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Spinal Cord Injury Update

Summer 2010: Volume 19, 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.


Bone Density

The effects of whole body vibration on bone mineral density for a person with a spinal cord injury: a case study.
Bone mineral density (BMD) loss is a medical concern for individuals with SCI. Whole body vibration (WBV) has been reported to improve BMD for postmenopausal women and suggested for SCI. In this case study, the subject received three progressive phases (standing only, partial standing, and combined stand with vibration), each lasting 10 weeks. Significant improvements in BMD were reported at the trunk and spine for the phase combining standing and vibration. Increases in leg lean tissue mass and reduction in total body fat were noted in all three phases.
Davis R, Sanborn C, Nichols D, et al.
Adapt Phys Activ Q. 2010 Jan;27(1):60-72.

Effects of functional electrical stimulation cycling exercise on bone mineral density loss in the early stages of spinal cord injury.
Twenty-four individuals with spinal cord injury (26-52 days after SCI) were divided into functional electrical stimulation cycling exercises (FESCE) or control groups. FESCE was applied for 3 months and then stopped for 3 months. Bone mineral density (BMD) in the femoral neck and distal femur was measured using dual energy X-ray absorptiometry before training, immediately after the initial 3 months of training, and 3 months later. The FESCE group lost significantly less BMD than the control group during the initial 3 months, but there was no significant difference in the subsequent 3 months. In conclusion, FESCE in the early stages of SCI can partly ease BMD loss in the distal femur. However, bone loss cannot be stopped completely, and the beneficial effect on bone loss faded once FESCE was discontinued.
Lai CH, Chang WH, Chan WP, et al.
J Rehabil Med. 2010 Feb;42(2):150-4.

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Review of the efficacy and safety of transanal irrigation for neurogenic bowel dysfunction.
Transanal irrigation (TAI) of the colon promotes the evacuation of feces by introducing water into the colon and rectum through a catheter inserted into the anus. In persons with neurogenic bowel dysfunction (NBD), regular and controlled evacuation in this manner aims at preventing both constipation and fecal incontinence (accidents). This author reviewed the current evidence for the efficacy and safety of TAI in patients with NBD due to SCI and other diagnoses. In SCI, TAI was found to be more effective than conservative bowel management in reducing NBD symptoms such as constipation and fecal incontinence and improving quality of life. Furthermore, success is maintained in the long term and the overall safety profile of TAI is good, with few, and rare, adverse effects.
Emmanuel A.
Spinal Cord. 2010 Feb 9. [Epub ahead of print]

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Cardiovascular health

Cardiovascular disease risk factors in persons with paraplegia: the Stockholm spinal cord injury study.
A total of 135 Swedish individuals aged 18-79 years with chronic (greater than one year) post-traumatic paraplegia participated in this study of factors that increase the risk for cardiovascular disease. Dyslipidemia (abnormal levels of blood fats), hypertension (high blood pressure), and being overweight were highly prevalent in this population. Hypertension was more common in low-level paraplegia, and prevalence of impaired fasting glucose was lower than previously reported after paraplegia. A high percentage of persons being prescribed drug treatment for dyslipidemia and hypertension did not achieve recommended targets for cardiovascular disease risk reduction.
Wahman K, Nash MS, Westgren N, et al.
J Rehabil Med. 2010 Mar;42(3):272-8.

Robotic treadmill training improves cardiovascular function in spinal cord injury patients.
This study investigated the effects of body weight supported treadmill training (BWSTT) assisted with a robotic driven gait orthosis (DGO) on: 1) left ventricular (LV) systo-diastolic function; 2) coronary flow reserve (CFR); 3) endothelial function in patients with lost sensorimotor function due to neurologic lesions. Fourteen adults (10 males) with motor incomplete SCI (2 to 10 years post-injury) due to trauma or spondylotic diseases underwent standard echocardiographic examination, non invasive assessment of CFR by dipyridamole stress echo and determination of plasma asymmetric dimethylarginine levels before and after 6 weeks of BWSTT. There was significant improvement in all parameters, demonstrating for the first time that BWSTT improves not only the sensorimotor function but also cardiovascular function in patients with incomplete SCI.
Turiel M, Sitia S, Cicala S, et al.
Int J Cardiol. 2010 Mar 8. [Epub ahead of print]

Exercise intensity during wheelchair rugby training.
The purpose of this study was to determine the ability of individuals with a cervical SCI to achieve and sustain a cardiorespiratory training intensity during wheelchair rugby. Nine wheelchair rugby players completed a continuous peak exercise test on a SciFit Pro I arm ergometer with stage increases each minute to determine peak heart rate and power output. Approximately one week later, heart rate was recorded at regular intervals during three regularly scheduled rugby training sessions. The percent of time spent at or above 70% heart rate reserve varied across participants and conditions. Continuous pushing resulted in participants spending greater than 73% of time on average above the target heart rate. Scrimmage training was highly variable with a range of 0% to 98% of time above the target. Results indicate that wheelchair rugby training enables some participants to reach a training intensity associated with improved cardiorespiratory fitness, and that the type (or kind) of training activity dictates the extent to which individuals sustain such a threshold.
Barfield JP, Malone LA, Arbo C, Jung AP.
J Sports Sci. 2010 Feb 2:1-10. [Epub ahead of print]

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Obesity & Diabetes

Association between obesity and diabetes mellitus in veterans with spinal cord injuries and disorders.
Clinical data was extracted from the medical records of 1,938 male veterans with spinal cord injuries and disorders (SCI/D) to examine the association between body mass index (BMI) and diabetes. The prevalence of diabetes was computed using three different BMI classification systems: World Health Organization; National Heart Lung Blood Institute (NHLBI); and a 10% reduction in the NHLBI categories to adjust for changes in muscle mass and body fat following SCI/D. BMI of 25 kg/m and above was associated with significantly higher rates of diabetes in this population, and this risk was especially pronounced at BMI of 27.5 kg/m and above. These findings do not support the need to create specific BMI definitions of overweight for purposes of determining risk for diabetes.
Rajan S, McNeely MJ, Hammond M, et al.
Am J Phys Med Rehabil. 2010 May;89(5):353-61.

Pressure Ulcers

Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury.
Twenty adults with spinal injury and a history of pressure ulcers participated in qualitative in-depth interviews. Eight interrelated daily lifestyle principles that explain pressure ulcer development were identified: perpetual danger; change/disruption of routine; decay of prevention behaviors; lifestyle risk ratio; individualization; simultaneous presence of prevention awareness and motivation; lifestyle trade-off; and access to needed care, services and supports. These principles underscore previous quantitative findings, but also lead to new understandings of how risk unfolds in everyday life situations. They can be used to drive future research or to guide innovative lifestyle-focused intervention approaches. Short-term preventive interventions at critical junctures throughout a person’s life should be considered.
Jackson J, Carlson M, Rubayi S, et al.
Disabil Rehabil. 2010;32(7):567-78.

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Psychosocial Adjustment

The impact of assuming the primary caregiver role following traumatic spinal cord injury: An interpretative phenomenological analysis of the spouse’s experience.
Individual in-depth interviews were conducted with 11 participants (10 females, 1 male) who were both the spouse and primary caregiver of an individual with a SCI. Three themes emerged: ‘The emotional impact of SCI’; ‘Post-injury shift in relationship dynamics’ and ‘Impact of caregiving on identity’. Participants reported an almost instantaneous sense of loss, emptiness and grief during the injured person’s rehabilitative period and feelings of anxiety in anticipation of their return to the family home. A distinct change in role from spouse and lover to care provider was reported and this ultimately contributed to relationship change and a loss of former identity.
Dickson A, O’Brien G, Ward R, et al.
Psychol Health. 2009 Nov 27:1-20. [Epub ahead of print]

Girls with spinal cord injury: social and job-related participation and psychosocial outcomes.
Ninety-seven girls (aged 7-17 years) who had sustained SCI at least 1 year prior to interview completed participation, depression and quality of life surveys. A broader context of social participation and a higher frequency of job-related participation were related to lower depression and higher quality of life. Participation in social and job-related activities should be a focus of rehabilitation for girls, because the skills gained from this involvement may help build resilience against future obstacles to socialization and employment
Gorzkowski JA, Kelly EH, Klaas SJ, Vogel LC.
Rehabil Psychol. 2010 Feb;55(1):58-67.

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Immediate effect of transcutaneous electrical nerve stimulation on spasticity in patients with spinal cord injury.
Eighteen subjects with spinal cord injury and symptoms of spasticity in lower limbs were randomly assigned to receive either 60 minutes of active transcutaneous electrical nerve stimulation (TENS) or 60 minutes of placebo non-electrically stimulated TENS over the common peroneal nerve. Composite Spasticity Score was used to assess the spasticity level of ankle plantar flexors immediately before and after TENS application. Significant reductions were shown in Composite Spasticity Score by 29.5%, resistance to full-range passive ankle dorsiflexion by 31.0% and ankle clonus by 29.6% in the TENS group but these reductions were not found in the placebo TENS group. This study showed that a single session of TENS could immediately reduce spasticity.
Chung BP, Cheng BK.
Clin Rehabil. 2010 Feb 15. [Epub ahead of print]


Efficacy of combined oral-intravesical oxybutynin hydrochloride treatment for patients with overactive detrusors and indwelling urethral catheters.
Twenty-five patients who were treated with oral oxybutynin hydrochloride (OH) for overactive detrusor (bladder), but who did not respond to treatment and were using indwelling urethral catheters, were given intravesical (within the bladder) OH without changing oral treatment. Pre- and post-treatment bladder capacities were compared in urodynamic studies. Positive clinical results were achieved, but a significant number of patients discontinued this treatment because of infection and difficulty in performing the procedure. Clinicians should provide education and support to eliminate these problems. The development of single-use standard sterile OH preparations for intravesical applications may increase the efficacy of the method.
Ersoz M, Yildiz N, Akyuz M, Koseoglu F.
Rehabil Nurs. 2010 Mar-Apr;35(2):80-6.

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Women with SCI

Long-term outcome of tension-free vaginal tape for treating stress incontinence in women with neuropathic bladders.
Twelve women (mean age 53.3 years) with neuropathic bladder dysfunction and stress urinary incontinence (SUI) were treated with tension-free vaginal tape (TVT) surgery. After 10 years, three were lost to follow-up; seven of the remaining nine patients were completely dry, and two improved and were satisfied with using one or two pads/day. In women with neuropathic bladder dysfunction and SUI due to spinal cord pathology, insertion of TVT can be a desirable treatment with very good long-term outcomes.
Abdul-Rahman A, Attar KH, Hamid R, Shah PJ
BJU Int. 2010 Feb 3. [Epub ahead of print]

Menopause characteristics and subjective symptoms in women with and without spinal cord injury.
Sixty-two women with SCI (C6-T12; 3 years or more postinjury) and 66 women without SCI completed self-report surveys 4 times over a 4-year period. All participants had intact ovaries, were not using hormone therapy, and were between the ages of 45 and 60. Age at final menstrual period did not differ between groups. Women with SCI had significantly less bother of vasomotor symptoms (hot flashes) and significantly greater bother of overall somatic symptoms, bladder infections and diminished sexual arousal than women without SCI. Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury.
Kalpakjian CZ, Quint EH, Bushnik T, et al.
Arch Phys Med Rehabil. 2010 Apr;91(4):562-9.

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Automobile crashes

Cost of spinal cord injuries caused by rollover automobile crashes.
The authors used crash data from the 1993-2006 National Automotive Sampling System Crashworthiness Data System to calculate the risk of SCI per rollover crash by belted/unbelted status and roof intrusion magnitude. Direct costs of SCI based on neurological level and completeness of SCI were calculated using data from the National SCI Statistical Center. Findings indicate that there would be a direct cost saving for treatment of SCI in the USA of over $97million annually if maximum roof intrusion in rollover crashes were limited to 8–15 cm for belted occupants, resulting from a prevention of 134 cases of SCI annually. Cost savings in this study only consider direct costs attributable to SCI in survivors of automobile crashes. Costs of fatalities (872 per year) and other injuries that could potentially be prevented, such as brain injury, are not included. These estimates do not consider the indirect costs of SCI estimated at about 58% of the direct cost.
Burns SP, Kaufman RP, Mack CD, Bulger E.
Inj Prev. 2010 Apr;16(2):74-8.

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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