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Spinal Cord Injury Update

Spring 2013: Volume 22, 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.



Patterns of pain across the acute SCI rehabilitation stay: evidence from hourly ratings.
Data were collected from the medical records of acute rehab inpatients with new SCI. A total of 11,001 hourly pain ratings on 1709 inpatient days were collected from 56 inpatients. Pain intensity and variability decreased during the inpatient stay. Compared with those with non-traumatic injuries, those with traumatic injuries had significantly higher pain; those with American Spinal Injury Association Impairment Score (AIS) A scores had a slower decline of pain, while those with AIS D scores had a sharper decline. Pain increased from morning to evening during the latter days of the inpatient stay whereas pain was relatively stable during the early days in the inpatient stay. Those not using a ventilator at admission were significantly less likely to receive a pain medication than those who were, despite no significant differences in pain levels. Since pain changes that occur during acute rehabilitation depend on a variety of injury characteristics, pain management should be individualized as well as sensitive to change over the entire acute hospital stay.
Kalpakjian CZ, Khoury PE, Chiodo AE, Kratz AL.
Spinal Cord. 2013 Apr;51(4):289-94

Pain and its impact on inpatient rehabilitation for acute traumatic spinal cord injury: analysis of observational data collected in the SCIRehab study.
Self-reported pain ratings were collected from 1,357 individuals with SCI undergoing acute rehab at six inpatient facilities. The vast majority of patients (97%) reported pain at least once during the rehabilitation stay. Average pain intensity over the stay was severe for 30% of patients, moderate for 42%, and mild for 25%. Most (79%) of the 177 participants who did not have pain at admission reported pain at least once later in the rehabilitation stay. Patients with severe pain spent fewer days in rehabilitation, received less rehabilitation treatment time, and had more treatment sessions altered in objective or content because of pain than those with lower pain levels. Pain is a common problem for persons receiving inpatient rehabilitation for traumatic SCI and adversely impacts delivery of therapy services.
Zanca JM, Dijkers MP, Hammond FM, Horn SD.
Arch Phys Med Rehabil. 2013 Apr;94(4 Suppl):S137-44

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Bladder Management

Use of botulinum toxin in individuals with neurogenic detrusor overactivity: State of the art review.
Botulinum neurotoxin (BoNT) injection into the bladder wall has been shown to be an effective alternative to anticholinergic medications and more invasive surgery in persons with SCI and MS who have neurogenic bladder overactivity and urinary incontinence. In August 2011, Botox received Food and Drug Administration (FDA) approval for this use. Clinically, injection of BoNT into the bladder has been found to decrease urinary incontinence, improve quality of life, increase bladder capacity and decrease bladder pressures. The most common side effects are urinary tract infections and urinary retention. BoNT has gained popularity because of its effectiveness and long duration of action, relative ease of administration, easy learning curve, reproducibility of results on repeated administration, and low incidence of complications. This paper provides a review of the structure and function, mechanisms of action, clinical and urodynamic studies, injection technique, potential beneficial and adverse effects, and potential areas of research of BoNT.
Linsenmeyer TA.
J Spinal Cord Med. 2013 Sep;36(5):402-19

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FES Cycling

Pilot study of the effect of low-cadence functional electrical stimulation cycling after spinal cord injury on thigh girth and strength.
Eight individuals with chronic SCI underwent six weeks of training three times per week on an isokinetic FES cycle ergometer. For each subject, one leg cycled at 10 revolutions per minute (rpm) (LOW) and the other at 50rpm (HIGH). Each leg performed 30 minutes of FES cycling while the other leg was moved passively at the same cadence. Thigh girth and electrically evoked thigh muscle torque were recorded before and after training. After six weeks of FES cycle training, thigh girth in both LOW and HIGH groups increased significantly. LOW cadence training resulted in larger girth at mid-thigh and greater gains in electrically evoked isometric torque than HIGH training. These results suggest that lower pedaling cadence cycling enhances the potential of FES cycling to build muscle. It is likely that fatigue develops more slowly during FES cycling at lower pedal cadences, allowing greater muscle forces to be maintained. Maximizing leg muscle mass in persons with paralysis is important for health outcomes and quality of life. Greater muscle size may help improve blood flow, reduce the incidence of pressure sores, and improve blood glycemic control and metabolism in the SCI population.
Fornusek C, Davis GM, Russold MF.
Arch Phys Med Rehabil. 2013 May;94(5):990-3.

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Vertical ground reaction force-based analysis of powered exoskeleton-assisted walking in persons with motor-complete paraplegia.
Six persons with thoracic motor-complete SCI (T1-T11 AIS A/B) were trained to walk over ground using powered exoskeleton-assisted walking (ReWalk). Vertical ground reaction force (vGRF) was recorded using the F-Scan system (TekScan). Results were compared to a control group of three age-, height-, weight- and gender-matched able-bodied volunteers. Participants with motor-complete SCI, ambulating independently with a ReWalk, had mechanical loading (weight bearing) similar to able-bodied gait. Powered exoskeleton-assisted walking may provide a way for persons with SCI to achieve mechanical loading to the lower extremities. vGRF profile can be used to examine both magnitude of loading and gait mechanics of powered exoskeleton-assisted walking among participants of different weight, gait speed, and level of assist.
Fineberg DB, Asselin P, Harel NY, et al.
J Spinal Cord Med. 2013 Jul;36(4):313-21.

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The impact of transfer setup on the performance of independent wheelchair transfers.
This study aimed to investigate three key criteria currently present in the Americans with Disabilities Act Accessibility Guidelines (ADAAG): vertical heights, clear space, and grab bar heights. A second aim was to evaluate two additional factors, gaps and obstacles, which are not presently included in the standards but were thought to be important for establishing new criteria. There were 120 participants (54 with SCI) who used wheeled mobility devices (WMDs) in this study. Each performed transfers using a modular transfer station that consisted of a height-adjustable platform with a lateral grab bar, optional obstacle to the transfer, and an optional height-adjustable front grab bar. Maximum and minimum vertical heights of the transfer surface, maximum gap distance between the WMD and transfer surface, grab bar use, and WMD space needs were recorded. Results showed that revisions to the ADAAG regarding transfer heights, gaps, clear spaces, and grab bar heights are necessary to make transfers more accessible to WMD users. The data will be used to revise the guidelines related to transfers and help designers and engineers create an environment that is more accessible.
Toro ML, Koontz AM, Cooper RA.
Hum Factors. 2013 Jun;55(3):567-80.

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Participation in organized sports is positively associated with employment in adults with spinal cord injury.
In this study of 149 adults with chronic SCI, information about demographics, employment, level of education, body mass index, duration of injury, participation in individually planned exercise, and participation in organized sports was collected using a standardized questionnaire. Motor level and completeness of injury were confirmed by physical examination. Analysis of these data found that employment was associated with younger age and a higher level of education, whereas obesity decreased the likelihood of employment. After adjusting for age, education, and body mass index, participation in organized sports was significantly associated with employment, but sex, duration of injury, wheelchair use, and participation in individually planned exercise were not. Further studies are necessary to determine how various factors related to sports participation contribute to its association with employment.
Blauwet C, Sudhakar S, Doherty AL, et al.
Am J Phys Med Rehabil. 2013 May;92(5):393-401.

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Oral Health

Predictors of oral health after spinal cord injury.
Ninety-two people with SCI (44% with cervical injuries) injured at least 6 months completed questionnaires and underwent oral examination. Most participants were able to bring at least one hand to the mouth (82%) and brush teeth independently (65%). Regarding daily oral habits, 84% reported brushing teeth, 48% rinsing mouth, 14% flossing, 33% tobacco use and 13% mouthstick use. Only 32% had teeth cleaned within the past year. Oral examination revealed three decayed and eight missing teeth on average, and 64% had periodontal disease. Employment before SCI and more risky oral habits were significant predictors of worse oral health score. Older age was the only predictor of worse decayed, missing and filled teeth score.
Sullivan AL, Bailey JH, Stokic DS.
Spinal Cord. 2013 Apr;51(4):300-5

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Falls in independent ambulatory patients with spinal cord injury: incidence, associated factors and levels of ability.
Seventy-seven independent ambulatory participants with SCI reported on their history of falls during the 6 months before participating in the study. They were also assessed for their functional ability using the timed up-and-go-test and the 6-minute walk test. Twenty-six subjects (34%) reported falls during 6 months (range 1-6 times). After falls, two subjects required medical attention due to wrist joint fracture and back pain. Walking without a walking device significantly increased the risk of fall, whereas using a walker significantly reduced the risk of fall. Moreover, those who had fallen showed better functional ability than those who had not. Therefore, apart from emphasizing the ability to walk independently, rehabilitation professionals may need to seek strategies that help ambulatory SCI patients to improve balance and safety.
Phonthee S, Saengsuwan J, Amatachaya S.
Spinal Cord. 2013 May;51(5):365-8.

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Soft-plastic brace for lower limb fractures in patients with spinal cord injury.
Fifteen wheelchair users with spinal cord injuries in a National Rehabilitation Center in Japan (male, n=10; female, n=5; average age, 52.7 years) with 19 fractures of the femur or tibia were treated with a newly developed hinged, soft-plastic brace. All the fractures were caused by relatively low-energy impact. The average time taken for fracture union was 80.1 (37-189) days, and the average amount of time spent wearing orthotics was 77.9 (42-197) days. On final X-ray imaging, the average femorotibial angle was 176.9°, and a 15° of misalignment in the sagittal plane occurred in one patient. Results showed that a hinged, soft-plastic brace is a useful option as a conservative approach for treating fractures of the lower extremities in patients with spinal cord injuries.
Uehara K, Akai M, Kubo T, et al.
Spinal Cord. 2013 Apr;51(4):327-30.

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Depression Treatment Preferences After Acute Traumatic Spinal Cord Injury.
A total of 183 individuals with SCI undergoing inpatient rehabilitation participated in this survey study. Fifty-one (28%) of participants had a Patient Health Questionnaire (PHQ-9) score of 10 or more, indicating probable major depression. Overall, 49 (96%) of depressed individuals and 121 (92%) of nondepressed individuals expressed a willingness to participate in at least 1 treatment modality. Depressed participants reported exercise and antidepressants prescribed by a primary care provider as the most favorable options, and group counseling was the least favorable option. For the nondepressed participants, exercise was the most favorable option followed by individual counseling in a medical or rehabilitation clinic and antidepressants prescribed by a primary care provider. Individual telephone counseling was the least favorable option. In general, more individuals preferred treatment in medical or rehabilitation settings than mental health settings. Those who had been diagnosed with depression in the past were more willing to take an antidepressant for treatment of depression than those who had not previously been diagnosed with depression. Treatment preferences and patient education are important factors when choosing a depression treatment modality for patients with SCI. The results suggest that antidepressants, counseling, and exercise may be promising components of depression treatment in this population, particularly if they are integrated into medical or rehabilitation care. Age ≥40 years was a significant predictor of willingness to receive individual counseling.
Fann JR, Crane DA, Graves DE, et al.
Arch Phys Med Rehabil. 2013 Jul 16.

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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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