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Spinal Cord Injury Update

Fall 2012: Volume 21, 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.



Development of a motor driven rowing machine with automatic functional electrical stimulation controller for individuals with paraplegia; a preliminary study.
Ten SCI patients with paraplegia performed two rowing techniques in this study. The first technique used a fixed seat with rowing achieved using only upper extremity movement (fixed rowing). The second used an automatically moving seat, facilitating active upper extremity movement and passive lower extremity movement via the motorized seat (motor rowing). Each patient performed two randomly assigned rowing exercise stress tests 1-3 days apart to measure cardiopulmonary responses such as work rate (WR), time, respiratory exchange ratio (R), oxygen consumption (VO(2)), heart rate (HR), metabolic equivalents (METs), and rating of perceived exertion (RPE). WR, time, VO(2), and METs were significantly higher and HR was significantly lower after the motor rowing test than after fixed motor rowing test. Motor rowing has an advantage of allowing natural rowing motion and passive leg movement as well as providing the significant change of cardiorespiratory exercise variables for individuals with SCI and no lower extremity motor function.
Jung DW, Park DS, Lee BS, Kim M.
Ann Rehabil Med. 2012 Jun;36(3):379-85

Increased risk of stroke after spinal cord injury: a nationwide 4-year follow-up cohort study.
This study used a comprehensive national database in Taiwan to investigate the incidence of stroke in a group of 2,806 chronic SCI patients with moderate to severe disability compared to a group of 28,060 non-injured individuals. Every subject was followed for 4 years (unless they died or had a stroke by December 31, 2006). The incidence rate of stroke in the SCI group (5.96 per 1,000 person-years) was higher than that of the comparison group. In the SCI group, the incidence of ischemic stroke was higher than that of hemorrhagic stroke. SCI patients with disability are at a higher risk of stroke, especially the ischemic type. Strategies to prevent stroke are suggested.
Wu JC, Chen YC, Liu L, et al.
Neurology. 2012 Apr 3;78(14):1051-7.

Management of cardiovascular disease risk factors in individuals with chronic spinal cord injury: an evidence-based review
A review of the medical literature revealed that almost all risk factors for cardiovascular disease (CVD) are higher in individuals with SCI, including physical inactivity, dyslipidemia, blood pressure irregularities, abnormal glycemic control, and chronic inflammation. Studies have also shown that these risk factors occur at an earlier age in persons with SCI. However, not enough studies have been done regarding treatment outcomes in SCI-specific study populations to allow for the development of evidence-informed clinical practice recommendations. Nevertheless, health care providers need to be aware that patients with SCI have a higher risk for CVD than the general population and should be offered screening and prevention strategies accordingly.
Cragg J, Stone J, Krassioukov AV.
J Neurotrauma. 2012 Jun 28.

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Robotic resistance treadmill training improves locomotor function in human spinal cord injury: a pilot study.
Ten individuals patients with chronic incomplete SCI were randomly assigned to 1 of 2 groups: one group received 4 weeks of assistance training followed by 4 weeks of resistance training, while the other group received the same in reverse order. Locomotor training was provided by using a cable-driven robotic locomotor training system that allows patients the freedom to voluntarily move their legs in a natural gait pattern during body weight supported treadmill training (BWSTT), while providing controlled assistance/resistance forces to the leg during the swing phase of gait. A significant improvement in walking speed and balance was observed after robotic treadmill training using the cable-driven robotic locomotor trainer. There was no significant difference in walking functional gains after resistance versus assistance training, although resistance training was more effective for higher functioning patients. Cable-driven robotic resistance training may be used as an adjunct to BWSTT for improving overground walking function in incomplete SCI, particularly for those patients with relatively high function.
Wu M, Landry JM, Schmit BD, et al.
Arch Phys Med Rehabil. 2012 May;93(5):782-9.

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Socioeconomic and behavioral risk factors for mortality: do risk factors observed after spinal cord injury parallel those from the general USA population?
Data were analyzed on 1,361 adults with traumatic SCI of at least 1-year duration who were recruited through a large specialty hospital in the southeastern U. S. Age, disability, smoking and income were significant predictors of mortality. Both current and former smokers were at elevated hazard of mortality, as were those with incomes below $10,000 and between $10,000 and $35,000. Even after controlling for health and severity of disability, smoking and income were significant predictors of mortality, exceeding that reported previously within the general population.
Krause JS, Saunders LL
Spinal Cord (2012) 50, 609–613.

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Incidence and predictors of contracture after spinal cord injury-a prospective cohort study.
A total of 92 consecutive patients with acute SCI in two Sydney spinal cord injury units were assessed within 35 days of injury and 1 year later. Incidence of contracture at 1 year was measured in the wrist, elbow, hip and ankle. At 1 year, 66% of participants developed at least one contracture. Incidence of contracture at each joint was: shoulder 43%, elbow and forearm 33%, wrist and hand 41%, hip 32%, knee 11% and ankle 40%. Incidence of contracture determined by standardized torque measures of range was: elbow 27%, wrist 26%, hip 23% and ankle 25%. The incidence of contracture in major joints 1 year after spinal cord injury ranges from 11-43%. The ankle, wrist and shoulder are most commonly affected. The authors could not determine which factors accurately predict which individuals are more susceptible to contracture soon after injury.
Diong J, Harvey LA, Kwah LK, et al.
Spinal Cord. 2012 Aug;50(8):579-84

Acromioclavicular joint arthrosis in persons with spinal cord injury and able-bodied persons.
This was a retrospective analysis of medical records and magnetic resonance images (MRIs) of 68 persons with SCI and 105 able-bodied persons who visited an outpatient orthopaedics clinic because of shoulder pain. AC joint arthrosis was found in 98% of the SCI group and 92% of the able-bodied group. Within the SCI group, 72% had paraplegia and 28% had tetraplegia; 80% had ASIA A (complete) injury; and the average time since injury was 23.3 years. Both groups in this setting had a high prevalence of AC joint arthrosis, but it was more severe and more advanced in the SCI group. The authors recommend routine assessment during check-ups, which includes assessment of shoulder pain, physical examination and diagnostic imaging (X-ray and when necessary MRI), in order to help to diagnose AC joint arthrosis at an earlier stage. Early diagnosis increases the likelihood that conservative interventions (e.g. optimizing transfer techniques, technique of wheelchair propulsion) can be used to successfully avoid further shoulder deterioration.
Eriks-Hoogland I, Engisch R, Brinkhof MW, van Drongelen S.
Spinal Cord. 2012 Jul 31

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Pressure Ulcers

Effects of electrical stimulation-induced gluteal versus gluteal and hamstring muscles activation on sitting pressure distribution in persons with a spinal cord injury.
Muscle contractions induced by electrical stimulation (ES) might help prevent pressure ulcers (PUs) by reducing atrophy (muscle shrinking) and improve blood flow, oxygenation, and improve sitting pressure distribution. In this study, ten participants with SCI underwent two ES protocols applied using a custom-made electrode garment with built-in electrodes. In one protocol, both the gluteal and hamstring (g+h) muscles were activated, in the other gluteal (g) muscles only. In all participants, both protocols caused a significant decrease in ischial tuberosities (ITs) or sitting bones pressure. IT pressure was significantly reduced by 34.5% after g+h muscle activation and by 10.2% after activation of g muscles only. g+h muscles activation showed a decrease in pressure relief over time compared with g muscles only. While both protocols gave pressure relief, activation of both g+h muscles resulted in better IT pressure reduction in sitting individuals with a SCI than activation of g muscles only. ES might be a promising method in preventing PUs on the ITs in people with SCI.
Smit CA, Haverkamp GL, de Groot S, et al.
Spinal Cord. 2012 Aug;50(8):590-4.


Spasticity changes in SCI following a dynamic standing program using the Segway.
Eight individuals with SCI ASIA (American Spinal Injury Association) A–D participated in a 4-week dynamic standing program of three 30-minute sessions using a Segway. The main outcome was spasticity as measured by the Modified Ashworth Scale (MAS). Secondary measures included the SCI-Spasticity Evaluation Tool, Pain Outcomes Questionnaire, and Fatigue Severity Scale. The dynamic standing sessions were associated with immediate improvements in spasticity and pain. Fatigue levels decreased, however this was not significant. Dynamic standing on the Segway may be effective for short-term spasticity reduction and decreased pain and fatigue.
G Boutilier, B J Sawatzky, C Grant, et al.
Spinal Cord (2012) 50, 595–598

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Increases in wheelchair breakdowns, repairs, and adverse consequences for people with traumatic spinal cord injury.
A survey of 723 participants with SCI who use a wheelchair for more than 40 hrs/wk treated at a SCI Model Systems center was conducted. Subjects were asked to indicate the number of times in the past 6 months the wheelchair they used most had been repaired. Those who reported repairs were asked to indicate which of the following five consequences occurred because of a wheelchair breakdown: (1) no consequence, (2) been stranded, (3) been injured, (4) missed work or school, or (5) missed a medical appointment. Significant increases were found in the number of participants reporting repairs (7.8%) and adverse consequences (23.5%) in a 6-mo period (2006-2011) compared with historical data (2004-2006). When examining current data, minorities experienced a greater frequency and higher number of reported consequences. Power wheelchair users reported a higher number of repairs and consequences than did manual wheelchair users. Wheelchairs equipped with seat functions had a greater frequency of adverse consequences. Repairs did not vary across funding source, but individuals with wheelchairs provided by Medicare and Medicaid reported a higher frequency of consequences than did the combined group of the Department of Vocational Rehabilitation, Worker’s Compensation, and the Veterans Administration. The incidence and consequences of repairs are increasing from what was already a very high statistic in this U.S. population. Further investigation into causality is required, and intervention is needed to reverse this potential trend.
Worobey L, Oyster M, Nemunaitis G, et al.
Am J Phys Med Rehabil. 2012 Jun;91(6):463-9

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Urological Problems

Effectiveness of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury: a randomized controlled trial.
Forty-two participants with SCI between C8 and T12 were randomized to receive a physical activity program (intervention group) or to maintain their current activities (control group). The intervention consisted of 16 weeks of moderate intensity aerobic physical conditioning for one hour, two or three times per week. It included cycloergometer of upper limbs (Cybex), performed distance with a wheelchair, and general exercises to gain muscle power with progressive loading of residual muscle and muscle stretching. All participants performed a baseline stress test, urine analysis and urine culture at the beginning of the study (pre-training tests) and after 16 weeks. The intervention group showed an increase of estimated peak oxygen consumption and a reduction of chronic asymptomatic bacteriuria, with no adverse effects. The regular practice of physical activity of moderate intensity may be an effective and safe method for the treatment of chronic asymptomatic bacteriuria in persons with SCI.
Lavado EL, Cardoso JR, Silva LG, et al.
Clin Rehabil. 2012 Jul 26.

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Testosterone Deficiency

Prevalence of testosterone deficiency after spinal cord injury.
Sixty male veterans with SCI in this study underwent testosterone blood tests for this study in addition to annual evaluation laboratory examination. A low serum testosterone level (<325 ng/dL) was detected in 43.3% of participants. The prevalence of testosterone deficiency was significantly greater in participants with motor complete (AIS A and B) injuries compared with those with motor incomplete (AIS C, D, and E) injuries. Testosterone levels also were significantly lower in participants who were taking narcotic medications for pain management. These findings reveal a substantial prevalence of testosterone deficiency in men with chronic SCI and confirm a significant association between injury severity and testosterone deficiency. Testosterone provides many potential health benefits, including increased bone mineral density, improved muscle mass and strength, increased sexual desire, increased energy, decreased irritability and depression, and improved cognition. Measuring serum total testosterone levels should be included in standard screenings for patients with SCI, particularly those with motor complete.
Durga A, Sepahpanah F, Regozzi M, et al.
PM R. 2011 Oct;3(10):929-32.

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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 http://www.lib.washington.edu/ill. (There is a fee for this service.)

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