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Spinal Cord Injury Update

Fall 2010: Volume 19, Number 3


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.


Autonomic dysreflexia

Boosting in athletes with high-level spinal cord injury: knowledge, incidence and attitudes of athletes in paralympic sport.
Autonomic dysreflexia (AD) is unique to individuals with SCI at T6 or above and can be voluntarily induced. Although AD improves wheelchair racing performance in some athletes, it also increases blood pressure, which could be dangerous. The International Paralympic Committee considers AD doping and banned its use. A survey of athletes at the Beijing Paralympic Games found that of 99 participants, 54.5% had previously heard of AD while 39.4% had not, and 16.7% (all males) had used AD to enhance performance. Participants reported that AD was useful for middle (78.6%) and long distance racing (71.4%), marathon (64.3%) and wheelchair rugby (64.3%). They also reported AD was somewhat dangerous (48.9%), dangerous (21.3%) or very dangerous (25.5%) to health. Results were not influenced by age, injury level or injury duration. Findings indicate the need for education to enhance the AD knowledge of professionals, coaches and trainers working with SCI individuals.
Bhambhani Y, Mactavish J, Warren S, et al.
Disabil Rehabil. 2010 Aug 18

Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury.
A group of 571 patients with SCI at T6 or above were assessed for the incidence of symptomatic AD according to age, sex, ASIA Impairment Scale, injury level, and bowel and bladder management techniques at discharge. The highest incidence of symptomatic AD was diagnosed in subjects using reflex voiding and in those using manual removal of stool. By contrast, the lowest incidence of symptomatic AD was in those on continent voiding and continent defecation.
Furusawa K, Tokuhiro A, Sugiyama H, et al.
Spinal Cord. 2010 Aug 10.

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Bladder Management

Treatment of neurogenic male urinary incontinence related to intrinsic sphincter insufficiency with an artificial urinary sphincter: a French retrospective multicentre study.
In this retrospective study, 51 patients with urinary incontinence due to sphincter problems had an artificial urinary sphincter (AUS) inserted. Sixteen (31%) had spina bifida and 35 (69%) had SCI. Perfect continence was defined as a period of dryness of at least 4 hours between two self-intermittent catheterizations or spontaneous voiding; moderate incontinence as nocturnal leakage or need to wear protection once during the day or for stress leakage; and severe incontinence as uncontrollable leakage. Mean age at the procedure was 35 years (18-58). Of the patients in the study, 74% had perfect or moderate continence with a working AUS after a 10-year follow-up.
Kastler EC, Genevois S, Gamé X, et al.
BJU Int. 2010 Jul 13.

Bladder management after spinal cord injury in the United States 1972 to 2005.
Bladder management with an indwelling catheter for patients with SCI can cause urological complications such as stones, urinary infection, urethral strictures and bladder cancer. Bladder management method of 24,762 patients in the National Spinal Cord Injury Database was determined at discharge from rehabilitation and at each 5-year followup period for 30 years. Bladder management with a condom catheter decreased steadily from a peak of 34.6% in 1972 to a low of 1.50% in 2001, whereas the use of clean intermittent catheterization increased from 12.6% in 1972 to a peak of 56.2% in 1991. Indwelling catheter use decreased from 33.1% in 1972 to 16.5% in 1991 but increased to 23.1% in 2001. Of 12,984 individuals with followup data, 71.1% of those originally using an indwelling catheter continued to use it at 30 years. Of those using clean intermittent catheterization and condom catheterization at discharge, only 20% and 34.6%, respectively, remained on the same management.
Cameron AP, Wallner LP, Tate DG, et al.
J Urol. 2010 Jul;184(1):213-7. Epub 2010 May 15.

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Body Fat and Health

Secondary complications and subjective well-being in individuals with chronic spinal cord injury: associations with self-reported adiposity.
A total of 531 men and 164 women who were enrolled in the Study of Health and Activity in People with Spinal Cord Injury (SHAPE-SCI) completed questionnaires about health complications, pain, satisfaction with life and depression during a telephone interview. Body mass index measurements were obtained from 73 of the SHAPE-SCI participants during home visits. Individuals who reported being overweight were more likely to have overuse injuries and fatigue, greater pain and depressive symptoms, and lower satisfaction with life than individuals who did not report being overweight. Future studies should examine whether losing body fat can improve symptoms and satisfaction with life.
Hetz SP, Latimer AE, Arbour-Nicitopoulos KP, Martin Ginis KA.
Spinal Cord. 2010 Aug 24.

Bone Health

Influence of season, ethnicity, and chronicity on vitamin D deficiency in traumatic spinal cord injury.
Inadequate levels of vitamin D increase the risk of osteoporosis, a common condition in people with SCI. Reduced sunlight and dark skin further contribute to low vitamin D levels. Ninety-six individuals with motor complete SCI (from C3-T10) were tested for 25-hydroxy vitamin D [vitamin D25(OH)] levels in summer and winter months. In summer, 65% of patients with acute SCI (2 to 6 months after injury) and 81% of patients with chronic SCI (more than one year after injury) were deficient in vitamin D. In winter, these percentages increased to 84% and 96%, respectively. Levels of vitamin D were lower in African Americans than whites. Because vitamin D deficiency is common in acute and chronic SCI, initial screening for serum vitamin D levels should be performed early in rehabilitation and regularly after that.
Oleson CV, Patel PH, Wuermser LA.
J Spinal Cord Med. 2010;33(3):202-13

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Cardiovascular disease

Cardiovascular disease, SCI and exercise: unique risks and focused countermeasures.
At least three cardiovascular disease risk factors (CVD) have unique profiles in the SCI population. Fasting dyslipidaemia is characterized in the SCI population by depressed HDL cholesterol and normal or low total cholesterol. After meals, persons with SCI have an exaggerated triglyceride rise and delayed clearance compared to non-disabled persons. Finally, vascular inflammation, indicated by C-reactive protein, is elevated in SCI. Fasting dyslipidaemia responds to 8 weeks of moderate intensity aerobic exercise performed 5 days weekly for 30 min daily. Post-prandial (after a meal) lipaemia treatment requires daily moderate or vigorous aerobic exercise, as the effect dissipates day by day.
Cowan RE, Nash MS.
Disabil Rehabil. 2010 Jun 7.

Dental Care

Factors that limit access to dental care for adults with spinal cord injury.
Use of dental services in 192 adults with SCI was compared to that of a sample from the general population. Although a similar proportion of both groups visited the dentist, those with SCI were less likely to go for a dental cleaning compared to the general population (54.6% vs. 69.4%). The three most commonly reported barriers to accessing dental care were cost (40.1%), physical barriers (22.9%), and dental fear (15.1%). Dentists should remodel their facilities to accommodate wheelchair users and have appropriate strategies for the management of dental fear among patients with SCI.
Yuen HK, Wolf BJ, Bandyopadhyay D, et al.
Spec Care Dentist. 2010 Jul-Aug;30(4):151-6.


Chronic spinal cord injury pain: pharmacological and non-pharmacological treatments and treatment effectiveness.
Of 279 persons with SCI who responded to a survey about pain, 215 (77.1%) reported having chronic SCI pain. Of these, 62.8% reported more than one pain type, of which neuropathic pain was most common (69.3%). Many of those with pain (63.8%) were receiving treatment but still had high levels of pain. The most common treatments were massage therapy/relaxation, anticonvulsants, and non-steroidal anti-inflammatory drugs (NSAIDs). The treatments most often thought to be effective were acupuncture/magnetising, cannabis/alcohol, physiotherapy and exercise, and massage therapy/relaxation. TENS/ultrasound and antidepressants were least often perceived as effective.
Heutink M, Post MW, Wollaars MM, van Asbeck FW.
Disabil Rehabil. 2010 Aug 9.

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Sexual Function

Sildenafil in women with sexual arousal disorder following spinal cord injury.
A group of 129 women with SCI were randomly divided into two groups and treated with either sildenafil or placebo for 12 weeks. Participants recorded their sexual activity and completed questionnaires about their sexual function, sexual quality of life, and sexual distress. Both the treatment and control groups had an increase in sexual activity during the study period, but there were no differences between the two groups in percentage of successful sexual activities or in their scores on the questionnaires. In conclusion, sildenafil was not beneficial in this population.
Alexander MS, Rosen RC, Steinberg S, et al.
Spinal Cord. 2010 Aug 24.

Treatment for ejaculatory dysfunction in men with spinal cord injury: an 18-year single center experience.
Semen retrieval success rate and semen quality was assessed in 3,152 samples from 500 men with SCI. Nine percent could ejaculate by masturbation. Penile vibratory stimulation was successful in 86% of patients with a T10 or higher injury level. Electroejaculation was successful in most cases of failed penile vibratory stimulation. Sperm were obtained without surgical sperm retrieval in 97% of patients. Total motile sperm counts exceeded 5 million in 63% of cases. Sperm can be easily obtained nonsurgically from most men with SCI, resulting in sufficient sperm for simple insemination procedures.
Brackett NL, Ibrahim E, Iremashvili V, et al.
J Urol. 2010 Jun;183(6):2304-8.

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Spontaneous Recovery

Extent of spontaneous motor recovery after traumatic cervical sensorimotor complete spinal cord injury.
This study used datasets from the European multicenter study about SCI (EMSCI) and the Sygen randomized clinical trial to determine how much spontaneous motor recovery took place in the first year after cervical (C4-C7) sensorimotor complete spinal cord injury. American Spinal Injury Association Impairment Scale (AIS) grade and upper extremity motor score or motor level were examined. There were no overall differences between the EMSCI and Sygen datasets in motor recovery patterns. After 1 year, up to 70% of subjects spontaneously recovered at least one motor level, but only 30% recovered two or more motor levels. Regardless of initial cervical motor level, most individuals recover a similar number of motor points or motor levels. Careful tracking of cervical motor recovery outcomes may help to reliably detect subtle but meaningful treatment effects in experimental studies.
Steeves JD, Kramer JK, Fawcett JW, et al.
Spinal Cord. 2010 Aug 17.

Stem Cells

First patient enters trial to test safety of stem cells in spinal injury
The first patient has been recruited to a Phase 1 clinical trial to assess the safety and tolerability of oligodendrocyte progenitor cells derived from human embryonic stem cells to treat complete spinal cord injury. This study is recruiting patients with T3-T10 complete (ASIA A) injuries within 14 days of injury from seven U.S. medical centers. The trial’s primary end point is safety, measured by the frequency and severity of adverse events related to the injected stem cells, to the injection procedure, or to the concomitant immunosuppression administered during the first year after treatment. Neurological function will also be assessed as a secondary end point. The stem cells being used in the trials have been developed by the U.S. company Geron. Animal studies showed that the cells migrated throughout the lesion site and matured into functional oligodendrocytes that remyelinated axons and produced neurotrophic factors, resulting in improved locomotion in the treated animals. The ultimate goal for the use of these cells in humans is to repair spinal cord injuries by injecting the cells directly into the spinal cord lesion.
Susan Mayor
BMJ 2010; 341:c5724

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Wheelchair Assessment

Are wheelchair-skills assessment and training relevant for long-standing wheelchair users? Two case reports.
A 60-year-old man with a 15-year history of T12 complete paraplegia fractured his femur due to a tip-over accident that occurred 2 days after a follow-up clinic visit at which no limitations in wheelchair-skill performance were identified. If a procedure had been in place to identify and correct his wheelchair-skill deficiencies, this injury might have been prevented. A 34-year-old woman with spina bifida, whose wheelchair use had gradually increased, was able to significantly improve her wheelchair abilities through training. The newly learned skills enhanced her community participation. These cases suggest that, even in long-standing wheelchair users, wheelchair skills should be routinely assessed and formal training offered when needed.
Mountain AD, Smith C, Kirby RL.
Disabil Rehabil Assist Technol. 2010 May;5(3):230-3.

How to obtain 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.)

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