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Spinal Cord Injury Update

Spring 2015: Volume 24, 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.


Cell-Based Therapies

The known-unknowns in spinal cord injury, with emphasis on cell-based therapies - a review with suggestive arenas for research.
In spite of extensive research, the progress toward a cure in spinal cord injury (SCI) is still elusive. Seven known gray areas in SCI cure research are: i) the gap between animal models and humans; ii) uncertainty about the time, route and dosage of cells applied; iii) source of the best cells for therapy; iv) inability to address the vascular compromise during SCI; v) lack of non-invasive methodologies to track the transplanted cells; vi) need for scaffolds to retain the cells at the site of injury; and vii) physical and chemical stimuli that might be required for synapses formation yielding functional neurons. To improve outcomes, further research is needed on scaffolds for retaining the transplanted cells at the lesion, chemical and physical stimuli that may help neurons become functional, a meta-analysis of timing of the cell therapy, mode of application and larger clinical studies.
Dedeepiya VD, William JB, Parthiban JK, et al.
Expert Opin Biol Ther. 2014 May;14(5):617-34

Autograft-derived spinal cord mass following olfactory mucosal cell transplantation in a spinal cord injury patient: Case report.
Human neural stem cells and cell transplantation are being investigated as potential therapies for spinal cord injury (SCI), neurodegenerative diseases and other conditions. However, significant concerns have been raised over the safety of this experimental therapeutic approach due to the possibility of tumor formation. This report describes the case of an 18-year-old women with T10-11 complete SCI who, three years after injury, underwent olfactory mucosal cell implantation at the site of injury. This procedure took place outside the U.S. She developed back pain 8 years later, and imaging showed a spinal cord tumor at the site of cell implantation, which had to be surgically removed. Intraoperative findings revealed an expanded spinal cord with a multicystic mass containing large amounts of thick mucus-like material. Histological examination and immunohistochemical staining revealed that the mass  was composed mostly of cysts lined by respiratory epithelium, submucosal glands with goblet cells, and intervening nerve twigs. This is the first report of a human spinal cord mass complicating spinal cord cell transplantation and neural stem cell therapy. Given how many years it took for the tumor to develop, patients with cell transplantation and neural stem cell implantation should be monitored for many years.
Dlouhy BJ, Awe O, Rao RC et al.
J Neurosurg Spine. 2014 Oct;21(4):618-22


Community-associated Clostridium difficile infection among veterans with spinal cord injury and disorder.
The impact of community-associated Clostridium difficile infection (CA-CDI) on patients with spinal cord injuries and disorders (SCI/Ds) is not fully understood. The authors examined CA-CDI cases among veterans with SCI/D, comparing them with community-onset, healthcare facility-associated (CO-HCFA) cases. Generally,  patients with CA-CDI had less comorbidity, less severe CDI, and lower likelihood  of antibiotic exposure.
Balbale SN, Johnson S, Burns SP, et al.
Infect Control Hosp Epidemiol. 2014 May;35(5):577-80.

Heart Disease

Self-reported physical activity and risk markers for cardiovascular disease after spinal cord injury.
Cardiovascular disease markers (hypertension, blood glucose and a blood  lipid panel) were analysed in a group of 134 wheelchair-users (103 men, 31 women) with paraplegia due to SCI of at least a year’s duration. Participants reported on the type and extent of their physical activity. Physical activity of at least 30 minutes a day positively influenced diastolic blood pressure. No other reductions in cardiovascular disease risk markers were seen after controlling for age. Men had significantly higher systolic and diastolic blood pressures than women, lower high-density lipoprotein cholesterol, higher low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio and higher triglycerides.  No other significant differences between men and women were found. These results indicate a positive effect of physical activity, but it cannot be concluded that recommendations about physical activity in cardiovascular disease prevention for the general population apply to wheelchair-users with spinal cord injury.
Flank P, Fahlström M, Boström C, et al.
J Rehabil Med. 2014 Oct;46(9):886-90.

Ambulatory blood pressure monitoring in spinal cord injury: clinical practicability.
After SCI, the loss of autonomic control over the cardiovascular system can cause blood pressure (BP) changes that may lead to increased cardiovascular disease (CVD) risk. Subjects with complete tetraplegia show the worst BP changes. Outpatient management of BP in this population is becoming increasingly important. In addition, SCI subjects are living longer and their risk for CVD may be increased. The use of ambulatory blood pressure monitoring (ABPM) allows insights into circadian BP profiles and have been shown to supply important information about CVD risks in able-bodied subjects. ABPM can be a helpful, non-invasive tool to look at changes in circadian BP patterns and factors related to episodes of orthostatic hypotension and autonomic dysreflexia. Further, abnormal patterns in ABPM, such as a loss of nocturnal dip, have been shown to be associated with increased risk for CVD in the able-bodied population. Therefore, presence of potentially life-threatening AD events as well as abnormal ABPM patterns, also might pose potential CVD risk factors in the SCI population. This relation is not well documented yet in patients with SCI but will be particularly important for people with complete tetraplegic who show adverse circadian BP profiles. The use of ABPM in this population might help detect these profiles and monitor the efficacy of various treatment strategies. Although further research is required in this area, we suggest that ABPM should be used to assess BP changes in patients with SCI.
Hubli M, Krassioukov AV.
J Neurotrauma. 2014 May 1;31(9):789-97.

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Understanding therapeutic benefits of overground bionic ambulation: exploratory case series in persons with chronic, complete spinal cord injury.
Two men and one woman aged 26 to 38 years with chronic complete SCI (American Spinal Injury Association Impairment Scale grade A) between the levels of T1 and T10 participated in an overground bionic ambulation (OBA) program using the Ekso Bionic lower extremity robotic exoskeleton. The program consisted of one-hour training sessions three times per week for six weeks. Even though there was little or no improvement in either activation of leg muscles or exercise conditioning after the program, participants reported lower overall pain severity, lower intensity of at-level neuropathic pain, and reduced sleep problems. Whether extended use would result in more favorable changes remains to be determined in follow-up studies.
Kressler J, Thomas CK, Field-Fote EC, et al.
Arch Phys Med Rehabil. 2014 Oct;95(10):1878-1887.

Repetitive mass practice or focused precise practice for retraining walking after incomplete spinal cord injury? A pilot randomized clinical trial.
A randomized, single-blind, crossover design was used to contrast 2 methods of retraining, one emphasizing precise, visually guided walking over obstacles and on targets (Precision Training), the other emphasizing mass practice of walking on a treadmill (Endurance Training). Twenty-two participants, at least 7 months postinjury, started Precision or Endurance Training. Each phase of training was 5 times per week for  2 months, followed by a 2-month rest. Both forms of training led to significant improvements in walking, with  Endurance Training resulting in bigger improvements in walking distance, especially for high-functioning walkers. The largest improvements in walking speed and distance occurred in the first month of Endurance Training, with minimal changes in the second month of training. In contrast, improvements in walking skill occurred over both months during both types of training. Retention of over ground walking  speed, distance, and skill was excellent for both types of training. Intensive walking training is effective in improving over ground walking in this population. Visually guided tasks for training individuals with chronic spinal cord injury were not better than mass practice on a treadmill.
Yang JF, Musselman KE, Livingstone D, et al.
Neurorehabil Neural Repair. 2014 May;28(4):314-24.


Effects of vibration on spasticity in individuals with spinal cord injury: a scoping systematic review.
Spasticity can lower quality-of-life by causing pain and fatigue, contributing to the development of contractures, pressure ulcers, infection, and negative self-image, and may interfere with a wheelchair user’s seating, transfers, and wheeling. Both whole-body vibration (WBV) and focal vibration (FV) have been used for spasticity management in individuals with SCI. To understand the effects of vibration on spasticity in SCI, the authors searched the published research literature and analyzed the strength of the findings. They found some encouraging results linking WBV and FV to improved spasticity, but the evidence is weak because of the limited number of studies. They hope researchers will conduct randomized controlled trial studies on vibration to provide clinicians and patients with a more clear direction on the use of vibration to manage spasticity for those with SCI.
Sadeghi M, Sawatzky B.
Am J Phys Med Rehabil. 2014 Nov;93(11):995-1007

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Rotator cuff surgery in persons with spinal cord injury: relevance of a multidisciplinary approach.
Thirty-eight patients with SCI (four with quadriplegia; 34 with paraplegia) received multidisciplinary medical and surgical consultations for pain in one or both shoulders. The participants’ average time since injury was 26.4 years. The main activities that triggered or aggravated shoulder pain were transfers, wheelchair propulsion, and lifting the arm above shoulder level. In two participants, pain was due to orthotic-assisted gait. Surgical management was guided by the intensity of the pain and its functional impact. Surgery was performed on 38 shoulders in 28 patients (33 were laparoscopies and 5 were open surgeries), followed by post-operative rehabilitative care of several months to two years or more. The mean pain intensity rating in the operative and nonoperative groups was 0 and 1.6, respectively, at rest and 2 and 4.9, respectively, during severest peaks. Functional independence also improved after surgery. When the surgical decision was based on a multidisciplinary assessment involving both surgeons and rehabilitation providers, no negative results were reported.
Fattal C, Coulet B, Gelis A, et al.
J Shoulder Elbow Surg. 2014 Sep;23(9):1263-71.

Long-term outcomes of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic spinal cord injury pain.
A total of 29 subjects with a spinal cord injury and chronic neuropathic pain participated in this unblinded multicenter randomized controlled trial. Participants were randomly assigned to an immediate intervention group or to a waiting list control group within each participating rehabilitation center. The control group was invited to go through the treatment program after a waiting period of 6 months. The treatment was a multidisciplinary program of 10 three-hour sessions over a 10-week period and comprised educational, cognitive, and behavioral elements targeted at coping with chronic neuropathic pain. Pain measurements taken before and after the treatment showed significant improvements in pain intensity, pain-related disability, anxiety and participation in activities. These findings highlight the potential of a multidisciplinary cognitive-behavioral approach in treating a common, debilitating problem in persons with SCI.
Heutink M, Post MW, Luthart P, et al.
J Rehabil Med. 2014 Jun 13;46(6):540-5.

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Urological Problems

Bladder stones in patients with spinal cord injury: a long-term study.
This retrospective follow-up study assessed the occurrence of bladder stones in patients with SCI. In a database of 2,825 SCI patients between 2004 and 2012, 93 (3.3%) underwent surgery for bladder stones. The rate of bladder stones by method of bladder management was 11% for suprapubic catheter (SPC), 6.6% for transurethral catheter (TC), 2% for intermittent catheterization (IC), and 1.1% for reflex micturition (RM). The mean time period to stone development was 95 months, with the TC group having the shortest time interval (31 months), followed by the SPC group (59 months), individuals performing IC (116 months) and RM (211 months). Bladder stone recurrence rate was 23% overall and most frequent in the TC group (40%), followed by SPC (28%)  and IC (22%), whereas no recurrences occurred in the RM group. In SCI patients, bladder management has an important role in the development of bladder stones. Indwelling catheters (TC/SPC) have the highest risk to develop bladder stones and should be avoided if possible. If unavoidable, SPC is superior to TC.
Bartel P, Krebs J, Wöllner J, et al.
Spinal Cord. 2014 Apr;52(4):295-7.

Surgical management of urolithiasis in spinal cord injury patients.
Urolithiasis (kidney stones) is a common condition in persons with spinal cord injury. Surgical management of stones in this population is less successful and has a higher rate of complications than the general population. Shock wave lithotripsy (SWL) has a low clearance  rate of 44-73 %. Percutaneous nephrolithotripsy is indicated for larger nephrolithiasis, but multiple procedures may be required to clear the stones. Ureteroscopy has been associated with low success rates because of difficulty in  obtaining ureteral access. Recently, good results have been reported with the combination of endoscopic and laparoscopic techniques. Surgical management of urolithiasis in patients with SCI should be performed in high-volume centers in light of the technical challenges and higher rate of perioperative complications.
Nabbout P, Slobodov G, Culkin DJ.
Curr Urol Rep. 2014 Jun;15(6):408.


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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