Appropriate nutritional support is important for the care of hospitalized patients. Undernutrition goes undetected and untreated in many instances, and leads to a wide range of adverse consequences. Evidence from the review of existing literature showed undernutrition to be a common occurrence among patients and has reported percentages ranging from 13%–78% [1,2]. The risk of undernutrition is high among patients diagnosed with spinal cord injury (SCI), and has been reported at 17.4%–46.7% [3,4]. Undernutrition can increase the risk of various complications including infections, impaired wound healing [5], increased hospital stay, and high mortality rates [6].

Drastic changes in the body composition occur following SCI. These include a reduction in the lean soft tissue mass, an increase in fat mass, as well as reductions in the metabolic rate, and in positive energy balance. In addition, the level of physical activity decreases and energy demand increases after an injury event occurs [7,8]. During the acute phase, following an injury, weight loss commonly occurs due to the continued catabolic status [9]. During the chronic phase, the catabolic phase is resolved, but weight gain tendency increases as low activity levels and low metabolic rate continue [10]. Therefore, the determination of adequate amounts of nutritional demand and supply via dietetic assessment is important for SCI patients following their hospital admission. The use of nutritional screening tools is also an important step in nutritional care. Many nutritional screening tools have been developed to assess the nutritional status of hospitalized patients. In this study, we assessed the nutritional status using the malnutrition universal screening tool (MUST) and the spinal nutrition screening tool (SNST).

Major guidelines on the use of nutritional screening tools that assesses various nutritional markers include those developed by the European Society for Parenteral and Enteral Nutrition (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN). The guide-line published by the ESPEN in 2002 recommends the use of the MUST, the Nutritional Risk Screening 2002 (NRS-2002), and the mini-nutritional assessment (MNA) in the assessment of patients in local communities, inpatients, and advanced age patients, respectively [11,12]. The ASPEN recommends the subjective global assessment (SGA), which was initially developed to assess surgical patients, but was suggested as significantly beneficial when applied to the malnutrition assessment of patients with various diseases including renal failure, cancer, and hepatic diseases [13,14]. Velasco et al. [15] compared four different nutritional screening tools for nutritional risk detection, and found the MUST, NRS-2002, and SGA to be appropriate for screening of inpatients’ nutritional status. This is because screening tools ideally should not require too much time and examiner training, and the MUST and the NRS-2002 are simpler compared to the more complex MNA and SGA. Therefore, the MUST and NRS-2002 are the most apt for inpatient assessment.

The SNST [16] is a SCI-specific nutritional screening tool that was developed to overcome the limitation of other nutritional screening tools where changes in the body composition (following the injury of the SCI patients), gave rise to false results. The SNST is the only SCI-specific nutritional screening tool that targets adults. The SNST was initially developed in 2012. Although there is a lack of follow-up studies to validate the SNST relative to the other nutritional screening tools mentioned previously, Wong et al. found the SNST to be a valid (sensitivity 85.7%, specificity 76.1%, PPV 62.0%, NPV 92.0%), and reliable tool (inter-rater reliability k=0.5, intra-rater reliability k=0.64) [16]. Research on malnutrition, particularly, undernutrition in patients with SCI is lacking worldwide and desperately needed.

The aim of this study was to (1) assess the early nutritional status of Korean SCI patients admitted to the rehabilitation hospital of Yonsei University Health System by using the MUST and SNST, and to analyze various nutritional markers; (2) investigate the association between early nutritional status and nutritional markers; and (3) examine the correlation between the nutritional status of SCI patients and clinical outcomes by looking at changes in the functional outcomes measured at the time of hospital admission and at discharge.

The major aim of this study was to use the MUST and the SNST to assess the nutritional status of 130 Korean SCI patients. In previous studies, multi-faceted research on malnutrition related to hospitalized patients’ care were conducted. Various nutritional markers that can be used in nutritional screening include height, weight change, subcutaneous fat, and total body protein mass [19]. All of these nutritional markers are measured, in anthropometric assessments, as biochemical markers, to examine patient’s clinical condition, and to assess the ability to eat. However, controversy exists regarding the nutritional markers that are most appropriate in the assessment of nutritional status. In the assessment of patients’ nutritional status, the use of a variety of markers instead of a single marker should be considered. Wong et al. [3,4] conducted a cross-sectional, multi-center study to investigate the prevalence of malnutrition among SCI patients in the United Kingdom by using the MUST, and the undernutrition risk among patients diagnosed with SCI was reported as 17.4%–46.7%. In this study, where MUST and SNST were used for the nutritional screening, 70 patients (50.8%) and 60 patients (46.2%) had under-nutrition risk based on the MUST and the SNST scores, respectively. The findings of our study are consistent with the findings of the previous literature [3,20]. The likelihood of being assessed as having undernutrition was higher for male patients with complete motor injuries when the MUST was used and also higher for male patients with complete motor injuries and tetraplegia when the SNST was used. Similarly, in a study by Chao et al. [18] on cancer patients, the risk for undernutrition was three times higher among male patients than female patients. However, the assessment of the undernutrition risk based on the NLI and ASIA classification scale (completeness of injury) was published for pediatric SCI patients only [21]. Assessment using STAMP scores showed a higher undernutrition risk for the tetraplegia group compared to the paraplegia group (82.2% vs. 47.5%). And for the complete motor injury group compared to the incomplete motor injury group (51.7% vs. 50.0%); however, the differences in this risk were not statistically significant. The inconsistency between these results and our results may be attributed to the fact that the STAMP assessment involved pediatric SCI patients, and used a small sample size of 45 patients.

The findings of our study indicate that both nutritional screening tools showed cholesterol and hemoglobin concentrations to be lower in the at-risk group. Creatinine levels and albumin concentrations were also significantly lower for the at-risk group with MUST and SNST respectively. In a study conducted by Wong et al. [3], the MUST, protein, albumin, CRP, Hb, Cr, and BMI were significantly lower in the at-risk group. In a later study by Wong et al. [20], the SNST, protein, albumin, CRP, Hb, white cell count, and BMI were significantly lower in the at-risk group. Studies have commonly used the following tools to assess blood test indices and nutritional status: the prognostic nutritional index, the prognostic inflammatory, the nutritional index, and the Maastricht index [22-24]. However, these indices have large periodic variations that reflect individual patients’ nutritional status and reflect other clinical patterns besides the nutritional status. Hence, these indices must be used in conjunction with other markers to assess the patients’ nutritional status. Furthermore, it may be more clinically useful to use a single measurement from a blood test to determine whether or not a patient’s nutritional status has improved following nutritional support, rather than using many measurements. This study was also aimed at investigating the association between the body composition parameters and nutritional status. Only body fat and percent body fat were found to be significantly low in the at-risk group. Further research is necessary to understand the implication of this significant finding.

Many studies have reported on the association between undernutrition and clinical outcomes such as the length of hospital stay and the mortality rate. Repeatedly, it was found that undernutrition increases the length of hospital stay and mortality rates [5,6,20,25,26]. In this study, we investigated the association between undernutrition and the clinical outcomes including motor and sensory recovery, and the changes in functional status assessment results of SCI patients (Table 4). In the functional status assessments (FIM, MBI, SCIM-III), significant differences were found between the low-risk group and the at-risk group. The level of motor and sensory recovery was lower in the at-risk group compared to the low-risk group, but not by a significant difference. There was no difference in neurological recovery (motor scores and sensory scores) according to nutritional status. However, functional recovery was significantly different between groups with different nutritional status. In addition, the reason why functional status assessment results were more significantly correlated with nutritional status compared to the motor sensory recovery may be because the nutritional screening tools also assessed medical problems, and the functional status of the patients may have been compromised due to deconditioning.