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Spinal Cord Injury Update


Spring 2016: Volume 25, 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. Information about how to obtain complete articles is at the bottom of this page.



The mechanism of neurofeedback training for treatment of central neuropathic pain in paraplegia: a pilot study.
Seven individuals with paraplegia and central neuropathic pain (CNP) participated in this study investigating the effect of neurofeedback training on pain reduction. Neurofeedback is a type of biofeedback in which participants are given information about their brain activity in a visual or auditory form and learn how to change their brain activity to reduce pain. Participants received between 20 and 40 treatment sessions. Six out of seven participants achieved short-term immediate reduction of pain during neurofeedback training. The study found that neurofeedback training produces both immediate and longer term reduction of CNP along with a measurable short and long term modulation of cortical activity. Controlled trials are needed to confirm the beneficial effect of this neurofeedback program on pain.
Hassan MA, Fraser M, Conway BA, et al.
BMC Neurol. 2015 Oct 13;15(1):200.

Capsaicin 8% Patch for Central and Peripheral Neuropathic Pain of Persons with Incomplete Spinal Cord Injury: Two Case Reports.
The capsaicin 8% patch is a Food and Drug Administration-approved treatment for neuropathic pain in postherpetic neuralgia (nerve pain due to damage caused by a virus) and has been effective in human immunodeficiency virus (HIV)-autonomic neuropathy. A retrospective review was conducted on the effects of the patch in two individuals with SCI and neuropathic pain that did not improve with standard treatments. Two weeks after application, both individuals reported complete pain relief. Average onset of relief was 4 days, and average duration of relief was 197 days, requiring only one to four applications per year. This paralleled findings reported in postherpetic neuralgia and HIV-autonomic neuropathy trials. The capsaicin 8% patch is a promising therapeutic agent for neuropathic pain in SCI.
Trbovich M, Yang H.
Am J Phys Med Rehabil. 2015 Aug;94(8):e66-72.

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Intrathecal versus Oral Baclofen; a Matched Cohort Study of Spasticity, Pain, Sleep, Fatigue and Quality of Life.
Sixty-two individuals who had been treated with intrathecal or oral baclofen for at least 1 year completed surveys measuring spasticity, pain, sleep, fatigue and quality of life. Participants included 38 individuals with SCI, 10 each with cerebral palsy and stroke, and 4 with multiple sclerosis. Average duration of intrathecal baclofen or oral baclofen treatment was 11 and 13 years, respectively. Participants receiving intrathecal baclofen had significantly fewer and less severe spasms than those receiving oral baclofen. There were no significant differences in pain, sleep, fatigue and quality of life between groups. The benefits of intrathecal baclofen must be weighed against the risks of internal pump and catheter placement.
McCormick ZL, Chu SK, Binler D, Neudorf D, et al.
PM R. 2015 Oct 20.

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Periferal Arterial Disease

Peripheral Arterial Disease and Spinal Cord Injury: A Retrospective Nationwide Cohort Study.
This study compared the risk for peripheral arterial disease (PAD) in 42,673 individuals with SCI and 170,389 matched controls without SCI. Persons with SCI had a significantly higher risk of PAD than individuals without SCI, and those with diabetes were at the highest risk. Furthermore, lumbar, sacral, or coccygeal spine, and multiple spine SCI were significantly associated with an increased risk of PAD. Future studies should focus on modifying risk factors to reduce PAD risk among individuals with SCI.
Su TW), Chou TY, Jou HJ, et al.
Medicine (Baltimore). 2015 Oct;94(41)


Long-term complications of continent cutaneous urinary diversion in adult spinal cord injured patients.
Continent cutaneous urinary diversion (CCUD) surgeries were performed on 29 individuals with SCI who had been unable to perform intermittent self-catheterization (ISC). Urodynamic parameters improved and, at last follow-up, 100% of patients had a catheterizable continent stoma and 96% had urethral continence. An improvement of quality-of-life was reported by 90% of patients. In this study, CCUD allowed these patients to keep ISC as a voiding pattern and to be continent without any appliance. The main complications were related to the tube and to bladder enlargement; thus, annual monitoring is needed.
Perrouin-Verbe MA, Chartier-Kastler E, Even A, et al.
Neurourol Urodyn. 2015 Sep 23

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Upper Limb

Ultrasonographic Median Nerve Changes After Repeated Wheelchair Transfers in Persons With Paraplegia: Relationship With Subject Characteristics and Transfer Skills.
The thirty wheelchair users who participated in this study had been injured for at least 1 year, used a manual wheelchair for more than 40 hours per week, and could complete transfers independently within 30 seconds without use of their legs. Participants completed questionnaires, underwent physical exams and ultrasonography of the median (wrist) nerve, and had their transfer technique evaluated using the Transfer Assessment Instrument (TAI). An acute increase was observed in the median nerve cross sectional area at the pisiform bone after repeated wheelchair transfers. Changes were greater in persons with higher body weight and in persons who did not perform certain transfer skills correctly (according to the TAI). It is possible that these factors contribute to chronic injury and possibly carpal tunnel syndrome.
Hogaboom NS, Diehl JA, Oyster ML, et al.
PM R. 2015 Aug 8

Wheelchair ergonomic hand drive mechanism use improves wrist mechanics associated with carpal tunnelsyndrome.
Carpal tunnel syndrome (CTS) is a painful, debilitating condition common in individuals who use manual wheelchairs full-time. CTS is likely due to large forces on the wrist and the extreme range of wrist motion when pushing. The purpose of this project was to evaluate the use of an ergonomic hand drive mechanism (EHDM) that puts the wrist in a more neutral position. The EHDM uses a cam pawl and ratchet mechanism that grabs onto the tire during forward propulsion and releases it during the recovery phase. The EHDM was attached to the axle of both wheels on a manual wheelchair and could be rotated to the back of the wheelchair when not in use. Eleven manual wheelchair users with SCI completed trials with both a conventional manual wheelchair (CMW) and with the same CMW fitted with the EHDM. Average angular wrist orientations were compared between the two propulsion styles. Use of the EHDM resulted in reduced wrist extension and ulnar deviation. The results of this study indicate that EHDM propulsion reduces the occurrence of CTS risk factors compared with CMW use.
Zukowski LA, Roper JA, Shechtman O, et al.
J Rehabil Res Dev. 2014;51(10):1515-24.

Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes.
This article reviews the literature and the authors’ cases series of 13 nerve transfers operations in nine individuals with mid to lower level cervical SCI. The nerve transfers used donor nerves that were taken from nonessential uninjured muscle and transferred to improve elbow extension, wrist extension, and/or hand function. Individual patient outcomes are subtle and variable and can take months to 1 year to measure; however, they can dramatically improve function and independence. Results from the literature and the authors’ patients (after a mean postsurgical follow-up of 12 months) showed gains in function based on manual muscle testing and patients’ own reports. Further work is needed to determine the best timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes.
Fox IK, Davidge KM, Novak CB, et al.
Plast Reconstr Surg. 2015 Oct;136(4):780-92

Functional electrical stimulation for the upper limb in tetraplegic spinal cord injury: a systematic review.
The aim of this study is to systematically review research on the effectiveness of functional electrical stimulation (FES) for improving functional tasks using the upper limb in people with tetraplegia. The authors systematically found 144 studies from September 2009 to September 2014. Only five studies met the inclusion criteria. All five reported improvements immediately and at follow-up in motor control and/or functional ability as a result of FES or FES combined with conventional therapy. There is some preliminary evidence that FES may reduce disability due to upper limb-related activity limitations in tetraplegia. Further work needs to examine the role of FES in more detail and in combination with other treatments.
Patil S, Raza WA, Jamil F, et al.
J Med Eng Technol. 2014 Oct;39(7):419-23

Car Transfer and Wheelchair Loading Techniques in Independent Drivers with Paraplegia.
In people with complete paraplegia from SCI, car transfers and wheelchair (WC) loading are crucial for independent community participation but are physically demanding and can cause shoulder pain. Four females and 25 males with T2 to L3 paraplegia were videotaped while transferring and loading their personal WCs into and out of their own cars or vans. Drivers who transferred with their leading hand on the steering wheel had significantly higher levels of shoulder pain than those who placed their hand on the driver’s seat or overhead. Those who loaded their WC frame into the back seat had significantly weaker right shoulder internal rotators. Understanding car transfers and WC loading in independent drivers is crucial to prevent shoulder pain and injury and preserve community participation.
Haubert LL, Mulroy SJ, Hatchett PE, et al.
Front Bioeng Biotechnol. 2015 Sep 17;3:139.

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Mobility Training

Does locomotor training improve pulmonary function in patients with spinal cord injury?
Fifty-two inpatients with SCI (both paraplegia and tetraplegia) were divided into two groups: group A received 4 weeks of both locomotor training (LT) and rehabilitation, and group B received 4 weeks of rehabilitation only. The LT program consisted of three 30-min sessions per week. Pulmonary function was evaluated spirometrically in both groups before and after the rehabilitation program. Forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow rate and vital capacity (VC) and VC% increased significantly with LT in the first group. Maximum voluntary ventilation increased significantly in both groups. These findings suggest that LT is effective for improving pulmonary function in SCI patients. We also highlight the useful effects of LT, which are likely the result of erect posture, gait and neuroplastic changes that prevent potential complications in SCI patients.
Tiftik T, Gökkaya NK, Malas FÜ, et al.
Spinal Cord. 2015 Jun;53(6):467-70.

Mobility Outcomes Following Five Training Sessions with a Powered Exoskeleton.
This study was conducted to evaluate mobility outcomes for individuals with SCI after 5 gait-training sessions with a powered exoskeleton. Sixteen subjects with SCI were enrolled in a pilot clinical trial, with injury levels ranging from C5 complete to L1 incomplete. An investigational Indego exoskeleton research kit was used. Outcome measures included the 10-meter walk test and the 6-minute walk test, and measures of independence including donning and doffing times and the ability to walk on various surfaces. Results after only 5 sessions suggest that persons with tetraplegia and paraplegia learn to use the Indego exoskeleton quickly and can manage a variety of surfaces. Walking speeds and distances achieved also indicate that some individuals with paraplegia can quickly become limited community walkers using this system.
Hartigan C, Kandilakis C, Dalley S, et al.
Top Spinal Cord Inj Rehabil. 2015 Spring;21(2):93-9

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Sexual Function, Satisfaction, and Use of Aids for Sexual Activity in Middle-Aged Adults with Long-Term Physical Disability.
For this study, middle-aged adults with physical disabilities completed a survey that included measures of sexual activity, function, and satisfaction. Consistent with studies of able-bodied adults, sexual function was the strongest predictor of satisfaction. However, depression also decreased sexual satisfaction in women. Use of aids for sexual activity varied by disability type and was generally associated with better sexual function. Lowest levels of sexual satisfaction were reported by men with SCI.
Smith AE, Molton IR, McMullen K, Jensen MP.
Top Spinal Cord Inj Rehabil. 2015 Spring;21(3):227-32

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Resilience and Coping

Resilience predicts functional outcomes in people aging with disability: a longitudinal investigation.
The average age of persons with long-term physical disabilities is increasing. Individuals aging with a physical disability have a higher risk of symptoms such as chronic pain, fatigue, and depression. However, functional decline is not inevitable, and individuals often report high quality of life despite physical disabilities. One factor in determining quality of life in this population is “resilience,” often defined as an ability to flourish in the face of negative life events. Resilience is based on several factors, including temperament (e.g., optimism), learned skills (e.g., mindfulness) and environmental supports (e.g., social connections). This longitudinal study was designed to investigate the links between resilience and depressive symptoms, social functioning, and physical functioning in people aging with disability and to investigate the effects of resilience on change in functional outcomes over time. Surveys were mailed to 1,594 individuals with: multiple sclerosis (509), muscular dystrophy (282), post poliomyelitis syndrome (389), or SCI (414). The survey response rate was 91% at baseline and 86% three years later. At baseline, resilience was negatively correlated with depression and positively correlated with social and physical functioning. Greater resilience at baseline predicted a decrease in depressive symptoms and an increase in social functioning three years later.
Silverman AM, Molton IR, Alschuler KN, et al.
Arch Phys Med Rehabil. 2015 Jul;96(7):1262-8.

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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