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Spinal Cord Injury Update

Spring 2009: Volume 18, 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.

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Coping with spinal cord injury: strategies used by adults who sustained their injuries as children or adolescents.
This study used telephone interviews to examine the coping skills of 259 adults who sustained SCI at age 18 or younger. Sixty-two percent were male and 58% had tetraplegia. The average age at injury was 14 years and average age at interview was 30 years (the range was 24-42 years). The main coping strategies reported were acceptance (99%), positive reframing (94%), active coping (93%), emotional support (89%), humor (89%) and religion (74%). The negative coping skills of behavioral disengagement and substance use were used by 28% and 15%, respectively. Positive coping strategies tend to be used by a majority of adults with pediatric-onset SCI, and several coping styles (seeking emotional support, acceptance and religion) are associated with greater life satisfaction. Substance abuse had a negative effect on life satisfaction.
Anderson CJ, Vogel LC, Chlan KM, Betz RR.
J Spinal Cord Med. 2008;31(3):290-6.

Computer access

Tooth-click control of a hands-free computer interface.
People with severe upper limb paralysis use devices that monitor head movements to control computer cursors. The three most common methods for producing mouse button clicks are dwell-time, sip-and-puff control, and voice-recognition. Here, we tested a new method in which small tooth-clicks were detected by an accelerometer contacting the side of the head. The resulting signals were paired with head tracking technology to provide combined cursor and button control. This system was compared with sip-and-puff control and dwell-time selection. Seventeen people with disabilities and ten people without disabilities tested each system. Tooth-click control was much faster than dwell-time control, and while it was not quite as fast as sip-and-puff control, it was more reliable and less cumbersome.
Simpson T, Broughton C, Gauthier MJ, Prochazka A.
IEEE Trans Biomed Eng. 2008 Aug;55(8):2050-6.

Brain-controlled FES

Direct control of paralysed muscles by cortical neurons.
This report describes an animal experiment into brain-controlled functional electrical stimulation (FES) of a muscle. In Macaca nemestrina monkeys, control signals from the brain were routed around the injury using artificial connections. The signals could then control electrical stimulation of muscles, thereby restoring voluntary movement to paralysed limbs. The motor cortex in the monkeys was connected to a device that converted neuron activity to FES signals. Monkeys learned to use these artificial connections from the cortical cells in their brains to their muscles to generate muscle movements. The transformation of cortical activity to muscle stimulation could be implemented by autonomous electronic circuitry, creating a relatively natural neuroprosthesis. These results are the first demonstration that direct artificial connections between cortical cells and muscles can compensate for interrupted physiological pathways and restore voluntary control of movement to paralysed limbs.
Moritz CT, Perlmutter SI, Fetz EE.
Nature. 2008 Oct 15.

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Exercise and fitness

Incomplete spinal cord injury, exercise and life satisfaction.
Sixty-nine individuals with incomplete SCI completed a questionnaire measuring life satisfaction, self-rated physical exercise and self-perceptions. Of those, 68% performed physical activity regularly once or more a week. This group scored significantly higher on life satisfaction and perceived fitness, but significantly lower on perceived exercise mastery, than those who did not exercise. Perceived exercise fitness was the psychological variable that contributed meaningfully to life satisfaction in this study
Lannem AM, Sørensen M, Frøslie KF, Hjeltnes N.
Spinal Cord. 2008 Oct 7.

Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study.
Forty-nine participants with SCI who used a manual wheelchair for primary mode of mobility completed the physical activity recall assessment for people with SCI (PARA-SCI). Approximately 50% of reported physical activity among individuals with SCI was due to activities of daily living. The amount of physical activity was not related to injury level, age, body mass index or waistline size. Greater amounts of heavy-intensity activity was related to lower levels of pain and fatigue and higher levels of self-efficacy. Higher amounts of mild-intensity activity and total activity were related to less depressive symptoms. Activities of daily living are a large component for physical activity among individuals with SCI. It appears that greater amounts of physical activity are associated with less pain, fatigue and depression in individuals with SCI.
Tawashy AE, Eng JJ, Lin KH, et al.
Spinal Cord. 2008 Oct 21.

Cardiorespiratory, metabolic, and biomechanical responses during functional electrical stimulation leg exercise: health and fitness benefits.
A review of the medical literature (from the 1960s to 2007) found that functional electrical stimulation (FES)-induced leg exercise in persons with SCI can produce several positive health benefits. Although it was originally intended to produce functional upright mobility, FES-evoked exercise increases the whole-body metabolism of individuals with SCI so that they may gain health and fitness benefits. Some of the advantages of such exercise include increased cardiorespiratory fitness, promotion of leg blood circulation, increased activity of specific metabolic enzymes or hormones, greater muscle volume and fiber size, enhanced functional exercise capacity such as strength and endurance, and altered bone mineral density. There were also psychological improvements.
Davis GM, Hamzaid NA, Fornusek C.
Artif Organs. 2008 Aug;32(8):625-9.

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Male hormones

Testosterone levels among men with spinal cord injury: relationship between time since injury and laboratory values.
Total serum testosterone level, demographic and injury information, and laboratory values were measured in 102 men with SCI (48% with paraplegia, 52% with tetraplegia; 42% with complete injuries). Sixty percent of men with spinal cord injury had low testosterone levels. Low testosterone was significantly associated with less time since injury, lower hemoglobin, and higher prolactin. Published evidence documents that testosterone replacement produced physical and psychological benefits in men with low testosterone, and this may also be true for men with SCI. These findings suggest the need for changes to occur in clinical practice. Future research should address the pathophysiology of low testosterone and the risks and benefits of testosterone treatment in this population.
Clark MJ, Schopp LH, Mazurek MO, et al.
Am J Phys Med Rehabil. 2008 Sep;87(9):758-67.

Nutrition

Evidence of dietary inadequacy in adults with chronic spinal cord injury.
Sixty-three men and 14 women with SCI completed interviews asking them to recall their dietary intake in the prior 24 hours. This dietary information was compared to nationally established guidelines for adequate intake of nutrients. Participants consumed a diet adequate in energy (calories) and macronutrients (protein, carbohydrates and fats), but inadequate in several micronutrients, including vitamin A, magnesium, folate, zinc, vitamin C, thiamine, vitamin B12, riboflavin and vitamin B6. Participants also consumed inadequate amounts of fiber, vitamin D, calcium and potassium. In all, 53% of participants consumed a micronutrient supplement. This is of special concern in the SCI population given the high prevalence of secondary complications that may increase nutrient requirements to levels above the established guidelines.
Walters JL, Buchholz AC, Martin Ginis KA.
Spinal Cord. 2008 Nov 11. [Epub ahead of print]

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Pregnancy and childbirth

Autonomic dysreflexia triggered by breastfeeding in a tetraplegic mother.
This is a case report of a 33-year-old woman with C6 incomplete tetraplegia who developed signs and symptoms of autonomic dysreflexia (AD) while breastfeeding. Stopping breastfeeding successfully stopped the AD. AD is a life-threatening problem in persons with tetraplegia (quadriplegia) that requires immediate attention. Identification of the triggering cause is vital in order to prevent further complications. Breastfeeding is an unusual and unexpected cause of autonomic dysreflexia.
Dakhil-Jerew F, Brook S, Derry F.
J Rehabil Med. 2008 Oct;40(9):780-2.

Pregnancy and women with spinal cord injuries.
Women with chronic SCI in their reproductive years represent a growing population. Approximately 20,000 women with SCI between the ages of 16 and 30 live in the USA today. Each year 2,000 additional women of childbearing age sustain an SCI. Female fertility is usually not affected by SCI. One hundred fourteen women with SCI between ages 18 and 40 completed questionnaires about pregnancy and SCI. Twenty-three (20%) reported they received information about pregnancy during rehabilitation, but only 12 (10%) found it adequate. However, adequacy of information did not affect whether or not the women eventually became pregnant. Preterm (premature) delivery occurred in 33% of women; 22% were unable to feel preterm labor. Thrombosis (8%), urinary complications (59%), dysreflexia (27%), and worsened spasticity (22%) were the most common complications in pregnancy. Post-partum depression (35%) was the most common postpartum complication. Inadequate information about pregnancy is common among young women with SCI. Those who become pregnant should be monitored carefully for complications.
Ghidini A, Healey A, Andreani M, Simonson MR.
Acta Obstet Gynecol Scand. 2008;87(10):1006-10.

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Pressure ulcer prevention

Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention.
Forty-one veteran men with spinal cord injury or dysfunction who were admitted for pressure ulcer surgery were randomly divided into three study groups. Group 1 (20 subjects) received individualized pressure ulcer education and monthly structured telephone follow-up Group 2 (11 subjects) received monthly mail or telephone follow-up without educational content. Group 3 (10 subjects) received quarterly mail or telephone follow-up without educational content. Follow-up continued for 24 months. Group 1 went longer before getting another pressure sore (average of 19.6 months) than group 2 (10.1 mo) or 3 (10.3 mo). Group 1 also had a lower rate of new or recurring pressure ulcers (33%, compared to 60% in Group 2 and 90% in Group 3). This study shows that individualized education and structured monthly contacts may help reduce the frequency of or delay pressure ulcer recurrence after surgical repair of an ulcer.
Rintala DH, Garber SL, Friedman JD, Holmes SA.
Arch Phys Med Rehabil. 2008 Aug;89(8):1429-41

The effect of surface electric stimulation of the gluteal muscles on the interface pressure in seated people with spinal cord injury.
Surface electric stimulation was applied to the gluteal muscles of 13 subjects with SCI. Each participant underwent two different stimulation protocols: in one, the left and right gluteal muscles were stimulated alternately; in the other, the gluteal muscles were stimulated at the same time. Interface pressure, maximum pressure, pressure spread, and pressure gradient were measured during stimulation and rest periods. The stimulation protocol caused a significant decrease in interface pressure and pressure gradient during stimulation periods compared with rest periods. There was no significant difference in effects between the two protocols. The decrease in interface pressure resulting from surface electric stimulation of the gluteal muscles may restore blood flow in compressed tissue and help prevent pressure ulcers in persons with SCI.
van Londen A, Herwegh M, van der Zee CH, et al.
Arch Phys Med Rehabil. 2008 Sep;89(9):1724-32.

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Tendon transfer surgery

Acceptable benefits and risks associated with surgically improving arm function in individuals living with cervical spinal cord injury.
A total of 137 participants with cervical SCI completed a survey about how they view tendon transfer surgeries (TTS) and what activities of daily living (ADL) involving arm/hand function are important in improving their quality of life. Over 90% felt that improving their arm/hand function would improve their quality of life. ADLs that were ranked most important to regain were dressing, feeding, transferring in/out of bed. TTS improves elbow extension, key pinch, and hook grip, which are vital for the independent performance of multiple activities of daily living (ADL). Less than half of the participants had ever been told about TTS and only 9% had ever had TTS. Nearly 80% reported that they would be willing to spend 2-3 months being less independent, while recovering from surgery, to ultimately become more independent. Despite the fact that these surgeries have been available and continuously improved upon for over 40 years, relatively few people with cervical SCI have had them, especially in the US, where only 14% of qualified candidates actually received the surgery. It is estimated that approximately 50% of the people with cervical SCI would benefit from some sort of upper limb reconstructive surgery. There is a critical need in the US to improve awareness of TTS as a viable option for improving arm/hand function in some people.
Anderson KD, Fridén J, Lieber RL.
Spinal Cord. 2008 Nov 25.

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.)

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