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Spinal Cord Injury Update

Spring 2013: Volume 22, 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.



A randomized trial of pregabalin in patients with neuropathic pain due to spinal cord injury.
A total of 220 participants with SCI and chronic neuropathic pain below the level of injury were randomly assigned to receive either 150 to 600 mg/d pregabalin or placebo for 17 weeks. The primary outcome measure was the amount of change in pain that occurred during the study period, based on participant pain diaries. Secondary outcome measures included sleep disturbance, anxiety and depression. Pregabalin treatment resulted in statistically significant improvements over placebo for all primary and key secondary outcome measures. Significant pain improvement was evident as early as week 1 and continued throughout the treatment period. Side effects—mainly sleepiness and dizziness—were mostly mild to moderate. This study demonstrates that pregabalin is effective and well tolerated in patients with neuropathic pain due to SCI.
Cardenas DD, Nieshoff EC, Suda K, et al.
Neurology. 2013 Feb 5;80(6):533-9.

Acceptance of chronic neuropathic pain in spinal cord injured persons: a qualitative approach.
This study explored the idea that acceptance may be a viable alternative to suffering when other treatments do not adequately reduce chronic neuropathic pain (CNP). Seven individuals with SCI were interviewed about their pain experiences. Six phases were identified from these interviews: “comprehending the perplexity of CNP,” “seeking pain resolution,” “acknowledging pain permanence,” “redefining core values,” “learning to live with the pain,” and “integrating pain.” Two driving forces, “increasing independence” and “evolving pain view,” helped move the process of acceptance forward. Acceptance of pain appeared to reduce suffering and lead to a more satisfying and fulfilling life in these individuals. A decreased emphasis on continued searching for a cure for the pain and movement toward a self-management approach increased their ability to cope with the pain. Patients may benefit from early intervention to help with coping and exploring the notion of acceptance of pain.
Henwood P, Ellis J, Logan J, et al.
Pain Manag Nurs. 2012 Dec;13(4):215-22

Pain and post-traumatic stress disorder symptoms during inpatient rehabilitation among operation enduring freedom/operation Iraqi freedom veterans with spinal cord injury.
This study examined the association of post-traumatic stress disorder (PTSD) symptoms with acute pain and the longitudinal course of pain during inpatient rehabilitation for SCI. Inpatient rehabilitation data were gathered from the electronic records of 87 veterans with SCI from the Operation Enduring Freedom/Operation Iraqi Freedom conflicts. Participants were divided into four groups based on PTSD screening at the start of rehabilitation: Pain and PTSD, Pain Alone, PTSD Alone, Neither Condition. It was more common to have pain and PTSD together than to have either condition by itself, and nearly as common as not having either condition. Participants with pain at the start of rehabilitation (either alone or with PTSD) showed declines in pain ratings over the course of rehabilitation. In contrast, participants in the PTSD-Alone group showed increasing pain over the course of rehabilitation. The authors recommend screening for pain and PTSD at multiple time points during inpatient rehabilitation to detect new or emerging problems.
Ullrich PM, Smith BM, Poggensee L, et al.
Arch Phys Med Rehabil. 2013 Jan;94(1):80-5

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Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation.
This study looked at rates of rehospitalization within the first year after injury among 951 individuals with SCI in six rehabilitation centers in the U.S. More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average length of stay per rehospitalization was 15.5 days. The three most common reasons for rehospitalization were problems with the genitourinary system (e.g., urinary tract infection), respiratory system (e.g., pneumonia), and skin (e.g., pressure ulcer). Odds of being hospitalized again were higher in women, younger people, retirees, the unemployed, as well as those with Medicaid coverage and more severe injuries. Those who had more intensive physical therapy during acute rehabilitation had lower odds of being hospitalized again. The 6 SCI rehabilitation centers varied nearly 2-fold (from 27.8% to 50%) in rates of rehospitalization. Future research should examine the role of health system variables in avoiding rehospitalization.
DeJong G, Tian W, Hsieh CH, et al.
Arch Phys Med Rehabil. 2013 Apr;94(4 Suppl):S87-97.

Relationship of nursing education and care management inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.
The authors reviewed the medical records of and conducted interviews with SCI patients to examine the relationship between nursing care and patient outcomes. Results showed that more nursing activities were associated with better outcomes. More time spent by registered nurses (RNs) in coordination with other members of the care team, consultants and specialists, along with participation in physician rounds (team process) was associated with patient report of higher life satisfaction and better function at one year after injury. More time providing psychosocial support is associated with higher mobility and occupation scores and with greater likelihood of working or being in school at one year after injury
Bailey J, Dijkers MP, Gassaway J, et al.
J Spinal Cord Med. 2012 Nov;35(6):593-610.

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Effectiveness of intense, activity-based physical therapy for individuals with spinal cord injury in promoting motor and sensory recovery: is olfactory mucosa autograft a factor?
Twenty-three people with SCI received either intense PT alone or intense PT and an olfactory mucosa autograft (OMA). Mean therapy dosage was 137.3 total hours. The participants’ total upper and lower extremity motor scores improved significantly while sensory scores did not improve during the first 60 days from initial to discharge examination. Incomplete SCI or paraplegia was associated with greater motor recovery. Five of 14 participants converted from motor-complete to motor-incomplete SCI. Individuals who had the OMA and participated in intense PT did not have greater sensory recovery or greater magnitude or rate of motor recovery as compared with participants who had intense PT alone. This study provides encouraging evidence as to the effectiveness of intense PT for individuals with SCI.
Larson CA, Dension PM.
J Spinal Cord Med. 2013 Jan;36(1):44-57.

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Bladder Management

Intermittent self-catheterization with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis.
Eight studies were included in this systematic review comparing the effectiveness and costs of hydrophilic, gel reservoir, and non-coated intermittent catheters. Most studies were conducted in patients with spinal cord injuries, and most of the participants were men. People using gel reservoir and hydrophilic catheters were significantly less likely to report one or more urinary tract infections (UTIs) compared with sterile non-coated catheters. However, there was no difference between hydrophilic and sterile non-coated catheters when outcomes were measured as mean monthly UTIs or total UTIs at 1 year. There was little difference in the incidence of UTIs for people using clean versus sterile non-coated catheters. The type of catheter used for intermittent self-catheterization seems to make little difference to the risk of symptomatic UTI; however, clean non-coated catheters are most cost effective. Because of limitations and gaps in the evidence base and the designation of non-coated catheters as single use devices, the authors recommend that patients should be offered a choice between hydrophilic and gel reservoir catheters.
Bermingham SL, Hodgkinson S, Wright S, et al.
BMJ. 2013 Jan 8;346:e8639.

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Skin care

Effect of durations of wheelchair tilt-in-space and recline on skin perfusion over the ischial tuberosity in people with spinal cord injury.
Nine power wheelchair users with SCI were randomly assigned to three protocols of wheelchair tilt-in-space and recline of various durations (3min, 1min, and 0min). Each protocol consisted of a baseline 15-minute sitting, a duration of 0- to 3-minute reclined and tilted, a second 15-minute sitting, and a 5-minute recovery. The position at the baseline and the second sitting was no tilt/recline of the participant and at the reclined and tilted and recovery was at 35° tilt-in-space and 120° recline. Skin perfusion (blood flow to the skin) was assessed by laser Doppler. The results showed that mean skin perfusion during recovery at the 3-minute duration was significantly higher than that at the 1-minute duration. There was no significant difference in mean skin perfusion between the 1-minute and 0-minute durations. Skin perfusion during the second sitting was significantly higher at the 3-minute duration than at the 1-minute and 0-minute durations. In conclusion, performing the 3-minute duration of wheelchair tilt-in-space and recline is more effective than the 1-minute duration in enhancing skin perfusion of weight-bearing soft tissues.
Jan YK, Liao F, Jones MA, et al.
Arch Phys Med Rehabil. 2013 Apr;94(4):667-72.

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Walking and Standing

Locomotor training for walking after spinal cord injury.
This systematic review examined 5 randomized controlled trials (RCTs) involving 309 people that looked at the effect of locomotor training on improvement in walking for people with traumatic SCI. There was no statistically significant superior effect of any locomotor training approach on walking function after SCI compared with any other kind of physical rehabilitation. The use of bodyweight supported treadmill training as locomotor training for people after SCI did not significantly increase walking velocity nor did it increase walking capacity. In all five studies there were no differences in adverse events or drop-outs between study groups. The authors conclude that no one locomotor training strategy improves walking function more than another for people with SCI. The effects especially of robotic-assisted locomotor training are not clear; therefore research in the form of large RCTs, particularly for robotic training, is needed.
Mehrholz J, Kugler J, Pohl M.
Cochrane Database Syst Rev. 2012 Nov 14;11:CD006676

Lokomat robotic-assisted versus overground training within 3 to 6 months of incomplete spinal cord lesion: randomized controlled trial.
Eighty participants (3 to 6 months after SCI) were randomly assigned to receive 40 sessions using either a robotic-assisted Lokomat program with overground mobility therapy or overground therapy alone. Primary measurements of outcome were walking speed and the Walking Index for Spinal Cord Injury (WISCI II). Secondary outcomes were the 6-minute walk test and measures of functional independence, motor scores, pain and spasticity. No significant differences were found at entry between treatment groups. After the walking training sessions, walking speed for Lokomat and overground therapy groups did not differ. However, the need for orthotics and assistive devices was reduced with Locomat, perhaps because of greater leg strength in the robotic group.
Alcobendas-Maestro M, Esclarín-Ruz A, Casado-López RM, et al.
Neurorehabil Neural Repair. 2012 Nov-Dec;26(9):1058-63.

The effect of supported standing in adults with upper motor neuron disorders: a systematic review.
This review examined 17 studies involving 540 participants that studied the effect of assisted standing on lower limb muscle length, spasticity, bone mineral density or function of adults with upper motor neuron disorders from stroke, multiple sclerosis, traumatic brain injury or SCI. High-quality evidence suggested tilt-table standing has a small effect on preventing loss of ankle dorsiflexion. One high-quality study found a low-dose standing program did not change bone loss early after spinal injury. There was limited evidence that standing improves spasticity or function. Supported standing can prevent small losses of ankle mobility, but the clinical importance of these effects is uncertain. Low-dose standing is unlikely to protect bone health.
Newman M, Barker K.
Clin Rehabil. 2012 Dec;26(12):1059-77.

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Abdominal binder improves lung volumes and voice in people with tetraplegic spinal cord injury.
Breathing, vocal function and blood pressure were measured in 14 acute rehab inpatients with ASIA A (complete) or B (motor complete) SCI above the T5 level at 6 weeks, 3 months and 6 months after commencing daily use of an upright wheelchair. Measurements were taken both with and without an abdominal binder (AB) on. All breathing measurements improved at each time point with the use of the AB compared with no AB. Overall, using an AB significantly improved forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximum sustained vowel time. There was no significant improvement in maximal expiratory pressure, mean arterial pressure or sound pressure level. Further study is needed into the effect of the long-term use of the AB on total lung capacity, functional residual capacity, breathing mechanics, rate of pulmonary complications, and overall respiratory health. Other factors to consider are whether a person with SCI will continue to use an AB and its impact on comfort, skin integrity, and likely postural changes during the initial years after injury.
Wadsworth BM, Haines TP, Cornwell PL, et al.
Arch Phys Med Rehabil. 2012 Dec;93(12):2189-97.

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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