Bioelectrical Impedance Analysis for Historical Evaluation in People with Spinal Cord Injury: A Systematic Review

: The objective of this study was to investigate the empirical evidence to support the use of bioimpedance analysis in persons with spinal cord injury (SCI). The Methods: A systematic review of “PubMed/Medline, EMBASE, CINAHL, Web of Science, PSYCHINFO, CINAHL, CENTRAL, and the library Cochrane for systematic review databases” were conducted to determine all possible trials that address “Bioelectrical Impedance Analysis” (BIA) in SCI before September 2020 in English. This systematic review was introduced as stated in the PRISMA Chosen Reporting Article strategies. The study was combined Using Boolean operators “OR” and “AND.” “Bioelectrical Impedance Analysis”, OR “body composition”, OR “fat-free mass”, OR “fat mass”, “Total body water obesity”, OR “weight gain”, OR “body mass index”, AND “Spinal Cord Injury.” The Results: In total, 3354 articles were identiﬁed, but 3303 were excluded. Among the 51 eligible studies, 21 were excluded since they did not fulﬁll the inclusion criteria. Finally, thirty studies fulﬁlled the inclusion criteria. The bioimpedance analysis method is used to estimate the body composition of SCI society during follow-up, rehabilitation therapy, monitoring obesity management, and nutrition; the study observed that BIA is beneﬁcial and predictable for evaluating the patient’s status of body composition. The Conclusion: BIA is a non-invasive, portable, fast, and inexpensive technique. This systematic review recommends further study on BIA to improve medicinal beneﬁts in prediction.


Introduction
Bioelectric impedance analysis (BIA) is a widely used technique for evaluating body composition (BC) and assessing clinical diagnostic tests [1][2][3]. Thus, BIA allows calculating or measuring necessary body compartments, such as: "Body Cell Mass (BCM), Body Mass Index (BMI), Fat Mass (FM), Fat-Free Mass (FFM), Total Body Water (TBW), Extracellular Water (ECW), Intracellular Water (ICW), Basal Metabolic Rate (BMR), Phase Angle (PhA), Resistance (R), Reactance (Xc), Body Capacitance (C)" [4][5][6][7]. There is a full range of physical training in clinical and healthcare tools, such as disease diagnosis and vital body condition detection. Accordingly, along with this comprehensive practice, we feel this necessitates a survey of essential features for bioimpedance analysis's clinical assessment and health care purposes [3,8]. Hence, articles on BIA since 1962 have been published. Thomasset examined the use of bioimpedance in the overall assessment of TBW using needle electrodes. Nyboer presented quadruple surface electrodes for bioimpedance measurements to determine an individual's FFM [9,10]. Hoffer discussed the relationship between tritium dilution techniques and TBW concentration. Natural resistance is defined as the capacity of biological tissues to obstruct electrical flow [11]. Bio-impedance analysis methods have been used because of their non-invasive approach, low cost, simplicity, and mobility. Therefore, numerous researchers have published BIA analysis experiments, demonstrating their use for calculating BC and measuring clinical fitness [12]. An examination of BIA criteria for assessing BC and monitoring chronic diseases using an inclusive collection of standards, widely used formulae, and novel techniques was developed [13]. H. Lukaski examined the conceptual requirements for evaluating bioimpedance to quantify physiological activity and predict illness. Scientists found that the multiple regression techniques used in the critical analysis of bioimpedance have limited utility in assessing an individual's capability. Accordingly, BIA may be classified as a measurement technique incorporating single or multiple MF [14]. Bioimpedance measurements were performed throughout the body using frame segments and other approaches. Various studies have examined BIA in SCI and shown its validity; for example, in an article published in 1995, Allison and his coworkers discovered that muscle potential in patients with spinal cord injuries is less influenced by cables linked to the lower limbs [15].
Similarly, in 1997, Kacina Paula has studied the BIA estimates of the BC of SCI adults. He found that FFM and total body fat measures are obtained [15]. Hence, skinfold and bio-impedance equations may be developed to estimate the BC of SCI accurately. In 2000, J. C. Desport et al. demonstrated that BIA's validity estimates the TBW and FFM in BC. The authors reasoned that utilizing BIA is better when comparing results with other methods [16].
Consequently, in 2007, C. Liu S. et al. considered BIA a simple, non-traumatic, and dependable process to analyze BC [17]. Azevedo and colleagues demonstrated that BIA is an effective, sensible, and practical technique for diagnosing obesity in SCI individuals [18]. Moreover, obesity or high-fat percentage and FM increase the risk of SCI patients. Additionally, in 2017, M. G. Panisset et al. established that BIA is feasible to implement for the classification of obesity in acute SCI [19]. This review aimed to emphasize the historical evolution role of bioimpedance analysis and validation of BIA for patients with SCI. In conclusion, the exercises improve the rehabilitation of SCI patients. We indicated that BIA effectively predicted the FFM, FM, MM, and TBW.

Materials and Methods
The "PubMed/Medline, EMBASE, CINAHL, Web of Science, PSYCHINFO, CEN-TRAL, and the library Cochrane of systematic review databases" were screened to find all possible trials published before September 2020 in English. This systematic review was initiated with the PRISMA Preferred Reporting Article strategies ( Figure 1) [20] to study published trials that have reported using Boolean operators "OR" and "AND "of the following keywords: "BIA", 'or,' "Bioimpedance", 'or,' "Body Composition", 'or,' "fat-free mass", 'or,' "fat mass", 'or,' "Total body water", 'or,' "obesity", 'or,' "Body mass index", 'And,' "spinal cord injury." The title and abstracts of publications were updated throughout the screening step, and duplicate research was eliminated. Following that, copies of the entire text were screened to determine their suitability for a systematic review. The inclusion criteria were broad and included any observational reviews with BIA and SCI regardless of the study, age, gender, or clinical environment. The research was completed in combination with medical history and information about other global locations. Reviews that did not include BIA or SCI parameters were omitted because they did not meet the requirements for a systematic review. The authors included this review due to their efforts to validate BIA in evaluating people with SCI.

Results and Discussion
Overall, 3354 reviews and the exclusion of 3303 references were identified. Twenty-one articles were excluded from the fifty-one qualifying studies since the revisions did not follow the inclusion criteria. As seen in Figure 1, PRISMA, thirty studies were finally reached and were incorporated into this study. In Table 1, we will briefly explain historical evidence of the role of bioimpedance analysis of BC in chronic SCI. The study was the first successful bioimpedance experiment using needles of low frequency. Experiment.
2 E.C. Hoffer et al., 1969 [9,10] Conducted experiments to prove the relationship between TBW and "biological impedance." Impedance estimation can be applied to conclude TBW. Hoffer proved the equation of the impedance index used in BIA.
Experiment. The body posture affects a person's bioelectrical resistance. Thus, passive resistance can be expected from assessments in a wheelchair.
BIA, BC. 9 Kacina.Paula. 1997 [27] The BIA estimated the BC of SCI Adults; reference FFM and total body fat (TBF) were obtained. Hence, skinfold and bio-impedance equations may be developed to estimate SCI's BC accurately.
BIA, BCM 11 Mikes et al., 1999 [29] BIA is predicated on how voltage alters when current flows through new surfaces. These progressions determined the attendant properties of these materials. Many scientists have investigated various techniques for evaluating body composition and the gap between them. There is a growing interest in indirect ways of estimating BC utilizing BIA measurements in epidemiological and clinical research [45]. These investigations demonstrated that researchers created novel equations and the role of BIA in enhancing performance. Seven studies were addressed in the first section of Table 1, addressing the development of new experimental prediction equations for use with the SF-BIA device. At 50 kHz, these equations were used in SF or MF to calculate parameters such as TBW, ICW, ECW, BCM, BMI, percent FM, FFM, PhA, resistance, and reactance. Thus, the majority of variables in the equations were created. The second section of Table 1 summarizes three experiments using the MF method to create new equations that included gender and age [9,46]. A direct sectional analysis created the world's first eight-point tactile electrode device. Recently developed by Dr. Kichul Cha's five separate body parts, impedance is measured using MF [40]. Consequently, scholars measured and validated the BC's BIAderived TBW and FFM values. The researchers contend that using BIA produces good performance compared to other techniques. In the third part of Table 1, thirteen studies have demonstrated that BIA's use in SCI has been confirmed to be extremely specific but barely susceptible to the disparity between obese and non-obese people with paraplegia. It is feasible to predict TBW, FFM, FM, and ECW quite well using a specific frequency computed by Bugaresti et al. to categorize SCI-specific BMI. As observed in the findings, BMI is often documented in the spinal cord literature. Years later, S. De Groot et al. discovered that when individuals who might have SCI undergo inpatient therapy, their BMI increases, with higher increases appearing within the year after release [47]. C. Yarar-fisher et al. have verified that the adiposity of BMI in women with SCI is reduced. Additionally, the BMI of the SCI population is substantially higher than the average population. Hence, it requires more studies on SCI across various injuries and validates BMI. Likewise, TY. Chiu et al. have emphasized that the BC of subjects with SCI differed from other non-SCI due to their injury. Consequently, the BIA way shows a suitable technique to evaluate SCI for BC calculation. Additionally, BIA has established that assessing obesity in individuals with SCI was a valid, feasible, and effective practice. In addition, high-fat percentage and FM increase the risk of SCI patients [48]. BIA has recognized validation for the classification of obesity in acute SCI [19]. In a recent study, the evaluation and classification of overweight persons with SCI were performed using BIA parameters such as BMI, BF%, and body weight. Henceforth, studies have exposed that SCI literature uses BMI as the most commonly used indicator of obesity [44]. Studies have shown a considerably lower body fat percentage in training with an FES rowing machine powered by a motor, as in the fourth part of Table 1. Exercise helped the patients improve BC in persons with SCI [49]. D. Kim et al. have verified that exercising with an indoor hand bike is an operative modality to enhance BC, fasting insulin, and healthiness in individuals with SCI [37]. Additionally, K. H. Cho et al. have proved that mass BC has no direct consequence on seat interface pressure under other conditions. Accordingly, reduced SMM and body water may affect the development of pressure sores [50].
Hereafter, C. Matthias et al. have provided new valid and unbiased standards for TBW, ECW, and ICW assessment in national athletes from different athletic. Hence, the new measures would ensure careful hydration control with applicability and benefits for athletes and medical experimenters since TBW and its sections are significant in health and athletic efficiency. Here, the exercises helped improve individuals with SCI rehabilitation [40]. Additionally, the level of injuries in the spinal showed a difference in the measurement using the BIA instrument. Hence, this difference should be considered when measuring persons with SCI. BIA is non-invasive and considered a simple, non-traumatic, low-cost, and reliable method to examine BC.

Limitations of the Study
There are certain limitations in this study that must be addressed. One instrument technique was included in this research. Many methods may be added in future research. Increased knowledge of these changes may be achieved by conducting biomedical and clinical investigations. We omitted non-English publications to avoid publication bias.
Additionally, we found locked sources for some parameters in our study. Hence, these were not included in the study. We did not find more studies on BCM and BMR parameters.
Despite these limitations, the research showed significant changes in body composition of individuals with spinal cord injuries, especially BMI, BFP, FM, TBW, and FFM. Thus, bio-impedance is a unique technique for determining BC and a patient's health status.

Conclusions
Bioimpedance analysis is a method used to estimate the body composition of individuals with SCI. Numerous academics and physicians have verified BIA diagnostic and therapeutic relevance. BIA has been used during the rehabilitation of SCI, and it has helped measure body composition. Accordingly, the level of injuries in the spinal has shown a difference in the measurement using the BIA tool. So, this difference should be considered when measuring SCI patients. Thus, the study revealed that BIA is beneficial and predictable for evaluating patients' status and clinical treatment. Therefore, BIA is an inexpensive technique but still not common practice. Furthermore, this systematic review recommends further research on BIA to enhance medical benefits in SCI body composition compartments equation. It suggests the BIA method because of its non-invasive, perfect results, portable, quickness, ease, and low-cost qualities.