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Spinal Cord Injury Update

Fall 2014: Volume 23, 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.


Pressure Relief

Effect of Tilt and Recline on Ischial and Coccygeal Interface Pressures in People with Spinal Cord Injury.
Clinicians commonly recommend that power wheelchair users with SCI perform wheelchair tilt and recline to redistribute pressure away from the ischial tuberosities (sitting bones). However, reducing ischial pressure may cause increased pressure over the coccyx. In this study of 13 power wheelchair users, ischial and coccygeal pressures were measured in six combinations of wheelchair tilt (15, 25, and 35 degrees) and recline (10 and 30 degrees) angles. Each combination was tested with 5 minutes of upright sitting, 5 mins of tilt and recline, as well as 5 mins of maximal pressure relief. Results showed steadily decreasing ischial pressure in response to tilt and recline maneuvers. For the four smallest (of six) tested combinations of tilt and recline, coccygeal pressure increased as ischial pressure declined. However, for the two largest combinations of tilt and recline, coccygeal pressure decreased, suggesting that pressures were redistributed to the back support.
Chen Y, Wang J, Lung CW, et al.
Am J Phys Med Rehabil. 2014 Oct 28.

Restoring Function

Brain machine interface and limb reanimation technologies: restoring function after spinal cord injury through development of a bypass system.
Researchers have spent decades searching for ways to restore function to individuals with SCI. Efforts to repair the injury site with biologic therapies have had limited success, and successful animal trials have not led to similar results in humans. In contrast, neural interface technologies, such as brain machine interface (BMI) and limb reanimation through electrical stimulators, focus on creating a bypass around the site of the SCI. The BMI systems analyze brain signals to allow control of devices that are used to assist SCI patients. Such devices may include a computer, robotic arm, or exoskeleton. Limb reanimation technologies, which include functional electrical stimulation, epidural stimulation, and intraspinal microstimulation systems, activate neuronal pathways below the level of the SCI. This article explains recent advances in the BMI and limb reanimation technologies and discusses some of the challenges to the practical implementation of these approaches.
Lobel DA, Lee KH.
Mayo Clin Proc. 2014 May;89(5):708-14

Restoring sensorimotor function through intracortical interfaces: progress and looming challenges.
One approach to restoring lost sensory and motor abilities in amputees and patients with tetraplegia is to supply them with implants that provide a direct interface with the central nervous system. Such brain-machine interfaces (BMI) might enable a patient to voluntarily control a prosthetic or robotic limb or electrically induced contractions of paralyzed muscles.  A parallel interface could convey sensory information about the consequences of these movements back to the patient. Recent developments in the algorithms that decode motor intention from neuronal activity and in approaches to convey sensory feedback by electrically stimulating neurons, using biomimetic and adaptation-based approaches, have shown promise, although substantial challenges remain. This article describes some of the most recent developments in using BMI for both restoring sensory and motor abilities.
Bensmaia SJ, Miller LE.
Nat Rev Neurosci. 2014 May;15(5):313-25

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Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans.
An epidural spinal cord stimulation unit and a 16-electrode array was implanted at vertebrae T11–T12 over spinal cord segments L1–S1 in four individuals who had motor complete SCI of at least two years’ duration. Two of the participants were also sensory complete. Injury level ranged from C7 to T5, and none of the subjects were able to stand or step independently before participating in this study. Before electrode implantation, participants received a minimum of 80 locomotor training sessions using body weight support on a treadmill with manual facilitation. After 7 months of epidural stimulation and stand training, subjects regained some voluntary movement. This report describes a fundamentally new intervention strategy that can dramatically affect recovery of voluntary movement in individuals with complete paralysis even years after injury.
Angeli CA, Edgerton VR, Gerasimenko YP, Harkema SJ.
Brain. 2014 May;137(Pt 5):1394-409.


Thiazide use is associated with reduced risk for incident lower extremity fractures in men with spinal cord injury.
Data from the national VA Spinal Cord Dysfunction (SCD) Registry were analyzed to determine the association between thiazide use and lower extremity  fractures in men with SCI. Of the 6,969 individuals included in this study, 1,433 (21%) used thiazide diuretics and 5,536 did not. There were 892 lower extremity fractures: 7.7% occurred in men who were users of thiazides; and 13% occurred in men who were nonusers of thiazides. Thiazide use was associated with substantial risk reduction in lower extremity fracture in this group. Conversely, use of heparin, BZDs, opioids, anticonvulsants, and calcium and vitamin D supplementation were associated with significantly increased lower extremity fracture risk. This is the first report of any medication or treatment in SCI to be associated with reduced fractures. Further studies using randomized controlled trials, including consideration of calcium and vitamin D intake, are needed to determine whether thiazide diuretics might be used to reduce fracture rates in SCI.
Carbone LD, Chin AS, Lee TA,Burns SP, et al.
Arch Phys Med Rehabil. 2014 Jun;95(6):1015-20

Urinary Problems

Bacterial persistence in the prostate after antibiotic treatment of chronic bacterial prostatitis in men with spinal cord injury.
This is the first investigation of the effectiveness of antibiotic treatment for chronic bacterial prostatitis (inflamed prostate) in men with neurogenic bladder due to SCI. The study included 34 men with SCI (10 with tetraplegia and 24 with paraplegia) who received antibiotic treatment for recurrent urinary tract infections and bacterial prostatitis. Microbiologic culture results of urine and ejaculate or prostatic fluid samples revealed that antibiotic treatment did not eliminate bacteria from the prostate of these men. The most commonly used antibiotics to treat bacterial prostatitis were fluoroquinolones (n = 41) followed by trimethoprim-sulfamethoxazole (n = 8) and second-generation cephalosporins (n = 7). Only two men in the study had no bacteria in the prostate after treatment. Most men (28 of 34; 82%) presented with mostly the same bacteria (55 of 62, 89%) in the urine as in the ejaculate or prostate samples. Antibiotic treatment should be based on treating symptoms not the presence of bacteria alone.
Krebs J, Bartel P, Pannek J.
Urology. 2014 Mar;83(3):515-20

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Sexual Function

Restoring tactile and erogenous penile sensation in low-spinal-lesion patients: procedural and technical aspects following 43 TOMAX nerve transfer procedures.
The TOMAX ((TO MAX-imize sensation, sexuality, and quality of life) procedure restores genital sensation in men with low spinal cord injuries who have sensation in the groin but not in the penis. The procedure involves transferring  a sensory nerve from the thigh skin to a sensory nerve of the penis. The goal of this article is to share up-to-date information on technical issues involving the TOMAX procedure that we came across after a series of 43 nerve transfers in 40 patients, with an emphasis on a detailed description (and video) of the surgical technique. The TOMAX procedure can be used to restore erogenous penile sensation and improve the quality of sexual health in this population.
Overgoor ML, de Jong TP, Kon M
Plast Reconstr Surg. 2014 Aug;134(2):294e-301e


Role of dorsal rhizotomy in spinal cord injury-induced spasticity.
Selective dorsal rhizotomy (SDR) is a surgery that involves cutting nerve roots in the spinal cord to reduce spasticity.  It is used to manage spasticity in selected children with cerebral palsy, but its use has not been reported in children with SCI. In this study, three children with spasticity due to SCI were treated with SDR. Two of the children had significant long-term improvement, whereas the third  patient had initial improvement followed by a return in spasticity that required additional treatment. SDR is an effective alternative to conventional treatment methods, which are not curative, generally require the repeated administration of medication or repeated procedures, are limited in their effectiveness, and are coupled with side effects and drug tolerance.  In conclusion, SDR may have a place in the treatment of selected children with spasticity due to SCI.  
Reynolds RM, Morton RP, Walker ML, et al.
J Neurosurg Pediatr. 2014 Sep;14(3):266-70

Weight Gain

Weight change after spinal cord injury.
Height and weight were assessed during inpatient rehabilitation and one year after injury for 1,094 individuals with SCI from the Spinal Cord Injury Model Systems (SCIMS) database. Mean body mass index decreased from 26.3 to 25.8 kg/m² during the first year after SCI. Weight loss mainly occurred among individuals who were overweight or obese during rehabilitation and varied significantly by sex, education, neurological level, and the presence of vertebral injury. Weight gain was noted among individuals classified as underweight or normal weight during rehabilitation. The findings suggest that weight management should be addressed after SCI to reduce unhealthy weight changes, particularly among at-risk groups.
Powell D, Affuso O, Chen Y.
J Spinal Cord Med. 2014 Oct 29

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Walking Rehabilitataion

Hybrid FES-robot cooperative control of ambulatory gait rehabilitation exoskeleton.
This article describes a hybrid exoskeleton strategy that combines robotic exoskeleton and  electrical stimulation, overcoming the drawbacks of each while preserving their advantages. The hybrid strategy is designed  to solve the main problem of muscular stimulation: electromechanical delay and change in muscle performance over time and balancing muscular and robotic actuation during walking. Experimental results in healthy subjects show the ability of the hybrid FES-robot to balance power contribution between exoskeleton and muscle stimulation. The robotic exoskeleton decreases assistance while maintaining adequate knee kinematics. A new technique to monitor muscle performance is employed, which allows to estimate muscle fatigue and implement muscle fatigue management strategies. This device, called Kinesis, is the first ambulatory hybrid exoskeleton that can effectively balance robotic and FES actuation during walking and represents a new opportunity to implement new rehabilitation interventions to induce locomotor activity in patients with paraplegia.
del-Ama AJ, Gil-Agudo A, Pons JL, Moreno JC.
J Neuroeng Rehabil. 2014 Mar 4;11:27

The effect of impedance-controlled robotic gait training on walking ability and quality in individuals with chronic incomplete spinal cord injury: an explorative study.
Robotic gait-training devices for walking rehabilitation in individuals with incomplete SCI can help increase the intensity of training and reduce physical demands on therapists. Despite these potential benefits, robotic gait-training devices have not yet demonstrated clear advantages over conventional gait-training approaches, in terms of functional outcomes. This might be due to the reduced active participation and step-to-step  variability in most robotic gait-training strategies. Impedance-controlled devices address these problems. In this study, 10 participants with chronic incomplete (ASIA C or D) SCIs trained three times a week for eight weeks using an impedance-controlled robotic gait trainer (LOPES: LOwer extremity  Powered ExoSkeleton). Tests before, during, after and at eight weeks follow-up showed significant improvements in walking speed, distance Timed Up and Go test, and Lower Extremity Motor Scores. Significant improvements were also found in spatiotemporal measures and hip range of motion. This study showed that the LOPES is feasible in gait rehabilitation of individuals with chronic SCI and leads to improvements in walking, muscle strength, and quality of walking.
Fleerkotte BM(1), Koopman B, Buurke JH, et al.
J Neuroeng Rehabil. 2014 Mar 4;11:26

Barriers to Care

Health care utilization and barriers experienced by individuals with spinal cord  injury.
A survey about health care utilization and barriers was completed by 108 adults with SCI who use wheelchairs as their primary means of community mobility. All but one participant had visited a primary care provider within the past 12 months, and 85% had at least one visit to specialty care providers. Accessibility barriers were encountered during both primary care (91.1%) and specialty care (80.2%) visits. The most prevalent barriers were inaccessible examination tables and lack of transfer aids. Most participants had not been weighed during their visit (89%) and had remained seated in their wheelchair during their examinations (85.2%). More than one third of individuals over age 50 had not received a screening colonoscopy, 60% of women over age 50 years had not had a mammogram, 39.58% of women had not received a Pap test within the previous 3 years, and only 45.37% of respondents had ever received bone density testing. Clinics need to ensure that their clinical staff are properly trained in assisting individuals with mobility disabilities and provide preventative care screenings for their patients who have SCI.
Stillman MD, Frost KL, Smalley C, et al.
Arch Phys Med Rehabil. 2014 Jun;95(6):1114-26

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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