Spinal Cord Injury Update
Spring 2007: Volume 16, Number 2
Literature Review
Pain
Pregabalin in central neuropathic pain associated with spinal cord injury: a placebo-controlled trial.
In a 12-week, multicenter study, 137 patients with SCI were randomized to receive either flexible-dose pregabalin (70 patients) or placebo (67 patients). Patients were allowed to remain on existing stable pain medications. Pain was recorded at baseline and daily throughout the study. The mean baseline pain score was 6.54 in the pregabalin group and 6.73 in the placebo group. The mean endpoint pain score (derived from patients' last 7 days daily pain diary entries) was significantly lower in the pregabalin group (4.62) than the placebo group (6.27), with improvement observed as early as week 1 and maintained for the duration of the study. The average pregabalin dose after the 3-week stabilization phase was 460 mg/day. Pregabalin was also associated with improved sleep, anxiety, and overall status. Mild or moderate, typically temporary, sleepiness and dizziness were the most common side effects. Pregabalin, at a adose of 150 to 600 mg/day, was significantly more effective than placebo in relieving moderate to severe neuropathic pain in patients with SCI.
Siddall PJ, Cousins MJ, Otte A, Griesing T, Chambers R, Murphy TK.
Neurology. 2006 Nov 28;67(10):1792-800.
Bowel management
Progressive protocol in the bowel management of spinal cord injuries.
Although the use of laxatives for neurogenic bowel in SCI is widespread, it is not supported by research evidence and is associated with problems such as dependency and suppression of bowel activity. In this within-subject prospective study of 17 rehabilitation inpatients with SCI, a bowel program that routinely uses laxatives (baseline) was compared to a bowel program that allows the use of physical interventions (abdominal massage, peri-anal digitation, ano-rectal digitation) and rectal stimulants (glycerine suppositories) prior to the use of laxatives (the intervention). Although individual responses varied, the number of successful bowel management episodes requiring laxatives, the time required to evacuation, and the use of manual evacuation were significantly less in the intervention phase than baseline. These findings suggest that use of laxatives in bowel management is not essential for all newly spinal cord injured individuals, while the use of physical interventions in this population may be beneficial..
Coggrave M, Burrows D, Durand MA.
Br J Nurs. 2006 Nov 9-22;15(20):1108-13.
Cardiovascular
Cardiovascular disease in spinal cord injury: an overview of prevalence, risk, evaluation, and management.
Cardiovascular disease (CVD) is now the leading cause of death in chronic SCI, ahead of renal and pulmonary conditions, the primary causes of mortality in previous decades. Nearly all the risk factors for CVD are more common in SCI subjects than the general population, including a greater occurrence of obesity, lipid (blood fat) disorders, metabolic syndrome (a prediabetic condition), and diabetes. Daily energy expenditure is significantly lower in SCI individuals, due to lack of motor function and fewer opportunities to engage in physical activity. Autonomic dysfunction caused by SCI is also associated with conditions that contribute to heightened cardiovascular risk, including abnormalities in blood pressure, heart rate variability, arrhythmias, and a blunted cardiovascular response to exercise that can limit the capacity to perform physical activity. Better recognition of the importance of CVD in SCI, which is often asyumptomoatic and thus undertreated, can reduce illness and death from this disease. This article reviews the cardiovascular consequences of chronic SCI and provides guidelines for screening, recognition and treatment of CVD in SCI, and emphasizes the importance of carefully treating risk factors.
Myers J, Lee M, Kiratli J.
Am J Phys Med Rehabil. 2007 Feb;86(2):142-52.
Respiratory function
Effect of intrathecal baclofen on sleep and respiratory function in patients with spasticity.
Twenty patients (eight with SCI, 12 with other neurological disorders) admitted for implantation of an intrathecal baclofen pump (IBP) for treatment of severe spasticity were followed prospectively in this study. Spasticity assessments, polysomnography (sleep tests), pulmonary function tests, and resting energy expenditure measurements were done 1 week before and at least 8 days after pump implantation. ITB reduced spasticity, improved total sleep time and sleep efficiency, and reduced periodic leg movements. ITB did not modify sleep-related respiratory events, lung function tests, CO2 rebreathing response, or resting energy expenditure. Compared with oral baclofen, intrathecal baclofen infusion did not affect respiratory function and improved sleep continuity.
Bensmail D, Quera Salva MA, Roche N, et al.
Neurology. 2006 Oct 24;67(8):1432-6.
Long-term survival of persons ventilator dependent after spinal cord injury.
The objective of this study was to identify factors related to long-term survival in persons with SCI who are ventilator dependent when discharged from inpatient rehabilitation, and to update estimates of life expectancy, and determine the leading causes of death in this population. Analysis of data from the National SCI Statistical Center on 319 individuals injured from 1973 through 2003 found that age at injury, time since injury, and level and completeness of injury were the key predictor of survival for persons who are ventilator dependent after SCI. The life expectancies were modestly lower than previous estimates. Pneumonia and other respiratory conditions remain the leading cause of death but account for only 31% of deaths of known causes. Whereas previous research has suggested a dramatic improvement in survival over the last few decades in this population, this is only the case during the critical first few years after injury. There was no evidence for such a trend in the subsequent years.
Shavelle RM, DeVivo MJ, Strauss DJ, et al.
Spinal Cord Med. 2006;29(5):511-9.
Urology
Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: a prospective, randomized, multicenter clinical trial.
In this prospective, randomized, multicenter clinical trial, 118 adult patients with spinal cord injury or dysfunction due to multiple sclerosis were randomized to have their indwelling bladder catheters secured in place by using the StatLock device (experimental group; 60 subjects) versus preexisting methods (control group that included tape, Velcro strap, CathSecure, or none; 58 subjects). Patients were monitored for the development of symptomatic UTI within a period of 8 weeks following enrollment. The 2 groups of patients were comparable in terms of clinical characteristics and risk factors for infection. Symptomatic UTI was diagnosed in 8 of 60 (13.3%) patients in the experimental group versus 14 of 58 (24.1%) patients in the control group. Although these results were not statistically significant due to trial size, the finding of a 45% reduction in the rate of symptomatic UTI in patients who received the StatLock securing device is clinically relevant and prompts further investigations.
Darouiche RO, Goetz L, Kaldis T, et al.
Am J Infect Control. 2006 Nov;34(9):555-60.
Accuracy of predicting bladder stones based on catheter encrustation in individuals with spinal cord injury.
In this prospective cohort study, the indwelling catheters of 49 individuals with SCI were examined for encrustation at the time of removal in preparation for cystoscopy. During the cystoscopy the presence or absence of bladder stones was noted. Bladder stones were found in 17 (35%) patients and catheter encrustation was noted in 13. Of these 13, 11 also had bladder stones. Of the 36 individuals who had no catheter encrustation, only 6 (16%) were found to have bladder stones. In this study, catheter encrustation was associated with bladder stones 85% of the time. Since catheter encrustation is highly predictive of the presence of bladder stones, cystoscopy should be scheduled in a person undergoing a catheter change if catheter encrustation is noted.
Linsenmeyer MA, Linsenmeyer TA.
J Spinal Cord Med. 2006;29(4):402-5.
Sexual Function
Spinal cord injury influences psychogenic as well as physical components of female sexual ability.
A survey about sexual function and activity, administered via secure Web site, was completed by 87 women with SCI over age 18. Bladder and bowel incontinence and autonomic dysreflexia were significant concerns and prevented some participants from seeking sexual activity. Most subjects reported difficulty becoming psychologically aroused (74.7%) and physically aroused (87.4%), which were both correlated with feeling that their SCI had altered their sexual sense of self. The majority of subjects reported having experienced intercourse postinjury. Most participants reported difficulty with positioning during foreplay and intercourse, vaginal lubrication, and spasticity during intercourse. Almost half (46%) reported experiencing orgasm postinjury (compared with 82.3% preinjury) and this was positively associated with the presence of genital sensation. SCI significantly impairs psychological and physical aspects of female sexual arousal.
Anderson KD, Borisoff JF, Johnson RD, Stiens SA, Elliott SL.
Spinal Cord. 2006 Oct 10; [Epub ahead of print]
The effects of spinal cord injury on psychogenic sexual arousal in males.
Forty-five men with SCI and 16 able-bodied control subjects underwent a 78-minute laboratory-based protocol in which subjective arousal, penile circumference (PC), blood pressure (BP), and heart rate (HR) were measured in response to separate periods of audiovisual (AV) erotic stimulation and AV erotic combined with manual penile stimulation. Able-bodied subjects generally had significantly greater PC than SCI subjects during the stimulation periods. The degree of preservation of combined pinprick and light touch sensation in the T11-L2 dermatomes distinguished those who did and did not have a significant increase in PC with AV stimulation. BP and HR readings were generally higher in able-bodied than SCI subjects throughout the experimental protocol. However, all readings were within normal limits. We found that the degree of preservation of sensory function in the T11-L2 dermatomes could be used to determine the potential for psychogenic erectile responses in men with spinal cord injury. Results support the hypothesis that psychogenic erection depends on the sympathetic nervous system, and men with sensory function preservation in the T11-L2 dermatomes should be encouraged to maximize the AV aspects of sexual activity to achieve maximum erectile function.
Sipski M, Alexander C, Gomez-Marin O, Spalding J.
Neurosurgery. 2006 Nov;59(5):957-82; discussion 982-7.
Application of 2 vibrators salvages ejaculatory failures to 1 vibrator during penile vibratory stimulation in men with spinal cord injuries.
A retrospective chart review of 297 men with SCI who, between 1991 and 2006, underwent a total of 965 trials of penile vibratory stimulation with high amplitude vibrators. All men underwent 2 or more penile vibratory stimulation trials using 1 vibrator applied to the dorsum or frenulum of the glans penis. Men failing to ejaculate with 1 vibrator received 1 or more trials in which the glans penis was then sandwiched between 2 vibrators. Forty-nine percent of the total, and 57% of those with injuries at T10 or above, responded to penile vibratory stimulation with 1 vibrator. Of those who did not respond with 1 vibrator, 22% responded to stimulation with 2 vibrators. This simple penile vibratory stimulation sandwich method is recommended before referring patients for more the invasive procedures of electroejaculation or surgical sperm retrieval.
Brackett NL, Kafetsoulis A, Ibrahim E, Aballa TC, Lynne CM.
J Urol. 2007 Feb;177(2):660-3.
Shoulder Pain
Clinical trial of exercise for shoulder pain in chronic spinal injury.
Forty-one manual wheelchairs users with SCI and spinal bifida (one subject) were divided into two groups: those with shoulder pain (21) consistent with rotator cuff dysfunction received an 8-week exercise intervention focusing on the scapula; those without shoulder pain (20) did not receive the intervention and served as the control group. All subjects completed shoulder pain and patient satisfaction questionnaires before and after the 8-week period. Subjects in the intervention group were instructed in a home exercise program consisting of stretching and strengthening exercises. Subjects in the intervention group showed significant improvements in all measures as a result of the intervention, whereas asymptomatic control group subjects remained stable. A selective 8-week home exercise program is effective in reducing pain and improving function and satisfaction in this population of wheelchair users.
Nawoczenski DA, Ritter-Soronen JM, Wilson CM, Howe BA, Ludewig PM.
Phys Ther. 2006 Dec;86(12):1604-18.