Spinal Cord Injury Update
Summer 2009: Volume 18, Number 2
Literature Review
The articles previewed below were selected by the editors because they include potentially useful information on the diagnosis or management of spinal cord injury and its complications. How to obtain complete articles.
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Bladder & Bowel
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Bone Health
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Breathing & Cough
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Exercise & Fitness
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Male Fertility
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Mortality
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Nutrition
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Wheelchair Seating & Propulsion
Bladder & Bowel
Long-term outcomes of external sphincterotomy in a spinal injured population.
External sphincterotomy surgery is often the treatment of choice for people with SCI and detrusor-sphincter dyssynergia (bladder spasticity) who cannot use intermittent catheterization. This study followed 84 individuals with SCI who had undergone external sphincterotomy. The mean duration of success was 81 months. A second procedure was required in 30 patients and mean duration of success thereafter was 80 months. Recurrent symptomatic episodes of urinary tract infection, recurrent detrusor-sphincter dyssynergia or upper tract dilatation eventually occurred in 57 of 84 patients (68%). Renal failure did not develop in any patients. External sphincterotomy protects the upper renal tracts and provides extended periods of satisfactory bladder emptying. However, it may require ongoing revision and should potentially be regarded as an ongoing intervention.
Pan D, Troy A, Rogerson J, et al.
J Urol. 2009 Feb;181(2):705-9. Epub 2008 Dec 16.
Efficacy of functional magnetic stimulation in neurogenic bowel dysfunction after spinal cord injury.
In this longitudinal, prospective before-after trial, 22 patients with chronic SCI and intractable neurogenic bowel dysfunction received a three-week protocol of functional magnetic stimulation (FMS), a noninvasive method of stimulating nerves and muscles. Treatment consisted of 20-minute FMS sessions twice a day. Colonic transit time was assessed before and after FMS. Symptoms (such as frequency and difficulty of bowel movements, time needed for evacuation, pain, discomfort, etc.) were evaluated using a standardized questionnaire administered before and after FMS and at two-week intervals for three months. After FMS, mean colonic transit time decreased significantly. Symptom scores also improved following stimulation, and this improvement was maintained overall, with a slight drop over the three-month follow-up. The improvements in bowel function indicate that FMS can be incorporated successfully into other therapies as an optimal adjuvant (supplemental) treatment for neurogenic bowel dysfunction resulting from SCI.
Tsai PY, Wang CP, Chiu FY, et al.
J Rehabil Med. 2009 Jan;41(1):41-7.
Bone health
Effect of detraining on bone and muscle tissue in subjects with chronic spinal cord injury after a period of electrically-stimulated cycling: a small cohort study.
Five subjects with motor-sensory complete paraplegia who took part in a previous study of a high-volume functional electrical stimulation (FES) cycling program (up to 5 sessions per week for one year) participated in this follow-up investigation. Four had stopped FES cycling completely after the training phase and one continued reduced FES-cycling (2-3 times/week, for 30 min). Bone and muscle parameters were assessed in the legs using peripheral quantitative computed tomography at 6 and 12 months after the training ended. Gains achieved in the distal femur (thigh bone) by high-volume FES-cycling were partly maintained one year after stopping the program. The subject who continued reduced FES-cycling maintained 96.2% to 95.0% of the previous gain in bone mineral density and 98.5% of the increase in muscle tissue. Bone and muscle benefits achieved by one year of high-volume FES-cycling are partly preserved after 12 months of detraining, whereas reduced cycling maintains bone and muscle mass gained. This suggests that high-volume FES-cycling has clinical relevance for at least one year after detraining.
Frotzler A, Coupaud S, Perret C, et al.
J Rehabil Med. 2009 Mar;41(4):282-5.
Breathing & Cough
Lower thoracic spinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health-Sponsored clinical trial. Part II: clinical outcomes.
Nine individuals with cervical SCI who were unable to produce a cough strong enough to expel secretions underwent implantation of a spinal cord stimulation (SCS) cough system to activate the expiratory (exhaling) muscles. Three weeks after implantation, participants were trained in the SCS cough system and instructed to use it every 30 seconds for 5 to 10 minutes, 2 to 3 times a day or more if needed. Follow-up at 28 and 40 weeks after implantation showed significant improvement in participants’ ability to raise secretions. The need for alternative methods of secretion removal was virtually eliminated. Participants reported greater control of breathing problems and improved quality of life related to breathing issues and had fewer acute respiratory tract infections. Side effects were either short-lived or mild and well-tolerated. Restoration of cough via SCS is safe, improves life quality and has the potential to reduce the morbidity and mortality associated with recurrent respiratory tract infections in this patient population.
DiMarco AF, Kowalski KE, Geertman RT, et al.
Arch Phys Med Rehabil. 2009 May;90(5):726-32.
Exercise & Fitness
Screening and habituation of functional electrical stimulation-leg cycle ergometry for individuals with spinal cord injury: a pilot study.
Functional electrical stimulation-leg cycle ergometry (FES-LCE) has many benefits for people with SCI, including increased muscle mass, improved cardiovascular fitness, slower rate of bone density loss, decreased pressure sores and pain, and improved energy and self-image. A pre-training or habituation period is often needed to build up to the ideal program of 30 minutes of sustained cycling at >35 rpm. Thirteen subjects with SCI (mean years since injury, 7; mean age, 34.8 years; injury range, C4-T10; 7 males) were screened for this study, but six were excluded due to pain, autonomic dysreflexia, excessive spasticity or other problems and one dropped out. Following a program of three 30-minute FES-LCE sessions per week, time to attain target cycle speed for 30 continuous minutes ranged from 30 to 779 minutes (1-31 training sessions) among the 6 participants who completed the training. Despite the small sample size, demographic diversity, and varying adherence rates, the habituation process was achieved in all six participants.
Tawashy AE, Eng JJ, Krassioukov AV, et al.
J Neurol Phys Ther. 2008 Dec;32(4):164-70.
Male Fertility
Anejaculation: an electrifying approach.
Men with anejaculation (inability to ejaculate) due to SCI are excellent candidates for ejaculation induction procedures and low-level assisted reproductive techniques. In many men with SCI, penile vibratory ejaculation can be performed by the patient himself, making home insemination possible as a very low cost alternative. For this reason, surgical sperm retrieval and intracytoplasmic sperm injection should not be first-line therapy in anejaculatory men with SCI.
Ohl DA, Quallich SA, Sønksen J, et al.
Semin Reprod Med. 2009 Mar;27(2):179-85. Epub 2009 Feb 26.
Is sperm cryopreservation an option for fertility preservation in patients with spinal cord injury-induced anejaculation?
SCI in men often results in impaired erection, ejaculation, and semen quality, and for this reason only 10% of males with SCI can father children without medical assistance. While semen can be retrieved using electroejaculation (EEJ) and penile vibratory stimulation (PVS), there is often a decrease in semen quality in men with SCI, notably low sperm motility. Cryopreservation can further reduce sperm quality. To learn more about its effects, this study compared sperm samples from 14 men with SCI and 14 men without. Before cryopreservation, there was no difference in concentration or total sperm count between the two groups; however, the SCI group had significantly lower ejaculate volume, decreased sperm morphology, and an increase in the round cell and neutrophils counts. In both groups, cryopreservation resulted in increased DNA fragmentation, a decrease in mitochondrial activity, and a decrease in motility. However, cryopreservation did not bring more damage to sperm from infertile men with SCI than to sperm from control subjects.
da Silva BF, Borrelli M Jr, Fariello RM, et al.
Fertil Steril. 2009 May 5. [Epub ahead of print]
Mortality
Behavioral risk factors of mortality after spinal cord injury.
Behavioral information was collected via a survey mailed to 1,251 individuals with SCI at least one year post injury. Eight years later, 188 of these individuals had died. Data were analyzed to determine which behavioral factors were associated most strongly with mortality, and a predictive model was created. The best behavioral predictors were: smoking, binge drinking (number of episodes with 5 or more drinks), prescription medication use, and number of hours out of bed per day. Inclusion of these variables improved prediction of survival compared with biographic and injury variables alone. The results affirm the importance of avoiding basic risk behaviors, such as smoking and alcohol misuse, and affirm their importance as targets of intervention during SCI rehabilitation.
Krause JS, Carter RE, Pickelsimer E.
Arch Phys Med Rehabil. 2009 Jan;90(1):95-101.
Nutrition
Nutrient intake and body habitus after spinal cord injury: an analysis by sex and level of injury.
Seventy-three individuals with SCI (C5-T12; ASIA A or B) were divided into 4 groups: male tetraplegia (N = 24), male paraplegia (N = 37), female tetraplegia (N =1), and female paraplegia (N = 11). Mean age was 38 years; 34% were white, 41% were African American, and 25% were Hispanic. Participants completed a 4-day food log examining habitual diet. Dietary composition was analyzed. Excluding the one woman with tetraplegia, total calorie intake was below the average for the general population. The female paraplegia group tended to have a healthier diet than the other groups, with lower total calorie intake and recommended macronutrient intake. The male tetraplegia group, male paraplegia group, and the one woman with tetraplegia all had higher than recommended fat, sodium and alcohol intake but inadequate intake of several vitamins, minerals, and macronutrients. Using adjusted BMI tables, 74.0% of participants were overweight or obese. Most people with SCI would benefit from nutritional counseling to prevent secondary conditions associated with overweight and inadequate diet.
Groah SL, Nash MS, Ljungberg IH, et al.
J Spinal Cord Med. 2009;32(1):25-33.
Wheelchair seating & Propulsion
Seat height: effects on submaximal hand rim wheelchair performance during spinal cord injury rehabilitation.
Twelve persons with SCI (age range 19-77 years; C5/C6-L2; 7 men; 8 incomplete) performed eight submaximal hand rim wheelchair exercise tests on a computer-controlled wheelchair ergometer at eight different seat heights. Elbow angle was used as a measure of seat height. Physical strain and mechanical efficiency changed significantly when seat height changed. Optimal elbow angle was between 100-130 degrees. Lower seat heights were clearly harmful. Forces on the hand rims were also affected by seat height, such that increasing seat height resulted in lower forces. Findings suggest that optimal seat height during SCI rehabilitation may lead to more efficient and less straining conditions for manual wheeling.
van der Woude LH, Bouw A, van Wegen J, et al.
J Rehabil Med. 2009 Feb;41(3):143-9.
Implanted electrical stimulation of the trunk for seated postural stability and function after cervical spinal cord injury: a single case study.
A 44-year-old man with complete C4 SCI, 20 years post injury, received a surgically implanted neuroprosthesis to stimulate the hip and trunk muscles. The subject was trained to use the device and perform conditioning exercises independently at home. Testing to determine the physical and functional effects of the neuroprosthesis started six months after implant surgery and continued every month for four months. Outcomes were assessed with and without stimulation, so the subject served as his own control. Stimulation improved control of the paralyzed torso and had a positive impact on spinal alignment, seated posture, pulmonary function, trunk stability, and reach. Stimulation of hip and trunk muscles can improve performance of activities of daily living as well as enable independent wheelchair and bed mobility.
Triolo RJ, Boggs L, Miller ME, et al.
Arch Phys Med Rehabil. 2009 Feb;90(2):340-7.
Biomechanical Analysis of Functional Electrical Stimulation on Trunk Musculature During Wheelchair Propulsion.
Eleven participants with SCI propelled their own wheelchairs on a dynamometer for three 5-minute trials. During each trial, 1 of 3 stimulation levels (HIGH, LOW, and OFF) was randomly applied to the participant’s abdominal and back muscle groups with a surface functional electrical stimulation (FES) device. Propulsion kinetics, trunk kinematics, metabolic responses, and surface electromyographic (EMG) activity of 6 shoulder muscles were collected. Kinetic, kinematic, and EMG variables were recorded during 3 time intervals (30 seconds each) within a 5-minute trial. Metabolic variables were recorded through the entire 5-minute trial. Participants with HIGH stimulation increased their gross mechanical efficiency during wheelchair propulsion. No differences were found in shoulder EMG activity, energy expenditure, and trunk motion between stimulation levels. FES on the trunk may help manual wheelchair users with SCI improve propulsion efficiency without placing additional demands on shoulder musculature.
Yang YS, Koontz AM, Triolo RJ, et al.
Neurorehabil Neural Repair. 2009 Mar 4. [Epub ahead of print]
How to obtain the complete articles
You may obtain copies of the complete articles through your local medical library or through the University of Washington Health Sciences Library Document Service at 206-543-3441 or http://healthlinks.washington.edu/hsl/docservices/illiad.htm. (There is a fee for this service.)