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Spinal Cord Injury Update

Summer 2008: Volume 17, Number 3

 

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.

 

Bladder management

Evaluation of cranberry tablets for the prevention of urinary tract infections in spinal cord injured patients with neurogenic bladder.
Forty-seven men with SCI (ASIA A, B and C; 23 with quadriplegia) and neurogenic bladder completed this randomized, double blind, placebo-controlled trial. Participants were randomized to receive 6 months of cranberry extract tablet or placebo, followed by the alternate preparation for an additional 6 months. The cranberry extract tablet contained concentrated cranberry fruit extract with 500 mg of Vaccinium macrocarpon (Cran-Max, Swiss Herbal, Canada). Tablets were taken twice per day during the study periods. During the 6 months of cranberry tablets, there was a significant reduction in both the incidence of UTI and the number of subjects with a UTI. Patients with a glomerular filtration rate received the most benefit. Cranberry extract tablets should be considered for the prevention of UTI in SCI patients with neurogenic bladder.
Hess MJ, Hess PE, Sullivan MR, et al.
Spinal Cord. 2008 Apr 8 [Epub ahead of print]

Effective treatment of neurogenic detrusor dysfunction by combined high-dosed antimuscarinics without increased side-effects.
This study involved 27 individuals (21 with SCI) who had participated in a previous study using double the usual dose of antimuscarinic drugs to treat neurogenic bladder. Doubling the usual dose of the antimuscarinics did not improve bladder symptoms in these participants but did not worsen side effects. In this study, participants were given an additional antimuscarinic in combination with the double dose of the antimuscarinic they were already taking. At four-week follow-up, incontinence episodes decreased from an average of 7 to 1 per day. Other neurogenic bladder symptoms (bladder capacity, reflex volume, detrusor compliance) also improved. In conclusion, 85% of the participants who were not satisfactorily treated using higher doses of a single antimuscarinic were treated successfully with combined high-dosage antimuscarinic medications. The appearance of side-effects was comparable to that of normal-dosed antimuscarinics.
Amend B, Hennenlotter J, Schafer T, et al.
Eur Urol. 2008 Jan 17 [Epub ahead of print]

Cardiovascular

C-reactive protein in adults with chronic spinal cord injury: increased chronic inflammation in tetraplegia vs paraplegia.
C-reactive protein (CRP), a substance secreted by the liver during inflammation, is known to indicate an increased risk for cardiovascular disease (CVD). Height, weight, waist circumference (WC), blood pressure, percent fat mass and fasting blood parameters (high-sensitivity CRP, lipids, insulin, glucose, insulin resistance by homeostasis model assessment (HOMA)) were measured in 69 individuals with SCI living in the community (32 with tetraplegia; 42 incomplete; 56 male). Average CRP of the group was 3.37, consistent with the American Heart Association (AHA) definition of high risk of CVD. CRP was 74% higher in persons with tetraplegia than those with paraplegia. Participants with high CRP had greater WC, body mass index, percent fat mass and HOMA values than those with lower CRP. There was no difference in risk factors between those with complete and incomplete injuries. Level of lesion and WC are independently associated with CRP in this population, suggesting that those with tetraplegia and larger WC may be at particularly high risk of CVD.
Gibson AE, Buchholz AC, Martin Ginis KA
Spinal Cord. 2008 Apr 15 [Epub ahead of print]

Recovery research

Stem and progenitor cell therapies: recent progress for spinal cord injury repair.
The authors review the current state of research in using stem and progenitor cells for the repair of SCI. The implantation of exogenous cells (from a source outside an organism’s body) or the stimulation of endogenous cells (from within the body), to repopulate and replace or to provide a conducive environment for repair, offers a promising therapeutic direction for overcoming the multitude of obstacles facing successful recovery from SCI. Although relatively new to the scene of cell based therapies for reparative medicine, stem cells and their progenitors have been labeled as the ‘cell of the future’ for revolutionizing the treatment of central nervous system injury and neurodegenerative disorders. This review examines the different types of stem cells and their progenitors and their usefulness in experimental models of SCI, and explores the outstanding issues that still need to be addressed before they can be used in treatments for humans with SCI.
Louro J, Pearse DD
Neurol Res. 2008 Jan;30(1):5-16

Clinical studies in spinal cord injury: moving towards successful trials.
Despite many laboratory and clinical trials conducted over the past few decades, there is still no cure or clinically relevant therapeutic intervention for SCI. Most of the therapeutic strategies for SCI aim to promote regeneration by creating a more permissive environment for cell regeneration, either by minimizing inhibitory effects, neuroprotection or cell transplantation. Most studies are preliminary and lack control groups, but provisional results can be attractive to clinicians and patients who are faced without an alternative. This review discusses previous clinical studies, strategies that are presently being translated into clinical studies, and guidelines for future trials.
Knafo S, Choi D
Br J Neurosurg. 2008 Feb;22(1):3-12.

Adaptive changes in the injured spinal cord and their role in promoting functional recovery.
Although axons in the injured spinal cord are unable to regenerate, a modest spontaneous recovery can often be found in both patients and animal models, suggesting that the potential for “repair” must exist somewhere. One possible mechanism behind this recovery involves rearrangements in the brain and spinal cord, often referred to as plasticity. In this review, the authors discuss plasticity throughout the entire central nervous system induced by SCIs, with an emphasis on sprouting of descending spinal tracts. Because this sprouting occurs spontaneously, it not only lends itself as a recovery mechanism, but also opens potential treatment avenues to promote further functional recovery. As such, various recent examples of approaches to pharmacologically promote plasticity within the spinal cord are discussed.
Fouad K, Tse A.
Neurol Res. 2008 Feb;30(1):17-27.

Acute SCI treatment

Methylprednisolone for acute spinal cord injury: 5-year practice reversal.
Forty-two surgeons and 21 residents in Canada directly involved in the acute management of SCI completed a questionnaire about their practice of methylprednisolone (MP) administration for acute SCI. Answers were compared to a similar questionnaire administered five years earlier. The large majority of spinal surgeons (76%) no longer prescribe MP for acute SCI compared to 76% who prescribed it five years ago. Eighty percent of surgeons now feel comfortable with the pertinent published literature compared to 30% previously. Of the 24% of orthopedic surgeons and neurosurgeons who continue to recommend MP for SCI, the majority do so because they believe it effective, not because of fear of litigation. Peer-reviewed independent interpretation of published results, guidelines formulation by parent organizations, and dissemination at specialty meetings are powerful tools for influencing practice patterns
Hurlbert RJ, Hamilton MG.
Can J Neurol Sci. 2008 Mar;35(1):41-5.

Bone mineral density

Training and detraining of a tetraplegic subject: high-volume fes cycle training.
A 31-year-old man with a C6-level SCI (ASIA B), 3 years after injury, performed one year of high-volume functional electrical stimulated (FES) cycle training (5 times per week, 1 hour per session, maximal sustainable power output) at home. Depending on the training compliance, which varied from 22.9% to 82.9%, maximal power output and peak oxygen uptake increased by 113% and 103%, respectively. During times when the subject could not maintain the training regimen, these improvements declined. Bone mineral density of the distal femoral epiphysis showed an increase of 3.9% after 12 months of cycle training. While it is possible to increase maximal power output, cardiopulmonary fitness, and bone density of the paralyzed limbs in tetraplegia by high-volume cycle training, these improvements are lost if training is not maintained. In tetraplegic subjects, it may be difficult to maintain the high level of training required to achieve benefits.
Kakebeeke TH, Hofer PJ, Frotzler A, et al.
Am J Phys Med Rehabil. 2008 Jan;87(1):56-64.

Male sexual function

Vardenafil improves ejaculation success rates and self-confidence in men with erectile dysfunction due to spinal cord injury.
A high proportion of men with SCI cannot ejaculate during sexual intercourse, and this is often the reason for male infertility. Sexual dysfunction after SCI can also affect men’s self-confidence. In this 12-week study, 418 men age 18 years or older with erectile dysfunction due to SCI and lasting longer than 6 months were randomized to receive 10 mg vardenafil or placebo for 4 weeks, then maintained or adjusted to 5 mg or 20 mg at weeks 4 and 8. The per patient ejaculation success rates were significantly greater with vardenafil than placebo over 12 weeks of treatment. Sixteen percent of men receiving vardenafil and 8% receiving placebo felt orgasm “almost always” or “always” at weeks 8-12, compared with 4% and 6%, respectively, at the beginning of the study. Significant improvements in confidence scores were observed with vardenafil compared with placebo. There were no differences in quality-of life measures between the two groups, but these had been in the normal range at baseline. Vardenafil significantly improved ejaculation and self-confidence in men with erectile dysfunction due to SCI.
Giuliano F, Rubio-Aurioles E, Kennelly M, et al.
Spine. 2008 Apr 1;33(7):709-15.

Testosterone replacement

Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis.
Individuals with SCI experience changes in body composition over time—namely, loss of muscle mass. They also have a decline in the secretion of the androgenic hormone testosterone, required for the maintenance of lean body mass and strength. This retrospective investigation tested the hypothesis that men with SCI given testosterone replacement therapy (TRT) would demonstrate greater improvement in motor function compared with an untreated comparison group. Fifty men with SCI admitted to an inpatient rehabilitation facility and were found to have low serum total testosterone levels received TRT. They were compared to 480 men with SCI admitted to different rehab facilities in the same period who had not been screened and were not receiving TRT. All subjects had injuries of one year or less. Among subjects with ASIA C and D impairments, motor scores at discharge were significantly better for the TRT group compared to the control group. There were no differences between the two groups for men with complete injuries. These findings suggest that TRT may improve motor function in men with incomplete SCI and provide a rationale for future prospective trials.
Clark MJ, Petroski GF, Mazurek MO, et al.
Am J Phys Med Rehabil. 2008 Apr;87(4):281-4.

Spasticity

The use of botulinum toxin for spasticity after spinal cord injury.
The authors conducted a medical chart review of 28 adults with SCI who had received botulinum toxin (BTX) type A injections for spasticity. Dosages ranged from 10 to 119 units per muscle. Improvement was noted for 56% in ambulation and 71% in positioning. Overall, upper-extremity function improved in 78%, hygiene improved in 66.6%, and pain decreased in 83.3%. Early use of BTX injections (less than a year after onset of symptoms) vs. late use of BTX injections did not influence effectiveness. BTX seems to be an effective treatment for spasticity and for reducing disability in persons with SCI. Randomized trials are needed to confirm the value of this treatment in this population.
Marciniak C, Rader L, Gagnon C.
Am J Phys Med Rehabil. 2008 Apr;87(4):312-7

Respiratory

Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency.
This was a prospective, 20-year study of 64 patients with respiratory device-dependent (RDD) SCI. Thirty-two subjects with functioning phrenic nerves and diaphragm muscles were treated with an implanted phrenic nerve stimulation (PNS) device and 32 with destroyed nerves were treated with mechanical ventilation (MV) through tracheostomy. Incidence of respiratory infections (RI) prior to the study was equal in both groups, but at the end of the study was significantly reduced in patients with PNS. Quality of speech was significantly better with PNS. Quality of life was reported as higher for the PNS group than for those using MV. The higher initial cost of PNS was paid off after about three years because of savings in equipment, nursing time, and the cost of RI treatments.
Hirschfeld S, Exner G, Luukkaala T, Baer GA.
Spinal Cord. 2008 May 13. [Epub ahead of print]

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.)