Spinal Cord Injury Update
Winter 2006: Volume 15, Number 1
Literature Review
Complications
Transcutaneous electrical nerve stimulation versus baclofen in spasticity: clinical and electrophysiologic comparison.
This randomized controlled trial included 21 adult patients with SCI and painful and/or ADL-limiting spasticity. Ten patients were randomized to receive oral baclofen treatment (gradually increased from 5 mg to 80 mg over 8 weeks) and 11 to transcutaneous electrical nerve stimulation (TENS) treatment (applied to the tibial nerve in 15-minute sessions over 15 days at a frequency of 100 Hz). Posttreatment evaluation was made 24 hrs after the 15th session in the TENS group. Clinical and electrophysiologic evaluations of the lower limb and functional evaluations were carried out in both groups before and after treatment. Significant improvement was detected in lower limb Ashworth score, spasm frequency scale, deep tendon reflex score, functional disability score, and FIM in the baclofen and TENS groups. Decrease in H-reflex maximum amplitude was significant in the TENS group. The percentage change in clinical, electrophysiologic, and functional variables caused by baclofen was not different from that caused by repeated applications of TENS in the short- and long-term evaluations. TENS is a noninvasive method that has few side effects and no drug interactions or toxicity, can be self-administered, and is less costly than baclofen. It may be helpful as a supplement to medication in the treatment of spasticity.
Aydin G, Tomruk S, Keles I, et al.
Am J Phys Med Rehabil. 2005 Aug;84(8):584-92.
Fitness, inflammation, and the metabolic syndrome in men with paraplegia.
Twenty-two men (T2-L2; average age 39; average duration of injury 17 years) with complete paraplegia were tested for peak aerobic capacity, physical activity, functional ability, and presence of metabolic syndrome (characterized by high-density lipoprotein cholesterol [ HDL -C], triglycerides [TG], glucose, insulin, abdominal obesity, high blood pressure), and inflammatory factors (interleukin-6 [IL-6], C-reactive protein [CRP]). Participants did not have diabetes, coronary heart disease or any acute infections. On average, participants were overweight, had low HDL -C levels, and had higher IL-6 and CRP values (42% and 62% higher, respectively) than healthy non-disabled men, suggesting the presence of chronic low-grade infection. Lower peak aerobic capacities were associated with lower HDL -C and lower physical activity levels, which in turn were associated with higher fasting glucose, lower HDL -C level, and larger abdomen girth. Larger abdomen was associated with higher fasting glucose, higher fasting and post load insulin, lower HDL -C, higher TG, and higher CRP levels. These findings suggest that metabolic syndrome is common in SCI ; diet and exercise trials are needed to determine the benefit of lifestyle interventions aimed at slowing the progression of the metabolic syndrome in this population.
Manns PJ, McCubbin JA, Williams DP.
Arch Phys Med Rehabil. 2005 Jun;86(6):1176-81.
Depression following traumatic spinal cord injury.
This was a retrospective record of 201 individuals who sustained SCI between April 1994 and March 1996 and were followed for up to six years. During the follow-up period (mean 4.79 years), 58 (28.9%) individuals were treated for depression, 34 (58.6%) of these during their initial hospitalization (acute and rehab); 6 (10.3%) during the remainder of their first post-injury year; 10 (17.2%) in year two; four (6.9%) each in years three and four. Individuals at highest risk were those with a pre-injury history of depression, a history of substance abuse, or permanent neurological deficit. Because depression occurs commonly and early in persons with SCI , a detailed psychiatric history should be completed for all SCI patients, and those with a history of depression should be offered focused assessment and psychological care both during inpatient stay and post-discharge.
Dryden DM, Saunders LD, Rowe BH, et al.
Neuroepidemiology. 2005;25(2):55-61. Epub 2005 Jun 8.
The effects of lower-extremity functional electric stimulation on the orthostatic responses of people with tetraplegia.
Orthostatic hypotension (blood pressure drops when assuming an erect posture) is a common problem for persons with cervical or high thoracic SCI and can restrict active participation in rehabilitation and potentially hasten the development of undesirable secondary complications related to immobilization. Sixteen acute and chronic subjects with motor complete tetraplegia (C3-7) were tested on a progressive head-up tilting maneuver with and without the application of functional electric stimulation (FES) to the lower extremities. When the tilt angle was increased (at angles of 0°, 15°, 30°, 45°, 60°, 75°, and 90° continuously for up to 1 hour), blood pressure tended to decrease while heart rate increased. The application of FES during the tilting maneuver lessened the drop in blood pressure and reduced the compensatory increase in heart rate. This application allows people with tetraplegia to stand up more frequently and for longer durations.
Chao CY, Cheing GL
Arch Phys Med Rehabil. 2005 Jul;86(7):1427-33.
Plasma glutamine concentration in spinal cord injured patients.
Reduction in plasma concentration of the amino acid glutamine is related to loss of immune function. Glutamine is largely produced by the skeletal muscles, which are severely compromised in persons with SCI , and this may be an important contributor to immunosuppression seen in SCI patients. In this clinical trial, blood was collected from seven subjects with complete SCI and 11 non-injured, sedentary controls before and after a treadmill exercise session. Samples were analyzed for plasma glutamine and glutamate concentrations and cytokine production by peripheral blood mononuclear cells. SCI subjects had 54% less plasma glutamine concentration than controls, as well as a decrease in the production of TNF and IL-1 by peripheral blood mononuclear cells cultivated for 48 hours.
Rogeri PS, Costa Rosa LF.
Life Sci. 2005 Sep 23;77(19):2351-60.
Genitourinary
Successful pregnancy achieved by intracytoplasmic sperm injection using cryopreserved electroejaculate sperm in a couple both with spinal cord injury: a case report.
A couple in which both the man and woman had SCI achieved pregnancy after intracytoplasmic sperm injection (ICSI) with cryopreserved electroejaculate sperm. The 33-year-old husband (T10 complete) had low sperm motility and quality. Sperm were collected from two electroejaculations and cryoperserved. The 30-year-old wife had L2 paraplegia with cauda equina syndrome, regular menstrual cycles, and normal hormone levels, uterus and ovaries. After controlled ovarian hyperstimulation, 10 oocytes were retrieved. Eight mature oocytes were injected using thawed sperm, resulting in 5 normal zygotes. Four embryos were transferred into the uterus. Pregnancy was achieved, and a healthy female baby was delivered vaginally at 39 weeks of gestation. The use of cryopreserved electroejaculated sperm for ICSI can avoid the inconvenience or cost to the patient of repeated electroejaculations.
Chen SU, Shieh JY, Wang YH, et al.
Arch Phys Med Rehabil. 2005 Sep;86(9):1884-6.
Abdominal electric stimulation facilitates penile vibratory stimulation for ejaculation after spinal cord injury: a single-subject trial.
A 37-year-old male with complete T3 SCI , 18 years post-injury, underwent penile vibratory stimulation (PVS) alone and PVS with abdominal electric stimulation ( AES ). Stimulation was presented to the frenulum using a Ferti Care Personal vibrator set at maximal settings. AES was applied to the abdomen using a commercially available muscle stimulator at maximal stimulus intensity and duration settings. Single-subject trials were randomized to PVS only or PVS plus AES . Ejaculates were produced in 4 of 30 trials (13.3%) with PVS alone but in 31 of 34 trials (91%) with PVS plus AES . There were no significant differences in time to ejaculation between the two techniques. AES significantly increased the success rate for ejaculation with the use of PVS compared to PVS alone.
Goetz LL, Stiens SA.
Arch Phys Med Rehabil. 2005 Sep;86(9):1879-83.
Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study.
Fifty-nine patients (53 with SCI ; 6 with MS) with urinary incontinence caused by neurogenic detrusor overactivity and using clean intermittent self-catheterization were randomized to receive a single dose into the detrusor of BTX -A (200 U or 300 U) or placebo. Urodynamic assessments to measure maximum cystometric capacity, reflex detrusor volume and maximum detrusor pressure during bladder contraction were performed at baseline, 2, 6 and 24 weeks. Changes in daily frequency of urinary incontinence episodes were monitored via a patient bladder diary over 24 weeks, and quality of life was assessed using the Incontinence Quality of Life questionnaire. Incontinence episodes decreased significantly from baseline, and there were significant improvements in bladder function and patient quality of life in the two BTX -A treatment groups but not in the placebo group. Benefits were observed from the first evaluation at week 2 to the end of the 24-week study. No safety concerns or adverse events were raised. No clear dose difference between the 220 U and 300 U groups were found.
Schurch B, de Seze M, Denys P, et al
J Urol. 2005 Jul;174(1):196-200.
Respiratory
Long-term treatment of sleep apnea in persons with spinal cord injury.
Postal surveys were sent to 72 SCI patients with sleep apnea. Forty individuals responded (54%), most (92%) had tetraplegia, and the average time since diagnosis of sleep apnea was 4 years. Continuous positive airway pressure (CPAP) had been tried by 80%, which 63% continued to use at the time of the survey for an average of 6.5 nights per week and 6.9 hrs per night. CPAP was rated as beneficial in comparison with its side effects. The most common side effects were nasal congestion and mask discomfort. Many SCI individuals with sleep apnea become long-term users of CPAP and perceive a subjective benefit from the treatment.
Burns SP, Rad MY, Bryant S, Kapur V.
Am J Phys Med Rehabil. 2005 Aug;84(8):620-6.
Combined intercostal and diaphragm pacing to provide artificial ventilation in patients with tetraplegia.
Four ventilator-dependent subjects with SCI and only unilateral phrenic nerve function received a surgical procedure in which a multipolar epidural disk electrode was positioned on the ventral surface of the upper-thoracic spinal cord via a hemilaminectomy to activate the inspiratory intercostal muscles. A phrenic nerve electrode was implanted unilaterally via the thoracic approach. After two weeks of recovery followed by muscle reconditioning, all subjects were able to significantly increase their respiratory capacity and achieved substantial independence (16 to 24 hours per day) from mechanical ventilatory support. Subjects reported improved sense of smell, mobility, quality of speech and overall sense of well-being. One subject became employable as a result. This combined intercostal and diaphragm pacing technique allows ventilator-dependent individuals who are not candidates for conventional phrenic pacing alone to breathe more normally, eliminating many of the disadvantages of mechanical ventilation.
DiMarco AF, Takaoka Y, Kowalski KE.
Arch Phys Med Rehabil. 2005 Jun;86(6):1200-7.
Other
Lidocaine anal block limits autonomic dysreflexia during anorectal procedures in spinal cord injury: a randomized, double-blind, placebo-controlled trial.
In this double-blind study, 26 patients with SCI at or above T6 who were already scheduled to undergo anorectal procedures (flexible sigmoidoscopy and/or anoscopic hemorrhoid ligation) were randomized to receive either intersphincteric anal block with 1 percent lidocaine (12 subjects) or normal saline (placebo) (13 subjects) before the procedure. Blood pressure was measured before, during, and after the block and procedure. The mean maximal systolic blood pressure increase for the lidocaine group was significantly lower than the placebo group, demonstrating that lidocaine anal block significantly limits the autonomic dysreflexia response in susceptible patients undergoing anorectal procedures, which are common in this population.
Dis Colon Rectum. 2005 Aug;48(8):1556-61.
Cosman BC, Vu TT.