Transcutaneous Electrical Stimulation for Neurogenic Bladder Dysfunction Following Spinal Cord Injury: Meta-Analysis of Randomized Controlled Trials

Efficacy and safety of transcutaneous electrical nerve stimulation combined with clean intermittent catheterization for neurogenic bladder dysfunction in patients with cauda equina syndrome

PURPOSE

Cauda equina syndrome (CES) due to lumbar disk herniation often leads to bladder dysfunction, severely affecting patients' quality of life. This study aims to evaluate the effectiveness of percutaneous electrical stimulation (TENS) combined with clean intermittent catheterization (CIC) for improving bladder function in CES patients.

METHODS

A total of 40 patients with bladder dysfunction caused by CES who underwent posterior lumbar spinal fusion from January 2020 to December 2022 were included. Based on the method of catheterization, patients were divided into the CIC or indwelling catheterization (IC) group. Both groups received TENS treatment twice a week for 8 weeks. Urodynamic parameters and quality of life (I-QOL) were assessed before and after treatment.

RESULTS

Significant improvements were observed in the CIC group, with reductions in daily urination frequency (DUF, p < 0.05), increases in daily average single urine volume (DASUV, p < 0.05), and improved urodynamic parameters (MBC, p = 0.031; DP, p < 0.001) compared to the IC group. The CIC group also showed a lower incidence of urinary tract infections. Quality of life significantly improved in both groups, with the CIC group showing a greater improvement (p = 0.036).

CONCLUSIONS

TENS combined with CIC significantly improves bladder function and quality of life in CES patients, with a lower risk of urinary tract infections compared to indwelling catheterization.

Effects of Noninvasive or Minimally Invasive Neuromodulation Techniques on Neurogenic Lower Urinary Tract Dysfunction After Spinal Cord Injury: A Network Meta-analysis

OBJECTIVE

To assess the available evidence of noninvasive or minimally invasive neuromodulation therapies in improving urodynamic outcomes, voiding diaries, and quality of life in patients with neurogenic lower urinary tract dysfunction (NLUTD) after spinal cord injury (SCI).

DATA SOURCES

A comprehensive search of 10 databases from inception until August 30, 2023, was conducted.

STUDY SELECTION

Randomized controlled trials (RCTs) assessing the effects of conventional treatment (CT) and CT combined with sham stimulation, transcranial magnetic stimulation (TMS), sacral nerve magnetic stimulation (SNMS), TMS+SNMS, sacral pulsed electromagnetic field therapy (SPEMFT), sacral transcutaneous electrical nerve stimulation (STENS), sacral dermatomal transcutaneous electrical nerve stimulation, bladder & STENS, transcutaneous tibial nerve stimulation (TTNS), transcutaneous electrical acupoint stimulation, pelvic floor electrical stimulation, or pelvic floor biofeedback therapy on postvoid residual volume (PVR), maximum cystometric capacity (MCC), number of voids per 24 hours (V24), mean urine volume per micturition, (MUV), maximum urinary flow rate (Qmax), maximum detrusor pressure (MDP), maximum voiding volume, number of leakages per 24 hours (L24), lower urinary tract symptoms score, and SCI-quality of life (SCI-QoL) score in patients with NLUTD after SCI were included.

DATA EXTRACTION

Two researchers independently extracted data on study characteristics and outcomes following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The Cochrane risk of bias tool (2.0) was used to assess the quality of RCTs.

DATA SYNTHESIS

Fifty-two RCTs with 2884 participants were included. CT+TMS was able to remarkably decrease PVR (mean difference [MD], -132.14; 95% confidence interval [CI], -230.97 to -33.31) and increase MUV (MD, 147.79; 95% CI, 64.51-231.06). CT+SNMS ranked high in improving V24 (MD, 2.76; 95% CI, 1.26-4.25) and reducing L24 (MD, -2.73; 95% CI, -4.46 to -1.01); CT+TMS+SNMS maximized the reduction of SCI-QoL scores (MD, -1.52; 95% CI, -2.97 to -0.25) and ranked second in both reducing PVR and improving MCC; CT+SPEMFT had a significant advantage in improving MCC (MD, 83.31; 95% CI, 39.73-126.88) and increasing Qmax (MD, 5.91; 95% CI, 2.99-8.84). Improvement in MDP was highly ranked by CT+TTNS (MD, 9.46; 95% CI, 2.15-16.76).

CONCLUSIONS

CT combined with magnetic stimulation therapy provided more benefits than its combination with electrical stimulation. TMS+SNMS seemed to be a promising noninvasive neuromodulation technique in managing NLUTD after SCI. High-quality RCTs should be conducted in the future to validate these findings.

Transcutaneous Electrical Stimulation for Neurogenic Bladder After Spinal Cord Injury: A Systematic Review and Meta-Analysis

OBJECTIVES

This review aims to assess the efficacy of transcutaneous electrical nerve stimulation (TENS) for neurogenic bladder after spinal cord injury (SCI).

MATERIALS AND METHODS

A systematic search was conducted of seven electronic data bases from inception to Dec 31, 2022, to identify randomized controlled trials that studied TENS for neurogenic bladder after SCI. The primary outcomes were maximum cystometric capacity (MCC) and residual urine volume (RUV). Secondary outcomes included maximum detrusor pressure, flow rate, and bladder diary. Random effects models were used in all analyses.

RESULTS

Eleven trials involving 881 participants were included. Meta-analysis showed that TENS in addition to conventional treatment had larger MCC (mean difference [MD] 50.55 ml, 95% CI 27.81-73.29, p＜0.0001) and lower RUV (MD -22.96 ml, 95% CI -33.45 to -12.47, p＜0.0001) than did conventional treatment only. Compared with magnetic stimulation, no differences were observed with TENS for MCC (MD -14.49 ml, 95% CI -48.97 to 19.98, p = 0.41) and RUV (MD 25 ml, 95% CI -61.79 to 111.79, p = 0.57). There also were no differences in MCC (MD -7.2 ml, 95% CI -14.56 to 0.16, p= 0.06) and (MD -5.2 ml, 95% CI -60.00 to 49.60, p = 0.851) when compared with solifenacin succinate and pelvic floor biofeedback, respectively.

CONCLUSIONS

TENS may be an effective treatment option for neurogenic bladder after SCI.

Beneficial carry-over effects of chronic at-home genital nerve stimulation on incontinence in individuals with spinal cord injury: A pragmatic trial

BACKGROUND

Genital nerve stimulation (GNS) is a promising, but under-researched, alternative treatment for neurogenic detrusor overactivity (NDO) in those with spinal cord injury (SCI).

OBJECTIVES

To investigate the urodynamic, quality-of-life (QOL) and carry-over effects of GNS when applied at home for 2 weeks by participants with incomplete SCI and NDO during activities of daily living.

METHODS

Seven men and 1 woman participated in this 1-month protocol study. Urodynamic and QOL data were gathered during week 1 (baseline measurements), followed by 2 weeks of daily GNS at home using a portable device. GNS was applied either on-demand or thrice daily, depending on the individual's sensation. At week 4, post-stimulation tests were repeated to record any carry-over effect from the GNS. Participants maintained voiding diaries throughout the study. Assessments were carried out at the end of each protocol period in a randomized order. Clinical procedures were conducted at Taipei Medical University Hospital (Taipei, Taiwan).

RESULTS

Everyone completed the study but only 7 of the 8 participants completed their voiding diary. Two weeks after GNS, average cystometric bladder capacity was increased by 30 % compared to baseline (P< 0.05). A 1-week carry-over effect was demonstrated as this capacity remained, on average, 35 % greater than baseline in week 4 after GNS was stopped (P< 0.05). Incontinence frequency significantly decreased by the end of week 3 (P< 0.05) but no significant improvements were recorded for either detrusor pressure or bladder compliance.

CONCLUSIONS

Chronic at-home GNS improved cystometric bladder capacity and reduced urinary incontinence for individuals with incomplete SCI and NDO. A carry-over effect of 1 week was observed following GNS treatment. The use of portable GNS treatment that can be applied by the individual at home merits further investigation as alternative treatment for NDO in those with SCI.

Rehabilitation approach and results of using the biofeedback method (GIGER MD device) in children with neurogenic bladder

Background

GIGER MD device applies a biofeedback method through stimulated coordinated rhythmic and dynamic movements of the trunk and extremities in an anti-gravity position, thus helping to regain lost motor functions.

Methods

In this article, the performance of the GIGER MD device was evaluated in 36 children with neurogenic bladder measuring gait speed, voiding bladder capacity, deviation from the age-adjusted bladder capacity (measured using the Koff scale), and urinary incontinence.

Results

Children using the GIGER MD device had an increase in voiding bladder capacity (33.79%, median volume increase of 50 ml) with a subsequent median decrease in median age-adjusted bladder capacity by 45.50% (median deviation before was 36% vs. 16% after treatment). The number of urinary incontinence episodes also reduced by 55.57% (7-3 episodes per day), and the 20-meter motor gait speed increased by 14.26% (from 23 to 19 s).

Conclusion

Children who follow the GIGER MD therapy regularly for a period of 6 months show that CNS functional damage can be significantly improved.

Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation

Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.

Machine Learning-based Prediction of Prolonged Intensive Care Unit Stay for Critical Patients with Spinal Cord Injury

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The objective of the study was to develop machine-learning (ML) classifiers for predicting prolonged intensive care unit (ICU)-stay and prolonged hospital-stay for critical patients with spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

Critical patients with SCI in ICU need more attention. SCI patients with prolonged stay in ICU usually occupy vast medical resources and hinder the rehabilitation deployment.

METHODS

A total of 1599 critical patients with SCI were included in the study and labeled with prolonged stay or normal stay. All data were extracted from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care III-IV Database. The extracted data were randomly divided into training, validation and testing (6:2:2) subdatasets. A total of 91 initial ML classifiers were developed, and the top three initial classifiers with the best performance were further stacked into an ensemble classifier with logistic regressor. The area under the curve (AUC) was the main indicator to assess the prediction performance of all classifiers. The primary predicting outcome was prolonged ICU-stay, while the secondary predicting outcome was prolonged hospital-stay.

RESULTS

In predicting prolonged ICU-stay, the AUC of the ensemble classifier was 0.864 ± 0.021 in the three-time five-fold cross-validation and 0.802 in the independent testing. In predicting prolonged hospital-stay, the AUC of the ensemble classifier was 0.815 ± 0.037 in the three-time five-fold cross-validation and 0.799 in the independent testing. Decision curve analysis showed the merits of the ensemble classifiers, as the curves of the top three initial classifiers varied a lot in either predicting prolonged ICU-stay or discriminating prolonged hospital-stay.

CONCLUSION

The ensemble classifiers successfully predict the prolonged ICU-stay and the prolonged hospital-stay, which showed a high potential of assisting physicians in managing SCI patients in ICU and make full use of medical resources.Level of Evidence: 3.