscle atrophy is present. A lower ratio of muscle to adipose-tissue-free mass indicates a lower proportion of muscle in the fat-free soft tissue mass. Cross-sectional area of skeletal muscle in the thighs after SCI is extensively reduced [48]. If this is the case

cortical bone, may respond variably in different physiopathological conditions [47].

sertation, Laboratory for Research of the Musculoskeletal System, University of Athens, 2008 [39].

University of Athens, Greece,

bone pixels cannot be measured, but only estimated [42].

Magnetic resonance imaging (MRI) provides remarkably accurate estimates of skeletal muscle in vivo [7]. MRI and also quantitative computed tomography (QCT) have been validated in studies of humancadavers in the assessment of regional skeletal muscle [35]. Although, these devices have disadvantages of high radiation exposure and are expensive.

#### **2.2. Dual-energy X-ray absorptiometry (DXA)**

Recently, dual-energy X-ray absorptiometry (DXA) has gained acceptance as a reference method for body composition analysis [36, 37]. Originally designed to determine bone density, DXA technology has subsequently been adopted for the assessment of whole body composi‐ tion and offers estimation rapidly, non-invasively and with minimal radiation exposure [4, 19]. Moreover, is well tolerated in subjects who would be unable to tolerate other body composition techniques, such as underwater weighing (hydro-densitometry). DXA software determines the bone mineral and soft tissue composition in different regions of the body being a three-compartment model that quantifies: (i) bone mineral density and content (BMD, BMC), (ii) fat mass (FM); and (iii) lean mass (LM), half of which is closely correlated with muscle mass and also yields regional as well as total body values [38] for example in the arms, legs, and trunk (figure 1).

body fat (< 5%). The second major problem is body asymmetry which renders the assumption

Isotope dilution measures the water compartment of the whole body rather than a single area assumed to mimic the composition of the whole body. Thus, the use of a stable isotope to measure body composition is ideal for people with CP because it is non-invasive, does not require the subject to remain still for the measurement, and is independent of height and body symmetry. However, the prohibitive cost of the isotopes and the need for a mass spectrometry facility and highly trained technicians make this method impractical for

To determine whether bioelectrical impedance analysis (BIA) and anthropometry can be used to determine body composition for clinical and research purposes in children with cerebral palsy 8 individuals (two female, mean age=10 years, mean gross motor function classifica‐ tion=4.6 [severe motor impairment]) recruited from an outpatient tertiary care setting under‐ went measurement of fat mass, fat-free mass, and percentage body fat using BIA, anthropometry (two and four skinfold equations), and dual-energy x-ray absorptiometry. Correlation were excellent for determination of fat-free mass for all methods (i.e., all were above 0.9) and moderate for determination of fat mass and percent body fat (range=0.4 to 0.8). Moreover, skinfolds were better predictors of percent body fat, while bioelectrical impedance was a better predictor for fat mass [33]. On the contrary another study investigated the pattern of body composition in 136 subjects with spastic quadriplegic cerebral palsy, 2 to 12 years of age, by anthropometric measures, or by anthropometric and total body water (TBW) measures (n=28), compared with 39 control subjects. Body composition and nutritional status indicators were significantly reduced. Calculation of body fat from two skinfolds correlated best with

Magnetic resonance imaging (MRI) provides remarkably accurate estimates of skeletal muscle in vivo [7]. MRI and also quantitative computed tomography (QCT) have been validated in studies of humancadavers in the assessment of regional skeletal muscle [35]. Although, these

Recently, dual-energy X-ray absorptiometry (DXA) has gained acceptance as a reference method for body composition analysis [36, 37]. Originally designed to determine bone density, DXA technology has subsequently been adopted for the assessment of whole body composi‐ tion and offers estimation rapidly, non-invasively and with minimal radiation exposure [4, 19]. Moreover, is well tolerated in subjects who would be unable to tolerate other body composition techniques, such as underwater weighing (hydro-densitometry). DXA software determines the bone mineral and soft tissue composition in different regions of the body being a three-compartment model that quantifies: (i) bone mineral density and content (BMD, BMC), (ii) fat mass (FM); and (iii) lean mass (LM), half of which is closely correlated with muscle mass and also yields regional as well as total body values [38] for example in the arms, legs, and

devices have disadvantages of high radiation exposure and are expensive.

of a symmetrical configuration of the human body invalid in this case [20, 32].

routine clinical use [32].

158 Topics in Paraplegia

measures of fat mass from TBW [34].

trunk (figure 1).

**2.2. Dual-energy X-ray absorptiometry (DXA)**

Figure 1. Whole body and regional distribution of fat mass, lean mass, bone mineral content (BMC) and bone mineral density (BMD) from paraplegic subject thoracic 6 (left picture) using whole body DXA (Norland X-36, Fort Atkinson, Wisconsin, USA) and values of measured parameters. Modified and translated with permission from: Dionyssiotis Y. (2008a). Doctoral Dissertation, Laboratory for Research of the Musculoskeletal System, University of Athens, Greece, **Figure 1.** Whole body and regional distribution of fat mass, lean mass, bone mineral content (BMC) and bone mineral density (BMD) from paraplegic subject thoracic 6 using whole body DXA (Norland X-36, Fort Atkinson, Wisconsin, USA) and values of measured parameters. Modified and translated with permission from Dionyssiotis Y, Doctoral Dis‐ sertation, Laboratory for Research of the Musculoskeletal System, University of Athens, 2008 [39].

 DXA analyzes differently the dense pixels in body composition. Soft tissue pixels are analyzed for two materials: fat and fat-free tissue mass. Variations in the fat mass/fat free tissue mass composition of the soft tissue produce differences in the respective attenua‐ tion coefficients at both energy levels. The ratio at the two main energy peaks is automat‐ ically calculated of the X-ray attenuation providing separation of the soft tissue compartment into fat mass and fat-free tissue mass (lean mass) [40, 41]. A bone-contain‐ ing pixel is analyzed for "bone mass" (bone mineral content, BMC) and soft tissue as the two materials. Thus, the fat mass/fat free tissue mass of the soft tissue component of the bone pixels cannot be measured, but only estimated [42].

The important issue on this the investigation of distribution of bone mineral, fat and mass throughout the body. These changes induce the risk for diseases such as diabetes, coronary heart disease, dyslipidaimias and osteoporosis [22, 43, 44, 45]. There is a need to quantify the alterations in body composition to prevent these diseases and their complications. Studies also reported that bone density measurements at one site cannot usefully predict the bone density elsewhere [46] because different skeletal regions, even with similar quantities of trabecular or cortical bone, may respond variably in different physiopathological conditions [47].

In disabled conditions the accuracy of skeletal muscle measured by DXA may be compro‐ mised when muscle atrophy is present. A lower ratio of muscle to adipose-tissue-free mass indicates a lower proportion of muscle in the fat-free soft tissue mass. Cross-sectional area of skeletal muscle in the thighs after SCI is extensively reduced [48]. If this is the case muscle mass would be overestimated by prediction models that assume that muscle represents all or a certain proportion of the fat-free soft tissue mass, i.e. in spinal cord injured subjects [7]. DXA technique has been used in assessment of SCI and appears to be tolerated well by this population [49, 50, 51]. Fort Atkinson, Wisconsin, USA) and values of measured parameters. Modified and translated with permission from: Dionyssiotis Y. (2008a). Doctoral Dissertation, Laboratory for Research of the Musculoskeletal System, University of Athens, Greece,

Figure 1. Whole body and regional distribution of fat mass, lean mass, bone mineral content (BMC) and bone mineral density (BMD) from paraplegic subject thoracic 6 (left picture) using whole body DXA (Norland X-36,

> paraplegics 1 year post injury. With reliance on the upper limbs to provide movement for activities of daily living in the SCI population, this area could be subjected to greater sitespecific loading, and thus increasing osteogenesis, than in the corresponding able-bodied population. At the lumbar spine, the trabecular bone demineralization remains relatively low compared to the cortical bone demineralization of long bones [56]. Normal [52, 57] or even higher than normal [58] values of BMD in the lumbar spine have been reported a phenomenon is named "dissociated hip and spine demineralization" [54]. One reason for preservation of bone mass in the vertebral column is because of its continued weight-bearing function in paraplegics. In a cross-sectional study of 135 SCI men, BMD in the lumbar spine was found to be stable with an insignificant decline in the tetraplegic population at 1±5 years post injury in the 20–39-year age group, whereas in the 40-59-year age group and the 60+-year age group, bone mass in the lumbar spine remained unchanged or even increased with age [49]. However, several factors may affect the results of BMD measurement: lumbar spine arthrosis, bone callus, vertebral fracture, aortic calcification, osteosynthesis material, etc. Degenerative changes in the spine may be the most possible reason to give falsely higher values of BMD [56]. An interesting question is why we don't see osteoporotic vertebral fractures in SCI patients to the

Body Composition in Paraplegia http://dx.doi.org/10.5772/58539 161

extent it occurs in post-menopausal osteoporotic women or senile osteoporotic men?

explained in the paper of Dionyssiotis et al. [19].

0

and translated from Dionyssiotis Y [39].

0.2

0.4

0.6

mean value in grcm-2

0.8

1

1.2

1.4

Figure 3 depicts the analysis of bone mineral density (BMD) in high and low level paraple‐ gics and controls. A statistically significant reduction in total BMD (p<0.001) and lower limbs BMD in body composition compared to able-bodied males was observed. On the con‐ trary, upper limbs BMD was higher in low paraplegics and controls, an unexpected finding

BMD ANALYSIS

High paraplegics Low paraplegics Controls \* \* \* \*

\* p < 0,05 vs control # p < 0,05 vs high


**4. Conclusions**

*Military Engineering*

**98**

**Figure 7.**

**Figure 6.**

(**Figure 8**). In comparing area (a) with area (b) using the NDVI (**Figure 8**), area (b)

Using the SR vegetation index (**Figure 7**), area (a) tends to exhibit a difference with respect to area (b) (**Figure 8**). More specifically, in target area (a) (**Figure 7**), the reflectance response is lower than area (b) (**Figure 8**), which indicates that the

has higher values due to the nonexistence of underground structures, while area (a) (**Figure 7**) has similar vegetation but lower NDVI values due to the existence of underground structures. Likewise, using the EVI, area (a) (**Figure 7**) has lower values due to the existence of underground structures, while area (b) (**Figure 8**)

*Image maps showing NDVI, EVI, and SR field data for area (a) during Head Emerging Stage.*

*Image maps showing NDVI, EVI, and SR field data for area (b) during Flag Leaf Emerging stage.*

has higher values due to nonexistence of structures.

Field spectroscopy can support satellite remote sensing studies for monitoring systematically critical areas of interest including the detection of underground bunkers.

The application of remote sensing in defense and security merges the technological improvements of remote sensing sensors with military needs to improve the quality of information retrieved from remote sensing data. Indeed, decision-making authorities can benefit from such efficient space imaging technology of underground targets.

The advantages of using vegetation indices as proxy variables for intercalibration among existing sensors are the low sensitivity to the uncertainties in atmospheric correction and the variation in the satellite viewing angle [30]. As shown in this paper, vegetation indices can corroborate areas of possible military underground structure.

In comparing the two areas, the spatial distributions of VIs exhibit no table differences (**Figures 7** and **8**). This is clear in **Figure 8**, where image maps illustrate the differences between the two areas using NDVI, EVI and SR Vegetation Indices. Mostly SR vegetation index is used for defining areas where military underground structures are present.

Consequently, the near-infrared (NIR) band of Landsat 8 sensor could be useful to identify the underground structure. It is apparent that the waveband analysis of the Landsat 8 sensor distinguishes between the two study sites. Monitoring variations of the NIR spectrum during the life cycle of vegetation is a key parameter for the field spectroscopy for the detection of military underground structures using remote sensing techniques.

In this chapter, it was demonstrated how remote sensing can be exploited as a monitoring and decision-making tool by any agency in tackling military and security issues related to the presence of underground military structures. Field spectroscopy measurements were used to detect underground military structures through variations in vegetation indices. Indeed, vegetation indices can be used to develop a suitable vegetation index for detecting military underground structures.

Areas covered by natural soil where underground structures are present or absent can easily be detected as a result of the change in the spectral signature of the overlying vegetation; in this respect, vegetation indices, such as the NDVI, SR, and EVI, may be used for this purpose.

It is recommended to collect field spectroradiometric measurements to other types of military underground structures to evaluate the above results and the satellites' spectral sensitivity. The development of a standard model/methodology framework to be produced through the stages of the study for locating military underground structures is an innovation in military operations research. Additionally, an unmanned aerial vehicle (UAV) may be used to survey the area with visible and near-infrared cameras to generate vegetation indices for comparison to the in situ spectroradiometric measurements [31].


**Author details**

nated proteins, and sarcomere disorganization [99]. In addition, the central role of the autoph‐ agy-lysosome system in muscle homeostasis is highlighted by lysosomal storage diseases (Pompe disease, Danon disease, and X-linked myopathy). These diseases are a group of debilitating muscle disorders characterized by alterations in lysosomal proteins and autopha‐ gosome buildup [124]. Intriguingly, the accumulation of autophagic vacuoles inside myofibers

**Figure 4.** The comparison of an autophagy-dependent system between young and sarcopenic muscle. In contrast to young muscle, sarcopenic muscle exhibits abundant p62/SQSTM1 proteins with no activation of LC3, showing appa‐

*p62/SQSTM1 LC3*

*degenerative protein*

Sarcopenic muscle

Various muscular dystrophies also exhibit the apparent defect of autophagy-dependent signaling. The first evidence of impaired autophagy in these models was provided by studies in mice and patients with mutations in collagen VI [125]. Mutations that inactivate Jumpy, a phosphatase that counteracts the activation of VPS34 for autophagosome formation and reduces autophagy, are associated with centronuclear myopathy [126]. De Palma et al. [127] have described a decreased expression of autophagic regulator proteins (i.e., LC3 II, Atg12, GABARAPL-1, Bnip3) in dystrophin-deficient mdx mice and DMD patients. In addition, starvation and treatment with chloroquine, potent inducers of autophagy, did not activate autophagy-dependent signaling in both tibialis anterior and diaphragm muscles of mdx mice [127]. Furthermore, mdx mice and DMD patients exhibited an unnecessary accumulation of p62/SQSTM1 protein, which was lost after prolonged autophagy induction by a low-protein diet [127]. A similar block in autophagy progression was described in lamin A/C null mice [128]. LGMD2A muscles showed up-regulation of p62/SQSTM1 (2.1-fold) and Bnip3 (3-fold) mRNA and slightly increased LC3-II/LC3-I protein ratio and p62/SQSTM1 [87]. Conversely, laminin-mutated (*dy/dy*) animals displayed excessive levels of autophagy, which is equally detrimental [129]. These findings suggest that the defect of autophagy signaling has a central

is recognized in all of these myopathies because of defects in their clearance.

Young muscle

158 Muscle Cell and Tissue

rent autophagy defects, which cannot destroy the degenerative proteins.

role in the degenerative symptoms in various types of muscular dystrophy.

Kunihiro Sakuma1\* and Akihiko Yamaguchi2

\*Address all correspondence to<EMAIL_ADDRESS>
1 Research Center for Physical Fitness, Sports and Health, Toyohashi University of Technol‐ ogy, 1-1 Hibarigaoka, Tenpaku-cho, Toyohashi, Japan

2 Department of Physical Therapy, Health Sciences University of Hokkaido, Kanazawa, Ishi‐ kari-Tobetsu, Hokkaido, Japan


**3. Final considerations**

Dairy industries, as potential polluters, need to seek improvements in processes and technologies, to remain competitive and to meet quality requirements in a sustainable way.

Membrane separation processes have been studied and used in the dairy industry, mainly aimed at treating effluents for reuse water generation, which ends up contributing to the preservation of water resources, generates savings for industries, and contributes to sustainability.

The possibilities of study are broadened in the case of membranes, as there is the possibility of reusing the permeate and the concentrate, allowing the reuse of water and materials for the production of byproducts. The studies presented demonstrate the relevance of membrane separation processes and their efficiency in the production of quality reuse water and the possibility of concentrating, separating, and purifying substances.


**7. Conclusion and future prospects**

Based on the literature reviewed in this chapter, we think that analogous research and advancement on pea proteins would be required if any significant boost in pea protein utilization is envisaged. While pea protein isolates have usually been discussed in the research literature as relatively mundane, you will find very few sensory analysis information to help the claim. The main limitation on the sales of pea protein meals components is the trouble in fighting with the well-established, versatile soy protein items which dominate the meals protein market. Soy proteins are already available for a very long time, and research by the main producing businesses has resulted in several tailored items for programs. Pea concentrates and flours are generally referred to as having a terrible taste (beany, bitter). The incorporation of pea concentrates and flours into meals products such as bread, is usually restricted by flavour problems. This truth is insignificant within the

#### *Grain and Seed Proteins Functionality*

foods ingredient industry because proteins in this particular marketplace are sold primarily by functional qualities and price. Although to be used in food aid plans for developing nations, this's of concern and demands that pea protein is together with a protein source that will offer a comprehensive source of sulfur amino acids. In pet feeding, the nutritional value of protein sources is likewise essential. Feeding studies show that pea protein requires supplementation with methionine to get it with the nutritional value of soy protein.