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Spinal Cord Injury Update

Spring 2008: Volume 17, 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.

Shoulder Pain

Arm crank ergometry and shoulder pain in persons with spinal cord injury.
Twenty-three individuals with SCI of a year or more participated in a fitness study that consisted of exercising with an arm crank ergometer (exercise machine in which arms are used to “pedal”) three times a week for 12 weeks. The researchers measured the participants’ shoulder pain using the Wheelchair User’s Shoulder Pain Index (WUSPI) at baseline (before starting the exercise program) and again at the end of the 12 weeks. There was no significant difference between the baseline and 12-week scores. This showed that a primary fitness program using arm crank ergometry does not increase shoulder pain in people with SCI who use wheelchairs. Larger studies are needed.
Dyson-Hudson TA, Sisto SA, Bond Q, Emmons R, Kirshblum SC.
Arch Phys Med Rehabil. 2007 Dec;88(12):1727-9.

Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial.
Seventeen manual wheelchair-using individuals with chronic SCI and chronic musculoskeletal shoulder pain were randomly assigned to receive 10 treatments of either acupuncture or a “sham” or placebo procedure (light needling of areas on the body that are not acupuncture points). Changes in shoulder pain intensity were measured using the Wheelchair User’s Shoulder Pain Index. Comparisons between the two groups (treatment and placebo) found that shoulder pain decreased significantly in both, with decreases of 66% with acupuncture and 43% with placebo. This difference was not significant, however; a larger randomized controlled trial is warranted.
Dyson-Hudson TA, Kadar P, LaFountaine M, et al.
Arch Phys Med Rehabil. 2007 Oct;88(10):1276-83.

Effect of 2-speed geared manual wheelchair propulsion on shoulder pain and function.
Seventeen full-time manual wheelchair users with shoulder pain participated in a five-month study using two-gear drive wheels (MAGICWheels). Pain and function measures (Wheelchair Users Shoulder Pain Index, Wheelchair Users Functional Assessment (WUFA), and timed hill climb test with rating of perceived exertion (RPE)), were administered at baseline (before starting the study) and at periodic intervals. Shoulder pain decreased significantly at weeks two through 16, and again at week 20. The WUFA scores did not change. Hill climb time was longer when using the 2-gear wheel, but there was no difference in RPE. The pain reductions after 2 weeks is a rapid response to the intervention and suggests good potential for shoulder pain reduction with this technology, even in highly functional manual wheelchair users.
Finley MA, Rodgers MM.
Arch Phys Med Rehabil. 2007 Dec;88(12):1622-7.

Neuropathic Pain

Comparison of the effectiveness of amitriptyline and gabapentin on chronic neuropathic pain in persons with spinal cord injury.
This was a randomized, controlled, double-blind trial involving 38 adults with SCI living in the community. Participants received amitriptyline, gabapentin, and an active placebo (diphenhydramine) separately for eight weeks each. Pain intensity and depressive symptoms were measured in each participant before and after each eight week trial using standardized scales. Contrary to previous studies, this study found amitriptyline be effective in relieving pain and more effective than gabapentin. This effect was greatest in participants who had many depressive symptoms at baseline. Most participants had a clinically meaningful decrease in pain when taking amitriptyline. Amitriptyline is also far less costly than gabapentin. Pain was not completely eliminated, however, and amitriptyline has considerable side effects, so more effective treatments are still needed. When treating persons with SCI for pain, assessment and treatment of depression should be part of the standard of care.
Rintala DH, Holmes SA, Courtade D, et al.
Arch Phys Med Rehabil. 2007 Dec;88(12):1547-60.

Pregabalin in the management of central neuropathic pain.
Central neuropathic pain is often severe and threatens a person’s quality of life and ability to perform even the most basic of tasks. Despite this high level of suffering there are relatively few studies investigating the management of central neuropathic pain. This review of the literature found two recent randomized placebo-controlled studies demonstrating the effectiveness of pregabalin in reducing central neuropathic pain due to SCI and central poststroke pain. Pregabalin, an anticonvulsant, has been shown to be effective in the management of peripheral neuropathic pain of various causes and now may have a role to play in central neuropathic pain.
Gray P.
Expert Opin Pharmacother. 2007 Dec;8(17):3035-41.

Women & SCI

Spinal cord injury rehabilitation: the experience of women.
Ten women with SCI were interviewed about their rehabilitation experience. Vulnerability was their biggest psychosocial problem, and it was compounded by lack of privacy within the rehabilitation center, by negative staff interactions (associated with perceived lack of control and lack of respect) and by women’s minority status in the rehabilitation setting, which at times left women feeling marginalized and inferior. Feelings of vulnerability were lessened by: increasing privacy and space; receiving support and encouragement from staff, other patients and family; and adopting a positive attitude. The SCI rehabilitation environment and interactions have a significant influence on women’s feelings and behaviors as they begin to develop a revised identity as a disabled person. More research will lead to a better understanding of women’s needs and concerns and better clinical practice for this population.
Samuel VM, Moses J, North N, et al.
Spinal Cord. 2007 Dec;45(12):758-64.

Recovery Research

Transplanted neural progenitor cells survive and differentiate but achieve limited functional recovery in the lesioned adult rat spinal cord.
To determine how spinal cord neural progenitor cells (SCNPCs) may contribute to spinal cord repair, SCNPCs isolated from rat fetal spinal cord were transplanted into the adult rat spinal cord after a dorsal column crush lesion. Transplanted cells survived 24 hours and 1, 2 and 6 weeks after injury and maintained their ability to differentiate: 40% differentiating into cells with a glial morphology, and 8% displaying a neural morphology. SCNPCs failed to promote significant functional recovery, and had small improvements in sensory function. Tracing of the corticospinal tract and ascending dorsal column pathway revealed no regeneration of the axons beyond the lesion site. Although transplanted SCNPCs show good survival in the SCI environment, combination with other treatment strategies will probably be necessary for these cells to be fully therapeutic.
Webber DJ, Bradbury EJ, McMahon SB, Minger SL.
Regen Med. 2007 Nov;2(6):929-45.

Structural differentiation of skeletal muscle fibers in the absence of innervation in humans.
After SCI, lack of innervation (nerve signals) to the muscles causes severe muscle atrophy (shrinking) and changes in muscle fiber properties. Complete inactivity and immobilization of the limbs causes poor blood supply below the injury level and secondary complications (osteoporosis, pressure sores, etc.). Muscle biopsies from SCI patients given functional electrical stimulation (FES) for prolonged periods (2.4-9.3 years), showed recovery of muscle structure, mass, and force. This was true even in patients whose muscles had been denervated (without nerve signals) for up to 2 years before starting FES and had lost most muscle-specific internal organization. In 4 of 5 patients, muscle force improved enough to allow for supported standing up, standing, and taking a few steps.
Boncompagni S, Kern H, Rossini K, et al.
Proc Natl Acad Sci U S A. 2007 Dec 4;104(49):19339-44.

Electrical stimulation of spared corticospinal axons augments connections with ipsilateral spinal motor circuits after injury.
To study whether activity would enhance sprouting and strengthen connections with spinal motor circuits after injury, the researchers electrically stimulated corticospinal (CS) tract axons in the medullary pyramid of rat spinal cords. Both stimulation and injury alone strengthened CS connectivity and increased outgrowth into the ipsilateral gray matter. CS terminations were densest within the ventral motor territories of the cord, and connections in these animals were significantly stronger than after injury alone, indicating that activity augments injury-induced plasticity. The study shows that activity promotes plasticity in the mature CS system and that the interplay between activity and injury preferentially promotes connections with ventral spinal motor circuits.
Brus-Ramer M, Carmel JB, Chakrabarty S, Martin JH.
J Neurosci. 2007 Dec 12;27(50):13793-801.

Bladder

Chronic suprapubic catheterization in the management of patients with spinal cord injuries: analysis of upper and lower urinary tract complications.
Of 149 patients with SCI who used suprapubic catheterization (SPC) for an average of six years, 49% had no complications from this method of bladder management. Most complications were minor (urinary tract infection 27%, bladder stones 22%) and easily managed. Only 20 patients had upper urinary tract complications. Nine patients had renal scarring and 14, all quadriplegic, had upper tract calculi (kidney stones). One patient developed well-differentiated superficial transitional cell bladder cancer. Patients with SCI often prefer SPC than other methods offered to them because of quality-of-life issues. With a commitment to careful follow-up and surveillance, SPC can be a safe option for carefully selected patients.
Sugimura T, Arnold E, English S, Moore J.
BJU Int. 2008 Jan 8

Syringomyelia

Minimally invasive insertion of syringosubarachnoid shunt for posttraumatic syringomyelia: technical case report.
This is the first report of syringosubarachnoid shunting (SSAS) inserted in a minimally invasive fashion through a tubular retractor for treatment of posttraumatic syringomyelia (cyst in the spinal cord). Four years after injury, a 27-year-old woman with C6-7 incomplete SCI had increasing pain and spasticity below the midthoracic region, and magnetic resonance imaging (MRI) scan revealed a midthoracic syrinx. SSAS was inserted using a minimally invasive technique, a hemilaminotomy was performed, and a midline durotomy and myelotomy were opened for SSAS insertion under microscopic visualization. Intraoperative ultrasonography revealed successful syrinx decompression after SSAS insertion. The patient was discharged 38.5 hours after surgery with resolution of her preoperative symptoms. Postoperative MRI scan revealed excellent decompression of the syrinx, and one year later, the patient has had no recurrence of her syrinx-related symptoms. This technique appears to be a safe and effective means of implanting an SSAS in these patients.
O’Toole JE, Eichholz KM, Fessler RG.
Neurosurgery. 2007 Nov;61(5 Suppl 2):E331-2.

Cardiovascular

Clinical significance of abnormal electrocardiographic findings in individuals aging with spinal injury and abnormal lipid profiles.
Cardiovascular risk factors are common in SCI, and their prevalence increases with age. In this study of 43 outpatients with SCI and abnormal lipid (blood fat) profiles. Electrocardiogram (ECG) abnormalities were found in 60.5%. Evidence of previous myocardial infarction (heart attack) was present in 7% of all individuals and in 12% of those with ECG abnormalities. Patients were mostly male, average age 43 and duration of injury 16.6 years. Number of years since injury was the sole predictor of abnormal ECGs. Although age is an important risk factor for cardiovascular disease (CVD) in persons without disabilities, injury duration is at least as important as age in those with SCI. Individuals with SCI and abnormal lipids should be screened for CVD regardless of age.
Szlachcic Y, Carrothers L, Adkins R, Waters R.
J Spinal Cord Med. 2007;30(5):473-6.

Open-heart operations in patients with a spinal cord injury.
In eight patients with chronic SCI (levels from T3 to L2, mean age 62) who had open-heart surgery between 1994 and 2006, seven had coronary artery bypass operations and two had aortic valve replacements. The mean cardiac ejection fraction was 44%. Seventy-five percent of the patients were extubated within 24 hours of the operation. The acute hospital stay averaged 14 days. One patient died from multiorgan failure on postoperative day 13, giving an in-hospital 30-day mortality of 12.5%. The 5-year survival was 75% with a mean follow-up of 67 months. This shows that open-heart operations in patients with SCI can be performed safely with acceptable early and late outcomes.
Chu D, Bakaeen FG, Shenaq SA, et al.
Am J Surg. 2007 Nov;194(5):663-7.

Male Sexual Function

Midodrine improves ejaculation in spinal cord injured men.
A total of 185 men with SCI who reported no ejaculation during sexual intercourse and no response to penile vibratory stimulation were treated with midodrine 30 – 120 minutes before a new stimulation. The procedure was repeated weekly, increasing doses by 7.5 mg to a maximum of 30 mg. Ejaculation was achieved in 102 men (64.6%) and was more common in patients with complete injuries and upper motor neuron injuries above T10. Midodrine induced a significant but moderate increase (maximum 10 mm Hg) in mean arterial pressure in all patients. The highest systolic blood pressure (more than 200 mm Hg) was seen in patients with quadriplegia. No other significant side effect was recorded. The average dose of midodrine required for ejaculation was 18.7 mg. Midodrine is a safe and efficient addition to penile vibratory stimulation in this population.
Soler JM, Previnaire JG, Plante P, et al.
J Urol. 2007 Nov;178(5):2082-6. Epub 2007 Sep 17.

 

How to obtain the 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 (206) 543-3441 or http://healthlinks.washington.edu/hsl/docservices/illiad.htm. (There is a fee for this service.)