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Spinal Cord Injury Update

Winter 2012: Volume 21, 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.


Exercise and Physical Activity

Effects of Resistance Training on Adiposity and Metabolism after Spinal Cord Injury.
Nine individuals with motor complete SCI were randomly assigned to follow a specific diet (RT + diet group) and receive neuromuscular electrical stimulation (NMES) resistance training (RT) or to only follow the diet. The RT+diet group underwent 12 weeks of twice-weekly RT to the knee extensor muscle groups using NMES and ankle weights. Body composition and metabolic studies were conducted before and after the 12-week study period. At the end of the study, the RT+diet group had a significant increase in leg lean (muscle) mass and reduction in fat mass compared to the diet-only group. The RT+diet group also had significant improvements in insulin profile and lipid metabolism. After SCI, individuals normally lose muscle and gain fat and are at increased risk for impaired glucose tolerance, insulin resistance and type 2 diabetes mellitus. Monitoring caloric intake alone is not enough to improve body composition or medabolic changes. NMES RT may help individuals with SCI who have limited access to aerobic training, since the protocol can be simply adopted and conducted at home without direct supervision after initial set-up.
Gorgey AS, Mather KJ, Cupp HR, Gater DR.
Med Sci Sports Exerc. 2011 Jun 8

The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review.
The authors reviewed 82 published studies on the effects of exercise on physical fitness in people with SCI. They found strong evidence that exercise, performed 2-3 times per week at moderate-to-vigorous intensity, increases physical capacity and muscular strength in the chronic SCI population. However, there was not adequate quality evidence in these studies to draw meaningful conclusions on the effect of exercise on body composition or functional capacity.
Hicks AL, Martin Ginis KA, Pelletier CA, et al.
Spinal Cord. 2011 Jun 7.

The development of evidence-informed physical activity guidelines for adults with spinal cord injury.
A multidisciplinary expert panel from research universities in Canada generated the following guidelines for achieving important fitness benefits among adults with a SCI: (1) engage in at least 20 min of moderate to vigorous intensity aerobic activity two times per week and (2) perform strength training exercises two times per week, consisting of three sets of 8-10 repetitions of each exercise for each major muscle group. People with SCI, clinicians, researchers and fitness programmers are encouraged to adopt these rigorously developed guidelines.
Ginis KA, Hicks AL, Latimer AE, et al.
Spinal Cord. 2011 Jun 7.

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Bladder Management

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder.
The authors conducted a review of medical records of 35 patients who underwent bladder neck closure (BNC) surgery with suprapubic catheter placement to treat urinary incontinence due to severe urethral erosion, severe scarring, or fistula. Pairing BNC with suprapubic catheter diversion does not require a bowel segment and results in shorter operative times and less opportunity for bowel-related problems. The authors examined preoperative characteristics, indications, complications, and long-term maintenance of renal function of these patients. Neurogenic bladder was due to spinal cord injury in 71% of participants, 23% had multiple sclerosis, and 9% had cerebrovascular accident. The overall complication rate after surgery was 17%. All but two patients were continent at follow-up. Results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence and has a low complication rate.
Colli J, Lloyd LK.
J Spinal Cord Med. 2011;34(3):273-7.

Intermittent catheterization with a hydrophilic coated catheter delays urinary tract infections in acute spinal cord injury: a prospective, randomized, multicenter trial.
A total of 224 individuals with traumatic SCI of less than 3 months’ duration were randomized within 10 days of starting intermittent catheterization (IC) to use either single-use hydrophilic-coated (SpeediCath) or polyvinyl chloride uncoated (Conveen) catheters. Participants were followed up while in the hospital or rehabilitation unit (institutional period) and up to 3 months after institutional discharge (community period). The time from the first catheterization to the first antibiotic-treated symptomatic UTI was measured as well as the total number of symptomatic UTIs during the study period. Using hydrophilic-coated catheters significantly delayed the onset of the first antibiotic-treated symptomatic UTI and reduced the incidence of symptomatic UTIs. Using a hydrophilic-coated catheter could minimize UTI-related complications, treatment costs, and rehabilitation delays in this group of patients, and reduce the emergence of antibiotic-resistant organisms.
Cardenas DD, Moore KN, Dannels-McClure A, et al.
PMR. 2011 May;3(5):408-17

Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial.
A total of 58 individuals with SCI or MS who had neurogenic detrusor overactivity and urinary incontinence (defined as 1 or more “accidents” daily) despite standard treatment were randomized to receive onabotulinumtoxinA 300 U or placebo injections to the bladder. Participants were followed for six months and recorded incontinence episodes during this time. Urodynamics and quality of life were measured. Participants in the treatment group had significantly fewer urinary incontinence episodes and better urodynamics and quality of life than those in the placebo group at weeks 6, 24 and 36. OnabotulinumtoxinA is well tolerated in these populations and provides clinically beneficial improvement for up to 9 months.
Herschorn S, Gajewski J, Ethans K, et al.
J Urol. 2011 Jun;185(6):2229-35

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Functional Electrical Stimulation (FES)

Functional electrical stimulation therapy for grasping in traumatic incomplete spinal cord injury: randomized control trial.
This study compared functional electrical stimulation (FES) therapy to usual occupational therapy (OT) for improving hand function in 22 individuals with incomplete C4-C7 SCI. Control subjects (12 participants) received two doses of conventional OT (one dose = 60 minutes per day, 5 days per week for 8 weeks) and the others (10 participants) received one dose of conventional OT plus one dose of FES hand therapy. Changes in hand function were measured using the Functional Independence Measure self-care subscore, Spinal Cord Independence Measure self-care subscore and Toronto Rehabilitation Institute Hand Function Test. The participants who received FES therapy showed significantly greater improvements in hand function at discharge and were able to maintain their gains at long-term follow-up. FES therapy increased independence and improved quality of life of individuals with tetraplegia when compared with conventional OT.
Kapadia NM, Zivanovic V, Furlan J, et al.
Artif Organs. 2011 Mar;35(3):212-6.

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Efficacy of cranial electrotherapy stimulation for neuropathic pain following spinal cord injury: a multi-site randomized controlled trial with a secondary 6-month open-label phase.
Neuropathic pain is a major problem for many with SCI and often does not get better with analgesic medications and other available treatments. This multi-site, double-blind, sham-controlled study examined the effectiveness of cranial electrotherapy stimulation (CES) for neuropathic pain in SCI. CES involves the application of a small amount of current through the head via ear clip electrodes. Adults with SCI and chronic neuropathic pain at or below the level of injury were randomized to receive active or sham CES for 1 hour daily for 21 days. On average, CES provided a small but statistically significant improvement in pain intensity and pain interference with few side effects. Individual results varied from no pain relief to a great deal of relief.
Tan G, Rintala DH, Jensen MP, et al.
J Spinal Cord Med. 2011;34(3):285-96.

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Pressure Ulcers

A case report on the use of sustained release platelet-rich plasma for the treatment of chronic pressure ulcers.
Chronic pressure ulcers affect patient health, emotional state and quality of life, and lead to increased health care costs from lengthy hospitalizations and surgery. Usual treatment of these wounds can be slow. Platelet-rich plasma (PRP) therapy has been growing as a viable treatment alternative for a number of clinical applications and has potential benefit for use in chronic wounds. Three veterans with SCI and chronic stage IV pressure ulcers were treated with a sustained-release PRP therapy to stimulate wound healing. PRP treatment consistently resulted in the formation of granulation tissue and improved vascularity for each of the three patients treated, while reducing the overall ulcer area and volume. The controlled release of growth factors from PRP demonstrated a positive stimulatory effect on the healing rate of chronic pressure ulcers in individuals with SCI.
Sell SA, Ericksen JJ, Reis TW, et al.
J Spinal Cord Med. 2011 Jan;34(1):122-7.

Evaluation of the cost-effectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury.
In a prior study, 29 individuals with SCI participated in a randomized controlled trial comparing electrical stimulation (ES) plus standard wound care (SWC) to SWC alone for the treatment of grade III/IV pressure ulcers (PUs). Costs included outpatient (clinic, home care, health professional) and inpatient management (surgery, complications). ES plus SWC treatment resulted in better healing and lower costs compared to SWC alone. There was a 16.4% increase in the PUs healed and a cost savings of $224 (Canadian) at 1 year.
Mittmann N, Chan BC, Craven BC, et al.
Arch Phys Med Rehabil. 2011 Jun;92(6):866-72

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Psychosocial Issues

An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post-spinal cord injury.
Following SCI, individuals can experience high levels of emotional distress and pain that can significantly lower quality of life. Cognitive behavioral therapy (CBT) is a psychotherapy approach for helping individuals who struggle with depression, anxiety, and coping and adjustment problems. Common techniques used in CBT include cognitive restructuring (encouraging a re-evaluation of distorted thoughts that underlie feelings of depression and anxiety), increasing the person’s access and willingness to engage in rewarding activities, various forms of relaxation training, problem solving strategies, as well as assertiveness and coping skills training. Nine studies were reviewed for this article: two random controlled trials, six prospective controlled trials and one cohort study. The evidence showed that CBT can benefit persons with SCI who have depression, anxiety, adjustment and coping problems. As CBT may involve many different components, it is important in future research to determine which of these elements alone or in combination is most effective in treating the emotional consequences of SCI.
Mehta S, Orenczuk S, Hansen KT, et al.
Rehabil Psychol. 2011 Feb;56(1):15-25.

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Stem Cell Therapies

Will stem cell therapies be safe and effective for treating spinal cord injuries?
A large number of different cells, including embryonic and adult stem cells, have been transplanted into animals with SCI, and in many cases these procedures have resulted in modest sensorimotor benefits. This review article examines some of the publically available preclinical evidence that some of these cell types improve outcome in animals with SCI. Transplantation of many different types of stem and progenitor cells acutely after SCI enhances spontaneous recovery of function in animals. The common mechanism(s) of this enhanced recovery of function are not well understood, although a range of possibilities are usually cited (including preservation of tissue, remyelination, axon sprouting, glial cell replacement). There is no agreement about the best cell type for transplantation. Transplantation of cells into animals with a long lifespan is important to determine whether or not tumors will eventually form. It will also be important to determine whether long-term survival of cells is required for functional recovery.
Thomas KE, Moon LD.
Br Med Bull. 2011;98:127-42.

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Weight Gain

Weight gain following spinal cord injury: a pilot study.
A retrospective chart review of 85 newly injured patients in a VA SCI Unit collected information about mean (average) change in body mass index (BMI) between rehabilitation admission and final follow-up. Mean BMI increased by 2.3 kg/m2 between rehabilitation admission (mean 45 days post-injury) and final follow-up (mean 5 years post-injury). The distribution of participants shifted from lower BMI classifications at rehabilitation admission to higher BMI classifications at final follow-up. For participants who went from normal to overweight or obese, the greatest increase occurred during the first year after acute rehabilitation. Neurological level, impairment category, primary mode of mobility, and age at rehabilitation admission did not significantly predict BMI change. BMI at rehabilitation admission correlated significantly with BMI at final follow-up. These findings confirm a significant increase in BMI after new SCI and suggest that persons with new SCI are at greatest weight gain risk during the first year following acute rehabilitation.
Crane DA, Little JW, Burns SP.
J Spinal Cord Med. 2011;34(2):227-32.

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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