Spinal Cord Injury Update

Fall 2015: Volume 24, 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. Information about how to obtain complete articles is at the bottom of this page.

Locomotor Training

Safety and efficacy of at-home robotic locomotion therapy in individuals with chronic incomplete spinal cord injury: a prospective, pre-post intervention, proof-of-concept study.
This study tested 5 prototypes of a robotic locomotion training device (MoreGait) for unsupervised home-based therapy. Twenty-five (5 tetraplegia, 20 paraplegia) participants with chronic sensorimotor incomplete SCI (7 ASIA Impairment Scale (AIS) C, 18 AIS D) completed a training program of 45 minutes per day, at least 4 days per week, for 8 weeks. After therapy, 9 of 25 participants improved with respect to the dependency on walking aids. For all individuals, the short-distance walking velocity measured by the 10-Meter Walk Test showed significant improvements compared to baseline. Only one device-related adverse event (pressure sore on the big toe) occurred in over 800 training sessions. The magnitude of functional improvements achieved by MoreGait in individuals with incomplete SCI is well within the range of complex locomotion robots used in hospitals. Thus, unsupervised MoreGait training is a possible option to continue training aimed at recovery of locomotor function beyond in-patient rehabilitation.
Rupp R, Schließmann D, Plewa H, et al.
PLoS One. 2015 Mar 24;10(3).

Facilitatory effects of anti-spastic medication on robotic locomotor training in people with chronic incomplete spinal cord injury.
This study investigated whether an anti-spasticity medication can enhance the effects of robotic locomotor treadmill training (LTT) to improve gait in people with incomplete SCI. Individuals with chronic incomplete SCI participated a 4-week program of either LTT alone (26 participants) or LTT combined with Tizanidine (TizLTT), an anti-spasticity medication (22 participants). Gait, speed, endurance, strength, active range of motion (AROM) and peak velocity (Vp) of ankle dorsi- and plantar-flexor muscles were recorded. Walking speed and dorsiflexion maximum strength improved in both groups, with no differences between groups. However, a higher proportion of subjects in the TizLTT group achieved the minimal important difference (MID) for walking speed (40%) compared with LTT alone (13%). Those that achieved the MID for walking speed were significantly higher functioning at baseline than those that did not in the TizLTT group, and the change in walking speed was associated with the change in dorsiflexion peak velocity using the MID for clinical scores analysis. Therefore, Tizanidine appears to enhance the effects of LTT on gait function in individuals with chronic SCI that are higher functioning at baseline. This may be due to restoration of inhibitory mechanisms by Tizanidine, resulting in greater stretch in the plantarflexor muscles during the LTT.
Duffell LD, Brown GL, Mirbagheri MM.
J Neuroeng Rehabil. 2015 Mar 20;12:29.

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Respiratory Health

Effects of air stacking on pulmonary function and peak cough flow in patients with cervical spinal cord injury.
This study evaluated the effects of air stacking (taking in a breath of air, and then without exhaling taking in another breath of air, multiple times prior to breathing out) on pulmonary function and peak cough flow. Twenty-six patients with cervical SCI were randomized into experimental (n = 14) and control (n = 12) groups. The control group performed incentive spirometry (a device used to measure how deeply a person breathes in), and the experimental group performed 20 repetitions of air stacking exercise twice a day. Both groups trained 5 days a week for 6 weeks. Forced vital capacity (FVC) and peak cough flow (PCF ) increased significantly in the experimental group compared to controls. All within-group variables in the experimental group differed significantly at 6 weeks compared to baseline, while in the control group only FVC differed significantly at 6 weeks compared to baseline. Air stacking exercise significantly improved pulmonary function and PCF in patients with a cervical spinal cord injury.
Jeong JH, Yoo WG.
J Phys Ther Sci. 2015 Jun;27(6):1951-2.

Abdominal Functional Electrical Stimulation to Assist Ventilator Weaning in Acute Tetraplegia: A Cohort Study.
The aim of this study was to investigate the clinical feasibility of using Abdominal Functional Electrical Stimulation (AFES) to improve respiratory function and assist ventilator weaning in acute tetraplegia. AFES was applied for between 20 and 40 minutes per day, five times per week on four alternate weeks, with 10 acute ventilator dependent participants with tetraplegia. Each participant was matched retrospectively with a ventilator dependent tetraplegic control, based on injury level, age and sex. Tidal Volume (VT) and Vital Capacity (VC) were measured weekly, with weaning progress compared to the controls. Stimulated VT was significantly greater than unstimulated VT, and VC increased throughout the study. Intervention participants weaned from mechanical ventilation on average 11 days faster than their matched controls. These results show that AFES is clinically feasible for these patients and may improve respiratory function and enable faster weaning from mechanical ventilation.
McCaughey EJ, Berry HR, McLean AN, et al.
PLoS One. 2015 Jun 5;10(6)

A Canada-wide survey of chronic respiratory disease and spinal cord injury.
The objective of this study was to evaluate the association between chronic respiratory diseases (asthma and chronic obstructive pulmonary disease) and SCI in a large representative sample. Data were compiled from more than 60,000 individuals from the 2010 cycle of the cross-sectional Canadian Community Health Survey (CCHS). After adjusting for age, sex, and smoking status, SCI was associated with significant increased odds of asthma and chronic obstructive pulmonary disease. These heightened odds highlight the need for targeted interventions and prevention strategies for respiratory health among individuals with SCI.
Cragg JJ, Warner FM, Kramer JK, Borisoff JF.
Neurology. 2015 Mar 31;84(13):1341-5.

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Bowel Management

Outcomes of neurogenic bowel management in individuals living with a spinal cord injury for at least 10 years.
In this Dutch study, 258 individuals with long-term SCI (at least 10 years) participated in a medical assessment, physical examination, interview and self-report questionnaire. Thirty-five percent used digital evacuation and 31% used mini enemas. Transanal irrigation (TAI) and surgical interventions were used by 11% and 8%, respectively. Participants using surgical bowel management had been injured significantly longer than those using TAI. Hemorrhoids (39%) and constipation (25%) were the most common problems. Severe neurogenic bowel dysfunction was present in 36% of all participants and in 40% of those using a conservative method. However, only 14% were (very) dissatisfied with their current bowel management. Dissatisfaction with bowel management was significantly associated with constipation and severe neurogenic bowel dysfunction.
Adriaansen JJ, van Asbeck FW, van Kuppevelt D, et al.
Arch Phys Med Rehabil. 2015 May;96(5):905-12.

SCI Trends

Traumatic spinal cord injury in the United States, 1993-2012.
The objective of this study was to assess trends in national incidence, cause, health care utilization, and in-hospital mortality in acute traumatic SCI from 1993 to 2012. Survey data from the US Nationwide Inpatient Sample databases for 1993-2012 identified 63,109 patients with acute SCI. Over the study period, the incidence rate of acute traumatic SCI remained relatively stable but, reflecting an increasing population, the total number of cases increased. The overall incidence rate of SCI in the male population aged 16 to 44 years substantially declined over time. Public education, improved motor vehicle safety features, stricter safety belt laws, and drunk driving laws and their enforcement may have contributed to this overall decline in SCI rates in these age groups. The largest increase in incidence was observed in older patients, largely due to an increase in falls, and in-hospital mortality remained high, especially among elderly persons.
Jain NB, Ayers GD, Peterson EN, et al.
JAMA. 2015 Jun 9;313(22):2236-43.

Mental Health

Novel risk factors associated with current suicidal ideation and lifetime suicide attempts in individuals with spinal cord injury.
Suicide risk after SCI is 3 or more times greater than in the general population. Understanding the risk factors for suicide specific to individuals with SCI can help guide prevention efforts. For this study, 2,533 participants with SCI from six U.S. SCI rehab centers were recruited and screened for depression. Of these, 179 (7.4%) reported a lifetime suicide attempt (SA) and 323 (13.3%) reported any suicidal ideation (SI) in the past 2 weeks. SA was associated with less education, younger age at injury, depression and current or past treatment of depression, and having bipolar disorder or schizophrenia. SI was associated with more years since injury and a history of SA. Further work needs to be done to identify ways to assess and treat suicide risk in this population.
McCullumsmith CB, Kalpakjian CZ, Richards JS, et al.
Arch Phys Med Rehabil. 2015 May;96(5):799-808.

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Fertility & Reproduction

Successful pregnancies and healthy live births using frozen-thawed sperm retrieved by a new modified Hotchkiss procedure in males with retrograde ejaculation: first case series.
This study analyzed the effectiveness of using a new protocol, including a modified Hotchkiss technique (MHT), for sperm retrieval and cryopreservation in 10 individuals with retrograde ejaculation (RE). Eight of these subjects had spinal cord injuries. The novel protocol is based on an asynchronous management, involving systematic freezing of spermatozoa recovered from the bladder. The ten couples underwent 26 intracytoplasmic sperm injection (ICSI) cycles: nine clinical pregnancies were achieved in six couples, including eight after fresh embryo transfer and one after thawed embryo transfer, resulting in seven live births. This is the largest series of births achieved using spermatozoa retrieved from post-ejaculatory urine by the new MHT and shows that the new MHT allowed for successful sperm cryopreservation, leading to the efficient and easier management of couples with RE.
Philippon M, Karsenty G, Bernuz B, et al.
Basic Clin Androl. 2015 May 15;25:5.

Cardiovascular Health

Lipoprotein heterogeneity in persons with Spinal Cord Injury: a model of prolonged sitting and restricted physical activity.
SCI results in unhealthy changes in body composition and metabolism that can lead to cardiovascular disease (CVD). Unsurprisingly, heart disease occurs earlier and more frequently in persons with SCI than in the general population. Effective treatment to reduce the risk of CVD depends on early and accurate diagnosis. This study used nuclear magnetic resonance (NMR) spectroscopy to provide more detailed information about the lipid profile that is known to be an independent risk factor for CVD. Fasting blood samples were obtained on 83 persons with chronic SCI and 62 able-bodied (AB) subjects. Fasting plasma insulin (FPI), triglycerides (TG), and P number and size of VLDL (very low density lipoprotein), LDL, and HDL subclasses were determined. Prolonged sitting and restricted physical activity in individuals with SCI had the most profound effect on the HDL-C and its lipoprotein P subclasses, but not on LDL-C. Its P subclasses were also unfavorably affected but not to the same degree. The insight gained from combining lipoprotein cholesterol concentration with that of the lipoprotein particle number can permit a more accurate estimate of risk for CVD in this population and can more appropriately guide treatment with pharmaceutical and/or lifestyle modification.
La Fountaine MF, Cirnigliaro CM, Emmons RR, et al.
Lipids Health Dis. 2015 Jul 28;14(1):81.

Lower-extremity muscle atrophy and fat infiltration after chronic spinal cord injury.
Atrophy (wasting) and fatty-infiltration of lower-extremity muscle after SCI predisposes individuals to metabolic disease and related mortality. The purpose of this study was to determine the magnitude of atrophy and fatty-infiltration of lower-extremity muscles and related factors in a group of individuals with chronic SCI. Muscle cross-sectional area and density were calculated from peripheral quantitative computed tomography scans of the calf of 70 participants with chronic SCI (50 males, mean age 49 years, C2-T12, AIS A-D) and matched controls. Participants with motor-complete SCI had approximately 32% less muscle area and 43% lower muscle density compared to controls. Participants with motor-incomplete SCI had muscle area and density values that were14% lower than controls. There are modifiable factors related to muscle size, body composition, and activity level that may offer therapeutic targets for preserving metabolic health after chronic SCI.
Moore CD, Craven BC, Thabane L, et al..
J Musculoskelet Neuronal Interact. 2015 Mar;15(1):32-41

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Bone Health

Longitudinal study of bone loss in chronic spinal cord injury patients.
This prospective longitudinal study evaluated the changes in bone metabolism markers and bone mineral density over 3 years in 20 participants with SCI. It also assessed the relationship between bone mineral density, bone metabolism, and clinical data (i.e., immobilization due to surgery, neurological status, neurological level, and extent of lesion). Bone mineral density, and hormonal and biochemical markers were measured at 0, 6, 12, and 36 months. Femoral neck T score (which defines bone density) decreased significantly at 36 months. Parathyroid hormone and vitamin D were significantly elevated, while bone turnover markers were significantly decreased at 12 and 36 months. Bone mineral density of the femoral neck decreases significantly during the long-term follow-up of patients with SCI. This could be due to changes in hormonal and bone turnover markers.
Karapolat I, Karapolat HU, Kirazli Y, et al.
J Phys Ther Sci. 2015 May;27(5):1429-33.

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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