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Spinal Cord Injury Update

Spring 2010: Volume 19, Number 1


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.

Bladder Management

Urethral versus suprapubic catheter: choosing the best bladder management for male spinal cord injury patients with indwelling catheters.
This review compared urological complications in SCI patients managed with indwelling urethral catheter (UC) to those with suprapubic tube (SPT). Of 179 SCI patients, 133 used UC and 46 used SPT. There was no significant difference between the two catheter groups in number of urinary tract infections, bladder stones, renal calculi and cancer. Each method had it’s own specific complications: erosion in the UC group and urethral leak, leakage from the SPT and SPT revision in the SPT group. Urethral and scrotal complications may be higher with UC, but complications from SPT may offset benefits from SPT. Overall, bladder management for patients with chronic indwelling catheters should be selected on the basis of long-term comfort for the patient.
Katsumi HK, Kalisvaart JF, Ronningen LD, Hovey RM.
Spinal Cord. 2009 Oct 13. [Epub ahead of print]

Long-term effects of repeated intradetrusor botulinum neurotoxin A injections on detrusor function in patients with neurogenic bladder dysfunction.
This study included 27 patients who had neurogenic detrusor (bladder) overactivity due to SCI and received at least five botulinum neurotoxin A (BoNT-A) treatments. After the first BoNT-A treatment, bladder capacity, reflex volume, continence status and detrusor compliance were significantly improved and maximum detrusor pressure (P(detmax)) was significantly reduced. Incontinence rate (seven patients) and the number of patients with an elevated P(detmax) (five patients) were slightly increased after the final BoNT-A treatment, compared to results after the first treatment. The long-term success rate was 74%. Every fourth patient needed a major surgical intervention. BoNT-A may lead to impaired detrusor contraction strength, which could influence future treatment options.
Pannek J, Göcking K, Bersch U.
BJU Int. 2009 Nov;104(9):1246-50

Cranberry is not effective for the prevention or treatment of urinary tract infections in individuals with spinal cord injury.
This review identified five studies (four randomized clinical control trials, three using cranberry tablets and one using cranberry juice) that evaluated the effectiveness of cranberry products for the prevention or treatment of urinary tract infections (UTIs) in the SCI population. Three studies reported no statistically significant effect of cranberry tablets on urinary pH, urinary bacterial count, urinary white blood cell (WBC) count, urinary bacterial or episodes of symptomatic UTIs. A fourth study showed that cranberry juice intake significantly reduced biofilm load compared with baseline. A final study reported fewer UTIs during the period with cranberry extract tablets vs placebo. Limited evidence from clinical trials suggests that cranberry, in juice or supplement form, does not seem to be effective in preventing or treating UTIs in the SCI population. More rigorous research is needed.
Opperman EA.
Spinal Cord. 2009 Nov 24. [Epub ahead of print.]

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Phrenic Nerve Stimulation

Phrenic nerve stimulation in patients with spinal cord injury.
Phrenic nerve pacing (PNP) is a clinically useful technique that replaces mechanical ventilation in individuals who cannot breathe independently due to SCI. This review article discusses patient evaluation, equipment, methods of implementation, clinical outcomes, and the complications and side effects of PNP. Despite considerable technical development and clinical success, current PNP systems have significant limitations. Even in patients with intact phrenic nerve function, PNP is successful in achieving full-time support in only 50% of patients. A novel method of pacing is under development which involves stimulating spinal cord tracts that synapse with the inspiratory motoneuron pools. This technique results in combined activation of the intercostal muscles and diaphragm in concert and holds promise to provide a more physiologic and effective method of PNP.
Dimarco AF.
Respir Physiol Neurobiol. 2009 Sep 26. [Epub ahead of print]

Physical Activity

Effects of hand cycle training on physical capacity in individuals with tetraplegia: a clinical trial.
Twenty-two individuals with motor incomplete C5–C8 tetraplegia (at least 2 years postinjury) participated in a structured hand cycle interval training program of 24 sessions, 35–45 minutes each, for 8–12 weeks. Training was conducted at home or in a rehabilitation center. After an average of 19 sessions, significant improvements were found in peak power output, peak oxygen uptake and mechanical efficiency as reflected by a decrease in submaximal oxygen uptake. Common health complications, such as urinary tract infections, bowel problems, and pressure sores, led to dropout and nonadherence. There was no participant-reported shoulder-arm pain or discomfort.
Valent LJ, Dallmeijer AJ, Houdijk H, et al.
Phys Ther. 2009 Oct;89(10):1051-60.

Glucose tolerance and physical activity level in people with spinal cord injury.
Twenty-five people (5 women, 20 men) with SCI (11 with tetraplegia, 14 with paraplegia) and no known coronary heart disease, stroke or diabetes were recruited for this cross-sectional observational study. Participants underwent an oral glucose tolerance test and completed the physical activity scale for individuals with physical disabilities. Nine participants had disordered glycemia (6 tetra; 3 para) and the remaining participants had normal glucose tolerance. As a group, participants with normal glucose tolerance spent significantly more time engaged in physical activity, including outdoor household activities, housework and non-exercise-related mobility tasks. Physical activity and age, but not lesion level, were related to glucose concentration.
Raymond J, Harmer AR, Temesi J, van Kemenade C.
Spinal Cord. 2010 Jan 5. [Epub ahead of print]

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Chronic neuropathic pain management in spinal cord injury patients. What is the efficacy of pharmacological treatments with a general mode of administration (oral, transdermal, intravenous)?
This review analyzed and classified pain studies in SCI into four levels of quality of evidence (1 to 4) and three grades of recommendations (A, B, C). The evidence showed that pregabalin is effective for neuropathic pain in SCI (grade A). Gabapentin has a lower level of evidence in SCI pain (grade B), but both drugs can be used as first line therapy and are safe to use. Tricyclic antidepressants (TCAs) can also be a first line drug (grade B for SCI pain associated with depression, grade A for other neuropathic pain conditions), especially in patients with both pain and depression. Tramadol, alone or in combination with antiepileptic drugs, can be used if the pain has a predominant non-neuropathic component. If these treatments fail, strong opioids can be used as second/third line (grade B in SCI, grade A in other types of neuropathic pain). Lamotrigine may also be used at this stage, particularly in patients with incomplete SCI associated with allodynia (grade B). For difficult central pain, cannabinoids may be used on the basis of positive results in other central pain conditions (e.g. multiple sclerosis). To date few clinical trials have been specifically devoted to this topic. Large scale studies and trials comparing several active drugs are needed.
Attal N, Mazaltarine G, Perrouin-Verbe B, Albert T.
Ann Phys Rehabil Med. 2009 Mar;52(2):124-41.


Effect of whole-body vibration on quadriceps spasticity in individuals with spastic hypertonia due to spinal cord injury.
Sixteen individuals with SCI and quadriceps (thigh muscle) spasticity had their spasticity measured by gravity-provoked stretch (Pendulum Test) before and after 12 sessions of 3 day/week whole-body vibration (WBV). Quadriceps spasticity was significantly reduced for at least eight days after the program. Improvements were similar whether or not a subject had been using antispastic medications. Vibration may be a useful addition to training in those with spasticity. Future studies should compare the antispastic effects of vibration to antispastic medications.
Ness LL, Field-Fote EC.
Restor Neurol Neurosci. 2009;27(6):621-31.

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Cognitive performance in hypotensive persons with spinal cord injury.
Individuals with SCI, especially those with tetraplegia, often have hypotension (low blood pressure). Twenty individuals with chronic SCI (2-39 years) participated in this study, 13 with tetraplegia and 7 with paraplegia. Hypotension was defined as having a mean 24-hour systolic blood pressure (SBP) below 110 mmHg for males and 100 mmHg for females at least 50% of the time. Most of the individuals (82%) in the hypotensive group had tetraplegia. Memory was significantly impaired and there was a trend toward slowed attention and processing speed in the hypotensive compared to the normal group. These findings are similar to effects of hypotension in the non-SCI population.
Jegede AB, Rosado-Rivera D, Bauman WA, et al.
Clin Auton Res. 2009 Oct 16. [Epub ahead of print]

Pressure Sores

Botulinum toxin type A in the healing of a chronic buttock ulcer in a patient with spastic paraplegia after spinal cord injury.
A 27-year-old man with paraplegia following SCI had developed recurrent severe muscular spasms, particularly in the buttock region. The patient had a grade IV pressure ulcer in the left gluteal region. Several treatments were administered without success, and all efforts at healing the ulcer by topical medication were hampered by recurrent spasms in the area of the ulcer. The left gluteus maximus muscle was treated with 2 infiltrations of 660 IU botulinum toxin type A. This allowed better care of the pressure ulcer, which healed by 6 months after the initial infiltration.
Intiso D, Basciani M.
J Rehabil Med. 2009 Nov;41(13):1100-2.

Promote pressure ulcer healing in individuals with spinal cord injury using an individualized cyclic pressure-relief protocol.
Forty-four individuals with SCI, aged 18-79 years, with a Stage II or III pressure ulcer (PrU), were randomly assigned to the control or treatment group. Those in the treatment group used wheelchairs equipped with an individually adjusted automated seat that provided cyclic pressure relief, and those in the control group used a standard wheelchair. All subjects sat in wheelchairs for at least 4 hours per day for 30 days. Wound characteristics were assessed using the Pressure Ulcer Scale for Healing (PUSH) tool and wound dimensions recorded with digital photographs twice a week. At the end of 30 days, both groups demonstrated a general trend of healing. However, the treatment group took significantly less time to achieve 30% healing and had greater improvement of the wound area compared with the control group. Individualized cyclic pressure relief may have substantial benefits in speeding up the healing process in wheelchair users with existing PrUs while maintaining their mobility.
Makhsous M, Lin F, Knaus E, et al.
Adv Skin Wound Care. 2009 Nov;22(11):514-21.

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Heterotopic Ossification (Abnormal Bone Growth)

A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury.
Thirteen studies, divided into prevention or treatment of heterotopic ossification (HO) after SCI, were included in this review. Nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, and pulse low-intensity electrogmagnetic field (PLIMF) therapy were reviewed as preventive measures. Bisphosphonates, radiotherapy and excision were reviewed as treatments. Pharmacological treatments of HO after SCI had the highest level of research evidence supporting their use. Of these, NSAIDs showed greatest efficacy in the prevention of HO when administered early after an SCI, whereas bisphosphonates had the strongest evidence once HO had developed. Of the non-pharmacological interventions, PLIMF had the best evidence; however, more research is needed to fully understand its role.
Teasell RW, Mehta S, Aubut JL, et al.
Spinal Cord. 2010 Jan 5. [Epub ahead of print]

Impact of late surgical intervention on heterotopic ossification of the hip after traumatic neurological injury.
Heterotopic ossification (HO) occurs in 16% to 53% of individuals with SCI. HO can limit range of movement, and the hip is the most frequently affected site. Total joint ankylosis (fixation) occurs in 5% to 16% of affected hips. This was a study of patients who developed HO of the hip after injury and required surgery to improve their range of movement. Of the 143 patients (183 hips) in the study, 65 (35.5%) had SCI and 118 (64.5%) had TBI. In all, 70 hips had ankylosis. Twenty-five fractures of the femoral neck occurred during surgery, all in patients with ankylosed hips. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimizes the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.
Genet F, Marmorat JL, Lautridou C, et al.
J Bone Joint Surg Br. 2009 Nov;91(11):1493-8.

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Assistive Technology

Evaluation of the tongue drive system by individuals with high-level spinal cord injury.
Tongue Drive System (TDS) is a tongue operated, unobtrusive, minimally invasive, wireless assistive technology (AT), which can enable people with severe disabilities to control different devices using their tongue motion. TDS can translate specific tongue movements into user-defined commands by detecting the position of a small permanent magnetic tracer attached to the user’s tongue. The prototype was built on a wireless headphone and interfaced to a laptop and a commercial powered wheelchair. The eTDS performance was evaluated by eight subjects with high level (C3–C5) SCI at the Shepherd Center in Atlanta, GA. All the subjects could successfully perform common tasks related to computer access, such as controlling a mouse cursor or playing a computer game, as well as complex wheelchair navigation tasks, such as driving through an obstacle course.
Huo X, Cheng C, Ghovanloo M.
Conf Proc IEEE Eng Med Biol Soc. 2009;1:555-8.

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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