Literature Review

Complications

Longitudinal analysis of cartilage atrophy in the knees of patients with spinal cord injury.
The right knees of 9 patients with complete, traumatic SCI were examined using magnetic resonance imaging shortly after the injury and at 6 and 12 months postinjury. Total knee cartilage volume (patella, medial and lateral tibia, and medial and lateral femur) was reduced by 7% at 6 months postinjury and by 10% by 12 months. The change was significant in all compartments but there was no significant difference in the rate of change between the 5 cartilage plates. All patients received a standard program of physical therapy after injury. Patient age was not a factor in these changes. The annual changes exceed those that occur during normal aging by a factor of more than 20:1. These changes may render the joint vulnerable to osteoarthritic degeneration. Post-SCI remobilization programs such as functional electrostimulated cycling or treadmill training using robotic orthosis to offset these changes should be investigated.
Vanwanseele B, Eckstein F, Knecht H, et al.
Arthritis Rheum. 2003 Dec; 48(12): 3377-81.

Spinal Cord Injury Risk Assessment for Thromboembolism (SPIRATE Study) .
A chart review was conducted of 243 patients admitted to hospital with acute SCI and assessed for deep vein thrombosis (DVT) to determine risk factors for venous thromboembolism (VTE). A total of 51 (21%) of the 243 patients were diagnosed with a DVT. Data analysis showed the highest risk for DVT was in patients with cancer over age 35. Women between age 36 and 58 without cancer were also at increased risk, as were cancer-free men with flaccid paralysis. The authors conclude that patients with SCI who are older, obese, and have flaccid paralysis or cancer should receive vigorous prophylaxis against VTE.
Green D, Hartwig D, Chen D, et al.
Am J Phys Med Rehabil. 2003 Dec; 82(12): 950-6.

Treatment of spasticity in a spinal cord-injured patient with intrathecal morphine due to intrathecal baclofen tolerance-a case report and review of literature.
A 36-year-old man with T6 complete paraplegia developed tolerance to increasing doses of intrathecal baclofen to treat his spasticity. He was switched to a continuous infusion of morphine intrathecally, and a low dose (300 mg) was effective in controlling spasticity for at least 13 months. The patient reported improvement in function and was able to return to work. Treatment with intrathecal morphine may be useful in spinal cord-injured patients with severe spasticity who become tolerant to intrathecal baclofen.
Soni BM, Mani RM, Oo T, Vaidyanathan S.
Spinal Cord. 2003 Oct; 41(10): 586-9.

Spinal cord injury and use of botulinum toxin in reducing spasticity.
Spasticity is common after SCI, and a large percentage of patients with SCI need treatment to control it. Drug therapy (such as oral or intrathecal baclofen, diazepam, tizanidine and phenol blocks) can be effective in controlling spasticity in most patients, but in some cases is inadequate and/or causes intolerable side effects. Botulinum toxin avoids sedation; does not require surgery; is simpler and less painful than phenol injections; and the amount of botulinum toxin and the injection sites can be tailored to meet individual patient needs. Botulinum toxins can reduce spasticity for approximately three months after injection, improving function and reducing the amount of needed assistance.
Fried GW, Fried KM.
Phys Med Rehabil Clin N Am. 2003 Nov; 14(4): 901-10.

Musculoskeletal

Shoulder pain, range of motion, and functional motor skills after acute tetraplegia.
Demographic information and measurements of pain intensity (using the 101-point Numerical Rating Scale), shoulder range of motion (ROM), and functional motor skills (using the Clinical Outcome Variables Scale-COVS) were obtained in this longitudinal study of 35 inpatients with acute tetraplegia. Pain prevalence during rehabilitation was 85%. Risk factors associated with pain during rehabilitation included age less than 30 years or more than 50, higher level of SCI (at or above C5), and shorter duration of bedrest. Subjects with pain lost ROM in left abduction and right abduction during rehabilitation. There was no relationship between pain and functional motor skills on discharge or on ASIA scores. The authors identify study limitations (small number of subjects, heterogeneous nature of the group, and the limited nature of the COVS), and suggest further areas of study.
Salisbury SK, Choy NL, Nitz J.
Arch Phys Med Rehabil. 2003 Oct; 84(10): 1480-5.

Rotator cuff repair in spinal cord injury patients.
This retrospective review reports on 5 male patients with 8 rotator cuff tears confirmed by physical exam and magnetic resonance imaging who underwent rotator cuff repair. Two of 8 shoulders were revisions. The patients were evaluated postoperatively with the American Shoulder and Elbow Surgeons Scoring System. These results were compared with preoperative functional assessment. Patients were given a subjective questionnaire to assess their overall experience. Postoperative range of motion improved and strength increased in 6 of 8 shoulders. Patients reported satisfaction with the results in 7 of 8 shoulders, and all 5 patients would recommend the procedure to other SCI patients. At recent follow-up, 7 of 8 shoulders returned to their preinjury level of function. Since compliance with the demanding postoperative rehabilitation is essential for success, proper patient selection is crucial.
Popowitz RL, Zvijac JE, Uribe JW, et al..
J Shoulder Elbow Surg. 2003 Jul-Aug; 12(4): 327-32.

Shoulder magnetic resonance imaging abnormalities, wheelchair propulsion, and gender.
Pushrim force data and bilateral shoulder magnetic resonance images (MRI) were obtained at baseline and 2 years later on 14 subjects with SCI (8 males; 6 females) who use manual wheelchairs. Peak pushrim forces in a pushrim coordinate system were calculated. MRI abnormalities were graded using a summated scale, and differences between the two MRI scores were calculated. Seven subjects (including all the females) were in the group with worsening scores, and 7 were in the group with improving or unchanging scores. Subjects who propelled with a greater percentage of force directed toward the axle were at increased risk of progression of MRI findings over time. Proper propulsion techniques that reduce forces during wheelchair propulsion may minimize the likelihood of developing shoulder injuries.
Boninger ML, Dicianno BE, Cooper RA, et al.
Arch Phys Med Rehabil. 2003 Nov; 84(11): 1615-20.

Personal Adjustment

Years to employment after spinal cord injury .
Surveys were given to 259 participants with SCI for at least 2 years who had been employed at some time since injury. Average age was 46.4 years, age at injury 22.9 years, and time since injury 23.7 years. Participants averaged 4.8 years from the time of SCI onset to their first postinjury job and 6.3 years until their first full-time postinjury job. Time to return to gainful employment was found to depend largely on education level at injury and on whether the individual returned to the preinjury job, was working as a professional at the time of injury, or had a noncervical injury.
Krause JS
Arch Phys Med Rehabil. 2003 Sep; 84(9): 1282-9

Urology

Bladder management and risk of bladder stone formation in spinal cord injured patients.
A retrospective cohort study of 457 patients with SCI and more than 6-months of follow-up care found that patients whose bladder management was either indwelling or suprapubic catheterization had a significantly greater risk of bladder stone formation (for both, an annual risk of first stone 4%; of recurring stones 16%) than those who used intermittent self-catheterization (ISC) or condom catheters (annual risks of 0.2% and 0%-0.5%, respectively). The indwelling and suprapubic catheter group was also the only group to get recurrent stones. These risks occur independently of age, sex and injury level. While ISC is considered the "gold standard" for managing the neuropathic bladder, many patients are unable to use this method because of limited hand function, or must change from this method due to problems such as incontinence or hydronephrosis. The researchers conclude that long-term use of indwelling or suprapubic catheterization should be avoided in this population whenever possible.
Ord J, Lunn D, Reynard J
J Urol. 2003 Nov; 170(5): 1734-7

Tamsulosin: efficacy and safety in patients with neurogenic lower urinary tract dysfunction due to suprasacral spinal cord injury.
A total of 263 patients with neurogenic lower urinary tract dysfunction secondary to suprasacral SCI were randomized to 4-week double-blind therapy with placebo, or 0.4 or 0.8 mg tamsulosin once daily. Of these, 244 patients completed the randomized controlled trial, 186 continued long-term tamsulosin therapy (0.4 or 0.8 mg once daily), and 134 continued treatment for one year. Although the mean decrease in maximum urethral pressure (MUP) at 4 weeks in the treatment groups compared to placebo did not reach statistical significance, in the long-term study there was a statistically significant mean decrease in MUP from baseline to end point, a decrease in maximum urethral closure pressure, improved cystometry parameters related to bladder storage and emptying, and increased mean voided volume based on the micturition diary. There was statistically significant improvement in symptoms and quality of life as reported by subjects. Both doses were effective and well tolerated. The results suggest that tamsulosin improves bladder storage and emptying, and decreases symptoms of autonomic dysreflexia.
Abrams P, Amarenco G, Bakke A, et al.
J Urol. 2003 Oct; 170(4 Pt 1): 1242-51.

An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients.
Fifteen male volunteers with hyperreflexic neurogenic bladder and detrusor external sphincter dyssynergia caused by complete suprasacral SCI underwent limited hemilaminectomy and ventral root (VR) micro anastomosis between the L5 and S2/3 VRs. The L5 dorsal root was left intact as the trigger of micturition after axonal regeneration. Mean follow-up was 3 years. Urodynamic studies found 10 (67%) patients regained satisfactory bladder control within 12 to 18 months after the procedure, and voided by initiating the skin-CNS-bladder reflex (scratching the skin). Average residual urine decreased from 332 to 31 ml and urinary infection as well as overflow incontinence disappeared. Two patients (13%) who required a skin stimulator to evoke voiding following the VR anastomosis had partial recovery but more than 100 ml residual urine. One patient was lost to follow-up and 2 had failure.
Xiao CG, Du MX, Dai C, et al.
J Urol. 2003 Oct; 170(4 Pt 1): 1237-41.

Other

The predictive value of creatine phosphokinase and alkaline phosphatase in identification of heterotopic ossification in patients after spinal cord injury.
In a prospective cohort study of 18 adults with acute SCI, creatine phosphokinase (CPK) and alkaline phosphatase (ALP) were assessed approximately 3 weeks after injury. Conventional hip radiographs were also taken approximately 3 weeks after injury and again between 3 and 6 months after injury. Patients were later separated into 2 groups: group 1 included subjects who developed heterotopic ossification (HO) and group 2 included those who did not. Initial radiographs showed no evidence of HO in either group. The radiographs taken at 3 to 6 months showed HO in 7 of 18 patients. The levels of CPK at the initial evaluation were significantly higher in group 1 than in group 2 and correlated with the severity of HO. There was no correlation between serum ALP levels and subsequent development of HO between the 2 groups. Elevated serum levels of CPK have value in predicting HO.
Singh RS, Craig MC, Katholi CR, et al.
Arch Phys Med Rehabil. 2003 Nov; 84(11): 1584-8.

Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals.
Six subjects with recent SCI were randomly assigned to a high-intensity (HI) or low-intensity (LI) arm training program of one-hour interval training, 3 times a week for 8 weeks. In addition, 11 subjects with SCI underwent an insulin sensitivity test followed by an exercise test in the same week. The 8-week training program resulted in a significant increase in peak aerobic capacity (VO2Peak) and maximal power output (POMax) for the group as a whole, and there was a greater increase in both VO2Peak and total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio, and a greater decrease in triglycerides, in the HI group than in the LI group. A significant positive correlation was found between VO2peak and insulin sensitivity. Improvements in physical capacity and lipid profile were more pronounced in response to high-intensity training. As in the able-bodied population, peak aerobic capacity is a predictive value with regard to insulin sensitivity in persons with SCI.
de Groot PC, Hjeltnes N, Heijboer AC, et al.
Spinal Cord. 2003 Dec; 41(12): 673-9.