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Spinal Cord Injury Update

Spring 2013: Volume 22, 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.



Training to achieve over ground walking after spinal cord injury: a review of who, what, when, and how.
A review was conducted of published findings about different training methods for over ground walking after SCI in order to understand who best responds to what type of treatment, how that treatment should be delivered, and at what stage after injury. Individuals with motor incomplete SCI (ASIA Impairment Scale C and D) are most likely to regain walking over ground. The effective methods of training all involved a lot of walking, and if assistance was provided, partial assistance was more effective than total assistance. Walking training resulted in an increase in over ground walking speed. The effective training schedules ranged from 10 to 130 sessions, with sessions ranging from two to five per week. Earlier training led to superior results both in the subacute (<6 months) and chronic phases (>6 months) after injury, but even individuals with chronic injuries of long duration can improve.
Yang JF, Musselman KE.
J Spinal Cord Med. 2012 Sep;35(5):293-304.

The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury.
This was an open, non-comparative, nonrandomized study of the safety and performance of the ReWalk powered exoskeleton in 12 participants with motor-complete paraplegia who used wheelchairs for mobility. Participants underwent gait training using the ReWalk for three 60- to 90-minute sessions over 8 weeks. By completion of the trial, all subjects had walked under their own control, without human assistance while using the ReWalk, for at least 50 to 100 meters continuously and for a period of at least 5 to 10 minutes. Some participants reported improvements in pain, bowel and bladder function, and spasticity during the trial, and all reported emotional/psychosocial benefits from the use of ReWalk. Most subjects achieved a level of walking proficiency close to that needed for limited community ambulation. ReWalk holds considerable potential as a safe ambulatory powered orthosis for individuals with motor-complete thoracic-level SCI.
Esquenazi A, Talaty M, Packel A, Saulino M.
Am J Phys Med Rehabil. 2012 Nov;91(11):911-21.

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Experimental Trials

Expectations of benefit and tolerance to risk of individuals with spinal cord injury regarding potential participation in clinical trials.
This 46-item questionnaire asked 224 individuals with SCI about their receptivity to participating in clinical trials of drug therapies or stem cell therapies, their anticipation of therapeutic benefits, and their tolerance to risk. The average age of respondents was 42 years; average of 5.5 years since injury; 74% were male; and 62% had cervical injuries. Respondents reported their ASIA Impairment Scale (AIS) levels as: 33% AIS-A, 12% AIS-B, and 55% AIS-C/D. Receptivity to neuroprotective drug trials in the acute setting was very high, but somewhat less so for stem cell trials in the subacute or chronic (current) setting. About one third of the respondents indicated that they would want a 5-25% chance of achieving some functional recovery if enrolling in a stem cell trial in the current, chronic injury state. Whereas the majority said the risk of spinal cord damage, cancer, infection, and nerve pain from cell transplantation trials would need to be less than 1%, 15-30% of respondents said they would participate regardless of the risk of these complications. Those who accepted risks were male, older, and had more self-reported knowledge of SCI research than those who did not accept those risks. These data underscore the need for careful communication with individuals with SCI to avoid unrealistic expectations and therapeutic misconception in experimental trials.
Kwon BK, Ghag A, Dvorak MF, et al.
J Neurotrauma. 2012 Dec 10;29(18):2727-37.

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Bladder Management

Treatment satisfaction and improvement in health-related quality of life with onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity.
In this double-blind, placebo-controlled study, patients with urinary incontinence due to neurogenic detrusor overactivity from multiple sclerosis or SCI were randomized to three different treatment groups: 92 patients received placebo (sham treatment); 92 received onabotulinumtoxinA 200 U; and 91 received a higher dose of onabotulinumtoxinA 300 U. Patients who received onabotulinumtoxinA 200 U or 300 U had significantly greater improvement in quality of life and greater treatment satisfaction compared to the placebo group. There was no difference between the different doses of onabotulinumtoxinA.
Sussman D, Patel V, Del Popolo G, et al.
Neurourol Urodyn. 2012 Sep 10.

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Bone Fractures

Treatment of lower-extremity long-bone fractures in active, nonambulatory, wheelchair-bound patients.
A retrospective review found 11 surgically treated lower-extremity long-bone fractures in nine wheelchair-bound patients in an orthopedic department between October 2000 and July 2009. Mechanism of injury for all patients was a low-energy fall that occurred while transferring. Four patients who sustained a distal femur fracture, one patient who sustained a distal femur fracture and a subsequent proximal tibia fracture, and one patient who sustained a proximal third tibia shaft fracture underwent open reduction and internal fixation with plates and screws. Three patients with four midshaft tibia fractures underwent intramedullary nailing. At last follow-up, all nine patients had returned to their baseline preoperative function. All fractures achieved complete union, and no complications were reported. This study’s findings demonstrate that operative treatment in active, long-term wheelchair-users can provide an improved quality of life postinjury and a rapid return to activities.
Sugi MT, Davidovitch R, Montero N, et al.
Orthopedics. 2012 Sep;35(9):e1376-82.

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Trajectories of resilience, depression, and anxiety following spinal cord injury.
This was a longitudinal study of 233 SCI patients in six European countries who were assessed for depression and anxiety symptoms at four time points: within six weeks of injury and then at three months, one year, and two years after injury. Different patterns of trajectories for depression and anxiety symptoms emerged, but each model revealed a resilient trajectory of low symptom levels and a delayed trajectory of worsening symptoms. The resilient pattern was most common, observed in more than half of the patients. Chronic high depression was also observed in some individuals but not chronic high anxiety. The best-adjusted patients viewed major stressors as challenges to be accepted and met with active coping efforts. Results demonstrate that SCI patients are likely to show different but observable patterns of long-term outcome. Although many SCI patients adjust remarkably well, some will fail to recover psychologically, and some (approximately 10%) will experience increased symptoms over time. The authors recommend early psychological interventions that target how patients perceive and cope with their injury.
Bonanno GA, Kennedy P, Galatzer-Levy IR, et al.
Rehabil Psychol. 2012 Aug;57(3):236-47.

Social networks and secondary health conditions: the critical secondary team for individuals with spinal cord injury.
In-depth semi-structured interviews with 14 community-dwelling individuals with an SCI (six men, eight women) in Canada were conducted in order to understand the nature and role of informal social networks in the prevention and management of secondary health conditions (SHCs). Participants were asked: (1) What have been your experiences with your health care in the community? (2) What have been your experiences with care related to prevention and/or management of SHCs? and (3)What has been the role of your informal social networks (friends/family) related to SHCs? Participants described their informal networks as a “secondary team” and a critical and essential force in dealing with SHCs that fills the gaps that exist within the formal health care system.
Guilcher SJ, Casciaro T, Lemieux-Charles L, et al.
J Spinal Cord Med. 2012 Sep;35(5):330-42.

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Wheelchair Skills

Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury.
This study looked at the relationship between proficiency in wheelchair (WC) skills and outcome measures of independence and quality of life. Participants were 214 individuals with SCI who used a manual WC for their primary mobility, had injuries between C3-L5, and averaged 8.6 years post-injury. Thirty-one WC skills were tested, including descending and ascending a 15-cm curb, holding a wheelie, and rotating a wheelie . Findings showed that better performance of WC skills was significantly related to better self-perceived health, higher life satisfaction, and more community participation. The ability to descend a 15-cm curb significantly predicted four of the outcome measures, more than any of the other individual WC skills. Factors contributing to low WC skill rates need to be investigated, and interventions to improve these rates are needed.
Hosseini SM, Oyster ML, Kirby RL, et al.
Arch Phys Med Rehabil. 2012 Dec;93(12):2237-43.

Most essential wheeled mobility skills for daily life: an international survey among paralympic wheelchair athletes with spinal cord injury.
A sample of 49 male and 30 female elite manual wheelchair user athletes with SCI (64 with paraplegia; 15 with tetraplegia) at the Beijing Paralympic Games completed a survey in which they rated the importance of 24 predefined wheeled mobility (WM ) skills on a 5-point scale (1=not essential; 5=extremely essential). They also were asked to state where, when, and with whom they have learned to perform each skill and to mark the level of WM they gained during and after their rehabilitation. Rated as the most essential skill was transfer into and out of a car. Of the respondents, 57% had learned the most essential skills in clinical rehabilitation, while 40% claimed to have learned those skills afterward in a community setting. Three percent never learned to perform the most essential skills. Of the very essential skills, 40% were self-taught. The authors recommend that the skills rated as very essential and extremely essential should be taught during inpatient rehabilitation or post-rehabilitation WM workshops.
Fliess-Douer O, Vanlandewijck YC, Van der Woude LH.
Arch Phys Med Rehabil. 2012 Apr;93(4):629-35.

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Bowel Management

Transanal irrigation in the management of neurogenic bowel dysfunction.
Eleven individuals with SCI who did not have satisfactory results using a conservative bowel management program were trained to use transanal irrigation (TAI) to empty their bowels. Participants ranged from 27 to 72 years old; nine had SCI and two had spina bifida; and there were seven males and four females. The Peristeen TAI system (Coloplast, Denmark) was used in this study, which allows patients to perform irrigations independently or, if necessary, by a patient’s carer. TAI was performed every second or third day. Severity of symptoms at initiation of TAI was measured using three questionnaires about bowel function and compared with severity of symptoms at follow-up (3-28 months). There was a significant decrease in bowel problems as measured on all three questionnaires, indicating a significant improvement in bowel function from using TAI. No serious adverse events occurred during the study. TAI is an effective treatment option for the management of neurogenic bowel dysfunction.
Loftus C, Wallace E, McCaughey M, Smith E.
Ir Med J. 2012 Jul-Aug;105(7):241-3.

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Pressure Ulcers

Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study.
Investigators examined knowledge, risk factors, skin protective behaviors, health beliefs and practices in 148 veterans hospitalized for pressure ulcers (PrUs) in six VA centers. Most ulcers were stage IV (73%), and about half of the patients had two or more PrUs. Most patients also had an average of 6.7 other medical conditions, including respiratory, gastrointestinal, renal disease/urinary tract infection, autonomic dysreflexia, diabetes, and bowel/bladder incontinence. Potential intervention opportunities include proactive assistance with management of multiple chronic conditions, substance abuse, nutrition, adherence to skin protective behaviors, readiness to change, and access to resources. Overall knowledge about PrUs was low, especially for how to prevent PrUs and what to do if skin breakdown occurs. These issues need to be addressed in order to reduce PrU incidence and recurrence in persons with SCI.
Guihan M, Bombardier CH.
J Spinal Cord Med. 2012 Jul;35(4):240-50

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Activity-Based Interventions

Basic concepts of activity-based interventions for improved recovery of motor function after spinal cord injury.
A number of advances have been made in the strategies used for rehabilitation, resulting in marked improved recovery, even after a complete SCI. Several rehabilitative interventions— assisted motor training, spinal cord epidural stimulation, and/or administration of pharmacologic agents, alone or in combination—have produced recovery in motor function in both humans and animals. The success with each of these interventions appears to be related to the fact that the spinal cord can use ensembles of sensory information to generate appropriate motor responses without input from supraspinal (above the spinal column) centers, a property commonly referred to as central pattern generation. This ability of the spinal cord reflects a level of automaticity, that is, the ability of the neural circuitry of the spinal cord to interpret complex sensory information and to make appropriate decisions to generate successful postural and locomotor tasks. In this article, the authors review of some of the neurophysiologic rationale for the success of these interventions.
Roy RR, Harkema SJ, Edgerton VR.
Arch Phys Med Rehabil. 2012 Sep;93(9):1487-97.

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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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