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Guideline Summary
Guideline Title
Spinal cord injury (SCI). Evidence-based nutrition practice guideline.
Bibliographic Source(s)
American Dietetic Association (ADA). Spinal cord injury (SCI). Evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association (ADA); 2009. Various p. [340 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Spinal cord injury

Guideline Category
Assessment of Therapeutic Effectiveness
Counseling
Evaluation
Management
Prevention
Rehabilitation
Risk Assessment
Screening
Treatment
Clinical Specialty
Critical Care
Neurological Surgery
Neurology
Nursing
Nutrition
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Respiratory Care Practitioners
Social Workers
Speech-Language Pathologists
Students
Guideline Objective(s)

Overall Objective

To provide medical nutrition therapy (MNT) guidelines that result in positive clinical outcomes in the acute, rehabilitation, and community-dwelling stages of spinal cord injury

Specific Objectives

  • To define evidence-based nutrition recommendations specific to spinal cord injury for Registered Dietitians (RDs) to implement in collaboration with other healthcare providers as part of the interdisciplinary care team
  • To guide practice decisions that promote good clinical outcomes
  • To reduce variations in practice among RDs
  • To promote the best possible nutrition quality of life in spinal cord-injured persons
  • To provide the RD with guidelines for making recommendations to adjust MNT or for recommending other therapies to achieve desired outcomes
  • To assist the RD in customizing nutrition strategies to each individual patient’s type and level of injury, ability to consume nutrients, metabolic profile, potential for rehabilitation, current lifestyle, and personal preferences
  • To define guidelines for interventions that have measurable clinical outcomes
  • To define the highest quality of care within cost constraints of the current healthcare environment
Target Population

Adults (>19 years) with spinal cord injury in acute care, rehabilitation, or community-dwelling settings

Interventions and Practices Considered

Evaluation

  1. Referral to a registered dietitian
  2. Nutritional assessment
    • Food/nutrition-related history
    • Anthropometric measurements including body composition assessment using bioelectric impedance analysis (BIA) or dual-energy X-ray absorptiometry (DEXA)
    • Biochemical data, medical tests and procedures
    • Comparative standards including estimating energy, protein, fiber, carbohydrate, fluid, and vitamin needs and ideal body weight

Management/Treatment/Prevention

  1. Individualized prescription for medical nutrition therapy
  2. Education and counseling for lipid abnormalities
  3. Education for physical activity
  4. Cranberry juice

    Note: Cranberry extract supplements were considered but not recommended.

  5. Prevention and treatment of overweight and obesity
  6. Prevention and treatment of pressure ulcers
  7. Coordination of nutrition care
  8. Monitoring and evaluation
Major Outcomes Considered
  • Nutritional status
  • Bowel function
  • Pressure ulcers
  • Wound healing
  • Hospitalization
  • Length of hospital stay
  • Quality of life
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Searches of PubMed and Central databases and hand searches of other relevant literature were performed on the following topics:

  • Caloric and protein needs in the acute and rehabilitation phases of spinal cord injury (SCI)
  • Lipid abnormalities in SCI
  • Role of the Registered Dietitian in SCI
  • Cranberry juice and urinary tract infections
  • Fiber/fluid and neurogenic bowel
  • Nutrition care for pressure ulcers
  • Nutrition care to prevent overweight in SCI
  • Physical activity and SCI

General Exclusion Criteria

As a general rule, studies are excluded if the:

  • Study sample size is less than 10 in each treatment group
  • Drop-out rate was >20%

Inclusion Criteria

  • Study design preferences: clinical trials preferred
  • Limited to articles in English

The American Dietetic Association (ADA) has determined that for narrowly focused questions dealing with therapy or treatment, six well designed randomized controlled trials that demonstrate similar results is sufficient to draw a conclusion.

No one study design was preferred for all questions. The preferred study design depended on the type of question. The ADA uses the following principles in the table below for identifying preferred study design.

Type of Question Preferred Study Designs

(in Order of Preference)
Diagnosis questions Sensitivity & specificity of diagnostic test

Cross-sectional study
Etiology, causation, or harm questions Prospective cohort

Case control study

Cross-sectional study
Therapy and prevention questions Randomized controlled trial

Nonrandomized trial
Natural history and prognosis questions Cohort study
Number of Source Documents

856 considered

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Grading the Strength of the Evidence for a Conclusion Statement or Recommendation Conclusion Grading Table

Strength of Evidence Elements Grade I

Good/Strong
Grade II

Fair
Grade III

Limited/Weak
Grade IV

Expert Opinion Only
Grade V

Grade Not Assignable
Quality
  • Scientific rigor/validity
  • Considers design and execution
Studies of strong design for question

Free from design flaws, bias and execution problems
Studies of strong design for question with minor methodological concerns

OR

Only studies of weaker study design for question
Studies of weak design for answering the question

OR

Inconclusive findings due to design flaws, bias or execution problems
No studies available

Conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from basic research
No evidence that pertains to question being addressed
Consistency

Of findings across studies
Findings generally consistent in direction and size of effect or degree of association, and statistical significance with minor exceptions at most Inconsistency among results of studies with strong design

OR

Consistency with minor exceptions across studies of weaker designs
Unexplained inconsistency among results from different studies

OR

Single study unconfirmed by other studies
Conclusion supported solely by statements of informed nutrition or medical commentators NA
Quantity
  • Number of studies
  • Number of subjects in studies
One to several good quality studies

Large number of subjects studies

Studies with negative results having sufficiently large sample size for adequate statistical power
Several studies by independent investigators

Doubts about adequacy of sample size to avoid Type I and Type II error
Limited number of studies

Low number of subjects studies and/or inadequate sample size within studies
Unsubstantiated by published studies Relevant studies have not been done
Clinical Impact
  • Importance of studies outcomes
  • Magnitude of effect
Studied outcome relates directly to the question

Size of effect is clinically meaningful

Significant (statistical) difference is large
Some doubt about the statistical or clinical significance of effect Studies outcome is an intermediate outcome or surrogate for the true outcome of interest

OR

Size of effect is small or lacks statistical and/or clinical significance
Objective data unavailable Indicates area for future research
Generalizability

To population of interest
Studied population, intervention and outcomes are free from serious doubts about generalizability Minor doubts about generalizability Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied Generalizability limited to scope of experience NA

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Step 1: Formulate the question

Specify a question in a defined area of practice; or state a tentative conclusion or recommendation that is being considered. Include the patient type and special needs of the target population involved, the alternatives under consideration, and the outcomes of interest.

Step 2: Gather and classify evidence reports

Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and classify them by type of evidence. Classes differentiate primary reports of new data according to study design, and distinguish them from reports that are a systematic review and synthesis of primary reports.

Step 3: Critically appraise each report

Review each report for relevance to the question and critique for scientific validity. Abstract key information from the report and assign a code to indicate the quality of the study by completing quality criteria checklist.

Step 4: Summarize evidence in a narrative and an overview table

Combine findings from all reports in a table that pulls out the important information from the article worksheets. Write a brief narrative that summarizes and synthesizes the information abstracted from the articles that is related to the question asked.

Step 5: Develop a conclusion statement and grade the strength of evidence supporting the conclusion

Develop a concise conclusion statement (the answer to the question), taking into account the synthesis of all relevant studies and reports, their class and their quality ratings. Assign a grade to indicate the overall strength or weakness of evidence informing the conclusion statement.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops the disease-specific guideline. The guideline development involves the following steps.

Review Evidence Based Conclusions

The workgroup meets to review the materials resulting from the evidence analysis, which may include review of the conclusion statements, evidence summaries and evidence worksheets.

Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis

The work group uses an expert consensus method to formulate recommendations, taking into account the following:

  • Recommendations for what the dietitian should do and why
  • Rating of recommendations based on strength of supporting evidence
  • Label of Conditional (clearly define a specific situation) or Imperative (broadly applicable to the target population without restraints on the pertinence)
  • Risks and Harms of Implementing the Recommendations, including potential risks, harms, or adverse consequences
  • Conditions of Application, including organizational barriers or conditions that may limit application
  • Potential Costs Associated with Application
  • Recommendation Narrative
  • Recommendation Strength Rationale, evidence strength and methodological issues
  • Minority Opinions, when the expert working group cannot reach consensus on a recommendation
  • Supporting Evidence
Rating Scheme for the Strength of the Recommendations

Criteria for Recommendation Rating

Statement Rating Definition Implication for Practice
Strong A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Fair A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences.
Weak A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.
Consensus A Consensus recommendation means that Expert opinion (grade IV)* supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. Practitioners should be flexible in deciding whether to follow a recommendation classified Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.
Insufficient Evidence An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.

Cost Analysis

The guideline workgroup investigated potential costs associated with application of specific interventions and practices.

Individualized nutrition care provided by a registered dietitian to persons with spinal cord injury may result in significant cost savings to organizations by reducing length of stay in acute care and rehabilitation settings, occurrence of pressure ulcers and other nutrition-related complications.

Organizational expenses incurred as a result of providing adequate nutrition care to reduce the risk of development of pressure ulcers may be cost-effective, as it is likely that costs associated with treating a pressure ulcer will be higher than preventive care.

Medical nutrition therapy (MNT) can be considered cost effective when weighing the benefits of appropriate nutrition therapy to prevent co-morbidities versus the cost of medical intervention. For example, MNT to ensure adequate protein and micronutrient intake may promote healthy skin integrity, thus saving the considerable costs of treatment for a developed pressure ulcer.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Each guideline is reviewed internally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument as the evaluation tool. The external reviewers consist of a multidisciplinary group of individuals (may include dietitians, doctors, psychologists, pharmacists, nurses, etc.). The review is done electronically. The guideline is adjusted by consensus of the expert panel and approved by American Dietetic Association's Evidence-Based Practice Committee prior to publication on the Evidence Analysis Library (EAL).

Recommendations

Major Recommendations

Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion grades (I-V), and statement labels (Conditional versus Imperative) are defined at the end of the "Major Recommendations" field.

Spinal Cord Injury (SCI) Role of the Registered Dietitian (RD)

SCI: Role of the RD

A RD should be an active participant of the interdisciplinary team providing care for patients with spinal cord injuries in the acute phase, rehabilitation setting and community setting. Evidence suggests that medical nutrition therapy provided to patients with spinal cord injuries by an RD results in improved nutrition-related patient outcomes, such as adequate nutrient intake and management of serum lipids, weight, dysphagia, bowel function and pressure ulcers.

Fair, Imperative

Recommendation Strength Rationale

  • Strong rating (Grade I conclusion statement) for starting enteral nutrition within 48 hours following injury or admission to reduce the incidence of infectious complications

SCI Nutrition Screening for Persons with SCI Living in the Community

SCI: Nutrition Screening for Lipid Abnormalities

Screening for lipid abnormalities is recommended for all persons with SCI living in the community setting in order to reduce morbidity and mortality. Studies show that SCI is associated with increased risk for cardiovascular disease due to inactivity and immobilization.

Fair, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade II

SCI Nutrition Assessment in Acute Care, Rehabilitation, and Community Setting

SCI: Nutrition Assessment in the Acute Care Setting

If a patient is in the acute phase of SCI, the RD should conduct a nutrition assessment within the first 48 hours post-injury, in order to determine nutrient needs, provide nutrition support recommendations and identify conditions that may predispose the patient to nutrition-related complications. Evidence suggests that early nutrition support is associated with improved patient outcomes.

The nutrition assessment should include but is not limited to:

  • Food- and nutrition-related history: Energy intake, diet order, food or beverage intake
  • Anthropometrics: Weight change
  • Biochemical and medical tests and procedures: Swallow study, inflammatory profile, metabolic profile, albumin, prealbumin
  • Nutrition-focused physical findings: Digestive system, cardiovascular and pulmonary systems
  • Client history: Treatment and therapy
  • Comparative studies: Energy needs, protein needs, ideal and reference body weight, fluid needs

Strong, Conditional

SCI: Nutrition Assessment in the Rehabilitation Setting

If a patient is in the rehabilitation phase of SCI, the RD should conduct a nutrition assessment to develop and implement an individualized therapeutic nutrition plan for the patient. Evidence suggests that medical nutrition therapy by a RD may result in improved ability to participate in therapies and in an improved transition into the community setting.

The nutrition assessment should include but is not limited to:

  • Food- and nutrition-related history: Energy intake, diet order, food beverage intake, fiber intake, medication and herbal supplement use, mealtime behavior, nutrition-related activities of daily living (ADLs) and instrumental ADLs (IADLs), physical activity, weight change
  • Anthropometrics: Weight change
  • Biochemical and medical tests and procedures: Swallow study, inflammatory profile, metabolic profile, albumin
  • Nutrition-focused physical findings: Digestive system, cardiovascular-pulmonary system, skin
  • Client history: Social history
  • Comparative studies: Energy needs, protein needs, ideal or reference body weight, fluid needs, fiber needs

Fair, Conditional

SCI: Nutrition Assessment in the Community Setting

If a person with SCI is living in the community setting, the RD should conduct a nutrition assessment as part of the annual medical exam to develop and implement an individualized therapeutic nutrition plan.

The nutrition assessment should include but is not limited to:

  • Food- and nutrition-related history (specifically knowledge deficits, beliefs and attitudes, body image, mealtime behaviors, physical ability to self-feed, access to food- and nutrition-related supplies, meal preparation and food avoidances)
  • Anthropometric measurements (specifically body composition, weight)
  • Biochemical data, medical tests and procedures (specifically serum lipid and glucose levels)
  • Social history (specifically isolation)
  • Nutrition-focused physical findings (specifically bowel and bladder function). Evidence suggests that annual nutrition assessment by an RD is necessary to identify nutrition-related concerns that may affect the health and quality of life of persons with SCI.

Fair, Conditional

Recommendation Strength Rationale

Nutrition Assessment in the Acute Care Setting

  • Strong rating (Grade I conclusion statement) for starting enteral nutrition within 48 hours following injury or admission to reduce the incidence of infectious complications.

SCI Nutrition Assessment of Lipid Abnormalities

SCI: Nutrition Assessment of Lipid Abnormalities

If persons with SCI living in the community setting have lipid abnormalities, the RD should include age, ethnicity, gender, time since injury, level of injury, activity level, dietary habits, smoking behavior, alcohol intake and overweight or obese status in the food and nutrition-related history. Studies show that these factors are associated with abnormal blood lipids, particularly decreased high-density lipoprotein (HDL) cholesterol, in persons with SCI.

Strong, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade II

SCI Nutrition Assessment of Body Composition

SCI: Assessment of Body Composition: Estimation of Ideal Body Weight

The RD should estimate ideal body weight for persons with SCI by adjusting the Metropolitan Life Insurance tables for individuals of equivalent height and weight. There are two reported methods for adjusting the tables:

  • Quadriplegia, reduction of 10% to 15% lower than table weight; paraplegia, reduction of 5% to 10% lower than table weight
  • Quadriplegia, 15 lbs to 20 lbs lower than table weight; paraplegia, 10 lbs to 15 lbs lower than table weight.

Consensus, Imperative

SCI: Assessment of Body Composition: Body Mass Index (BMI) and skinfold measurements

The RD should not use BMI or skinfold measurements to measure body composition in persons with SCI. These methods may not provide reliable results since they were developed based on able-bodied persons.

Fair, Imperative

SCI: Assessment of Body Composition: Bioelectric Impedance Analysis (BIA) and Dual-Energy X-Ray Absorptiometry (DEXA)

For persons with SCI who are medically stable, the RD should consider using BIA or DEXA to assess body composition. Evidence suggests that BIA and DEXA correlate with measures of total body water (TBW) when labeled water is used to provide a reference value for TBW. Persons with SCI have significantly higher fat mass and lower lean mass than persons without SCI.

Fair, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade II

SCI Assessment: Energy Needs in Acute and Rehabilitation Phases

SCI: Assessment: Energy Needs in the Acute Phase

If the patient with SCI is in the acute phase of SCI, the RD should assess energy needs by measuring energy expenditure. Patients with SCI have reduced metabolic activity due to denervated muscle. Actual energy needs are at least 10% below predicted needs. Indirect calorimetry is more accurate than estimation of energy needs in critically ill patients.

Strong, Conditional

SCI: Assessment: Energy Needs in the Acute Phase using Predictive Equations

If the patient with SCI is in the acute phase of SCI, and indirect calorimetry is not available, the RD may consider estimating energy needs with the Harris-Benedict formula, using admission weight, an injury factor of 1.2 and an activity factor of 1.1. No research was available to compare Harris-Benedict with other predictive equations in this population.

Weak, Conditional

SCI: Assessment: Energy Needs in the Rehabilitation Phase

If the patient with SCI is in the rehabilitation phase, the RD may estimate energy needs using 22.7 kcal per kg body weight for patients with quadriplegia and 27.9 kcal per kg for those with paraplegia. Patients with SCI have reduced metabolic activity due to denervated muscle.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statements are Grades I and III

SCI Assessment of Physical Activity and Energy Needs

SCI: Physical Activity and Energy Needs

The RD should consider the body weight, co-morbid conditions including abnormal blood lipids and obesity, level of energy, rate of propulsion and type of wheelchair used by the person with SCI when assessing energy needs. Evidence suggests that the use of a manual standard wheelchair increases energy needs, heart rate, oxygen consumption and ventilation, especially as speed and resistance levels increase, compared to ultralight wheelchairs and pushrim-activated, power-assisted wheelchairs.

Fair, Imperative

Recommendation Strength Rationale

  • Conclusion statements are Grades II and III

SCI Assessment of Protein Needs

SCI: Assessment of Protein Needs in the Acute Phase

If the patient with SCI is in the acute phase, the RD should calculate protein needs at 2.0 g per kg of body weight per day to lessen the obligatory negative nitrogen balance that occurs during the acute phase.

Weak, Conditional

SCI: Assessment of Protein Needs in the Rehabilitation and Community Living Phases

If the person with SCI is in the rehabilitation phase or community living phase, then the RD should calculate protein needs at 0.8 g to 1.0 g per kg of body weight per day for maintenance of protein status in the absence of pressure ulcers or infection.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade III

SCI Assessment for Prevention of Pressure Ulcers

SCI: Pressure Ulcers: Prevention

The RD should assess persons with SCI for risk factors associated with the development of pressure ulcers. The RD should determine the frequency of nutrition reassessment based on changes in nutritional or medical parameters and institutional protocols. Research suggests that maintenance of nutrition-related parameters, including anthropometrics, skin integrity, dietary intake, lifestyle factors and biochemical indices, may be associated with reduced risk of pressure ulcers.

Fair, Imperative

SCI: Assessment of Biochemical Parameters Associated with Prevention of Pressure Ulcers

The RD should assess laboratory indices associated with the risk of pressure ulcers such as albumin, prealbumin, zinc, vitamin A and vitamin C as part of the nutrition assessment of persons with SCI. Biochemical parameters as close to normal as possible or within the normal range are associated with reduced risk of pressure ulcers.

Fair, Imperative

SCI: Assessment of Anthropometric, Nutrition and Lifestyle Factors Associated with Prevention of Pressure Ulcers

The RD should assess anthropometric, nutrition and lifestyle factors, including weight, food and nutrition-related history (food intake, alcohol intake, physical activity and function) and smoking history for persons with SCI. Evidence suggests that the risk of developing pressure ulcers is reduced in individuals who maintain a normal weight, consume adequate amounts of nutrients and do not have a history of smoking or alcohol abuse.

Fair, Imperative

SCI Assessment of Nutritional Needs for Pressure Ulcers

SCI: Assessment: Energy Needs For Persons with SCI with Pressure Ulcers

If a person with SCI has a pressure ulcer, the RD should measure energy needs by indirect calorimetry (IC). If indirect calorimetry is not available, any of the following predictive equations may be used to calculate energy needs:

  • 30 kcal to 40 kcal per kg of body weight per day
  • Harris-Benedict times stress factor (1.2 for stage II ulcer, 1.5 for stage III and IV ulcers)

No evidence currently exists to suggest that any one of the above predictive equations is superior to the others.

Persons with SCI with pressure ulcers have higher energy needs than persons with SCI who have similar levels of injury and no pressure ulcers. Evidence suggests that additional energy is needed for optimal healing of pressure ulcers.

Consensus, Conditional

SCI: Assessment: Protein Needs For Persons with SCI with Pressure Ulcers

If a person with SCI has a pressure ulcer, the RD should calculate protein needs as follows:

  • 1.2 g to 1.5 g of protein per kg body weight per day (Stage II pressure ulcers)
  • 1.5 g to 2.0 g of protein per kg body weight per day (Stage III and IV pressure ulcers)

Persons with SCI with pressure ulcers have higher protein needs than persons with SCI who have similar levels of injury and no pressure ulcers. Evidence suggests that additional protein is needed for optimal healing of pressure ulcers.

  • Arginine and its relationship to wound healing has been researched for over 30 years, primarily in animal models. Clear and definitive guidelines for its safe and effective use have yet to be established.
  • Glutamine should not be routinely provided to all patients with wounds due to insufficient data.

Consensus, Conditional

SCI: Assessment: Fluid Needs for Persons with SCI with Pressure Ulcers

If a person with SCI has a pressure ulcer, the RD should assess hydration status to determine fluid needs. Assessment of hydration status includes evaluation of parameters such as input and output, urine color, skin turgor, blood urea nitrogen (BUN) and serum sodium. Increased fluid losses may result from the evaporation of fluids from a severe pressure ulcer, draining or open wounds, fever or the use of an air-fluidized bed. Current fluid recommendations are based on guidelines for the non-SCI population.

  • Normal requirement: 30 mL to 40 mL per kg
  • Minimum of 1.0 mL per kcal per day
  • 10 mL to 15 mL per kg additional fluids may be required with the use of air fluidized beds set at a high temperature (more than 31° to 34°C or more than 88° to 93°F)
    • Fluid loss includes evaporation from open wounds, wound drainage and fever
    • These guidelines are only a general indication of insensible water loss; the RD will need to monitor other parameters of hydration status.

Consensus, Conditional

SCI: Assessment: Micronutrient Needs for Persons with SCI with Pressure Ulcers

If a person with SCI has a pressure ulcer, the RD should recommend a daily vitamin and mineral supplement that meets no more than 100% of the recommended daily allowance (RDA).

Certain micronutrients play a role in the process of wound healing; however, the optimal nutrient intake is not known at this time. Few rigorous scientific studies exist in this area, even for the non-SCI population. Therefore, comprehensive evidence-based practice guidelines are not developed for micronutrient needs.

If a person with SCI has a pressure ulcer and has a suspected or documented micronutrient deficiency, the RD should provide additional supplementation. Caution should be used when supplementing greater than the tolerable upper intake level (UL). The dietitian should re-evaluate the need for micronutrient supplementation every seven to 10 days.

Vitamin A

Vitamin A deficiency results in impaired wound healing and alteration in immune function that may increase the likelihood of wound infections. Documented recommendations for amount of Vitamin A for enhanced wound healing in injured patients is 10,000 international units (IU) to 50,000 IU per day and 10,000 IU intravenously (IV) for moderate-severely injured patients or malnourished patients for a limit of 10 days. For patients receiving steroids, 10,000 IU to 15,000 IU for one week has been recommended to counteract the anti-inflammatory effects of steroids. Vitamin A supplementation should be implemented cautiously and judiciously because of potential toxicity.

Additional research is needed to confirm optimal dosage.

Vitamin C

Vitamin C deficiency has been associated with delayed wound healing. In patients with Vitamin C deficiency, supplementation has been shown to enhance wound healing. High doses of Vitamin C for healing chronic wounds is widely recommended in the literature. The Agency for Health Care Research and Quality recommends 100 mg to 200 mg per day of Vitamin C for Stage I and II pressure ulcers and 1,000 mg to 2,000 mg per day of Vitamin C for Stage III and IV pressure ulcers.

Additional research is needed to confirm optimal dosage.

Vitamin E

The effect of Vitamin E in healing acute and chronic wounds is controversial. Further research is needed in humans with controlled randomized trials to determine risks and benefits of various doses of Vitamin E and the effect on healing.

Zinc

Zinc deficiency is associated with delayed wound healing due to a decrease in collagen and protein synthesis and impaired immune competence. Replacement therapy guidelines have not been well defined in the literature. ZnS04 220 mg (50 mg elemental Zinc) twice per day is recommended as a standard adult oral replacement. High-dose supplementation of zinc should be limited to two to three weeks. Dosage should be individualized according to zinc status and metabolic demands.

Iron

Anemia assessed by hemoglobin and hematocrit levels reduces oxygen supply to tissues, thus impairing healing of pressure ulcers. If low hemoglobin concentration is due to iron deficiency anemia, it may be a factor in tissue hypoxia and impaired wound healing. Supplementation should be provided as indicated to correct iron deficiency anemia.

Consensus, Conditional

Recommendation Strength Rationale

  • Rating is based on expert consensus, clinical guidelines, and textbooks

SCI Nutrition Assessment for Prevention and Treatment of Overweight and Obesity

SCI: Nutrition Assessment for Prevention and Treatment of Overweight and Obesity

The RD should assess the weight and body composition of persons with SCI, and adjust energy level or implement weight management strategies as appropriate. The SCI population is at a higher risk of associated comorbidities such as diabetes, metabolic syndrome and cardiovascular disease. Lower levels of spontaneous physical activity and a lower thermic effect of food result in decreased energy expenditure and energy needs. See Nutrition Assessment recommendations for methods to determine weight and energy needs, for methods to manage overweight and obesity.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statements are Grades II and III

SCI Nutrition Intervention for Lipid Abnormalities

SCI: Nutrition Education and Counseling for Lipid Abnormalities

If persons with SCI living in the community setting have total cholesterol levels more than 200 mg per dL (5.2 mmol per L), then an RD should provide comprehensive nutrition education and counseling regarding a cardioprotective diet. Persons with SCI can achieve improvements in lipid values similar to those of other individuals with disorders of lipid metabolism, and persons with SCI are at higher risk of cardiovascular conditions.

Fair, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade II

SCI Physical Activity in Spinal Cord Injured Persons

SCI: Nutrition Education Regarding Physical Activity

If a person with SCI has lipid abnormalities and weight management issues, then the RD should provide initial brief nutrition education regarding the relationship between physical activity and improving lipid levels. Evidence suggests that appropriate physical activity may result in improvements of blood lipid parameters and weight in persons with SCI.

Fair, Conditional

SCI: Nutrition Education Regarding Physical Activity in Overweight and Obese Persons with SCI

If a person with SCI is overweight or obese, the RD should encourage physical activity as part of a comprehensive weight management program. A carefully planned weight management program incorporating physical activity has been shown to reduce and maintain weight in overweight and obese persons with SCI. Evidence suggests that appropriate physical activity, such as wheelchair sports, swimming, electrical stimulation exercise and body weight supported treadmill training may result in improvements of blood lipid parameters and weight in persons with SCI.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade II

SCI Fluid and Neurogenic Bowel

SCI: Fluid and Neurogenic Bowel: Estimating Fluid Needs to Promote Optimal Stool Consistency

The RD should estimate the fluid needs of persons with SCI with neurogenic bowel by using the guidelines of the Consortium on Spinal Cord Medicine, as follows:

  • 1 mL fluid per kcal estimated energy needs plus 500 mL
  • 40 mL per kg body weight plus 500 mL

A minimum of 1.5 L of fluid per day may promote optimal stool consistency in persons with SCI and neurogenic bowel. Persons with SCI and neurogenic bowel often have an increase in colonic transit time, resulting in excessive fluid reabsorption and the formation of hardened stools.

Further research is needed to establish fluid intake guidelines for this population.

Consensus, Conditional

Recommendation Strength Rationale

  • Recommendation based on expert consensus only

SCI Fiber and Neurogenic Bowel

SCI: Fiber and Neurogenic Bowel: Level of Fiber Intake

The RD should prescribe for persons with SCI with neurogenic bowel an initial fiber intake of 15 g per day, with gradual increases up to 30 g per day of fiber, as tolerated from a variety of sources. A fiber intake of 15 g per day may be associated with significant improvements in bowel function. However, fiber intake greater than 20 g per day may be associated with undesirable prolonged intestinal transit times in persons with SCI.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade III

SCI Cranberry Juice

SCI: Cranberry Juice

If consistent with patient preference and other nutritional considerations, the RD may recommend that cranberry juice be included in the diet of persons with SCI to reduce urinary tract infections (UTIs). Consumption of one cup (250 ml) cranberry juice, three times per day, may be associated with a reduced urinary tract biofilm load.

Weak, Conditional

SCI Cranberry Supplements

SCI: Urologic Health: Cranberry Extract Supplements

The RD should not recommend cranberry extract supplements to promote urologic health (prevention of urinary tract infections, urologic stones, etc.) in spinal cord injured persons. Evidence suggests that cranberry extract supplements, ingested in tablet or capsule form, are not effective in prolonging the UTI-free period or decreasing bacteriuria or white blood cell (WBC) count in persons with spinal cord injuries.

Fair, Imperative

SCI Nutrition Intervention for Prevention and Treatment of Overweight and Obesity

SCI: Nutrition Intervention for Treatment of Overweight and Obesity

If a person with SCI is overweight or obese, the RD should implement weight management strategies as appropriate. The SCI population is at a higher risk of associated comorbidities such as diabetes, metabolic syndrome and cardiovascular disease. Lower levels of spontaneous physical activity and a lower thermic effect of food result in decreased energy expenditure and energy needs. See the Nutrition Assessment recommendations for methods to determine weight and energy needs and for methods to manage overweight and obesity.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statement is Grade II

SCI Nutrition Intervention for Prevention of Pressure Ulcers

SCI: Nutrition Intervention to Prevent Development of Pressure Ulcers

If a patient with SCI is at risk of pressure ulcer development as indicated by biochemical, anthropometric and lifestyle factors, the RD should implement aggressive nutrition support measures. The range of options may include medical food supplements and enteral and parenteral nutrition. Research suggests that improved nutrition intake, body weight and biochemical parameters may be associated with reduced risk of pressure ulcer development.

Strong, Conditional

SCI Nutrition Prescription for SCI Persons with Pressure Ulcers 

SCI: Nutrition Prescription for SCI Persons with Pressure Ulcers

A nutrition prescription should be formulated as part of the nutrition intervention for persons with SCI and pressure ulcers, which includes the energy, protein, fluid and micronutrient requirements. Evidence suggests that additional energy and protein is needed for optimal healing of pressure ulcers. Fluid and micronutrient needs will vary depending on the person's status. See the Assessment of Nutritional Needs for Pressure Ulcers External Web Site Policy for determining levels of each of these.

Consensus, Imperative

Recommendation Strength Rationale

  • Rating is based on expert consensus, clinical guidelines, and textbooks

SCI Coordination of Care in SCI

SCI: Coordination of Care in SCI

The RD should implement medical nutrition treatment (MNT) and coordinate care with the interdisciplinary team providing care for persons with SCI in the acute phase, rehabilitation setting and community setting. The interdisciplinary team is composed of health professionals including but not limited to: Physicians, nurses, occupational therapists, physical therapists, speech therapists, RDs, exercise physiologists and mental health professionals. Evidence suggests that optimal care of each patient requires a multidisciplinary approach in all aspects of patient care, including nutrition.

Weak, Imperative

Recommendation Strength Rationale

  • Conclusion statements are Grade III

SCI Monitoring and Evaluation in Acute Care Setting 

SCI: Monitoring and Evaluation in Acute Care Setting

If a patient is in the acute phase of SCI, a RD should provide ongoing monitoring of the patient's nutrition status. Evidence suggests that conditions such as hypoproteinemia, hypoalbuminemia, anemia, poor bowel function and dysphagia are better managed when patients receive adequate nutrition care from an RD.

Fair, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade III

SCI Monitoring and Evaluation of Protein Intake in Acute Care Setting: Overfeeding

SCI: Monitoring and Evaluation of Protein Intake in Acute Care Setting: Overfeeding

If a patient with SCI is in the acute phase (zero to four weeks post-injury), the RD should monitor the patient's protein intake to ensure that the patient does not consume more than 2.0 g per kg of body weight per day. Efforts to achieve positive nitrogen balance with excessive nutrition support are generally unsuccessful and may result in substrate overload and metabolic complications with subsequent poor outcomes.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade III

SCI Nutrition Monitoring and Evaluation of Energy Needs During the Rehabilitation Phase

SCI: Monitoring and Evaluation of Energy Needs During the Rehabilitation Phase

The RD should monitor weight, functional capacity and physical activity and adjust energy needs as necessary. As patients with SCI progress through the rehabilitation phase and move into the community setting, changes in these factors may affect energy needs.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade III

SCI Nutrition Monitoring and Evaluation of Fiber and Neurogenic Bowel

SCI: Nutrition Monitoring and Evaluation for Fiber and Neurogenic Bowel

The RD should monitor at regular intervals the fiber intake of persons with SCI and neurogenic bowel, and the amount of dietary fiber provided should be adjusted as necessary. Provision of excessive fiber may result in unacceptable flatulence, significant increase in stool volume and painful abdominal distension, while provision of inadequate fiber may result in constipation or bowel impaction.

Weak, Conditional

Recommendation Strength Rationale

  • Conclusion statement is Grade III

Definitions:

Conditional versus Imperative Recommendations

Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., if an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).

In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text that would limit their applicability to specified circumstances. (e.g., portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss).

Levels of Evidence

Strength of Evidence Elements Grade I

Good/Strong
Grade II

Fair
Grade III

Limited/Weak
Grade IV

Expert Opinion Only
Grade V

Grade Not Assignable
Quality
  • Scientific rigor/validity
  • Considers design and execution
Studies of strong design for question

Free from design flaws, bias and execution problems
Studies of strong design for question with minor methodological concerns

OR

Only studies of weaker study design for question
Studies of weak design for answering the question

OR

Inconclusive findings due to design flaws, bias or execution problems
No studies available

Conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from basic research
No evidence that pertains to question being addressed
Consistency

Of findings across studies
Findings generally consistent in direction and size of effect or degree of association, and statistical significance with minor exceptions at most Inconsistency among results of studies with strong design

OR

Consistency with minor exceptions across studies of weaker designs
Unexplained inconsistency among results from different studies

OR

Single study unconfirmed by other studies
Conclusion supported solely by statements of informed nutrition or medical commentators NA
Quantity
  • Number of studies
  • Number of subjects in studies
One to several good quality studies

Large number of subjects studies

Studies with negative results having sufficiently large sample size for adequate statistical power
Several studies by independent investigators

Doubts about adequacy of sample size to avoid Type I and Type II error
Limited number of studies

Low number of subjects studies and/or inadequate sample size within studies
Unsubstantiated by published studies Relevant studies have not been done
Clinical Impact
  • Importance of studies outcomes
  • Magnitude of effect
Studied outcome relates directly to the question

Size of effect is clinically meaningful

Significant (statistical) difference is large
Some doubt about the statistical or clinical significance of effect Studies outcome is an intermediate outcome or surrogate for the true outcome of interest

OR

Size of effect is small or lacks statistical and/or clinical significance
Objective data unavailable Indicates area for future research
Generalizability

To population of interest
Studied population, intervention and outcomes are free from serious doubts about generalizability Minor doubts about generalizability Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied Generalizability limited to scope of experience NA

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Criteria for Recommendation Rating

Statement Rating Definition Implication for Practice
Strong A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Fair A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences.
Weak A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.
Consensus A Consensus recommendation means that Expert opinion (grade IV)* supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. Practitioners should be flexible in deciding whether to follow a recommendation classified Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.
Insufficient Evidence An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.

Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • Spinal Cord Injury
  • Spinal Cord Injury Nutrition Assessment
  • Spinal Cord Injury Nutrition Diagnosis
  • Spinal Cord Injury Nutrition Intervention
  • Spinal Cord Injury Nutrition Monitoring and Evaluation

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These resources summarize the important studies (randomized controlled trials [RCTs], clinical studies, observational studies, cohort and case-control studies) pertaining to the conclusion statement and provide the study details.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • A primary goal of implementing these recommendations includes improving the nutritional status and quality of life of adults with spinal cord injury. Medical nutrition therapy (MNT) employing a variety of nutrition interventions may result in improved nutritional intake, mobility, nutrition-related clinical parameters, weight management, and improved overall nutritional quality of life. Additional benefits of nutrition care provided by a Registered Dietitian may include increased ability to participate in therapies, reduction in the risk of onset and progression of nutrition-related comorbidities such as pressure ulcers, and increased ability to participate in home and community activities. MNT can reduce complications, decrease length of stay and enhance rehabilitation outcomes.
  • Although costs of MNT sessions and reimbursement vary, MNT is essential for improved outcomes in patients with spinal cord injury. MNT can be considered cost effective when weighing the benefits of appropriate nutrition therapy to prevent co-morbidities versus the cost of medical intervention. For example, MNT to ensure adequate protein and micronutrient intake may promote healthy skin integrity, thus saving the considerable costs of treatment for a developed pressure ulcer.
Potential Harms

Overall Risk/Harm Considerations

Safety issues must be reviewed carefully for each adult with spinal cord injury. General benefits and risks associated with implementation of the guideline are addressed for each recommendation.

When implementing these recommendations:

  • Review the patient's age, socioeconomic status, cultural issues, health history, and co-morbid conditions. An individualized assessment of each patient's home resources, including caregiver availability and meal preparation resources, is vital in this population.
  • Because the life adjustments associated with a catastrophic spinal cord injury are usually overwhelming to both the patient and the patient's family, appropriate consultations with mental health and social services professionals should be considered when planning nutrition care.

Recommendation-Specific Risks/Harms

Role of the Registered Dietician and Provision of Nutrition Support

Provision of nutrition support, including enteral or parenteral nutrition, to nutritionally compromised patients with spinal cord injuries may be associated with patient complications including, but not limited to:

  • Aspiration
  • Infections, including catheter-related infections
  • Metabolic complications resulting from under- or overfeeding
  • Gastrointestinal complications, including diarrhea

Dual-Energy X-ray Absorptiometry (DEXA) Screening

DEXA screening requires exposure to radiation.

Assessment of Energy Needs

Use of predictive equations rather than measured energy expenditure may result in under- or overfeeding persons with spinal cord injury (SCI) and may lead to metabolic complications with subsequent poor outcomes such as obesity, pressure ulcer development, decreased ability to perform activities of daily living (ADLs) and transfers, heart disease and diabetes.

The weight of stabilization devices such as braces and halos should be considered when determining the body weight of persons with spinal cord injury to avoid overfeeding.

Refer to the original guideline document for information on hazards and complications, limitation of the procedure, and infection control in mechanically ventilated patients.

Physical Activity

Physical activity without medical clearance may contribute to further disability or death, thus physician, physiatrist and physiotherapy consultation for exercise recommendations based on level of spinal cord injury should be obtained before beginning an exercise program.

Assessment of Nutrition Needs in Patients with Pressure Ulcers

  • Additional consideration should be given to fluid intake in patients with conditions in which fluid should be restricted such as renal disease, heart failure, and bladder management programs.
  • Vitamin A: Caution that supplementation of Vitamin A, even at the lower range of the recommendations, is not strongly justified. Systematic Vitamin A could potentially reactivate the inflammatory reaction against which the steroid use was aimed. The benefits of high doses should be weighed against the potential risk of toxicity. Use of a water soluble form of Vitamin A should be considered in cases of fat malabsorption.
  • Vitamin C: Use caution with higher doses of vitamin C in those with renal failure due to the possibility of renal oxalate stone formation. Adverse effects such as nausea, abdominal cramping and diarrhea may occur with increased doses.
  • Vitamin E: Use caution when supplementing with Vitamin E, as there is evidence from animal studies that vitamin E may delay wound healing by impairing collagen synthesis.
  • Zinc: High-dose supplementation can adversely affect copper status, immune response and lipid profiles and may cause gastrointestinal (GI) side effects. Some authors have suggested that high-dose supplementation should be limited to two to three weeks to minimize the risk of adverse effects unless justified by ongoing losses. Parenteral dose of zinc is less than oral and enteral recommendations due to differences in bioavailability

Fluid Intake

Provision of inadequate fluid per day (less than 1.5 L fluid per day) or more than 40 mL per kg of body weight fluid per day may result in poor clinical outcomes; adjustment should be made for individual needs such as medical conditions (including but not limited to congestive heart failure, renal disease) or bladder management programs.

Fiber Intake

Failure to monitor fiber intake closely may lead to provision of inadequate or excessive fiber with subsequent poor clinical outcomes such as constipation, bowel impaction, increased amount of stool, excessive flatulence or abdominal distention.

Cranberry Juice

  • Consumption of one to three cups of cranberry juice per day may exceed the patient's caloric requirements, thus promoting obesity
  • Consumption of one to three cups of cranberry juice per day may result in poor blood glucose control in persons with diabetes
  • Consumption of one to three cups of cranberry juice per day may result in noncompliance with medically indicated fluid restriction.

Protein Intake

Protein intake of patients with renal and hepatic dysfunction should be individualized based on the patient’s overall condition. The limit defined in the recommendation may exceed tolerance in these patients.

Contraindications

Contraindications

Clinical judgment is crucial in the application of these guidelines. Careful consideration should be given to the application of these guidelines for patients with significant medical co-morbidities.

The protein needs recommendation may be contraindicated in persons with spinal cord injury who have concurrent hepatic or renal dysfunction.

Qualifying Statements

Qualifying Statements
  • While the American Dietetic Association (ADA) evidence-based nutrition practice guideline represents a statement of promising practice based on the latest available evidence at the time of publication, the guideline is not intended to overrule professional judgment. Rather, it may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance. The independent skill and judgment of the health care provider must always dictate treatment decisions. These nutrition practice guidelines are provided with the express understanding that they do not establish or specify particular standards of care, whether legal, medical or other.
  • ADA Evidence-Based Nutrition Practice Guidelines are intended as a general framework for the care of patients/clients with particular health problems and not for application to the treatment of all patients/clients in all circumstances. Complicating conditions such as severe illness or co-morbidity, for example, may require different treatments or considerations. The independent skill and judgment of the registered dietitian or referring health care provider must always determine treatment decisions. Protocols/guides for practices are provided with the express understanding that they do not establish or specify particular standards of care for legal, medical, or other purposes.
  • While the guideline represents a statement of best practice based on the latest available evidence at the time of publishing, they are not intended to overrule professional judgment. Rather, they may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance.
  • This guideline recognizes the role of patient preferences for possible outcomes of care, when the appropriateness of a clinical intervention involves a substantial element of personal choice or values.

Implementation of the Guideline

Description of Implementation Strategy

The publication of this guideline is an integral part of the plans for getting the American Dietetic Association Medical Nutrition Therapy (ADA MNT) evidence-based recommendations on spinal cord injury to all dietetics practitioners engaged in, teaching about or researching the topic. National implementation workshops at various sites around the country and during the ADA Food Nutrition Conference Expo (FNCE) are planned. Additionally, there are recommended dissemination and adoption strategies for local use of the ADA Spinal Cord Injury Evidence-Based Nutrition Practice Guideline.

The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its implementation. Management support and learning through social influence are likely to be effective in implementing guidelines in dietetic practice. However, additional interventions may be needed to achieve real change in practice routines.

Implementation of the guideline will be achieved by announcement at professional events, presentations and training. Some strategies include:

  • National and local events: State dietetic association meetings and media coverage will help launch the guideline
  • Local feedback adaptation: Presentation by members of the work group at peer review meetings and opportunities for continuing education units (CEUs) for courses completed
  • Education initiatives: The guideline and supplementary resources will be freely available for use in the education and training of dietetic interns and students in approved Commission on Accreditation of Dietetics Education (CADE) programs
  • Champions: Local champions will be identified and expert members of the guideline team will prepare articles for publications. Resources will be provided that include PowerPoint presentations, full guidelines and pre-prepared case studies.
  • Practical tools: Some of the tools that will be developed to help implement the guideline include specially-designed resources such as clinical algorithms, slide presentations, training and toolkits.

Specific distribution strategies include:

Publication in full: The guideline is available electronically at the ADA Evidence Analysis Library website (www.adaevidencelibrary.com External Web Site Policy) and announced to all ADA Dietetic Practice Groups. The ADA Evidence Analysis Library will also provide downloadable supporting information and links to relevant position papers.

Implementation Tools
Clinical Algorithm
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Dietetic Association (ADA). Spinal cord injury (SCI). Evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association (ADA); 2009. Various p. [340 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009
Guideline Developer(s)
Academy of Nutrition and Dietetics - Professional Association
Source(s) of Funding
  • American Dietetic Association
  • Paralyzed Veterans of America (PVA) Education Fund
  • American Dietetic Association Foundation
  • Dietitians in Physical Medicine and Rehabilitation Practice Group
  • Herbert and Nylda Gemple
Guideline Committee

Expert Work Group

Composition of Group That Authored the Guideline

Work Group Members: Angela T. Paison DiTucci, RD, Chair; Vickeri Barton, RD, CD; Erin DeDecker, BSc, HBSc, RD; Mary Ann Djonne, RD, MEd; Yvonne C. Portelli, RD, LD, CDE; Melissa M. Shock, PhD, RD

Financial Disclosures/Conflicts of Interest

In the interest of full disclosure, American Dietetic Association (ADA) has adopted the policy of revealing relationships workgroup members have with companies that sell products or services that are relevant to this topic. Workgroup members are required to disclose potential conflicts of interest by completing the ADA Conflict of Interest Form. It should not be assumed that these financial interests will have an adverse impact on the content, but they are noted here to fully inform readers.

None of the work group members listed above disclosed potential conflicts of interest.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available to members from the American Dietetic Association Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Executive summary of recommendations. Chicago (IL): American Dietetic Association; 2009. Electronic copies: Available from the American Dietetic Association Web site External Web Site Policy.
  • American Dietetic Association spinal cord injury evidence-based nutrition practice guideline. Slide set. Chicago (IL): American Dietetic Association; 2009. Electronic copies: Available for purchase from the American Dietetic Association Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on February 12, 2010. The information was verified by the guideline developer on March 9, 2010.

Copyright Statement

The American Dietetic Association encourages the free exchange of evidence in nutrition practice guidelines and promotes the adaptation of the guidelines for local conditions. However, please note that guidelines are subject to copyright provisions. To replicate or reproduce this guideline, in part or in full, please obtain agreement from the American Dietetic Association. Please contact Kari Kren at kkren@eatright.org for copyright permission.

When modifying the guidelines for local circumstances, significant departures from these comprehensive guidelines should be fully documented and the reasons for the differences explicitly detailed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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