Obesity and Inpatient Rehabilitation Outcomes for Patients With a Traumatic Spinal Cord Injury

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1 384 ORIGINAL ARTICLE Obesity and Inpatient Rehabilitation Outcomes for Patients With a Traumatic Spinal Cord Injury Katherine W. Stenson, MD, Anne Deutsch, RN, PhD, CRRN, Allen W. Heinemann, PhD, David Chen, MD ABSTRACT. Stenson KW, Deutsch A, Heinemann AW, THERE HAS BEEN A DRAMATIC increase in the prevalence of obesity in the United States during the past 20 Chen D. Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury. Arch Phys Med years. 1 The current prevalence of obesity, characterized as BMI Rehabil 2011;92: of 30 kg/m 2 or greater, is estimated to be 33% to 35%. 2 As obesity becomes more prevalent in the general population, Objective: To examine the effect of obesity on change in rehabilitation facilities may admit a higher number of patients FIM self-care and mobility ratings and community discharge with a new SCI and comorbid obesity. for patients with traumatic spinal cord injury (SCI). Identification of obesity in people with chronic SCI and risks Design: Retrospective cohort study analyzing National to long-term health are an increasing research focus. 3-8 Acute Model Systems SCI Database data. SCI has been less of a focus in the literature, but case studies Setting: Fourteen Model Systems SCI programs. suggested that inpatients with acute SCI who were obese made Participants: Patients (N 1524) with a new traumatic SCI lower FIM score gains, had more medical complications during discharged from Model Systems rehabilitation centers between acute rehabilitation, and more frequently were discharged to October 2006 and October long-term care facilities than similar patients with normal Interventions: None. BMI. 9 It also is recognized that caring for obese patients with Main Outcome Measures: Change in FIM self-care and SCI poses a unique challenge to nursing staff and necessitates mobility ratings, discharge destination. Separate analyses were selection of appropriate equipment to maintain the safety of conducted by neurologic category: paraplegia incomplete, paraplegia complete, tetraplegia incomplete, and tetraplegia complete. both patient and staff during inpatient rehabilitation. 10 Other than these observational case series, we were unable to Results: Of all patients with traumatic SCI, approximately locate published studies examining the effect of obesity on 25% were obese at admission. Patients who were obese were more functional recovery or discharge destination for patients with likely to be married and slightly older than nonobese patients. In acute SCI undergoing rehabilitation. Several studies have examined the impact of BMI on outcomes of patients with other patients with paraplegia incomplete, obese patients had lower FIM self-care ( 1.9; 95% confidence interval [CI], 3.4 to.4) and rehabilitation diagnoses, such as deconditioning and acute mobility score gains ( 1.5; 95% CI, 2.9 to.1) than normalweight patients. For patients with paraplegia complete, obese burns. 11,12 Patients with deconditioning and obesity tended to make larger FIM score gains than their nonobese counterparts, patients had significantly lower self-care ( 2.2; 95% CI, 3.5 to whereas, depending on age and extent of injury, patients with.8) and mobility score gains ( 2.7; 95% CI, 3.9 to 1.5). For acute burns and obesity tended to make smaller FIM score gains patients with tetraplegia incomplete and tetraplegia complete, FIM and more frequently were discharged to noncommunity settings. self-care and mobility ratings for obese patients were not significantly different from ratings for normal-weight patients. Within The older age and lack of neurologic deficits in these 2 populations made it difficult to generalize findings to the SCI population. each neurologic category, the percentage of patients discharged to It is important to study the effect of obesity in the acute SCI the community was not significantly different for nonobese and population given the general health risks of obesity and the obese patients. paucity of published reports. Our goal was to examine the Conclusions: Obesity appears to be a barrier to meeting effect of obesity on the rehabilitation course of patients with a self-care and mobility functional goals for patients with paraplegia in inpatient SCI rehabilitation. new traumatic SCI. We hypothesized that, across neurologic categories, patients with obesity would have lower functional Key Words: Obesity; Outcome assessment (health care); improvement and be less likely to be discharged to a community-based destination than their normal-weight counterparts. Rehabilitation; Spinal cord injuries by the American Congress of Rehabilitation Medicine METHODS From the Department of Physical Medicine and Rehabilitation, Feinbery School of Medicine, Northwestern University, Chicago (Stenson, Deutsch, Heinemann, Chen); and the Rehabilitation Institute of Chicago (Stenson, Deutsch, Heinemann, Chen), Chicago, IL. Supported by the U.S. Department of Education, National Institute on Disability and Rehabilitation Research, Midwest Regional Spinal Cord Injury Care System (grant no. H133N060014). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Katherine W. Stenson, MD, Rehabilitation Institute of Chicago, 345 E Superior St, 16th Fl, Chicago, IL 60611, kwhite005@md. northwestern.edu. Reprints are not available from the author. Published online January 31, 2011 at /11/ $36.00/0 doi: /j.apmr Study Design and Data Source This was a retrospective cohort study that involved secondary analysis of the National SCI Database. We obtained data from the National SCI Database after signing a data use agreement with the National SCI Statistical Center at the University of AIS BMI CI SCI List of Abbreviations American Spinal Injury Association Impairment Scale body mass index confidence interval spinal cord injury

2 OBESITY AND REHABILITATION OUTCOMES WITH SPINAL CORD INJURY, Stenson 385 Alabama at Birmingham and received approval to conduct the study from the Institutional Review Board at Northwestern University, Chicago, Illinois. The National SCI Database project is a key component of the SCI Model System effort funded by the U.S. Department of Education s National Institute on Disability and Rehabilitation Research. The National SCI Database is a multicenter prospective longitudinal project. Inclusion criteria for the National SCI Statistical Center are (1) an external traumatic event that results in SCI, including surgical procedures, radiation, and medical complications; (2) temporary or permanent loss of sensory or motor function as a result of the traumatic event; (3) admission to a system within 1 year of injury; (4) hospitalization in the system (for at least 1 week before discharge); (5) discharge from the system as having completed inpatient acute rehabilitation, achieved a neurologic status of normal or minimal deficit, or died; and (6) informed consent to participate in the database project. Our sample included patients discharged beginning in October 2006, when height and weight started to be reported, through October SCI Database Variables National SCI Database variables include demographic, diagnostic, AIS, and functional status data, as well as hospitalization data from the acute-care and rehabilitation stays. Functional status data in the National SCI Database are admission and discharge FIM motor scores. The FIM is a standardized tool used to document the need for assistance for patients receiving rehabilitation care. FIM items are rated on a 7-level rating scale, with 1 referring to a patient who requires total assistance and 7 indicating complete independence. We summed the 6 self-care items (eating, grooming, bathing, upper-body dressing, lower-body dressing, toileting) to create a self-care score with a possible range of 6 to 42. We also summed the 5 mobility items (transfer: bed/wheelchair, transfer: toilet, transfer: tub/shower, walk/wheelchair, stairs) to create a mobility score with a possible range of 5 to 35. Cronbach values for the self-care items were.85 (admission) and.96 (discharge), and for the mobility items,.72 (admission) and.87 (discharge). BMI and Categories For patients 20 years and older, we calculated BMI using the formula BMI kilograms/meters 2. Patients with BMI less than 18.5 kg/m 2 were classified as underweight, patients with BMI of 18.5 to 24.9 kg/m 2 were labeled normal weight, patients with BMI of 25.0 to 29.9 kg/m 2 were classified as overweight, and patients with BMI of 30.0 or higher were considered obese. For patients younger than 20 years, weight status was determined based on percentiles, and we used the BMI calculator on the Centers for Disease Control and Prevention website ( apps.nccd.cdc.gov/dnpabmi/) to calculate BMI and classify the person s weight status. Stratification Variable and Outcome Measures Because the level and completeness of an SCI are associated strongly with outcomes, we reported data by discharge neurologic category: paraplegia incomplete, paraplegia complete, tetraplegia incomplete, and tetraplegia complete. Outcome measures included (1) mean change in FIM selfcare rating (discharge FIM self-care rating admission FIM self-care rating), (2) mean change in FIM mobility ratings (discharge FIM mobility rating admission FIM mobility rating), and (3) percentage of patients discharged to a community residence (private residence or group living situation) versus a nursing home (skilled nursing facilities, hospital-based settings providing custodial chronic disease care, assistive living units in a retirement village). Exclusion Criteria Because the focus of our study was to examine the effect of weight status on functional outcomes and discharge destination, we excluded a subgroup of patients whose outcomes would be affected by atypical stays or atypical preinjury or discharge residences. More specifically, we excluded patients who had a rehabilitation length of stay of fewer than 3 days (n 9); patients who died during the rehabilitation stay (n 34); patients whose preinjury residence was a hospital (n 11), nursing home (n 1), homeless (n 6), or unknown/other (n 4); and patients discharged to a hospital (n 51), correctional facility (n 8), or unknown/other (n 4). We reported data by discharge neurologic category (paraplegia incomplete, paraplegia complete, tetraplegia incomplete, tetraplegia complete) and thus excluded the small number of patients whose neurologic recovery at discharge was normal (n 6). We excluded patients who were underweight (n 113). Finally, we excluded patients whose records contained missing data for the following key variables: admission FIM ratings (n 77), discharge FIM ratings (n 126), age (n 1), preinjury residence (n 2), discharge neurologic category (n 158), and discharge AIS grade (n 169). The National SCI Database included the records of 2128 patients discharged between October 2006 and October 2009 from the 14 SCI Model System centers that contributed data during that time. We excluded 604 patient records when applying the exclusion criteria ( 1 criterion applies to some patients), leaving the final sample of 1524 patients. Statistical Analysis Patients were characterized by weight category (normal, overweight, obese) within each neurologic category (paraplegia incomplete, paraplegia complete, tetraplegia incomplete, tetraplegia complete). Within each neurologic category, we compared the observed (ie, unadjusted) mean change in FIM self-care and FIM mobility ratings by weight status by using analysis of variance and Bonferroni post hoc tests. Within each neurologic category, we compared the percentage of patients discharged to the community by weight status by using chisquare tests. We then examined the association between weight category and each outcome measure by using regression models to control for covariates. Linear regression models (1 model for each neurologic category) were used for change in FIM self-care ratings and change in FIM mobility ratings, and covariates in these regression models were admission functional status, age, sex, onset time, spinal surgery (yes/no), vertebral fracture (yes/no), halo (yes/no), thoracic lumbar sacral orthosis device (yes/no), and AIS grade for patients with incomplete injuries. Logistic regression models (1 model for each neurologic category) were used for the outcome variable community discharge, and covariates in these regression models were admission functional status, age, sex, onset time, vertebral fracture (yes/no), spinal surgery (yes/no), halo (yes/ no), thoracic lumbar sacral orthosis device (yes/no), AIS grade for patients with incomplete injuries, and marital status. Data were analyzed using SPSS, Version 17 a and P less than.05 was considered significant for all analyses. RESULTS Of 1524 patients meeting criteria, 318 (20.9%) had paraplegia incomplete, 357 (23.4%) had paraplegia complete, 606

3 386 OBESITY AND REHABILITATION OUTCOMES WITH SPINAL CORD INJURY, Stenson Table 1: Sociodemographic s of Patients With Traumatic SCI, SCI Model Systems Database, 2006 to 2009 PI (n 318) PC (n 357) With PI (n 318) (n 131) (n 100) (n 87) With PC (n 357) (n 175) (n 99) (n 83) Patients in neurologic category Sex Men Women Age at injury, (y) Race White African American or black Native American, Eskimo, or Aleut Asian or Pacific Islander Other, unclassified Unknown Hispanic origin Currently married Educated beyond high school TI (n 606) TC (n 243) With TI (n 606) (n 263) (n 185) (n 158) With TC (n 243) (n 120) (n 68) (n 55) Patients in neurologic category Sex Men Women Age at injury, (y) Race White African American or black Native American, Eskimo, or Aleut Asian or Pacific Islander Other, unclassified Unknown Hispanic origin Currently married Educated beyond high school NOTE. Values expressed as mean SD or %. Abbreviations: NA, not applicable; PC, paraplegia complete; PI, paraplegia incomplete; TC, tetraplegia complete; TI, tetraplegia incomplete. (39.8%) had tetraplegia incomplete, and 243 (15.9%) had tetraplegia complete (table 1). Within each group, the proportion of patients who were normal weight ranged from 41.2% (paraplegia incomplete) to 49.4% (tetraplegia complete), and the percentage who were obese ranged from 22.6% (tetraplegia complete) to 27.4% (paraplegia incomplete). Consistent with previous research focused on patients with traumatic SCI, most patients were men, ranging from 75.5% for patients with paraplegia incomplete to 82.7% for tetraplegia complete. For each neurologic category, women were overrepresented in the obese category, and overweight and obese patients were older than normal-weight patients within each category. Most patients were white, ranging from 57.4% of patients with paraplegia complete to 70.0% of patients with tetraplegia incomplete, and blacks represented 24.8% (tetraplegia incomplete) to 35.0% (paraplegia complete) of patients. Less than 10% of patients were Hispanic. and obese patients were more likely to be married than normal-weight patients within each neurologic category, and overweight patients were more likely to have education beyond high school relative to normalweight and obese patients. Table 2 lists injury characteristics and hospitalization experiences of patients by weight status within each neurologic category. The most frequent cause of SCI overall was vehicular collisions, but for overweight patients with an incomplete injury, falls and flying objects was the most frequent cause (36.0% for paraplegia incomplete, 45.4% for tetraplegia incomplete). Most patients had spinal surgery,

4 OBESITY AND REHABILITATION OUTCOMES WITH SPINAL CORD INJURY, Stenson 387 Table 2: Injury s and Hospitalization Experience for Patients With Traumatic SCI, SCI Model Systems Database, 2006 to 2009 PI (n 318) PC (n 357) With PI (n 318) (n 131) (n 100) (n 87) With PC (n 357) (n 175) (n 99) (n 83) Cause of trauma Vehicular Violence Sports/recreation Falls/flying objects Pedestrian Medical/surgical complication Other/unknown Spinal surgery Yes AIS grade at discharge A NA NA NA NA B NA NA NA NA C NA NA NA NA D NA NA NA NA Time from injury to rehabilitation admission, (d) Length of rehabilitation stay, (d) TI (n 606) TC (n 243) With TI (n 606) (n 263) (n 185) (n 158) With TC (n 243) (n 120) (n 68) (n 55) Cause of trauma Vehicular Violence Sports/recreation Falls/flying objects Pedestrian Medical/surgical complication Other Spinal surgery Yes AIS grade at discharge A NA NA NA NA B NA NA NA NA C NA NA NA NA D NA NA NA NA Time from injury to rehabilitation admission, (d) Length of rehabilitation stay, (d) NOTE. Values expressed as mean SD or %. Abbreviations: NA, not applicable; PC, paraplegia complete; PI, paraplegia incomplete; TC, tetraplegia complete; TI, tetraplegia incomplete. and for patients with incomplete injuries, the most frequent AIS grade at discharge was D (40.3% for paraplegia incomplete, 56.6% for tetraplegia incomplete). Time between the injury and rehabilitation admission varied from 23.6 days for patients with paraplegia incomplete and normal weight to 46.2 days for patients with tetraplegia complete and normal weight. Rehabilitation length of stay varied from a mean of 39.6 days for obese patients with paraplegia incomplete to 79.1 days for overweight patients with tetraplegia complete. As shown in figure 1A, for each neurologic category, normal-weight or overweight patients achieved higher unadjusted FIM gains in self-care ratings than obese patients. Post hoc tests showed that obese patients with paraplegia incomplete and paraplegia complete had significantly lower unadjusted FIM self-care score gains compared with normal-weight patients with paraplegia incomplete and paraplegia complete. For patients with tetraplegia incomplete and tetraplegia complete, unadjusted FIM self-care score gains were not statistically significant for the 3 groups. As shown in figure 1B, for each neurologic category, normal-weight and overweight patients achieved the highest unadjusted FIM mobility gains. Post hoc testing showed that obese patients with paraplegia incomplete and paraplegia complete had significantly lower unadjusted FIM mobility score gains than normal-weight and overweight patients with paraplegia incomplete and paraplegia complete. For patients with tetraplegia incomplete and tetraplegia complete, differences were not statistically significant across the 3 groups.

5 388 OBESITY AND REHABILITATION OUTCOMES WITH SPINAL CORD INJURY, Stenson Fig 1. Unadjusted (A) self-care and (B) mobility FIM score changes by neurologic category and weight status. As shown in figure 2, most patients were discharged to a community-based setting; unadjusted discharge rates did not differ significantly across weight groups. We used regression analyses to quantify the effect of weight status on change in self-care ratings, change in mobility ratings, and community discharge while adjusting for covariates. In table 3, we reported regression coefficients for only weight variables, which showed that obesity was associated with lower self-care and mobility gains for some, but not all, neurologic categories. For patients with paraplegia incomplete, those who were obese had self-care score gains of 1.9 (95% CI, 3.4 to.4) FIM units different from those of normal-weight patients. Mobility score gains were 1.5 (95% CI, 2.9 to.1) FIM units different from those of normal-weight patients. status was unrelated to the likelihood of returning to a community residence for patients with paraplegia incomplete. In patients with paraplegia complete, obese patients had significantly lower self-care ( 2.2; 95% CI, 3.5 to.8) and mobility rating gains ( 2.7; 95% CI, 3.9 to 1.5) than normal-weight patients. status did not affect the likelihood of returning to a community residence for patients with paraplegia complete. In patients with tetraplegia incomplete, obesity was not associated significantly with functional outcomes, but they were more likely to return home (adjusted odds ratio, 2.00; 95% CI, ). For patients with tetraplegia complete, weight was not associated with any of the outcomes. DISCUSSION We found that about 25% of patients admitted for acute inpatient rehabilitation for an acute SCI to model system centers were obese. Mean changes in self-care and mobility FIM scores are significantly lower for obese patients with paraplegia, suggesting that obesity is a barrier to meeting functional goals for some patients with SCI. These data support the few existing observational studies in the literature. 9,10 However, we were surprised to find that most patients went home, with no significant association with obesity for any neurologic category. Differences in mobility and self-care FIM scores for patients with paraplegia between normal-weight and obese subjects were approximately 3 and 5 FIM units. Regarding clinical implications, studies have estimated how FIM ratings were associated with minutes of caregiver assistance a day. One study specifically looking at this relationship in the spinal cord injured population suggested that, depending on total FIM score, there was a 3- to 7-minute decrease in daily

6 OBESITY AND REHABILITATION OUTCOMES WITH SPINAL CORD INJURY, Stenson 389 Fig 2. Unadjusted percentage of patients discharged to a community-based setting by neurologic category and weight status. assistance needed by a caregiver per FIM score increase. 13 As such, it is clinically relevant to consider that patients with obesity and paraplegia incomplete may require approximately 9 to 21 additional minutes and patients with obesity and paraplegia complete may require approximately 15 to 35 additional minutes of functional assistance a day than patients with normal weight. Obesity may be more of a functional barrier to patients with paraplegia than to patients with tetraplegia in that the physical therapy goals of the former tend to require being able to support one s own body weight, especially in transfers and wheelchair propulsion. Patients with tetraplegia, depending on the level and completeness of injury, may not be attempting tasks requiring supporting or propelling their own body weight. The smaller numbers of patients attempting these tasks in the tetraplegia incomplete and tetraplegia complete groups may be a factor in the smaller differences between normal-weight and obese subjects changes in FIM scores from rehabilitation. We would like to stratify the tetraplegia incomplete group by actual level of injury when there are a sufficient number of patients to do so with adequate statistical power; this would give a clearer idea of the effect of obesity on tasks carried out at different levels of tetraplegia. The FIM measure also is insensitive for showing functional gains in tetraplegia. However, that there was a difference and obese patients with paraplegia had lower FIM scores remains an important finding with clinical implications for patients and caregivers. The lack of significance in the effect of obesity on discharge destination may reflect a lack of statistical power to show the effect, rather than a lack of the effect itself. Most patients were discharged to a community-based setting. Height and weight data were available in the Model Systems database since 2006; therefore only 3 years of data were available. Ongoing analyses of height and weight data will be worthwhile, including longterm implications of obesity on quality of life, community integration, caregiver burden, perceived health status, and health care use after discharge. Table 3: Association Between Status and Self-care Change, Mobility Change, and Community Discharge for Patients With Traumatic SCI, SCI Model Systems Database, 2006 to 2009 Neurologic Category & Status Adjusted mean difference in self-care FIM score change (95% CI)* Incomplete paraplegia Reference category 0.4 ( 1.8 to 1.0) 1.9 ( 3.4 to 0.4) Complete paraplegia Reference category 0.5 ( 0.7 to 1.8) 2.2 ( 3.5 to 0.8) Incomplete tetraplegia Reference category 0.5 ( 1.0 to 2.1) 0.4 ( 1.2 to 2.0) Complete tetraplegia Reference category 0.4 ( 1.3 to 2.1) 0.4 ( 2.3 to 1.5) Adjusted mean difference in mobility FIM score change (95% CI)* Incomplete paraplegia Reference category 0.04 ( 1.3 to 1.3) 1.5 ( 2.9 to 0.1) Complete paraplegia Reference category 0.5 ( 1.7 to 0.6) 2.7 ( 3.9 to 1.5) Incomplete tetraplegia Reference category 0.4 ( 1.1 to 1.9) 0.3 ( 1.4 to 1.9) Complete tetraplegia Reference category 0.03 ( 1.0 to 1.1) 0.02 ( 1.2 to 1.2) Adjusted odds ratio for community discharge (95% CI) Incomplete paraplegia Reference category 0.99 (0.27 to 3.61) 1.01 (0.28 to 3.69) Complete paraplegia Reference category 1.26 (0.44 to 3.63) 1.12 (0.39 to 3.22) Incomplete tetraplegia Reference category 2.00 (1.08 to 3.69) 1.30 (0.71 to 2.39) Complete tetraplegia Reference category 0.65 (0.23 to 1.82) 0.53 (0.19 to 1.50) NOTE. Adjusted for admission functional status, age, sex, onset time, vertebral fracture (yes/no), spinal surgery (yes/no), halo (yes/no), thoracic lumbar sacral orthosis device (yes/no), AIS grade for patients with incomplete injuries, and marital status for discharge to community. *Multiple linear regression results; inclusion of 0 in the 95% CI indicates the variable is not associated significantly with the outcome. P.05. Multiple logistic regression; inclusion of 1 in the 95% CI indicates the variable is not associated significantly with the outcome.

7 390 OBESITY AND REHABILITATION OUTCOMES WITH SPINAL CORD INJURY, Stenson Study Limitations One limitation inherent in working with the Model Systems database is that participating centers tend to be urban, not-forprofit, often university-based settings, and as such, the outcomes may not be generalizable to all patients in all rehabilitation centers. In addition, the database does not include data for comorbid conditions, preexisting level of fitness, and social support, factors that may affect outcomes. Despite these limitations, the Model Systems database affords us the opportunity to assess an emerging problem. With obesity at epidemic proportions in the United States, it is important to understand how obesity can affect outcomes and how it may affect resource allocation in an inpatient rehabilitation facility. Recognizing the problem may provide the impetus for looking at the way we care for patients with SCI and obesity; better understanding coupled with further training for staff and the presence of appropriate equipment eventually may help improve outcomes. Patients identified as overweight in the acute phase of SCI are at high risk for becoming obese given the decreased metabolic demands and immobility that result from SCI. Furthermore, because a patient is discharged to home from inpatient rehabilitation does not necessarily mean that obesity does not pose added difficulties for the patient or his/her caregiver. Now that there is information that the amount of time needed for a caregiver to assist with functional tasks is linked to obesity, there is 1 more reason to focus on how to best guide patients with SCI who are at risk for obesity on how to achieve and maintain a healthy weight. Although there is a pilot study in the literature looking at weight loss through diet and exercise 14 and a case study looking at bariatric surgery in a patient with paraplegia, 15 these are the beginning of what will hopefully become a large body of research on how to reverse the trend of obesity as it is manifested in the population of people with SCI. CONCLUSIONS Patients with paraplegia who are obese have significantly lower mean FIM score gains than their nonobese counterparts at discharge from inpatient rehabilitation. This study suggests that obesity is a barrier to achieving maximum functional independence while undergoing acute inpatient SCI rehabilitation. Acknowledgments: We thank Steven Kirshblum, MD, and Yuying Chen, MD, PhD, for feedback on an earlier version of the manuscript, Holly DeMark and Esther Liu for technical assistance with manuscript preparation, the model system staff for data collection/ chart abstraction work, and the clinicians for reporting impairment and functional status data. References 1. Centers for Disease Control and Prevention. and obesity: US obesity trends. Available at: dnpa/obesity/trend/maps/. Accessed: September WHO. Global database on body mass index: BMI classification. Available at: Page intro_3.html. Accessed: September Gupta N, White KT, Sandford PR. Body mass index in spinal cord injury a retrospective study. Spinal Cord 2006;44: Weaver FM, Collins EG, Kurichi J, et al. Prevalence of obesity and high blood pressure in veterans with spinal cord injuries and disorders: a retrospective review. Am J Phys Med Rehabil 2007; 86: Maruyama Y, Mizuguchi M, Yaginuma T, et al. Serum leptin, abdominal obesity and the metabolic syndrome in individuals with chronic spinal cord injury. Spinal Cord 2008;46: Jones LM, Legge M, Goulding A. Healthy body mass index values often underestimate body fat in men with spinal cord injury. Arch Phys Med Rehabil 2003:84: Laughton GE, Buchholz AC, Martin Ginis Ka, Goy RE. Lowering body mass index cutoffs better identifies obese persons with spinal cord injury. Spinal Cord 2009;47: Rajan S, McNeely MJ, Warms C, Goldstein B. Clinical assessment and management of obesity in individuals with spinal cord injury: a review. J Spinal Cord Med 2008;31: Blackmer J, Marshall S. Obesity and spinal cord injury: an observational study. Spinal Cord 1997;35: Beck LA. Morbid obesity and spinal cord injury: a case study. SCI Nurs 1998;15: Jain NB, Al-Adawi S, Dorvlo ASS, Burke DT. Association between body mass index and Functional Independence Measure in patients with deconditioning. Am J Phys Med Rehabil 2007;87: Farrell RT, Gamelli RL, Aleem RF, Sinacore JM. The relationship of body mass index and functional outcomes in patients with acute burns. J Burn Care Res 2008;29: Hamilton BB, Deutsch A, Russell C, Fiedler RC, Granger CV. Relation of disability costs to function: spinal cord injury. Arch Phys Med Rehabil 1999;80: Chen Y, Henson S, Jackson AB, Richards JS. Obesity intervention in persons with spinal cord injury. Spinal Cord 2006;44: Aladeen DI, Jasper J. Gastric bypass surgery in a paraplegic morbidly obese patient. Obes Surg 2006;16: Supplier a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL