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Spinal Cord Injury Update

Spring 2011: Volume 20, 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.


Male Fertility

Semen quality remains stable during the chronic phase of spinal cord injury: a longitudinal study.
Semen samples from 87 men with SCI were analyzed on at least 2 occasions, with at least 3 years between first and last sample. Semen was collected by masturbation, penile vibratory stimulation or electroejaculation. Subjects were on average 30 years old and 7 years post injury (at time of first sample). Sperm concentration decreased slightly with time, but all other parameters were unchanged, including total sperm count. Semen quality does not show clinically significant progressive changes during years after injury in men with SCI. This information is relevant for urologists who counsel these patients on family planning. Also, routine sperm freezing for fertility preservation is not necessary in this patient population.
Iremashvili V, Brackett NL, Ibrahim E, et al.
J Urol. 2010 Nov;184(5):2073-7.

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Pain Management

Effectiveness of transcranial direct current stimulation and visual illusion on neuropathic pain in spinal cord injury.
Pain was assessed in 40 study subjects with SCI who had neuropathic pain for at least 6 months. Subjects were randomly assigned to one of four treatment groups: transcranial direct current stimulation (DCS) while watching a walking visual illusion (combined treatment group); transcranial DCS + control (not walking) visual illusion (transcranial DCS group), transcranial DCS sham + visual illusion (visual illusion group) and transcranial DCS sham + control illusion (placebo group). Each person received ten treatment sessions, 20 minutes each, during 2 consecutive weeks. Their pain was assessed before and after the two-week program, at 2 and 4 weeks follow-up and after 12 weeks. The combined treatment reduced the intensity of neuropathic pain significantly more than any of the other interventions. At 12 weeks the combined treatment group still had significant improvement on the overall pain intensity perception, whereas no improvements were reported in the other three groups. Results demonstrate that transcranial direct current stimulation combined with walking visual illusion can be effective in the management of neuropathic pain following SCI, with minimal side effects and good tolerability.
Soler MD, Kumru H, Pelayo R, et al.
Brain. 2010 Sep;133(9):2565-77.

Oxycodone improves pain control and quality of life in anticonvulsant-pretreated spinal cord-injured patients with neuropathic pain.
Fifty-four persons with SCI and moderate to severe neuropathic pain were treated with oxycodone, either in combination with anticonvulsant medication (83% of subjects) or alone (17%). Pain intensity and interference with life, which were measured at baseline and one and three months, decreased significantly from baseline to month three. A total of 53.7% patients showed at least one treatment-related adverse event, most often constipation (33.3%). Oxycodone treatment, mostly in combination with anticonvulsants, in SCI patients with neuropathic pain decreases pain intensity, improves health-related quality of life and diminishes the impact of pain on physical activity and sleep.
Barrera-Chacon JM, Mendez-Suarez JL, Jáuregui-Abrisqueta ML, et al.
Spinal Cord. 2011 Jan;49(1):36-42.

Effect of dronabinol on central neuropathic pain after spinal cord injury: a pilot study.
This was a randomized, double-blind, crossover, controlled study comparing the effectiveness of the cannabinoid (a chemical constituent of marijuana) dronabinol, to that of diphenhydramine in managing central neuropathic pain below the level of injury in persons with SCI. Diphenhydramine was selected as an active control because it does not have pain relief properties but mimics some of the possible side effects of dronabinol. The primary outcome measure was the change in average pain intensity from baseline to the end of the maintenance phase of each medication. For the five adults with SCI and neuropathic pain who completed this study, dronabinol was no more effective than diphenhydramine for relieving chronic neuropathic pain below the level of injury. The most common side effects were dry mouth, constipation, fatigue, and drowsiness for both medications.
Rintala DH, Fiess RN, Tan G, Holmes SA, Bruel BM.
Am J Phys Med Rehabil. 2010 Oct;89(10):840-8.

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Skin Care and Pressure Sores

Effect of Wheelchair Tilt-in-Space and Recline Angles on Skin Perfusion Over the Ischial Tuberosity in People With Spinal Cord Injury.
Eleven wheelchair users with SCI sat without tilt or recline for 5 minutes and then sat in 1 of 6 tilted and reclined wheelchair positions, including (1) 15° tilt-in-space and 100° recline, (2) 25° tilt-in-space and 100° recline, (3) 35° tilt-in-space and 100° recline, (4) 15° tilt-in-space and 120° recline, (5) 25° tilt-in-space and 120° recline, and (6) 35° tilt-in-space and 120° recline. A 5-minute washout period (at 35° tilt-in-space and 120° recline) was allowed between protocols. Laser Doppler flowmetry was used to measure skin perfusion (blood flow to the skin) over the ischial tuberosity (sitting bones) in response to these different body positions. Combined with 100° recline, wheelchair tilt-in-space at 35° resulted in a significant increase in skin perfusion compared with the upright seated position (no tilt/recline), whereas there was no significant increase in skin perfusion at 15° and 25° tilt-in-space. Combined with 120° recline, wheelchair tilt-in-space at 15°, 25°, and 35° showed a significant increase in skin perfusion compared with the upright seated position. For best blood flow to the skin over the ischial tuberosity, wheelchair tilt should be at least 35° when combined with recline at 100° and at least 25° when combined with recline at 120°.
Jan Y-K, Jones MA, Rabadi MH, Foreman RD, Thiessen A
Arch Phys Med Rehabil. 2010 Nov;91(11):1758-64

Poor nutrition is a relative contraindication to negative pressure wound therapy for pressure ulcers: preliminary observations in patients with spinal cord injury.
Negative-pressure wound therapy (NPWT) has been shown to improve wound healing in some populations. This is the first study in patients with SCI to compare the addition of NPWT to the recommended standards of wound care. Subjects were 86 SCI inpatients in 10 VA centers being treated for severe (Stage III/IV) pressure sores over a 28-day period. Subjects were not assigned to treatment groups; rather, they received standard wound therapies as well as additional therapies (including NPWT) at the discretion of the attending physician. Wounds were measured several times over the 28-day period. No significant difference was found in the rate of wound healing between the 33 patients who received NPWT and those who did not. In malnourished individuals (defined as low serum albumin levels), NPWT was not helpful. Healing outcomes in the NPWT group were significantly influenced by albumin levels, this was not true for the non-NPWT group. Nutritional status appears to be important in the effectiveness of NPWT.
Ho CH, Powell HL, Collins JF, et al.
Adv Skin Wound Care. 2010 Nov;23(11):508-16.

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Regeneration Research

Neural stem cells in regenerative medicine: bridging the gap.
Repair of the chronically injured spinal cord presents multiple challenges, including neuronal/axonal loss and demyelination as a result of primary injury (usually a physical insult), as well as secondary damage, which includes ischemia, inflammation, oxidative injury and glutamatergic toxicity. A promising therapeutic intervention for SCI is the use of neural stem cells. Cell replacement strategies using neural precursor cells (NPCs) and oligodendroglial precursor cells (OPCs) have been shown to replace lost/damaged cells, secrete trophic factors, regulate gliosis and scar formation, reduce cystic cavity size and axonal dieback, and enhance plasticity, axonal elongation and neuroprotection. These progenitor cells can be obtained through a variety of sources, including adult neural tissue, embryonic blastocysts and adult somatic cells via induced pluripotent stem cell (iPSC) technology. The use of stem cell technology - especially autologous cell transplantation strategies - in regenerative therapy for SCI holds much promise; these therapies show high potential for clinical translation and for future disease treatment.
Ruff CA, Fehlings MG.
Panminerva Med. 2010 Jun;52(2):125-47.

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Bladder management

Botulinum toxin-A injections into neurogenic overactive bladder--to include or exclude the trigone? A prospective, randomized, controlled trial.
A total of 38 individuals with urinary incontinence and overactive bladder due to SCI were randomly assigned to receive either botulinum toxin-A (BTX-A) injections into the detrusor (bladder muscle) only or BTX-A injections into both the detrusor and trigone area of the bladder. Participants were using clean intermittent catheterization and were not using anticholinergic medications during the study. Analysis included 18 patients per group, with no significant baseline differences. At baseline and during the study period, several parameters were evaluated, including number of incontinence episodes, number of subjects who became completely dry, quality of life, and the need to start taking anticholinergics again. Both groups had improvements, but those who received BTX-A injections in both the detrusor and trigone area had superior dryness, incontinence and reflex volume.
Abdel-Meguid TA.
J Urol. 2010 Dec;184(6):2423-8.


Tolerance to continuous intrathecal baclofen infusion can be reversed by pulsatile bolus infusion.
Intrathecal baclofen (ITB) therapy is a safe and effective treatment for severe spasticity, but some patients develop tolerance and require continued increasing doses. A drug holiday—tapering off baclofen and substituting an alternate drug—is the standard way to reverse this tolerance, but this requires close monitoring to avoid withdrawal symptoms. For this study, data on dosages and effectiveness were gathered from four patients who were switched from continuous to pulsatile bolus infusion (given in a series of separate large doses rather than a continuos flow) of ITB because of ITB tolerance. This switch resulted in a decrease of the daily ITB dose, while spasticity symptoms remained stable, without causing adverse symptoms. Therefore, pulsatile bolus infusion of ITB seems to be an effective and safe way to reverse the need for increasing ITB dosages in patients who have developed tolerance to ITB.
Heetla HW, Staal MJ, van Laar T.
Spinal Cord. 2010 Jun;48(6):483-6.

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Weight Management

Feasibility of functional electrical stimulated cycling in subjects with spinal cord injury: an energetic assessment.
Individuals with SCI have difficulty getting enough exercise to reduce their risk for high blood pressure, obesity, diabetes and cardiovascular disease. The aim of this study was to determine how much functional electrical stimulated (FES) cycling is necessary to reach the generally recommended weekly exercise caloric expenditure of 1000–2200 kcal. Eight (7 males, 1 female) subjects performed an FES-training session at their highest level of effort for 60 minutes. Gas exchange was measured while exercising, allowing the calculation of mean fat and carbohydrate oxidation rates and of total energy expenditure by means of indirect calorimetry. Mean energy expenditure per session was 288 kcal/h, corresponding to a mean oxidation rate of 49.5 g/h for carbohydrate and 8.5 g/hour for fat. Findings suggest that 4 to 8 hours of FES-cycling per week are necessary to reach the recommended weekly exercise caloric expenditure that seems to be essential to produce ongoing health benefits. FES-cycling is a feasible and promising training alternative to upper body exercise for individuals with SCI.
Perret C, Berry H, Hunt KJ, et al.
J Rehabil Med. 2010 Oct;42(9):873-5.

Prospective analysis of body mass index during and up to 5 years after discharge from inpatient spinal cord injury rehabilitation.
In this multi-center study of 184 persons with SCI in the Netherlands, body mass index was calculated at the beginning of rehabilitation, 3 months later, at discharge, and 1, 2 and 5 years after discharge. The percentage of persons who were overweight/obese increased over the years from 56% to 75%. The absolute BMI did not significantly increase during rehabilitation, but showed a significant increase the year after discharge. Men, persons with paraplegia and older people had more chance of being overweight/obese compared with women, persons with tetraplegia and younger people. The BMI of people with SCI gradually increases during and after inpatient rehabilitation, with significant increases in the first year after discharge. Clinicians should encourage an active lifestyle and give proper dietary advice to patients with SCI.
de Groot S, Post MW, Postma K, et al.
J Rehabil Med. 2010 Nov;42(10):922-8.

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Electrical Stimulation for Cough

Posterolateral Surface Electrical Stimulation of Abdominal Expiratory Muscles to Enhance Cough in Spinal Cord Injury.
Spinal cord injury (SCI) patients have respiratory complications because of abdominal muscle weakness and paralysis, which impair the ability to cough. This study aimed to enhance cough in 11 high-level (T6 and above) SCI subjects using surface electrical stimulation of the abdominal muscles via 2 pairs of electrodes placed posterolaterally. Subjects performed maximum expiratory pressure (MEP) efforts against a closed airway and voluntary cough efforts with and without electrical stimulation. In every subject, electrical stimulation improved peak expiratory flow during cough efforts. The improvements were 2 to 3 times greater than improvements reported in other studies. Wearing an abdominal binder did not improve stimulated cough flows or pressures. These findings suggests that posterolateral electrical stimulation of abdominal muscles is a simple noninvasive way to enhance cough in individuals with SCI.
Butler JE, Lim J, Gorman RB, et al.
Neurorehabil Neural Repair. 2010 Oct 15.

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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