Contents:
Complications | Musculoskeletal | Outcome | Rehabilitation Therapies | Urology
Complications
Is there a relationship between chronic pain and autonomic dysreflexia in persons with cervical spinal cord injury?
Of 181 persons with chronic cervical SCI who reported pain in a previous study, 117 ( 64.6%) completed a mail-in survey on autonomic dysreflexia (AD), demographic factors, clinical characteristics of pain, and affective symptoms. The only difference between those who did and did not respond to the survey was that responders tended to be injured longer (average 2.5 years) than non-responders. Thirty-five people (29.9%) reported AD. Those with AD reported more painful areas, had more anxiety and sadness, and more common aggravation of pain due to muscle spasms, infections, full bladder, and constipation. A combination of having widespread pain, experiencing aggravation of pain due to infections, having a complete injury, and experiencing anxiety, significantly predicted AD. Since the mechanisms underlying pain may also elicit AD, attention to pain as a triggering factor appears to be warranted.
Widerstrom-Noga E, Cruz-Almeida Y, Krassioukov A.
J Neurotrauma. 2004 Feb;21(2):195-204.
Cost-effectiveness of duplex ultrasound surveillance in spinal cord injury.
A retrospective review of 369 subjects with SCI who received duplex ultrasound on admission for inpatient rehabilitation found that 37 (10.03%) had deep venous thrombosis (DVT) during their inpatient stay. A statistical model analyzing costs and mortality (from pulmonary embolism) found that the cost of one life saved when performing admission duplex ultrasound surveillance is calculated to be $61,542, with cost per life-year gained between $1,193 and $9,050, depending on age at time of injury and severity of injury. Since this compares favorably with the cost-effectiveness of other currently accepted mass screening programs, duplex ultrasound is considered to be a cost-effective tool for DVT surveillance in individuals with acute traumatic SCI.
Kadyan V, Clinchot DM, Colachis SC.
Am J Phys Med Rehabil. 2004 Mar;83(3):191-7.
Gabapentin is a first line drug for the treatment of neuropathic pain in spinal cord injury.
To determine the efficacy, effective dose, and side-effect profile of gabapentin (GBP) in the treatment of neuropathic pain related to SCI, 20 patients with paraplegia participated in an 18-week, prospective, randomized, double blind, placebo-controlled, crossover clinical trial consisting of a 4-week GBP /placebo titration period; 4-week stable dosing; 2-week washout; followed by two 4-week periods of crossover titration and dosing. GBP significantly reduced the intensity and frequency of pain; relieved all neuropathic pain descriptors except itchy, sensitive, dull, and cold types; and improved quality of life. GBP had minor adverse effects in this study and all subjects completed the trial.
Levendoglu F, Ogun CO, Ozerbil O, et al.
Spine. 2004 Apr 16;29(7):743-51 Spine. 2004 Apr 16;29(7):743-51
Effects of regular use of neuromuscular electrical stimulation on tissue health.
Eight subjects with SCI (C6-T12) with implanted neuromuscular electrical stimulation (NMES) systems (for participating in a standing and transfer study) had their tissue health evaluated through 1) monitoring tissue oxygen levels in the ischial region, and 2) measuring interface pressures at the seating support interface. Baseline assessments were done at study enrollment and repeated on completion of an 8-week conditioning exercise program that included several stimulation patterns. Unloaded tissue oxygen levels in the ischial region tended to increase following the NMES exercise program but was not statistically significant. While overall mean interface pressure showed no significant differences between baseline and after the exercise program, pressures in the ischial region showed a significant decrease, indicating a quantifiable benefit to tissue health.
Bogie KM, Triolo RJ.
J Rehabil Res Dev. 2003 Nov-Dec;40(6):469-75.
Musculoskeletal
Longitudinal analysis of cartilage atrophy in the knees of patients with spinal cord injury.
The right knees of 9 patients with complete SCI were examined shortly after the injury (mean +/- SD 9 +/- 4 weeks) and at 6 and 12 months postinjury. Three-dimensional morphology of the patellar, tibial, and femoral cartilage (mean and maximum thickness, volume, and surface area) was determined from coronal and transversal magnetic resonance. Total knee cartilage volume (patella, medial and lateral tibia, and medial and lateral femur) was reduced by 7% at 6 months and by 10% at 12 months postinjury. In this study, knee cartilage atrophied at a higher rate than that observed in osteoarthritis (OA). Cartilage thinning after SCI may affect stress distribution in the joint and render it vulnerable to OA. Future studies should focus on specific exercise and rehabilitation programs to prevent cartilage thinning.
Vanwanseele B, Eckstein F, Knecht H, et al.
Arthritis Rheum. 2003 Dec;48(12):3377-81.
Increased blood pressure can reduce fatigue of thenar muscles paralyzed after spinal cord injury.
Eight subjects with cervical SCI (C4-C6) and low blood pressure (64 +/- 2 mmHg) performed two experiments in random order in which the fatigability of the thenar muscles was assessed in response to repetitive electrical stimulation of the median nerve. In one test, a concurrent sustained voluntary contraction of the contralateral elbow flexors was used to increase resting mean arterial pressure (MAP) (by 22%, on average). The second test had no voluntary contraction. In seven subjects, changes in MAP with exercise correlated with changes in thenar muscle fatigue. For every 10% increase in MAP, fatigue was reduced by approximately 3%. The data suggest that low blood pressure after chronic cervical SCI and poor blood pressure control during exercise exacerbate the fatigability of paralyzed muscles.
Butler JE, Ribot-Ciscar E, Zijdewind I, et al.
Muscle Nerve. 2004 Apr;29(4):575-84.
Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users.
Of 56 individuals with SCI (>1 year duration) who responded to a questionnaire, 21 (37.5%) reported having shoulder pain in the last month. Subjects who reported shoulder pain did not differ from those without pain regarding age, gender, years of wheelchair use, weekly hours of work, number of transfers per day, participation in sports, or time spent in the wheelchair per day. Thirteen of the respondents with pain received further examination by a physical therapist and standardized questionnaires on the effect of shoulder pain on activity and participation. Fifty-two problems with occupational performance due to shoulder pain were identified, and 54% of these were related to self-care activities that involved wheelchair use, such as loading the wheelchair into the car, pushing up ramps, and transferring.
Samuelsson KA, Tropp H, Gerdle B.
Spinal Cord. 2004 Jan;42(1):41-6.
Bone density loss after spinal cord injury: elite paraplegic basketball players vs. paraplegic sedentary persons.
Seventeen male basketball players and 17 sedentary males-all with paraplegia-were matched for age and time since injury. Bone mineral densities (BMD) of the distal third of the radius of the dominant arm, L2-L4 spine, and the trochanters, Ward's triangles, and femoral necks of both hips were measured using Lunar DPX-MD dual x-ray absorptiometry. Below the lesion level, no significant difference was found between the two groups. Radial BMD was significantly higher in the athletes than the sedentary group, whereas the groups were not significantly different for lumbar density.
Goktepe AS, Yilmaz B, Alaca R, et al.
Am J Phys Med Rehabil. 2004 Apr;83(4):279-83
Outcome
High Rates of Neurological Improvement Following Severe Traumatic Pediatric Spinal Cord Injury.
Of 4,876 pediatric trauma cases at a Los Angeles hospital between 1993 and 2001, 30 involved SCI (7 craniocervical, 12 cervical, 5 thoracic, and 6 thoracolumbar) with neurologic deficit (20 ASIA grade A, two ASIA B, six ASIA C, two ASIA D). Of the 22 patients who survived their injuries, 14 (64%) made some functional improvement. Younger age, incomplete impairment, and SCI without radiographic abnormality was associated with likelihood to improve. Five of the 20 patients who initially presented with complete injuries eventually became ambulatory. Recovery of neurological function after severe injury occurs with a significantly greater incidence in children than adults, and improvements can occur over a prolonged postinjury period. These results suggest that physicians caring for this unique trauma population should exercise aggressive measures in both acute and rehabilitative phases of recovery.
Wang MY, Hoh DJ, Leary SP, et al.
Spine. 2004 Jul 1;29(13):1493-1497
Outcomes after spinal cord injury: comparisons as a function of gender and race and ethnicity.
In this multi-site, cross-sectional study, 475 participants with SCI completed questionnaires on subjective well-being (SWB), community integration and participation, health behaviors, and health. There were relatively equal portions of whites, African Americans, American Indians, and Hispanics. Approximately 40% of the sample were women. The majority of racial and ethnic differences in SWB related to specific life areas (eg, economics, employment), rather than more global outcomes (eg, community engagement, health), with whites generally reporting the best outcomes, followed by African Americans. American Indians and whites generally reported the highest participation scores, whereas limited differences were noted between the racial and ethnic groups on health indicators. Women reported lower satisfaction with health, more poor mental health days, and lower SWB related to home life, but higher SWB related to interpersonal relations.
Krause JS, Broderick L.
Arch Phys Med Rehabil. 2004 Mar;85(3):355-62
Rehabilitation Therapies
Functional electric stimulation to augment partial weight-bearing supported treadmill training for patients with acute incomplete spinal cord injury: A pilot study.
Fourteen inpatients with acute incomplete SCI (ASIA C or D) participated in a before-after crossover trial of partial weight-bearing (PWB)-supported treadmill gait training with functional electric stimulation (FES) augmentation. The intervention consisted of walking on a treadmill for up to 25 minutes a day, 5 days a week for 4 weeks, and this was compared with a 4-week control period in which standard PT was given. Subjects were randomly assigned to an intervention-control or control-intervention sequence. Several parameters were measured at the end of each period. A greater increase in overground walking endurance and speed was achieved after the intervention period as compared with standard PT, indicating that PWB-supported treadmill gait training with FES had a positive effect and could accelerate gait training in persons with incomplete SCI.
Postans NJ, Hasler JP, Granat MH, et al.
Arch Phys Med Rehabil. 2004 Apr;85(4):604-10.
Using an evidence-based protocol to guide rehabilitation and weaning of ventilator-dependent cervical spinal cord injury patients.
Seven ventilator-dependent males with SCI (C2 to C7) participated in a pilot study of an evidence-based clinical protocol to improve ventilatory muscle strength and endurance in order to discontinue mechanical ventilation. The protocol consisted of pretraining optimization, as well as progressive resistance and endurance training. Following the protocol, mean maximal inspiratory pressure for low tetraplegic (C4-7) patients improved 75 percent, mean maximal expiratory pressure improved 71 percent, mean vital capacity increased 59 percent, mean on-vent endurance time increased 91.6 percent, and mean off-vent breathing time increased 76.7 percent. Both high and low tetraplegic patients achieved gains in inspiratory and expiratory muscle strength, vital capacity, on-vent endurance, and off-vent breathing times. High tetraplegic (C2) patients improved their ability to spontaneously ventilate for short periods in case of accidental disconnection from the ventilator. Low tetraplegic patients were able to discontinue mechanical ventilation.
Gutierrez CJ, Harrow J, Haines F.
J Rehabil Res Dev. 2003 Sep-Oct;40(5 Suppl 2):99-110.
Urology
Bladder cancer in patients with spinal cord injuries.
Records were reviewed for 1,324 patients with SCI in a U.K. medical center; dates of SCI or first attendance at the center were between 1940 and 1998. The length of follow-up and age-specific incidence rates of bladder cancer were calculated using 5-year age bands. Overall incidence rate was also calculated. The 1,324 patients contributed a total of 12,444 person-years of follow-up. There were four cases of bladder cancer, giving an age-standardized incidence rate of 30.7 per 100,000 person-years, which is not statistically different from that of the general population. Histochemical analysis confirmed a squamous cell phenotype in these tumors.
Subramonian K, Cartwright RA, Harnden P, et al.
BJU Int. 2004 Apr;93(6):739-43.