Web-Based Information on Spinal Cord Stimulation: Qualitative Assessment of Publicly Accessible Online Resources

BACKGROUND

Despite the growing accessibility of web-based information related to spinal cord stimulation (SCS), the content and quality of commonly encountered websites remain unknown.

OBJECTIVE

This study aimed to assess the content and quality of web-based information on SCS.

METHODS

This qualitative study was prospectively registered in Open Science Framework. Google Trends was used to identify the top trending, SCS-related search queries from 2012 to 2022. Top queried terms were then entered into separate search engines. Information found on websites within the first 2 pages of results was extracted and assessed for quality using the DISCERN instrument, the Journal of the American Medical Association benchmark criteria, and the Health on the Net Foundation code of conduct certification. Website readability and SCS-related information were also assessed.

RESULTS

After exclusions, 42 unique sites were identified (scientific resources: n=6, nonprofit: n=12, for-profit: n=20, news or media: n=2, and personal or blog: n=2). Overall, information quality was moderate (DISCERN). Few sites met all the Journal of the American Medical Association benchmark criteria (n=3, 7%) or had Health on the Net Foundation certification (n=7, 16%). On average, information was difficult to read, requiring a 9th- to 10th-grade level of reading comprehension. Sites described SCS subcategories (n=14, 33%), indications (n=38, 90%), contraindications (n=14, 33%), side effects or risks (n=28, 66%), device considerations (n=25, 59%), follow-up (n=22, 52%), expected outcomes (n=31, 73%), provided authorship details (n=20, 47%), and publication dates (n=19, 45%). The proportion of for-profit sites reporting authorship information was comparatively less than other site types (n=3, 15%). Almost all sites focused on surgically implanted SCS (n=37, 88%). On average, nonprofit sites contained the greatest number of peer-reviewed reference citations (n=6, 50%). For-profit sites showed the highest proportion of physician or clinical referrals among site types (n=17, 85%) indicating implicit bias (ie, auto-referral).

CONCLUSIONS

Overall, our findings suggest the public may be exposed to incomplete or dated information from unidentifiable sources that could put consumers and patient groups at risk.

Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations

PURPOSE

Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD.

METHODS

After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

Neurogenic Bowel Dysfunction in Patients with Spinal Cord Injury and Multiple Sclerosis-An Updated and Simplified Treatment Algorithm

Neurogenic bowel dysfunction (NBD) is a common condition in individuals with spinal cord injury (SCI) or multiple sclerosis (MS). It usually entails constipation, difficult evacuation of the rectum, and fecal incontinence (FI); often in combination. It is highly burdensome for affected patients and is correlated with poor quality of life. The current treatment algorithm, or treatment pyramid, does not completely correspond to actual clinical practice, and the known and classical pyramid contains both treatments still in their experimental stage as well as several treatments which are not available at all treatment centers. Thus, an updated treatment algorithm is called upon, and the authors of this paper therefore propose a simplified version of the treatment pyramid, aiming to guide clinicians in treating NBD.

Risk factors for urinary tract infections associated with lower quality of life among intermittent catheter users

BACKGROUND

Evidence shows that intermittent catheterisation (IC) for bladder emptying is linked to urinary tract infections (UTIs) and poor quality of life (QoL).

AIM

To investigate the association between UTI risk factors and QoL and patient-reported UTIs respectively.

METHODS

A survey was distributed to IC users from 13 countries.

FINDINGS

Among 3464 respondents, a significantly poorer QoL was observed when experiencing blood in the urine, residual urine, bowel dysfunction, recurrent UTIs, being female, and applying withdrawal techniques. A lower UTI risk was found when blood was not apparent in urine (RR: 0.63; 95% CI: 0.55-0.71), the bladder was perceived empty (RR: 0.83; 95% CI: 0.72-0.96), not having bowel dysfunction (RR: 0.86; 95% CI: 0.76-0.98), and being male (RR: 0.70; 95% CI: 0.62-0.79).

CONCLUSION

This study underlines the importance of risk factors and their link to QoL and UTIs, highlighting the need for addressing symptoms before UTIs become problematic.

Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke

Background

High blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke.

Methods

This is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40-60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension.

Results

No effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12-0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05-0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01-1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73-18.17) mmHg, higher DBP by 5.57 (2.02-9.12) mmHg, and 42.22 (6.60-270.08) times the odds of being hypertensive at each timepoint, compared to those without.

Conclusion

Blood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory.

Cardiovascular Effects of Spinal Cord Stimulation: The Highs, the Lows, and the Don't Knows

BACKGROUND AND OBJECTIVES

There are many potential etiologies of impaired cardiovascular control, from chronic stress to neurodegenerative conditions or central nervous system lesions. Since 1959, spinal cord stimulation (SCS) has been reported to modulate blood pressure (BP), heart rate (HR), and HR variability (HRV), yet the specific stimulation sites and parameters to induce a targeted cardiovascular (CV) change for mitigating abnormal hemodynamics remain unclear. To investigate the ability and parameters of SCS to modulate the CV, we reviewed clinical studies using SCS with reported HR, BP, or HRV findings.

MATERIALS AND METHODS

A keyword-based electronic search was conducted through MEDLINE, Embase, and PubMed data bases, last searched on February 3, 2023. Inclusion criteria were studies with human participants receiving SCS with comparison with SCS turned off, with reporting of either HR, HRV, or BP findings. Non-English studies, conference abstracts, and studies not reporting standalone effects of SCS when comparing SCS with non-SCS interventions were excluded. Results were plotted for visual analysis. When available, participant-specific stimulation parameters and effects were extracted and quantitatively analyzed using ordinary least squares regression.

RESULTS

A total of 59 studies were included in this review; 51 studies delivered SCS invasively through implanted/percutaneous leads. Eight studies used noninvasive, transcutaneous electrodes. We found numerous reports of cervical, high thoracic, and mid-to-low thoracolumbar SCS increasing resting BP, and cervical/mid-to-low thoracolumbar SCS decreasing BP. The effect of SCS location on HR and HRV was equivocal. We were unable to analyze stimulation parameters owing to inadequate parameter reporting in many publications.

CONCLUSIONS

Our findings suggest CV neuromodulation, particularly BP modulation, with SCS to be a promising frontier. Further research with larger randomized controlled trials and detailed reporting of SCS parameters will be necessary for appropriate evaluation of SCS as a CV therapy.

Changes to physical activity behavior during the COVID-19 pandemic and their associated factors: a cross sectional survey of Mexican women

BACKGROUND

On March 24, 2020, the Mexican Government established social distancing measures to address the outbreak of the COVID-19 pandemic. The resulting home confinement affected daily lifestyle habits such as eating, sleeping, and physical activity (PA). The objectives of this study were to determine changes in PA behaviors among Mexican women due to the COVID-19 pandemic and to assess potential factors associated with these changes.

METHODS

This was a cross-sectional study based on an anonymous online questionnaire developed by the Task Force on Physical Activity for Persons with Disabilities (PAPD) within the International Society of Physical and Rehabilitation Medicine (ISPRM). Descriptive, quantitative statistics were used for data analysis. A Chi-squared (χ²) test was used to explore associations between dependent and independent variables.

RESULTS

A total of 1882 surveys were completed. Among the respondents, 53.3% declared that their PA was reduced during the pandemic, 26.6% reported similar PA behavior, and 20.1% declared that their PA had increased during the pandemic. Lower PA behavior during the pandemic was associated with lower education levels, stricter pandemic constraints, obesity, and lower self-perceived functioning levels. A statistically significant association between poorer self-perceived mental health and decreased PA behaviors was also found. Respondents who were younger, self-perceived as unimpaired, not overweight, and whose income was not impacted by COVID-19 were associated with higher levels of reported physical and mental health.

CONCLUSIONS

The study results identify disparities experienced in PA behavior during the COVID-19 pandemic among Mexican women and highlights the need for social support for PA participation.

Effect of epidural spinal cord stimulation on female sexual function after spinal cord injury

Sexual dysfunction is a common consequence for women with spinal cord injury (SCI); however, current treatments are ineffective, especially in the under-prioritized population of women with SCI. This case-series, a secondary analysis of the Epidural Stimulation After Neurologic Damage (E-STAND) clinical trial aimed to investigate the effect of epidural spinal cord stimulation (ESCS) on sexual function and distress in women with SCI. Three females, with chronic, thoracic, sensorimotor complete SCI received daily (24 h/day) tonic ESCS for 13 months. Questionnaires, including the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS) were collected monthly. There was a 3.2-point (13.2%) mean increase in total FSFI from baseline (24.5 ± 4.1) to post-intervention (27.8 ± 6.6), with a 4.8-50% improvement in the sub-domains of desire, arousal, orgasm and satisfaction. Sexual distress was reduced by 55%, with a mean decrease of 12 points (55.4%) from baseline (21.7 ± 17.2) to post-intervention (9.7 ± 10.8). There was a clinically meaningful change of 14 points in the International Standards for Neurological Classification of Spinal Cord Injury total sensory score from baseline (102 ± 10.5) to post-intervention (116 ± 17.4), without aggravating dyspareunia. ESCS is a promising treatment for sexual dysfunction and distress in women with severe SCI. Developing therapeutic interventions for sexual function is one of the most meaningful recovery targets for people with SCI. Additional large-scale investigations are needed to understand the long-term safety and feasibility of ESCS as a viable therapy for sexual dysfunction. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03026816, NCT03026816.

No pain, no strain: Targin® mitigates pain and constipation following spinal cord injury

BACKGROUND

Opioids effectively reduce chronic pain, but present significant side effects including opioid-induced constipation. Oxycodone/naloxone decreases pain and constipation in cancer patients, however its effect on spinal cord injury population remains understudied.

METHODS

We assessed whether oxycodone/naloxone reduces pain, constipation, and severity of autonomic dysreflexia in an individual with spinal cord injury. A 55-year-old male with C5 lesion presented with chief complaint of chronic pain received 5/2.5 mg and 20/10 mg oxycodone/naloxone for 6 and 2 weeks, respectively.

RESULTS

Oxycodone/naloxone improved pain, bowel function, and autonomic dysreflexia severity.

INTERPRETATION

Oxycodone/naloxone was effective in managing chronic pain and constipation in the studied case.

Rectal Application of Lidocaine Reduces the Severity of Autonomic Dysreflexia following Experimental Spinal Cord Injury

Spinal cord injury (SCI) results in devastating cardiovascular dysfunction. Noxious stimuli from the rectum during bowel routine often trigger life-threatening blood pressure surges, termed autonomic dysreflexia (AD). Rectal application of anesthetic lidocaine jelly has been recommended during bowel care to reduce AD severity by mitigating sensory input. However, clinical studies have reported contradicting evidence. We performed a pre-clinical study on the efficacy of rectal lidocaine in a standardized rodent T3 transection model. We found that 2% and 10% lidocaine significantly reduced AD severity by 32% and 50%, respectively, compared with control (p < 0.0001). Our pre-clinical experiments support the current recommendation of rectal lidocaine application during bowel care.

A survey of clinical practice concerning long-term follow-up of neurogenic lower urinary tract dysfunction due to spinal cord injury in Italy

CONTEXT/OBJECTIVE

This study aimed to assess the clinical practice for long-term follow-up (FU) of neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) in Italy and compare this practice with the clinical practice in other countries and with the international guidelines.

DESIGN

Data concerning the long-term urological FU of individuals with SCI were collected using a questionnaire and analyzed by means of descriptive and inferential statistics.

SETTING

Twenty-one Italian centers following SCI patients.

PARTICIPANTS

One physician at each center (either a permanent staff member or chief).

OUTCOME MEASURES

Questions addressed the treatment of urinary tract infections (UTI), frequency of visits, urinary tract imaging examinations and urodynamic tests (UD), distinguishing between suprasacral and sacral SCI.

RESULTS

Nineteen out of 21 centers completed the survey. In most centers, patients were recommended to undergo a visit and an ultrasound examination of urinary tract (UT) at least once a year. While the median interval between FU visits was identical (12 months) for individuals with suprasacral and sacral SCI, the two interval distributions were significantly different (suprasacral SCI: min-max 4-18, IQR = 6; sacral SCI: min-max 6-24; IQR = 8.5; P = 0.02), showing people with suprasacral SCI are followed up more often. Approximately 80% of the surveyed centers performed scheduled UD, with a yearly median frequency of 12 months (range 6-36) for patients with suprasacral SCI, as compared to a median frequency of 18 months for sacral SCI (range 0-36, P = 0.04). VideoUD and antibiotic prophylaxis for recurrent UTIs are carried out only by urologists in 63% and 47.4% of the centers, respectively. Overall, Italian centers share common strategies that compare to standards, including yearly visits, yearly UT examinations and stricter follow-up of people with suprasacral SCI, but may not have standard protocols for antibiotic prophylaxis of UTI, and in few cases control visits and UD are carried out too often.

CONCLUSIONS

Even though most Italian centers follow up patients with NLUTD secondary to SCI according to international guidelines, heterogeneity in frequency of FU examinations still exists. A tailored approach to the SCI patient that minimizes unnecessary examinations and groups different tests in a single access could improve patients' compliance with FU and reduce costs for the Health system.

UTI assessment tool for intermittent catheter users: a way to include user perspectives and enhance quality of UTI management

BACKGROUND

Urinary Tract Infections (UTIs) are among the most severe complications for users of intermittent catheterisation (IC), with numerous risk factors contributing to their occurrence. The aim of this study was to develop a tool to assess UTI risk factors among IC users in a systematic way that considers the perspective of the individual user.

METHODS

The Design Thinking Process was used to guide the development of the content and format of the tool. The UTI Risk Factors model by Kennelly et al. was used as a basis for developing the content. Insights on the appropriate content and format were collected via the Coloplast Nurse Advisory Boards and by conducting a qualitative evidence synthesis on user perspectives and practices in relation to UTIs.

RESULTS

The literature search identified a total of 3544 articles, out of which 22 met the inclusion criteria. Additionally, three rounds of meetings were conducted with approximately 90 nurses from the Nurse Advisory Boards across Europe. The qualitative evidence synthesis showed that users describe their UTI symptoms in different terms and that personal needs and priorities impact their adherence and catheter selection. Furthermore, some users lack relevant and updated knowledge about IC and UTIs. The nurses described that correct UTI diagnosis is essential. They pointed that they would assess the user's general condition, adherence, technique, and catheter type as potential areas of risk factors and emphasised the importance of adequate support for users. The study resulted in the development of the UTI assessment tool for intermittent catheter users, which comprises three elements: a guide for healthcare professionals, a dialogue board, and a notepad. The tool starts with a confirmation of the UTI incidence, and then assesses risk factors via questions on health, adherence, technique, and catheter, and concludes with a support section.

CONCLUSIONS

The UTI assessment tool for intermittent catheter users is designed to help healthcare professionals assess UTI risk factors in a systematic way, while engaging users and taking their perspective into account. By identifying the relevant risk factors, the use of this tool has the potential to reduce the occurrence of UTIs for the individual IC user.

Effect of epidural spinal cord stimulation after chronic spinal cord injury on volitional movement and cardiovascular function: study protocol for the phase II open label controlled E-STAND trial

INTRODUCTION

Spinal cord injury (SCI) leads to significant changes in morbidity, mortality and quality of life (QOL). Currently, there are no effective therapies to restore function after chronic SCI. Preliminary studies have indicated that epidural spinal cord stimulation (eSCS) is a promising therapy to improve motor control and autonomic function for patients with chronic SCI. The aim of this study is to assess the effects of tonic eSCS after chronic SCI on quantitative outcomes of volitional movement and cardiovascular function. Our secondary objective is to optimise spinal cord stimulation parameters for volitional movement.

METHODS AND ANALYSIS

The Epidural Stimulation After Neurologic Damage (ESTAND) trial is a phase II single-site self-controlled trial of epidural stimulation with the goal of restoring volitional movement and autonomic function after motor complete SCI. Participants undergo epidural stimulator implantation and are followed up over 15 months while completing at-home, mobile application-based movement testing. The primary outcome measure integrates quantity of volitional movement and similarity to normal controls using the volitional response index (VRI) and the modified Brain Motor Control Assessment. The mobile application is a custom-designed platform to support participant response and a kinematic task to optimise the settings for each participant. The application optimises stimulation settings by evaluating the parameter space using movement data collected from the tablet application and accelerometers. A subgroup of participants with cardiovascular dysautonomia are included for optimisation of blood pressure stabilisation. Indirect effects of stimulation on cardiovascular function, pain, sexual function, bowel/bladder, QOL and psychiatric measures are analysed to assess generalisability of this targeted intervention.

ETHICS AND DISSEMINATION

This study has been approved after full review by the Minneapolis Medical Research Foundation Institutional Review Board and by the Minneapolis VA Health Care System. This project has received Food and Drug Administration investigational device exemption approval. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars.

TRIAL REGISTRATION NUMBER

NCT03026816.

The Impact of the COVID-19 Pandemic on Healthy Lifestyle Behaviors and Perceived Mental and Physical Health of People Living with Non-Communicable Diseases: An International Cross-Sectional Survey

The huge burden and vulnerability imposed by non-communicable diseases (NCDs) during the COVID-19 pandemic highlighted how healthy lifestyle behaviors and the well-being of people living with NCDs need to be prioritized. The aim of our study is to better understand the impact of the COVID-19 pandemic on healthy lifestyle behaviors and perceived mental and physical health among adults living with NCDs, as compared to people without NCDs. We conducted a cross-sectional study using a global online survey through Qualtrics. Over four months, 3550 participants from 65 countries worldwide responded to the survey. The study included 3079 surveys with no missing data (complete survey responses) that were used for analysis. People with NCDs were more likely to report statistically significant worsening physical health (p = 0.001) and statistically insignificant worsening mental health (p = 0.354) when compared to pre-pandemic levels. They reported lower rates of smoking during the pandemic than those without NCDs, and a statistically significant (p < 0.001) relationship was found between weight gain and NCDs. Therefore, the perceived physical and mental health, including changes in body weight and tobacco consumption, of people with NCDs were significantly impacted during the pandemic. In conclusion, this study indicates that the pandemic had a significant impact on perceived physical and mental health, changes in body weight, and tobacco consumption among people with NCDs.

Perceived Physical and Mental Health and Healthy Eating Habits During the COVID-19 Pandemic in Korea

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has disrupted the lives of people around the world since 2020. This study aims to reveal perceived impact of the coronavirus pandemic on physical and mental health and eating behaviors among people with disabilities and without disabilities in South Korea, as compared to other countries.

METHODS

A secondary analysis of a prospective cross-sectional study which was conducted with a web-based global survey.

RESULTS

Among the 3,550 responses from 65 countries, 2,621 responses with nation information were set as full data, 189 for South Korea and 2,432 for other countries. In Korea, there was no significant difference in healthy lifestyle behaviors between people with and without disabilities before the COVID-19 pandemic. Perceived physical and mental health and changes in eating habits during the COVID-19 pandemic showed no significant difference between people with and without disabilities in Korea. There were significant differences in physical health and dietary habits, but no differences in its effect on mental health between people living in Korea and other countries in both people with and without disabilities groups. In other words, more than 60% of people in all groups (disability vs. non-disability, Korea vs. non-Korea) reported worse mental health than before the COVID-19 pandemic.

CONCLUSION

In Korea and other countries, mental health showed a tendency to deteriorate regardless of the presence or absence of disability during the COVID-19 pandemic. In terms of healthy eating habits, Koreans were relatively less affected than people from other countries.

What do X-ray images of the bladder during video urodynamics show us in patients with spinal cord injury?

STUDY DESIGN

Retrospective anonymized cohort study.

OBJECTIVES

To study X-ray images of video urodynamics (VUD) in patients with spinal cord injury (SCI).

SETTING

Single-center study.

METHODS

X-ray images during VUD were categorized. Relation with the American Spinal Injury Association Impairment Scale (AIS), time since and level of SCI, cystometric data, method of bladder management, findings of flexible cystoscopy, and renal ultrasound were evaluated. Changes over time were studied.

RESULTS

In 231 consecutive patients, VUD was done at a mean of 8.5 years after SCI. X3-ray bladder appearance was categorized as normal/standard, tonic, or flaccid. In 19 patients, specific findings were seen: diverticula, cystocele, vesicoureteral reflux. X-ray images differed by maximum cystometric capacity, presence of neurogenic detrusor overactivity, and maximum detrusor pressure during detrusor overactivity, but not by bladder compliance. There was no difference in the categories found in different levels and completeness of SCI. In the 23 patients able to void no pathology was seen on urethral images. Renal ultrasound was normal in >99%. In 86 patients, repeated testing after 72 ± 143 weeks showed changed findings in 30%. Cystoscopy showed significantly more local pathologies.

CONCLUSION

Complications in the lower urinary tract were seen on imaging only in a limited number of our cohort. As our findings represent a real-life example of the actual yield of VUD in patients with neurogenic bladder due to SCI treated following the international guidelines, further multicentre evaluation is needed to determine when imaging should be used or not.

Passive leg cycling increases activity of the cardiorespiratory system in people with tetraplegia

Individuals with cervical spinal cord injury (SCI) are at an increased risk for cardiovascular disease. Exercise is well-established for preventing cardiovascular disease, however, there are limited straightforward and safe exercise approaches for increasing the activity of the cardiorespiratory system after cervical SCI. The objective of this study was to investigate the cardiorespiratory response to passive leg cycling in people with cervical SCI. Beat-by-beat blood pressure, heart rate, and cerebral blood flow were measured before and throughout 10 minutes of cycling in 11 people with SCI. Femoral artery flow-mediated dilation was also assessed before and immediately after passive cycling. Safety was monitored throughout all study visits. Passive cycling elevated systolic blood pressure (5±2 mmHg), mean arterial pressure (5±3 mmHg), stroke volume (2.4±0.8 mL), heart rate (2±1 beats/min) and cardiac output (0.3±0.07 L/min; all p<0.05). Minute ventilation (0.67±0.23 L/min), tidal volume (70±30 mL) and end-tidal PO2 (2.6±1.23 mmHg) also increased (all p<0.05). Endothelial function was improved immediately after exercise (1.62±0.13%, p<0.01). Passive cycling resulted in one incidence of autonomic dysreflexia. Therefore, passive leg cycling increased the activity of the cardiorespiratory system, improved endothelial function, indicating it may be a beneficial exercise intervention for the cardiovascular and respiratory systems in people with cervical SCI. Novelty: ● Passive leg cycling increases the activity of the cardiorespiratory system and improves markers of cardiovascular health in cervical SCI. ● Passive leg cycling exercise is an effective, low-cost, practical, alternative exercise modality for people with cervical SCI.

A neuro-cardiac self-regulation therapy to improve autonomic and neural function after SCI: a randomized controlled trial protocol

BACKGROUND

Spinal cord injury (SCI) is associated with autonomic imbalance and significant secondary conditions, including cardiac and brain dysfunction that adversely impact health and wellbeing. This study will investigate the effectiveness (intention-to-treat) of a neuro-cardiac self-regulation therapy to improve autonomic and neural/brain activity in adults with SCI living in the community.

METHODS

A two-arm parallel, randomised controlled trial in which adults with SCI living in the community post-rehabilitation will be randomly assigned to a treatment or control group. The treatment group (N = 60) aged 18-70 years with a chronic traumatic or non-traumatic SCI, will receive intervention sessions once per week for 10 weeks, designed to regulate autonomic activity using computer-based feedback of heart rate variability and controlled breathing (called HRV-F). Comprehensive neurophysiological and psychological assessment will occur at baseline, immediate post-treatment, and 6 and 12-months post-treatment. Primary outcome measures include electrocardiography/heart rate variability (to assess autonomic nervous system function) and transcranial doppler sonography (to assess cerebral blood circulation in basal cerebral arteries). Secondary outcomes measures include continuous blood pressure, electroencephalography, functional near-infrared spectroscopy, respiration/breath rate, electrooculography, cognitive capacity, psychological status, pain, fatigue, sleep and quality of life. Controls (N = 60) will receive usual community care, reading material and a brief telephone call once per week for 10 weeks and be similarly assessed over the same time period as the HRV-F group. Linear mixed model analysis with repeated measures will determine effectiveness of HRV-F and latent class mixture modelling used to determine trajectories for primary and selected secondary outcomes of interest.

DISCUSSION

Treatments for improving autonomic function after SCI are limited. It is therefore important to establish whether a neuro-cardiac self-regulation therapy can result in improved autonomic functioning post-SCI, as well as whether HRV-F is associated with better outcomes for secondary conditions such as cardiovascular health, cognitive capacity and mental health.

TRIAL REGISTRATION

The study has been prospectively registered with the Australian and New Zealand Clinical Trial Registry ( ACTRN12621000870853 .aspx). Date of Registration: 6th July 2021. Trial Sponsor: The University of Sydney, NSW 2006. Protocol version: 22/07/2021.

Markers of susceptibility to cardiac arrhythmia in experimental spinal cord injury and the impact of sympathetic stimulation and exercise training

Injury to descending autonomic (sympathetic) pathways is common after high-level spinal cord injury (SCI) and associated with abnormal blood pressure and heart rate regulation. In individuals with high-level SCI, abnormal sympathovagal balance (such as during autonomic dysreflexia; paroxysmal hypertension provoked by sensory stimuli below the injury) is proarrhythmogenic. Exercise training is a key component of SCI rehabilitation and management of cardiovascular disease risk, but it is unclear whether exercise training influences susceptibility to cardiac arrhythmia. We aimed to evaluate: (i) whether susceptibility to arrhythmia increases in a rodent-model of SCI; (ii) the impact of the sympathomimetic drug dobutamine (DOB) on arrhythmia risk; (iii) whether exercise training ameliorates arrhythmia risk. Twenty-one Wistar rats were divided into 3 subgroups: T2-contusive SCI (T2, n = 7), T2-contusive SCI completing passive hindlimb cycling training (PHLC, n = 7), and T10-contusive SCI (T10, n = 7). Known electrocardiographic arrhythmia markers and heart rate variability parameters were evaluated before (PRE), 1-week (POST) and 5-weeks post-SCI (TERM) at baseline and during DOB infusion (30 μg/kg/min). Baseline markers of arrhythmia risk were increased in both T2 and T10 animals. DOB decreased R-R interval (p < 0.001), and increased markers of risk for ventricular arrhythmia, particularly in high-level (T2) animals (p < 0.05). Exercise training blunted the exacerbation of markers of arrhythmia risk in the presence of DOB. Markers of risk for cardiac arrhythmia are increased in experimental SCI, and DOB further increases arrhythmia risk in high-level SCI. Exercise training did not improve markers of arrhythmia risk at rest, but did ameliorate markers of arrhythmia risk during sympathetic stimulation.

PRES secondary to autonomic dysreflexia: A case series and review of the literature

Context: Autonomic dysreflexia (AD) is a complex syndrome seen in patients with spinal cord injuries (SCI) and can be life-threatening with a significant negative impact on the health of the individual. Posterior reversible encephalopathy syndrome (PRES) is thought to be caused, in part, by rapid elevations in blood pressure; leading to posterior cerebral circulatory edema. This can result in seizures, blindness and can progress to fatal intracranial hemorrhages.Findings: Here we present two cases of patients with SCI who developed PRES from AD. Each patient was correctly diagnosed, leading to appropriate treatment of the factors leading to their AD and subsequent resolution of their PRES symptoms.Conclusions/Clinical Relevance: In SCI patients who present with new seizures, visual deficits, or other neurologic signs, PRES should be considered as a part of the differential diagnosis as a good outcome relies on rapid recognition and treatment of AD.

Access denied: the shortage of digitized fitness resources for people with disabilities

PURPOSE

The COVID-19 pandemic has drastically impacted every aspect of life, including how people exercise and access fitness resources. Prior to COVID-19, the global burden of disease attributable to sedentary behavior disproportionately affected the health of people with disabilities (PWD). This pre-existing gap has only widened during COVID-19 due to limited disability-friendly digital exercise resources. The purpose of this work is to examine this gap in accessibility to digital fitness resources, and re-frame the notion of accessibility to suit the contemporary context.

MATERIALS AND METHODS

Using machine learning, video titles/descriptions about home exercise ordered by relevance populated on YouTube between 1 January 2020 and 30 June 2020 were examined.

RESULTS

Using the search terms, "home exercise," "home-based exercise," "exercise no equipment," "workout no equipment," "exercise at home," or "at-home exercise," 700 videos ordered by relevance included 28 (4%) that were inclusive of participants with disabilities. Unfortunately, most digital fitness resources are therefore inaccessible to PWD. The global pause the pandemic has induced may be the right moment to construct a comprehensive, indexed digital library of home-based fitness video content for the disabled. There is a further need for more nuanced understandings of accessibility as technological advancements continue.Implications for RehabilitationPhysical activity is incredibly important to the quality of life and health of all people.Physical activity levels, however, remain lower among persons with disabilities.Access to disability-friendly resources remains a challenge and worsened by the circumstances of COVID-19 due to an apparent lack of digital fitness resources for persons with disabilities.A broader and comprehensive definition of accessibility must recognize digital advances and access to physical activity for persons with disabilities must feature digital resources.

Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation

BACKGROUND AND PURPOSE

We investigated the effect of higher therapeutic exercise doses on walking during inpatient rehabilitation, typically commencing 1 to 4 weeks poststroke.

METHODS

This phase II, blinded-assessor, randomized controlled trial recruited from 6 Canadian inpatient rehabilitation units, between 2014 and 2018. Subjects (n=75; 25/group) were randomized into: control (usual care) physical therapy: typically, 1 hour, 5 days/week; Determining Optimal Post-Stroke Exercise (DOSE1): 1 hour, 5 days/week, more than double the intensity of Control (based on aerobic minutes and walking steps); and DOSE2: 2 hours, 5 days/week, more than quadruple the intensity of Control, each for 4 weeks duration. The primary outcome, walking endurance at completion of the 4-week intervention (post-evaluation), was compared across these groups using linear regression. Secondary outcomes at post-evaluation, and longitudinal outcomes at 6 and 12-month evaluations, were also analyzed.

RESULTS

Both DOSE1 (mean change 61 m [95% CI, 9-113], P=0.02) and DOSE2 (mean change 58 m, 6-110, P=0.03) demonstrated greater walking endurance compared with Control at the post-evaluation. Significant improvements were also observed with DOSE2 in gait speed (5-m walk), and both DOSE groups in quality of life (EQ-5D-5 L) compared with Control. Longitudinal analyses revealed that improvements in walking endurance from the DOSE intervention were retained during the 1-year follow-up period over usual care.

CONCLUSIONS

This study provides the first preliminary evidence that patients with stroke can improve their walking recovery and quality of life with higher doses of aerobic and stepping activity within a critical time period for neurological recovery. Furthermore, walking endurance benefits achieved from a 4-week intervention are retained over the first-year poststroke. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01915368.

A Primary Care Provider's Guide to Autonomic Dysfunction Following Spinal Cord Injury

Spinal cord injury (SCI) disrupts the crucial "crosstalk" between the spinal autonomic nervous system and supraspinal control centers. Therefore, SCI may result not only in motor paralysis but also in potentially life-threatening impairments of many autonomic functions including, but not limited to, blood pressure regulation. Despite the detrimental consequences of autonomic dysregulation, management and recovery of autonomic functions after SCI is greatly underexplored. Although impaired autonomic function may impact several organ systems, this overview will focus primarily on disruptions of cardiovascular and thermoregulation and will offer suggestions for management of these secondary effects of SCI.

Long-Term Spinal Cord Stimulation After Chronic Complete Spinal Cord Injury Enables Volitional Movement in the Absence of Stimulation

Background: Chronic spinal cord injury (SCI) portends a low probability of recovery, especially in the most severe subset of motor-complete injuries. Active spinal cord stimulation with or without intensive locomotor training has been reported to restore movement after traumatic SCI. Only three cases have been reported where participants developed restored volitional movement with active stimulation turned off after a period of chronic stimulation and only after intensive rehabilitation with locomotor training. It is unknown whether restoration of movement without stimulation is possible after stimulation alone.

Objective: We describe the development of spontaneous volitional movement (SVM) without active stimulation in a subset of participants in the Epidural Stimulation After Neurologic Damage (ESTAND) trial, in which locomotor training is not prescribed as part of the study protocol, and subject’s rehabilitation therapies are not modified.

Methods: Volitional movement was evaluated with the Brain Motor Control Assessment using sEMG recordings and visual examination at baseline and at follow-up visits with and without stimulation. Additional functional assessment with a motor-assisted bicycle exercise at follow-up with and without stimulation identified generated work with and without effort.

Results: The first seven participants had ASIA Impairment Scale (AIS) A or B thoracic SCI, a mean age of 42 years, and 7.7 years post-injury on average. Four patients developed evidence of sustained volitional movement, even in the absence of active stimulation after undergoing chronic epidural spinal cord stimulation (eSCS). Significant increases in volitional power were found between those observed to spontaneously move without stimulation and those unable (p < 0.0005). The likelihood of recovery of spontaneous volitional control was correlated with spasticity scores prior to the start of eSCS therapy (p = 0.048). Volitional power progressively improved over time (p = 0.016). Additionally, cycling was possible without stimulation (p < 0.005).

Conclusion: While some SVM after eSCS has been reported in the literature, this study demonstrates sustained restoration without active stimulation after long-term eSCS stimulation in chronic and complete SCI in a subset of participants. This finding supports previous studies suggesting that “complete” SCI is likely not as common as previously believed, if it exists at all in the absence of transection and that preserved pathways are substrates for eSCS-mediated recovery in clinically motor-complete SCI.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03026816.

Radial palsy in an individual with high-level chronic spinal cord injury

INTRODUCTION

Prolonged compression is a common cause of radial neuropathy in able-bodied individuals but has not been reported in individuals with chronic SCI. This is despite the fact that individuals with SCI may be at increased risk of peripheral nerve injuries due to wheelchair mobility and baseline sensory deficits. Furthermore, diagnosis of peripheral nerve injury poses a unique challenge in this population because symptoms and signs are superimposed on pre-existing central deficits.

CASE PRESENTATION

We present the case of a 48-year-old man with a C6 AIS A SCI from a motor vehicle accident 22 years earlier who had a new onset compressive radial neuropathy. At initial assessment he complained of paresthesia along his lateral right arm accompanied by new onset wrist-drop. Subsequent radial nerve conduction studies revealed severe reductions in amplitude for sensory and motor action potentials. The patient was managed with mobility exercises and vitamin B supplementation and showed full recovery of motor and sensory function to baseline levels on follow-up 4 months after the injury.

DISCUSSION

The electrophysiologic profile of this patient is illustrative of severe nerve compression for an extended time period. Unlike able-bodied individuals who can reposition themselves to alleviate nerve compression, individuals with SCI may be unaware of nerve compression or unable to reposition themselves. This highlights the need for precautionary measures such as maneuvers and devices to provide trunk and limb stability along with the use of medical alert devices that allow individuals to access timely help when unattended.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Falls during inpatient rehabilitation in spinal cord injury, acquired brain injury, and neurologmusculoskeletal disease programs

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To compare the proportion of fallers and the patient level and fall characteristics among inpatients who had experienced at least one fall in a spinal cord injury (SCI), an acquired brain injury (ABI), and a neuromusculoskeletal disease (NMS) rehabilitation program.

SETTING

Tertiary rehabilitation hospital.

SUBJECTS

Inpatients who had experienced at least one fall during rehabilitation.

METHODS

Patient and fall level variables were extracted from electronic medical records over a 5-year period (January 1, 2011 to January 1, 2016): hospital program, age, sex, Functional Independence Measure (FIM) scores, length of stay, number of medications, as well as fall date, time, location, cause, harm, fall risk assessment data, and whether the fall was witnessed. The impact of hospital program on fall was examined using bivariate and multivariable analysis.

RESULTS

Two hundred and thirty-seven (16%) inpatients experienced at least one fall during the study period. Inpatients with SCI had the highest proportion of fallers (20%) and fell later after admission than inpatients in the other programs. Patients with ABI were more likely to sustain moderate-to-severe physical harm from falls. Taking >5 medications at time of fall and being earlier in one's rehabilitation course were associated with increased fall rate among fallers.

CONCLUSIONS

Although the type of program was not a significant predictor of fall rate in the multivariable analysis, there were some important differences among the rehabilitation programs on patient and fall level characteristics. These results may be useful when developing and timing fall prevention interventions for inpatient rehabilitation.

Recommendations for evaluation of bladder and bowel function in pre-clinical spinal cord injury research

Objective: In order to encourage the inclusion of bladder and bowel outcome measures in preclinical spinal cord injury (SCI) research, this paper identifies and categorizes 1) fundamental, 2) recommended, 3) supplemental and 4) exploratory sets of outcome measures for pre-clinical assessment of bladder and bowel function with broad applicability to animal models of SCI.Methods: Drawing upon the collective research experience of autonomic physiologists and informed in consultation with clinical experts, a critical assessment of currently available bladder and bowel outcome measures (histological, biochemical, in vivo functional, ex vivo physiological and electrophysiological tests) was made to identify the strengths, deficiencies and ease of inclusion for future studies of experimental SCI.Results: Based upon pre-established criteria generated by the Neurogenic Bladder and Bowel Working Group that included history of use in experimental settings, citations in the literature by multiple independent groups, ease of general use, reproducibility and sensitivity to change, three fundamental measures each for bladder and bowel assessments were identified. Briefly defined, these assessments centered upon tissue morphology, voiding efficiency/volume and smooth muscle-mediated pressure studies. Additional assessment measures were categorized as recommended, supplemental or exploratory based upon the balance between technical requirements and potential mechanistic insights to be gained by the study.Conclusion: Several fundamental assessments share reasonable levels of technical and material investment, including some that could assess bladder and bowel function non-invasively and simultaneously. Such measures used more inclusively across SCI studies would advance progress in this high priority area. When complemented with a few additional investigator-selected study-relevant supplemental measures, they are highly recommended for research programs investigating the efficacy of therapeutic interventions in preclinical animal models of SCI that have a bladder and/or bowel focus.

Reliability of Cognitive Measures in Individuals With a Chronic Spinal Cord Injury

BACKGROUND

Following spinal cord injury (SCI), up to 64% of individuals experience cognitive deficit. However, the reliability of commonly used neuropsychological tests is currently unknown in this population.

OBJECTIVES

To evaluate the test-retest reliability of cognitive measures in individuals with SCI.

DESIGN

Cross-sectional study.

SETTING

Vancouver General Hospital.

PARTICIPANTS

Individuals with a chronic (>2 years) SCI (n = 22).

METHODS

Across three visits (separated by ~16 days), 22 participants with chronic SCI completed a neuropsychological battery evaluating memory (Rey Auditory-Verbal Learning Test [RAVLT]), attention/concentration/psychomotor speed (Digit Span Task, Stroop Test), and executive function (Trail Making Test A&B, Symbol Digit Modalities Test, Controlled Oral Word Association Test). Coefficients of variation (CV_intra ) and intraclass correlation coefficients (ICCs) were calculated to determine the reliability of each test between visits. Linear regressions were performed to assess the associations between variability (CV_intra ) and participant characteristics, such as age or highest education level attained. Repeated-measures, one-way analysis of variance (ANOVA) was conducted to determine any significant practice effects, and smallest real differences (SRDs) were calculated.

MAIN OUTCOME MEASUREMENTS

Repeated scores on aforementioned neuropsychological tests.

RESULTS

ICCs ranged from 0.77 to 0.93, with the exception of RAVLT recognition score (ICC = 0.27). Age showed a moderate association with CV_intra in RAVLT interference recall scores (r = 0.43, P = .047), but was not a confounding factor for other measures. Education was not associated with CV_intra . Significant practice effects were noted for most of the cognitive tests assessed.

CONCLUSIONS

Other than the RAVLT recognition score, these cognitive measures demonstrated good-to-excellent reliability. Although this is encouraging, test-retest variability should be considered when interpreting the efficacy of various cognitive training strategies to mitigate cognitive decline in this population. Thus, the SRD values presented herein will allow researchers and clinicians to identify "true" changes in cognitive function with repeated testing.

LEVEL OF EVIDENCE

III.

Epidural Spinal Cord Stimulation Facilitates Immediate Restoration of Dormant Motor and Autonomic Supraspinal Pathways after Chronic Neurologically Complete Spinal Cord Injury

Epidural Spinal Cord Stimulation (eSCS) in combination with extensive rehabilitation has been reported to restore volitional movement in a select group of subjects after motor-complete spinal cord injury (SCI). Numerous questions about the generalizability of these findings to patients with longer term SCI have arisen, especially regarding the possibility of restoring autonomic function. To better understand the effect of eSCS on volitional movement and autonomic function, two female participants five and 10 years after injury at ages 48 and 52, respectively, with minimal spinal cord preservation on magnetic resonance imaging were implanted with an eSCS system at the vertebral T12 level. We demonstrated that eSCS can restore volitional movement immediately in two female participants in their fifth and sixth decade of life with motor and sensory-complete SCI, five and 10 years after sustaining severe radiographic injuries, and without prescribed or significant pre-habilitation. Both patients experienced significant improvements in surface electromyography power during a volitional control task with eSCS on. Cardiovascular function was also restored with eSCS in one participant with cardiovascular dysautonomia using specific eSCS settings during tilt challenge while not affecting function in a participant with normal cardiovascular function. Orgasm was achieved for the first time since injury in one participant with and immediately after eSCS. Bowel-bladder synergy improved in both participants while restoring volitional urination in one with eSCS. While numerous questions remain, the ability to restore some supraspinal control over motor function below the level of injury, cardiovascular function, sexual function, and bowel and bladder function should promote intense efforts to investigate and develop optimization strategies to maximize recovery in all participants with chronic SCI.

Determining optimal poststroke exercise: Study protocol for a randomized controlled trial investigating therapeutic intensity and dose on functional recovery during stroke inpatient rehabilitation

RATIONALE

A top priority in stroke rehabilitation research is determining the appropriate exercise dose to optimize recovery. Although more intensive rehabilitation very early after stroke may be deleterious to recovery, inpatient rehabilitation, occurring after acute care, may be a more appropriate setting to assess therapeutic dose on neurological recovery.

HYPOTHESIS

Individuals receiving higher intensity and dose exercise programs will yield greater improvements in walking ability over usual inpatient physical therapy care.

METHODS AND DESIGN

Seventy-five individuals across seven inpatient rehabilitation sites in Canada will be randomized into one of three treatment programs, each 5 days/week, for four weeks and monitored for exertion (heart rate) and repetitions (step count).

STUDY OUTCOMES

The primary outcome measure is the 6 min walk and secondary outcomes include functional independence, cognitive, and quality-of-life measures. Outcome data will be assessed at four time points.

SUMMARY

This trial will contribute to our knowledge of the therapeutic intensity and dose necessary to maximize functional recovery at a very important stage of rehabilitation and neural recovery poststroke.

Gains in health utility associated with urinary catheter innovations

Purpose

To estimate gains in health utility for two different catheter features and a support service related to urinary catheters used for intermittent catheterization.

Patients and methods

Two internet-based time trade-off (TTO) surveys were undertaken to value vignettes describing two innovative catheter features and a support service. The first TTO survey “Size and Service” included catheters with compact design and the availability of a support service for users; the second TTO survey “Phthalates” included avoidance of potentially harmful phthalates in the material of the catheters. All participants were from the UK; they traded health states against a time horizon that matched their total life expectancy. Sensitivity analyses were done to estimate the impact of extreme values on disutilities.

Results

The participants (n=890) estimated the incremental value of 0.031 (95% CI: 0.024–0.039), 0.009 (95% CI: 0.003–0.015), and 0.037 (95% CI: 0.027–0.046), respectively, for catheters with compact design, availability of support service, and catheters not containing phthalates.

Conclusions

Participants valued all three improvements in catheter design. To capture the impact of such design improvements on quality of life and utilities, vignette-based approaches can be a useful supplement to the conventional, generic tools.

Neural Control and Physiology of Sexual Function: Effect of Spinal Cord Injury

Objective: To present the current understanding of normal anatomy, physiology, sexual physiology, pathophysiology and the consequential sexual changes and dysfunctions following a spinal cord injury (SCI). Methods: Narrative review of the latest literature. Results: Peripheral innervations of the pelvis involve 3 sets of efferent neurons coordinated though the pelvic plexus (somatic, thoracolumbar sympathetic, and sacral parasympathetic), and these are under cerebral descending excitatory and inhibitory control. SCI, depending on the level of lesion and completeness, can alter this cerebral control, affecting the psychological and reflexogenic potential for genital arousal and also ejaculation and orgasm. During arousal, nitric oxide is the main neurotransmitter for smooth muscle relaxation in both male and female erectile tissue. In men, erection, ejaculation, and orgasm are under separate neurological control and can be individually affected by SCI. Conclusions: Since sexual function is rated amongst the highest priorities by individuals living with SCI, methods employed to affect the neurological changes to maximize sexual neurophysiology prior to initiating medical therapies including paying attention to sexual sensate areas and visceral signals with mindfulness techniques, practicing body mapping, and sexual stimulation of sensate areas to encourage neuroplasticity. Attention should be paid to the biopsychosocial sexual contexts within which persons with SCI live to maximize their sexual and fertility rehabilitation.

The impact of different scenarios for intermittent bladder catheterization on health state utilities: results from an internet-based time trade-off survey

AIMS

Intermittent catheterization (IC) is the gold standard for bladder management in patients with chronic urinary retention. Despite its medical benefits, IC users experience a negative impact on their quality of life (QoL). For health economics based decision making, this impact is normally measured using generic QoL measures (such as EQ-5D) that estimate a single utility score which can be used to calculate quality-adjusted life years (QALYs). But these generic measures may not be sensitive to all relevant aspects of QoL affected by intermittent catheters. This study used alternative methods to estimate the health state utilities associated with different scenarios: using a multiple-use catheter, one-time-use catheter, pre-lubricated one-time-use catheter and pre-lubricated one-time-use catheter with one less urinary tract infection (UTI) per year.

METHODS

Health state utilities were elicited through an internet-based time trade-off (TTO) survey in adult volunteers representing the general population in Canada and the UK. Health states were developed to represent the catheters based on the following four attributes: steps and time needed for IC process, pain and the frequency of UTIs.

RESULTS

The survey was completed by 956 respondents. One-time-use catheters, pre-lubricated one-time-use catheters and ready-to-use catheters were preferred to multiple-use catheters. The utility gains were associated with the following features: one time use (Canada: +0.013, UK: +0.021), ready to use (all: +0.017) and one less UTI/year (all: +0.011).

LIMITATIONS

Internet-based survey responders may have valued health states differently from the rest of the population: this might be a source of bias.

CONCLUSION

Steps and time needed for the IC process, pain related to IC and the frequency of UTIs have a significant impact on IC related utilities. These values could be incorporated into a cost utility analysis.

Cost-effectiveness of hydrophilic-coated intermittent catheters compared with uncoated catheters in Canada: a public payer perspective

STUDY DESIGN

A Markov model was used to analyze cost-effectiveness over a lifetime horizon.

OBJECTIVE

To investigate the cost-effectiveness of hydrophilic-coated intermittent catheters (HCICs) compared with uncoated catheters (UCs) among individuals with neurogenic bladder dysfunction (NB) due to spinal cord injury (SCI).

SETTING

A Canadian public payer perspective based on data from Ontario; including a scenario analysis from the societal perspective.

METHODS

A previously published Markov decision model was modified to compare the lifetime costs and quality-adjusted life years (QALYs) for the two interventions. Three renal function and three urinary tract infection (UTI) health states as well as other catheter-related events were included. Scenario analyses, including utility gain from compact catheter and phthalate free catheter use, were performed. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of the model.

RESULTS

The model predicted that a 50-year-old patient with SCI would gain an additional 0.72 QALYs if HCICs were used instead of UCs at an incremental cost of $48,016, leading to an incremental cost-effectiveness ratio (ICER) of $66,634/QALY. Moreover, using HCICs could reduce the lifetime number of UTI events by 11%. From the societal perspective, HCICs cost less than UCs, while providing superior outcomes in terms of QALYs, life years gained (LYG), and UTIs. The cost per QALY further decreased when health-related quality-of-life (HRQoL) gains associated with compact HCICs or catheters not containing phthalates were included.

CONCLUSION

In general, ICERs in the range of CAD$50-100,000 could be considered cost-effective. The ICERs for the base case and sensitivity analyses suggest that HCICs could be cost-effective. From the societal perspective, HCICs were associated with potential cost savings in our model. The results suggest that reimbursement of HCICs should be considered in these settings.

Epidural Spinal Cord Stimulation of Lumbosacral Networks Modulates Arterial Blood Pressure in Individuals With Spinal Cord Injury-Induced Cardiovascular Deficits

Disruption of motor and autonomic pathways induced by spinal cord injury (SCI) often leads to persistent low arterial blood pressure and orthostatic intolerance. Spinal cord epidural stimulation (scES) has been shown to enable independent standing and voluntary movement in individuals with clinically motor complete SCI. In this study, we addressed whether scES configured to activate motor lumbosacral networks can also modulate arterial blood pressure by assessing continuous, beat-by-beat blood pressure and lower extremity electromyography during supine and standing in seven individuals with C5-T4 SCI. In three research participants with arterial hypotension, orthostatic intolerance, and low levels of circulating catecholamines (group 1), scES applied while supine and standing resulted in increased arterial blood pressure. In four research participants without evidence of arterial hypotension or orthostatic intolerance and normative circulating catecholamines (group 2), scES did not induce significant increases in arterial blood pressure. During scES, there were no significant differences in electromyographic (EMG) activity between group 1 and group 2. In group 1, during standing assisted by scES, blood pressure was maintained at 119/72 ± 7/14 mmHg (mean ± SD) compared with 70/45 ± 5/7 mmHg without scES. In group 2 there were no arterial blood pressure changes during standing with or without scES. These findings demonstrate that scES configured to facilitate motor function can acutely increase arterial blood pressure in individuals with SCI-induced cardiovascular deficits.

Translating promising strategies for bowel and bladder management in spinal cord injury

Loss of control over voiding following spinal cord injury (SCI) impacts autonomy, participation and dignity, and can cause life-threatening complications. The importance of SCI bowel and bladder dysfunction warrants significantly more attention from researchers in the field. To address this gap, key SCI clinicians, researchers, government and private funding organizations met to share knowledge and examine emerging approaches. This report reviews recommendations from this effort to identify and prioritize near-term treatment, investigational and translational approaches to addressing the pressing needs of people with SCI.

Pulse article: Survey on the current usage of the International Standards for the Assessment of Autonomic Function after Spinal Cord Injury (ISAFSCI)

Study design

Online questionnaire.

Objectives

To identify the awareness, and current use, of the International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) and suggest necessary revisions.

Setting

An international collaboration of committee members.

Methods

A survey was drafted and consensus achieved among members of the International Standards Committee of the ASIA. The questionnaire was posted on SurveyMonkey for 2 months. A survey link was posted on the ASIA and ISCoS websites, and committee members circulated the survey to colleagues with the goal of obtaining a wide-spread international response.

Results

A total of 173 providers responded. About half (n = 84) of the respondents used the standards in some form. Forty-four percent (n = 72) felt they knew the difference between the standards and the data sets. Among 135 responses on the usefulness of the ISAFSCI, the bladder, bowel, and sexual function sections, and the heart rate, respiratory rate, blood pressure, and sudomotor sections for use in patients with tetraplegia were reported as most useful. Comments revealed that respondents would like more explanation regarding specific definitions of components of the standards, how/when to use the ISAFSCI, and how the ISAFSCI may assist in clinical care.

Conclusion

The ISAFSCI is used by a subset of SCI clinicians. Some find the standards useful, while others are unaware of the utility of the ISAFSCI to prevent morbidity and assist in documentation of autonomic recovery post SCI. Further clarification regarding the definition of various disorders, and how and why to use the ISAFSCI in the SCI population, is needed.

Cardiovascular Responses to Sexual Activity in Able-Bodied Individuals and Those Living with Spinal Cord Injury

Sexuality is an integral part of the human experience and persists in health and disability. The cardiovascular system is crucial to sexual function and can be affected profoundly by spinal cord injury (SCI). The effects of sexual activity on the cardiovascular system in SCI have not been summarized and compared with sexual activity in able-bodied individuals. A keyword search of Embase, PubMed, and Medline was conducted. From 471 retrieved studies for able-bodied individuals, 11 were included that met the strict criteria of medically uncomplicated participants. In the SCI literature, 117 studies were screened, with 18 meeting criteria. In able-bodied persons, sexual activity resulted in modest increases in systolic blood pressure peaking at orgasm (males of 163 mm Hg and females of 142 mm Hg) and returning to baseline shortly afterward. In persons with SCI, results varied from minimal changes to significant elevations in systolic blood pressure because of episodes of autonomic dysreflexia, especially in those with high thoracic and cervical lesions. Peak systolic blood pressure in these individuals was measured to be as high as 325 mm Hg. In the SCI population, more intense stimuli (including penile vibrostimulation and electroejaculation) tended to result in a greater increase in systolic blood pressure compared with self-stimulation. Studies that used continuous versus intermittent monitoring were more likely to report greater changes in systolic blood pressure. In able-bodied persons, sexual activity results in modest increases in blood pressure. In those with SCI, intense stimulation and higher injury levels result in a higher likelihood of autonomic dysreflexia and elevated blood pressure. Because of rapid changes in blood pressure, continuous monitoring is more advantageous than intermittent measurement, because the latter may miss peak values.