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Spinal Cord Injury Update

Spring 2012: Volume 21, 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.


Sexual Function & Fertility

Pregnancy outcomes by intravaginal and intrauterine insemination in 82 couples with male factor infertility due to spinal cord injuries.
Eighty-two male patients with spinal cord injuries and their female partners received infertility services in this study. Sperm were obtained by masturbation in 4 men (4.9%), penile vibratory stimulation in 42 men (51.2%), and electroejaculation in 36 men (43.9%). Intravaginal insemination (IVI), performed mostly at home, was undertaken in 45 couples, 17 of whom (37.8%) achieved 20 pregnancies.  Intrauterine insemination (IUI)was performed in 57 couples, 14 of whom (24.6%) achieved 19 pregnancies. Overall, 18 live births occurred  by IVI and  21 occurred by IUI. The authors conclude that IVI and IUI are reasonable options for this patient population and should be used before proceeding to assisted reproductive technologies (ART).
Kathiresan AS, Ibrahim E, Aballa TC, et al.
Fertil Steril. 2011 Aug;96(2):328-31.

Assessing and conceptualizing orgasm after a spinal cord injury.
A total of 97 men with SCI underwent sexual stimulation using various techniques (natural stimulation, vibrostimulation or vibrostimulation combined with midodrine). Injury level ranged from C2 to S5 and involved both complete (49%) and incomplete (51%) lesions. Among the 89 (92%) who achieved ejaculation, 50 experienced autonomic hyperreflexia (AHR, also known as autonomic dysreflexia or AD) at ejaculation and 39 did not. Significantly more sensations were described at ejaculation than with sexual stimulation alone. Men with SCI who experienced AHR at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who did not. There was no difference between men with complete and those with incomplete lesions. The findings show that the questionnaire is a useful tool to assess orgasm and to guide patients in identifying the bodily sensations that accompany or build up to orgasm. The findings also support the hypothesis that orgasm may be related to the presence of AHR in individuals with SCI.
Courtois F, Charvier K, Vézina JG, et al.
BJU Int. 2011 Nov;108(10):1624-33.

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Arm, Hand & Shoulder

Changes in skills required for using a manual wheelchair after reconstructive hand surgery in tetraplegia. 
Surgical reconstruction of arm and hand function has developed tremendously over the last decade. Several studies have documented the functional improvements after surgery and rehabilitation: better control and strength of elbow extensors; lateral pinch; grip function; and opening of the hand. In this study, 16 individuals with C5-C7 tetraplegia underwent a total of 23 grip and/or elbow extension reconstruction surgeries to improve arm and/or hand function. Functional tests of wheelchair control were performed before and 12 months after the reconstructive surgery. Sixty-eight percent of the individuals improved their wheelchair maneuvering skills after hand surgery. Improvements were also observed in their ability to perform tests that were impossible to perform before surgery. The type of reconstruction and level of injury affected the degree of improvement achieved. Hand and arm function are highly prioritized goals in this population, and increased mobility is a crucial factor in living a more active life.
Lamberg AS, Fridén J. 
J Rehabil Med. 2011 Jul;43(8):714-9. 

A cross-sectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients.
Shoulder pain affects up to 67% of the SCI population, a rate that is four times higher than the able-bodied population. In this study, 317 individuals with paraplegia between T2 and L3 underwent clinical exams and magnetic resonance imaging (MRI) of both shoulders. Participants averaged 26.7 years of wheelchair dependency (range, 5-56 years). While 161 patients (51%) had no rotator cuff tears, 156 (49%) had tears in one (unilateral, 20%) or both (bilateral, 29%) shoulders. Patients with bilateral tears were older and had been injured longer than those with unilateral or no tears. In patients with unilateral tears, a full-thickness rupture of the supraspinatus tendon was found in 67%, whereas a partial-rupture was detected in 33%. Of the patients with bilateral tears, 75% presented with a full-thickness rupture and 25% with a partial rupture. These findings support the theory of “wear and tear” in patients with spinal cord injury and that the occurrence of cuff tears depends on the duration of wheelchair dependency as well as age.
Akbar M, Brunner M, Balean G, et al.
J Shoulder Elbow Surg. 2011 Oct;20(7):1108-13. Epub 2011 Jul 2

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Autonomic Dysreflexia

Autonomic dysreflexia: current evidence related to unstable arterial blood pressure control among athletes with spinal cord injury.
Spinal cord injury is commonly associated with a range of autonomic dysregulation that can interfere with cardiovascular, bladder, bowel, temperature, and sexual function. Individuals with a cervical or high-thoracic SCI face lifelong abnormalities in systemic arterial pressure control. In general, their resting arterial pressure is lower than that in able-bodied individuals and is commonly associated with persistent orthostatic intolerance. In addition, they experience fleeting episodes of life-threatening hypertension, known as autonomic dysreflexia (AD), which often is associated with disturbances in heart rate and rhythm. AD occurs in up to 90% of individuals with a cervical or high-thoracic SCI and requires immediate medical attention. During athletic activities, self-induced AD is used by some individuals to improve their performance, a technique known as “boosting.” For health safety reasons, boosting is officially banned by the International Paralympic Committee. Medical practitioners who are involved in the care of wheelchair athletes should be aware of the unique cardiovascular dysfunction that results from SCI and may occur at any time, even with seemingly harmless triggers. Prompt recognition and management of these conditions, including episodes of AD, could be life saving.
Krassioukov A.
Clin J Sport Med. 2012 Jan;22(1):39-45.

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Urological Problems

Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder.
This study involved individuals with neurogenic bladder due to spinal cord injury and a history of recurrent urinary tract infections (UTIs). Participants were randomized to receive a bladder inoculation of either Escherichia coli HU2117 (experimental group) or sterile saline (control group). Urine cultures were obtained weekly during the first month and then monthly for 1 year. Of 17 patients colonized with E. coli HU2117 and the 10 control patients, 5 (29%) and 7 (70%) developed more than 1 episode of UTI, respectively. The average number of episodes of UTI per year was also lower in the experimental than in the control group. E. coli HU2117 did not cause symptomatic UTI. The authors conclude that bladder colonization with E. coli HU2117 safely reduces the risk of symptomatic UTI in patients with spinal cord injury. Effective, but less complex, methods for achieving bladder colonization with E. coli HU2117 are under investigation.
Darouiche RO, Green BG, Donovan WH, et al.
Urology. 2011 Aug;78(2):341-6. Epub 2011 Jun 17

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Technology and Mobility

Technology for mobility in SCI 10 years from now.
A person’s level of disability is an interaction between their impairment and the environment. Technology impacts this in a number of ways and has the potential to fully eliminate disability. The authors believe technology will eventually allow complete independence someday, but economic factors and systems of care will impact the extent to which individuals with SCI will fully benefit from technological advances.  The authors review expected advances in specific areas of technology, such as power sources, processing, sensors and software, and describe the ways specific devices will be impacted by them. They also discuss the social context of technology for mobility and how the political, social and economic environment is likely to impact advances. Although technology advances are exciting, a large challenge for the research community will be how to effectively apply and deploy this technology. Advances occurring in the next 10 years that reduce cost of technology may be more important to the population with SCI than brand new technologies.
Boninger M, French J, Abbas J, et al.
Spinal Cord. 2012 Jan 17.

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Electrical Stimulation

Muscle changes following cycling and/or electrical stimulation in pediatric spinal cord injury
Muscle atrophy (wasting) is common in people with SCI and has negative health effects such as increased risk for cardiovascular disease, insulin resistance, glucose intolerance and type 2 diabetes. Children with SCI also are at higher risk for these problems, and intervening at an earlier age may be beneficial. Functional electrical stimulation while cycling (FESC) can increase muscle mass and strength in adults with SCI, and this study examined whether it can be helpful for children with SCI. Thirty children with SCI aged 5-13 were randomly assigned to do FESC, passive cycling (no electrical stimulation) or electrical stimulation without cycling (ES) at home  for 1 hour, 3 times per week. After 6 months, tests showed that children receiving either FESC or ES exercise had changes in muscle size, stimulated strength, or both. The ES group had greater changes in quadriceps muscle size, and the FESC group had greater changes in strength. These changes may decrease their risk of cardiovascular disease, insulin resistance, glucose intolerance, and type 2 diabetes. Children in the PC group had no improvements.
Johnston TE, Modlesky CM, Betz RR, Lauer RT.
Arch Phys Med Rehabil. 2011 Dec;92(12):1937-43.

Increased Aerobic Fitness After Neuromuscular Electrical Stimulation Training in Adults With Spinal Cord Injury.
Fourteen participants with SCI (T4-11; ASIA A and B) completed training of a new neuromuscular electrical stimulation (NMES) system designed to improve aerobic fitness in persons with SCI. For the training, four electrodes were placed on the quadriceps and hamstrings muscle groups, and subtetanic contractions were elicited using the NMES device. Participants did the training unsupervised at home for 1 hour, 5 days/wk for 8 weeks. A treadmill wheelchair propulsion exercise test with simultaneous cardiopulmonary gas exchange analysis found a significant increase in Vo(2) peak and HRpeak between baseline and follow-up testing. This novel form of NMES is an effective method of improving aerobic fitness in a sedentary adult SCI population. Compliance with training was high, possibly indicating the convenience of using this system. Results compare favorably with current functional electrical stimulation exercise systems. This system offers a portable and convenient method of aerobic exercise, with the potential to provide the associated health benefits of exercise to the SCI population.
Carty A, McCormack K, Coughlan GF, et al.
Arch Phys Med Rehabil. 2012 Mar 21.

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Pressure Ulcers

A telerehabilitation intervention for persons with spinal cord dysfunction.
Pressure ulcers and depression are common preventable conditions in people with spinal cord dysfunction (SCD). However, few successful, low-cost preventive approaches have been identified. The authors developed a dynamic automated telephone calling system, termed Care Call, to motivate people with SCD to improve their skin care, seek treatment for depression, and appropriately use the healthcare system. This system supplements face-to-face health care with a clinician. It uses a digitized human voice and functions as an at-home monitor, educator and counselor for reinforcing or changing health-related behaviors. Individuals with SCD pilot-tested the system and provided feedback. Results of a randomized controlled trial using this system will test whether the intervention will successfully promote self-management in a cost-effective manner.
Houlihan BV, Jette A, Paasche-Orlow M, et al.
Am J Phys Med Rehabil. 2011 Sep;90(9):756-64.

Necrotizing fasciitis in patients with spinal cord injury: an analysis of 25 patients.
A retrospective chart review found 25 SCI patients (19 with paraplegia and 6 with tetraplegia) who were treated for  necrotizing fasciitis during a 9-month period. Necrotizing fasciitis (NF) is an infection that causes tissue to die (sometimes called “flesh-eating bacteria”). In 18 cases, NF developed due to pressure sores. Grade 4 pressure sores were identified in 15 cases and grade 3 pressure sores in 3 cases. The incidence of developing NF is significantly higher in patients with grade 4 pressure sores than in those with a lower-grade lesion. The most common bacteria were streptococci. During the hospital stay, six patients developed sepsis and two died because of septic multi-organ failure. The authors recommend that close clinical and laboratory monitoring of all patients with grade 3 or 4 pressure sores is appropriate so that any early clinical signs of NF can be recognized and evaluated for early and aggressive treatment.
Citak M, Backhaus M, Tilkorn DJ, et al.
Spine 2011 Aug 15;36(18):E1225-9.

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Psychological Issues

An Exploration of Modifiable Risk Factors for Depression After Spinal Cord Injury: Which Factors Should We Target?
A total of 244 community-dwelling individuals with SCI (77% men, 61% white; mean age, 43.1y; 43% with tetraplegia) who were at least 1 month postinjury completed questionnaires on depression (PHQ-9), physical activity (International Physical Activity Questionnaire [IPAQ]), pleasant and rewarding activities (Environment Rewards Observation Scale [EROS]), and self-efficacy to manage the effects of SCI (Modified Lorig Chronic Disease Self-Management Scale). The study found that more severe depression was associated with being 20 to 29 years of age, not completing high school, not working or attending school, and being 4 or fewer years post-SCI. Having rewarding activities and, to a lesser extent, having confidence in one’s abilities to manage SCI, were associated with being less depressed. Treatments designed to increase the level of rewarding activities and positive reinforcement in the daily lives of people with SCI may be an especially promising approach to treating depression in this population.
Bombardier CH, Fann JR, Tate DG, et al.
Arch Phys Med Rehabil 2012;93(5):775-781


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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