Skin and not dorsal root stimulation reduces hypertonus in thoracic motor complete spinal cord injury: a single case report

On demand and localized treatment for excessive muscle tone after spinal cord injury (SCI) is currently not available. Here, we examine the reduction in leg hypertonus in a person with mid-thoracic, motor complete SCI using a commercial transcutaneous electrical stimulator (TES) applied at 50 or 150 Hz to the lower back and the possible mechanisms producing this bilateral reduction in leg tone. Hypertonus of knee extensors without and during TES, with both cathode (T11-L2) and anode (L3-L5) placed over the spinal column (midline, MID) or 10 cm to the left of midline (lateral, LAT) to only active underlying skin and muscle afferents, was simultaneously measured in both legs with the pendulum test. Spinal reflexes mediated by proprioceptive (H-reflex) and cutaneomuscular reflex (CMR) afferents were examined in the right leg opposite to the applied LAT TES. Hypertonus disappeared in both legs but only during thoracolumbar TES, and even during LAT TES. The marked reduction in tone was reflected in the greater distance both lower legs first dropped to after being released from a fully extended position, increasing by 172.8% and 94.2% during MID and LAT TES, respectively, compared with without TES. Both MID and LAT (left) TES increased H-reflexes but decreased the first burst, and lengthened the onset of subsequent bursts, in the cutaneomuscular reflex of the right leg. Thoracolumbar TES is a promising method to decrease leg hypertonus in chronic, motor complete SCI without activating spinal cord structures and may work by facilitating proprioceptive inputs that activate excitatory interneurons with bilateral projections that in turn recruit recurrent inhibitory neurons.NEW & NOTEWORTHY We present proof of concept that surface stimulation of the lower back can reduce severe leg hypertonus in a participant with motor complete, thoracic spinal cord injury (SCI) but only during the applied stimulation. We propose that activation of skin and muscle afferents from thoracolumbar transcutaneous electrical stimulation (TES) may recruit excitatory spinal interneurons with bilateral projections that in turn recruit recurrent inhibitory networks to provide on demand suppression of ongoing involuntary motoneuron activity.

[Sacral neuromodulation for bladder voiding dysfunction: Experience at a French university center]

OBJECTIVE

To report the experience of a university hospital center with sacral neuromodulation for patients with bladder voiding disorders.

MATERIAL AND METHODS

All patients who underwent sacral neuromodulation between 1998 and 2022 for bladder voiding disorders were included. Medical records were analyzed retrospectively, and population, efficacy and follow-up data were collected.

RESULTS

A total of 134 patients underwent test implantation and 122 patients were analyzed. 68 patients (56%) were implanted with a definitive neuromodulation device. Mean age was 43±16 years and BMI 25.5±5.4kg/m2. 74% were women. Bladder voiding disorder was due to sphincter hypertonia in 51% of cases, with associated bladder hypocontractility in 29%. The spontaneous micturition rate after implantation increased from 34% to 92%. Implantation results appeared to be better in patients with sphincter hypertonia, whether or not associated with bladder hypocontractility. The benefit was most often present with a frequency of 5Hz (54.4%). Side-effects were present in 52% of cases at 5 years, and in 85% of cases were pain in relation to the implanted devices. They resolved under medical treatment or after revision of the device (27% of cases at 5 years).

CONCLUSION

SNM is effective in micturition recovery, but has side effects. Urodynamic mechanism and etiology may provide clues for modulating NMS box settings and determining predictive factors for NMS success. Data from other centers are needed to identify reliable predictive factors.

Effects of the Structured Water Dance Intervention (SWAN) on muscular hypertonia in adults with profound intellectual and multiple disabilities

This study aimed to evaluate the effect of Structured Water Dance Intervention (SWAN) on muscular hypertonia in individuals with profound intellectual and multiple disability (PIMD). Muscular hypertonia has a multitude of negative consequences for people with PIMD because it can lead to contractures, pain, mobility impairment, pressure ulcers that limits functional behavior as well as gross and fine motor function. Thirty-six individuals with PIMD in four Swedish regions were randomized to two groups in a multicenter, crossover design. Two withdrew participation, thus 34 individuals completed the intervention. The intervention was administered for 40 min once a week during a 12-week period. Outcomes related to muscular hypertonia were examined using the Modified Ashworth Scale (MAS), and based on accompanying assistants' assessments. Hypertonia decreased from baseline to the end of the intervention period, as demonstrated by a decrease in MAS score. Hypertonia also decreased during the sessions, as shown by the assistants' ratings. In conclusion, this study demonstrates that SWAN holds potential to reduce muscular hypertonia in people with PIMD and points out the importance of customized physical treatment alternatives. The study provides useful information for the design of future non-invasive, non-pharmacological interventions to reduce muscular hypertonia in PIMD.

Prevalence and Treatment Characteristics of Spastic Hypertonia on First-Time Admission to Acute Inpatient Rehabilitation

OBJECTIVE

The aim of the study was to report the prevalence of spasticity and treatment patterns during first-time admission to inpatient rehabilitation after acute stroke, traumatic brain injury, and spinal cord injury.

DESIGN

This is a retrospective cohort study.

METHODS

A review of 285 adult patients consecutively admitted to inpatient rehabilitation was conducted. Patients with a history of spasticity and inpatient rehabilitation course and those younger than 18 yrs were excluded. Main outcome measures are as follows: admitting diagnosis, length of stay, time from injury to admission, acute transfer rate, prevalence and severity of spasticity using Modified Ashworth Scale at admission and discharge, Functional Independence Measure scores at admission and discharge, Functional Independence Measure efficiency, and treatments for spasticity.

RESULTS

Stroke patients had the highest prevalence of spasticity: 68% on admission and 50% at discharge. In traumatic brain injury, spasticity prevalence was 55% on admission and 30% at discharge. In spinal cord injury, spasticity prevalence was 48% on admission and 46% at discharge. Patients with spinal cord injury received the most medications to control spasticity, whereas those with traumatic brain injury and stroke received the most procedural interventions.

CONCLUSIONS

Spasticity is a common sequela of upper motor neuron injury for patients admitted to inpatient rehabilitation. Early recognition and management are essential to prevent contractures, minimize pain, and maximize functional recovery.

Identification of a new syndrome: ASS-SSA or anal sphincter syndrome

AIM

The author proposes a new, original Syndrome, observing the relationship between some of the most frequent anal pathologies, apparently different from each other in terms of morphological aspect and symptomatologic expression, but united by the same pathogenic cause, represented by the hypertonicity of the anal sphincter apparatus. There are already descriptions of other "syndromes" of the pelvic floor, inaccurate and subject to different interpretations. The proposed syndrome, instead, called Anal Sphincter Syndrome - ASS (in Italian SSA - Sindrome dello Sfintere Anale) presents clarity on the determining cause (sphincter hypertonicity) and descriptive simplicity, including only two welldefined pathological conditions: anal fissure and anal thrombosis; other ancillary conditions or symptoms are inconstantly possible, but not decisive. The author will present, as soon as possible, in subsequent works, a retrospective study (still to be completed) on a wide personal case history, dating back to the 1990s.

KEY WORDS

Anal sphincter hypertonia, Anal thrombosis, Anal fissure, Syndrome, Proctology, Somatization.

Managing Paratonia in Persons With Dementia: Short-term Effects of Supporting Cushions and Harmonic Techniques

OBJECTIVES

Paratonia, a form of hypertonia typically seen in dementia, is often associated with difficulties in positioning and daily care. No evidence-based therapy or clinical guideline for management is available. In this study, the short-term effect of harmonic techniques (HT) and supporting cushions (SC) on paratonia was explored.

DESIGN

This was a multicenter interventional clinical trial with AB/BA crossover design. Each intervention (SC or HT) was subsequently implemented over 1 week in each of the participants.

SETTING AND PARTICIPANTS

The study included 22 participants with moderate to severe paratonia from 9 different nursing homes in Flanders, Belgium.

METHODS

Measurements of biceps brachii and rectus femoris muscle tone (MyotonPRO), maximal elbow and knee extension (goniometer), and pain (Pain Assessment Checklist for Seniors With Limited Ability to Communicate) were performed on 3 different days within 1 week. The effect of HT on nursing care was evaluated with the Pain Assessment Checklist for Seniors With Limited Ability to Communicate and visual analog scale ratings of discomfort items.

RESULTS

After 30 minutes of positioning with SC, participants had lower biceps brachii muscle tone (P = .041) and higher maximal elbow extension (P = .006) than without SC. After a 30-minute session of HT, a significant increase in biceps brachii muscle tone (P = .032) and maximal extension of elbow (P < .001) and knee (P = .028) was found. Pain (P = .003) and discomfort (P = .001 to P = .019) during morning care were significantly lower when care was preceded by 30 minutes of HT.

CONCLUSIONS/IMPLICATIONS

This explorative study revealed beneficial short-term effects on range of motion for both SC and HT and a positive effect of SC on upper limb muscle tone. Beneficial effects of HT were found on resident's pain and caregiver's discomfort during care. The results of the present study are encouraging and can contribute to the development of evidence-based interventions for paratonia.

Paratonia in Flemish Nursing Homes: Current State of Practice

BACKGROUND

Paratonia is a major underlying motor problem impeding functionality and locomotion in dementia. Despite its undeniable impact on patient's quality of life and daily care, there is a lack of evidence-based therapy on patients with this condition.

METHODS

We surveyed physiotherapists working in nursing homes in Flanders (Belgium) concerning the use and perceived effect of therapeutic strategies and positioning methods/aids.

RESULTS

Positioning and soft passive mobilization were the most applied and positively appraised therapeutic interventions. Highest ratings for positioning were found for C-shaped positioning cushions and multi-position wheelchair. According to the respondents, key points for paratonia approach were relaxation, positioning, active movement stimulation, and-to some extent-passive mobilization. Indispensable for any success however is multidisciplinary cooperation.

CONCLUSION

These findings might provide an inspirational path for research to verify possible (evidence based) beneficial treatments that could be applied to improve current and future treatment of patients with paratonia.

Mobility and gait outcomes following intensive rehabilitation, onabotulinumtoxin A, and baclofen treatment chronic post-stroke: a case report

PURPOSE. This case report describes the effects of intensive rehabilitation with systemic antispasticity and local neurotoxin pharmacological interventions on gait and activity outcomes for a patient with chronic impairments post-stroke. CASE DESCRIPTION. The 56-year-old male patient was 13 months post-stroke with left hemiparesis and hypertonicity in the left upper and lower extremities. The patient received oral baclofen for widespread hypertonicity and intramuscular onabotulinumtoxin A injections in muscles of the left upper and lower extremities to target local areas of hypertonicity. The patient received weight-supported treadmill training, over-ground gait training, neuromuscular re-education, and balance training three times per week during 20 of the 25 weeks of the study period. OUTCOMES. The patient demonstrated improvements in balance (Berg Balance Scale), mobility (Timed Up and Go test), and motor function (Stroke Rehabilitation Assessment of Movement Measure). Kinematic measures of gait also improved in ankle and knee range of motion during both stance and swing phases. DISCUSSION. This case demonstrates that improvements in impairment and activity outcomes can occur in an individual with significant post-stroke chronic impairments after receiving intensive physical therapy in conjunction with pharmacologic interventions to control hypertonicity. The persistence and generalizability of these results need to be determined.

Managing lower extremity muscle tone and function in children with cerebral palsy via eight-week repetitive passive knee movement intervention

This study used a repeated measures design to assess the effect of an eight-week repetitive passive movement (RPM) intervention on lower extremity muscle tone and function in children with cerebral palsy (CP). Eighteen children (aged 9.5 ± 2.1 years) with spastic CP were randomly assigned to a knee RPM intervention condition of 3 times a week for 8 weeks or a control condition. The 8 weeks were followed by 4 weeks of washout period, after which the participants were crossed over to the other group. In the RPM condition, each subject's knees were intervened with continuous passive motion device (at a velocity of 15°/s) for 20 min. The subjects were evaluated via variables measuring range-of-motion, muscle tone, and ambulatory function before, after, 1 day after, and 3 days after each intervention. Repeated-measures statistical analyses found significant differences between condition variable on active range-of-motion of the knee (AROM, increased), relaxation index (RI, increased), Modified Ashworth Scale (MAS, decreased), timed up-and-go (TUG, decreased), 6-min walk test (6 MWT, increased); and significant differences among time variable including RI, MAS, and 6 MWT. No difference was found in passive range-of-motion measurements. Repetitive passive movement reduced lower extremity spastic hypertonia in children with cerebral palsy, and it also improved ambulatory function in terms of walking speed. Effects of this treatment protocol on ambulation lasted up to 3 days post intervention. Findings of this study provide clinicians and patients an alternative, effective and efficient strategy for spastic control and ambulatory improvement.

[Cohort study of hyperbaric oxygention (HBO) in controlling hypermyotonia caused by spinal cord injury]

OBJECTIVE

To evaluate the clinical effects of hyperbaric oxygention (HBO) in treating hypermyotonia caused by spinal cord injury (SCI).

METHODS

From March 2009 to April 2011, 80 patients with hypermyotonia caused by SCI were divided into treatment group and control group, with 40 cases in each group. There were 49 males and 31 females with an average age of (34.12 +/- 6.61) years (ranged, 17 to 60) in the study. Course of disease was from 14 to 30 d with an average of (20.16 +/- 5.08) d. The patients of the treatment group were treated with HBO, rehabilitation exercise and baclofen medication. With pressure of HBO was 2ATA, the treatment project including mask oxygen-inspiration for 20 minutes and resting 5 min, repeating 3 circulations as once, once every day and 10 times as a course of treatment, a total of 6 courses. In the control group, the patients were only treated with rehabilitation exercise and baclofen medication. Course of treatment was same with treatment group. The muscular tensions of patients were evaluated according to method of Modified Ashworth scale (MAS) at 3 courses and 6 courses after treatment.

RESULTS

After 3 courses of treatment,5 cases were effective in treatment group and 4 cases were effective in control group. There was no significant difference between two groups. After 6 courses of treatment, 24 cases were effective and 5 cases were obvious effective in treatment group; 14 cases were effective and 2 cases were obvious effective in control group. Clinical effect of treatment group was better than that of control group after 6 courses of treatment.

CONCLUSION

HBO was effective to controlling hypermyotonia caused by SCI, it can be used widely as a routine adjuvant therapy in clinic, but adequate course of treatment is necessary.

Passive movement therapy in patients with moderate to severe paratonia; study protocol of a randomised clinical trial (ISRCTN43069940)

BACKGROUND

Paratonia, a form of hypertonia, is associated with loss of mobility and with the development of contractures especially in the late stages of the dementia. Passive movement therapy (PMT) currently is the main physiotherapeutic intervention. General doubt about the beneficial effects of this widely used therapy necessitates a randomised clinical trial (RCT) to study the efficacy of PMT on the severity of paratonia and on the improvement of daily care.

METHODS/DESIGN

A RCT with a 4-week follow-up period. Patients with dementia (according to the DSM-IV-TR Criteria) and moderate to severe paratonia are included in the study after proxy consent. By means of computerised and concealed block randomisation (block-size of 4) patients are included in one of two groups. The first group receives PMT, the second group receives usual care without PMT. PMT is given according to a protocol by physical therapist three times a week for four weeks in a row. The severity of paratonia (Modified Ashworth scale), the severity of the dementia (Global Deterioration Scale), the clinical improvement (Clinical Global Impressions), the difficulty in daily care (Patient Specific Complaints) and the experienced pain in daily care of the participant (PACSLAC-D) is assessed by assessors blind to treatment allocation at baseline, after 6 and 12 treatments. Success of the intervention is defined as a significant increase of decline on the modified Ashworth scale. The 'proportion of change' in two and four weeks time on this scale will be analysed. Also a multiple logistic regression analysis using declined/not declined criteria as dependent variable with correction for relevant confounders (e.g. stage of dementia, medication, co-morbidity) will be used.

DISCUSSION

This study is the first RCT of this size to gain further insight on the effect of passive movement therapy on the severity of paratonia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43069940.

Dental hygiene residential care in a 3-year dental hygiene education programme in Japan: towards dysphagia management based on the dental hygiene process of care

This paper reports an evaluation of a residential care practice, which was part of a 'Dysphagia Management' course introduced into a 3-year dental hygiene curriculum in Japan. The clinical practice was performed at a care facility for the elderly people. Dental hygiene interventions, which consisted mainly of professional oral care, were implemented on a client who was bed-bound after suffering from a stroke. As the client had severe tension in muscles around oral cavity, it was difficult for the facility care workers to provide daily oral hygiene care. The goals of the dental hygiene care plan included decreasing tension of oral muscles and reducing periodontal inflammation and halitosis. The dental hygiene interventions were given once a month for 5 months. Evaluation in the fifth month demonstrated relaxation of oral muscles, decrease in plaque accumulation, and improvements in levels of gingival inflammation, indicating the partial achievements of the initial goals. Possibilities for revision of the care plan could call for more active involvement of the facility care workers and client-centered goal setting. This learning experience provided an opportunity for continuing intervention and evaluation of dental hygiene care for the same client. The positive results of our limited interventions further confirmed the importance of professional oral care in organic and functional improvements in oral health for the elderly people.

Repetitive transcranial magnetic stimulation of the motor cortex ameliorates spasticity in multiple sclerosis

OBJECTIVE

To investigate whether repetitive transcranial magnetic stimulation (rTMS) can modify spasticity.

METHODS

We used high-frequency (5 Hz) and low-frequency (1 Hz) rTMS protocols in 19 remitting patients with relapsing-remitting multiple sclerosis and lower limb spasticity.

RESULTS

A single session of 1 Hz rTMS over the leg primary motor cortex increased H/M amplitude ratio of the soleus H reflex, a reliable neurophysiologic measure of stretch reflex. Five hertz rTMS decreased H/M amplitude ratio of the soleus H reflex and increased corticospinal excitability. Single sessions did not induce any effect on spasticity. A significant improvement of lower limb spasticity was observed when rTMS applications were repeated during a 2-week period. Clinical improvement was long-lasting (at least 7 days after the end of treatment) when the patients underwent 5 Hz rTMS treatment during a 2-week protocol. No effect was obtained after a 2-week sham stimulation.

CONCLUSIONS

Repetitive transcranial magnetic stimulation may improve spasticity in multiple sclerosis.

Event driven electrical stimulation of the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in multiple sclerosis

AIMS

The aim of this study was to evaluate the effect of automatic event driven electrical stimulation on the dorsal penile/clitoral nerve for management of neurogenic detrusor overactivity in patients suffering from Multiple Sclerosis.

METHODS

A total of 10 patients participated in the study. Detrusor pressure was recorded during physiological filling of the bladder and electrical stimulation was applied with surface electrodes whenever the detrusor pressure exceeded 10 cm H(2)O.

RESULTS

In seven of the eight patients, where neurogenic detrusor overactivity was observed an average of 12 detrusor contractions could be inhibited by stimulation. In one patient, however, stimulation failed to inhibit the detrusor contractions. The average increase in bladder volume from first suppressed detrusor contraction until leakage was 94% (range: 22-366%). On average, the time from first suppressed contraction until leakage was 15 min and 50 sec (range: 4 min 58 sec-32 min 5 sec) with an average physiological filling rate of 8 ml/min. Urgency was effectively suppressed at the onset of stimulation.

CONCLUSIONS

The results indicate that involuntary detrusor contractions in patients with multiple sclerosis can effectively be inhibited with event driven stimulation, hereby improving bladder capacity and reducing the number of incontinence episodes. However, the used method for detecting detrusor contractions is not suitable in a chronic setting and alternative techniques needs to be investigated if stimulation should be applied automatically.

USING THE CIRCUMSTANCES OF SYMPTOM EXPERIENCE TO ASSESS THE SEVERITY OF URGENCY IN THE OVERACTIVE BLADDER

PURPOSE

We identified a method for quantifying the symptoms of the overactive bladder that addresses the assessment of urgency.

MATERIALS AND METHODS

An observational study of a cohort was used. Data were collected prospectively from 5,423 consultations on 1,797 patients (158 males and 1,639 females) being assessed and treated for the overactive bladder. The study was conducted during 5 years. The reported frequencies and incontinence episodes were recorded. Using ranked ordinal scales (none, mild, moderate, severe) the symptoms of urgency and urge incontinence associated with waking and rising, hearing running water, arriving home ("latchkey"), cold weather and when feeling tired or worried were noted. The experiences of urgency and urge incontinence, without reference to the circumstances in which they were experienced were similarly assessed and if on treatment, they were asked to grade their overall response.

RESULTS

Reported urinary frequency and incontinence episodes were strongly associated with patient grading of response to treatment. Therefore, the symptoms assessed on the scale of none, mild, moderate and severe were compared with disease severity by using reported frequency and incontinence episodes. The description of the symptoms with reference to the situations in which they were experienced showed clear associations with frequency and incontinence, falling along a progressive scale. An overall pattern could be detected in that at points on the scale of none, mild, moderate and severe, the least frequency and incontinence tended to be associated with waking, rising and latchkey symptoms. Next followed symptoms precipitated by running water and cold weather. Aggravation by fatigue or worry was associated with the greatest disease severity (ANOVA F = 8.9, p <0.001). This scale covered a wide range from frequencies of 7 to 15 times daily and incontinence episodes through 0 to 4 times daily.

CONCLUSIONS

Qualifying the experience of urgency and urge incontinence, according to the circumstances in which these symptoms are experienced, seems to offer a promising new method for assessing the severity of urgency and urge incontinence.

Long-term effect of shock wave therapy on upper limb hypertonia in patients affected by stroke

BACKGROUND AND PURPOSE

Spasticity is a disabling complication of stroke and different noninvasive treatments are used to reduce muscle hypertonia. Shock waves are defined as a sequence of single sonic pulses largely used in the treatment of diseases involving bone and tendon as well as muscular contractures. The effect and duration of extracorporeal shock wave therapy (ESWT) was investigated on muscle hypertonia of the hand and wrist.

METHODS

A total of 20 patients affected by stroke associated with severe hypertonia in upper limbs were evaluated. Placebo stimulation was performed 1 week before active stimulation in each patient. Evaluation was performed using the National Institutes of Health and Ashworth scales and video monitoring with a digital goniometer before and immediately after placebo or active stimulation. Motor nerve conduction velocity from abductor digiti minimi were recorded. Patients were monitored at 1, 4, and 12 weeks after active treatment.

RESULTS

After active ESWT, patients showed greater improvement in flexor tone of wrist and fingers compared with placebo stimulation. At the 1- and 4-week follow-up visits, a significant decrease of passive muscle tonicity was noted on muscles in all patients receiving active treatment. At 12 weeks after therapy, 10 of the 20 patients showed persistent reduction in muscle tone. There were no adverse events associated with ESWT.

CONCLUSIONS

ESWT reduces hypertonia of the wrist and finger muscles for > or =12 weeks after treatment. The possible mechanisms of action of ESWT are discussed.

Chronic pudendal nerve neuromodulation in women with idiopathic refractory detrusor overactivity incontinence: results of a pilot study with a novel minimally invasive implantable mini-stimulator

AIMS

To assess the results of chronic pudendal nerve neuromodulation with a novel technique in a pilot study on women with idiopathic refractory detrusor overactivity incontinence.

MATERIALS AND METHODS

A percutaneous screening test (PST) was performed in patients with urodynamically demonstrated detrusor overactivity incontinence. Such a test includes the performance of a cystometrogram without and with percutaneous pudendal nerve stimulation and is considered positive if stimulation results in a more than 50% increase in the bladder volume at the first involuntary detrusor contraction or the maximum cystometric capacity. Patients with a positive PST qualified for the implantation of a mini-neurostimulator with an integrated electrode, a so-called bion(R), adjacent to the pudendal nerve at Alcock's Canal. Five-day voiding-incontinence diaries were the main tool for the evaluation of therapy.

RESULTS

A PST was performed in 14 women. Six patients responded positively and received a bion. The degree of incontinence decreased significantly in this group, which also included patients in whom sacral neuromodulation had failed. There were no severe adverse events.

CONCLUSIONS

Chronic pudendal nerve stimulation may reduce the degree of detrusor overactivity incontinence, even in patients in whom sacral neuromodulation fails. Bion therapy is relatively simple and minimally invasive and is well tolerated by the patient.

[Female urinary incontinence]

Several million women suffer from urinary incontinence in Germany. Stress and urge incontinence are especially clinically relevant. Training of the pelvic floor muscles (vaginal cones, electrical stimulation, biofeedback, and so forth) plays a central role in the conservative therapy of stress incontinence. The use of devices such as incontinence tampons and urethral pessaries is also common. A medication for the therapy of stress incontinence, which improves the closure of the urethral sphincter, has been on the market since 2004. In the operative area,the insertion of a tension-free vaginal tape (TVT) has gained acceptance in recent years. Anticholinergics are the primary medication used in the treatment of urge incontinence. Local estrogens, low frequency electrical stimulation, phytotherapeutics and the like have supportive effects.

[Management of urinary incontinence in the aging man]

The increasing prevalence and incidence of male urinary incontinence in senium-necessitate a specific as well as symptom and etiologically-oriented therapy. In addition to the conservative care with absorbent products, catheterization methods are available. Moreover, the problem can be successfully controlled in the majority of the patients through very specific drug and surgical therapeutic concepts.

Treatment of neurogenic detrusor overactivity in spinal cord injured patients by conditional electrical stimulation

PURPOSE

The feasibility of automatic event driven electrical stimulation of the dorsal penile/clitoral nerve in the treatment of neurogenic detrusor overactivity (NDO) was evaluated in individuals with spinal cord injury.

MATERIALS AND METHODS

The study included 2 women and 14 men older than 18 years with NDO, bladder capacity below 500 ml and complete or incomplete suprasacral spinal cord injury. Detrusor pressure (Pdet) was recorded during ordinary, natural bladder filling. In a similar subsequent recording Pdet was used to trigger electrical stimulation when pressure exceeded 10 cm H2O.

RESULTS

Of the 16 patients enrolled in this study 13 had increased bladder capacity together with a storage pressure decrease as a result of automatic, event driven electrical stimulation. In 2 patients stimulation could not inhibit the first undesired contraction, leakage occurred and finally 1 could not tolerate stimulation. During stimulated filling Pdet never exceeded 55 cm H2O. Thus, storage pressure was sufficiently low to prevent kidney damage. An average bladder capacity increase of 53% was achieved.

CONCLUSIONS

This study demonstrates the feasibility of automatic, event driven electrical stimulation in the treatment of NDO. Although the setup in this experiment is not suitable in a clinical setting, the treatment modality is promising and it warrants further investigation.

[Pudendal nerve stimulation therapy of the overactive bladder -- an alternative to sacral neuromodulation?]

PURPOSE

Sacral neuromodulation is known to be an alternative therapeutic option for patients with anticholinergic resistant overactive bladder (OAB). For the same indication, a microstimulation system called BION is available since last year. The BION-stimulator, which only measures 2.8 x 0.3 cm, is designed for pudendal nerve stimulation. Its implantation technique as well as the first clinical results are presented and discussed.

MATERIALS AND METHODS

During an outpatient percutaneous screening test (PST), a pudendal nerve stimulation is performed with a needle electrode in local anesthesia. A 50 % increase in the urodynamic parameters (bladder capacity, first desire to void, compliance, etc.) is an indication for a chronic implantation of the BION stimulator, which also can be placed in local anesthesia.

RESULTS

Two patients have been treated with a BION-stimulator in our clinic so far. Patient I suffered from an OAB with frequent urinary incontinence and patient II had a sensory OAB with high voiding frequency. After the BION(R)-implantation, patient I showed a reduction in incontinence episodes by 31.5 % a day and patient II had lowered voiding frequencies from 12.6 to 7 a day. The postoperative urodynamic investigations confirmed these clinical results.

CONCLUSIONS

The BION-system and chronic pudendal nerve stimulation seem to be alternatives to sacral neuromodulation, however, patient selection is difficult as subchronic stimulation for a longer period of time is not possible so far.

[Overactive bladder syndrome in children]

According to recent terminology, the symptom complex of frequency and urgency with or without urge incontinence in childhood is called overactive bladder. The main etiologic factor seems to be a delayed maturation of complex neuroanatomic structures responsible for normal bladder control. Afflicted children show a typical pattern of reflex voiding with different degrees of severity. In many cases nocturnal incontinence is the main complaint and this may lead to the wrong diagnosis of nocturnal enuresis with resulting false treatment. The diagnostic work-up consists of standardized evaluation of children with enuresis and voiding dysfunction and should concentrate on the exclusion of any possible underlying neurological disorder. Treatment focuses primarily on behavioral modification and cognitive education with regard to bladder sensation and voluntary micturition. Muscarinic receptor antagonists are very useful as supportive medical treatment with a rather low rate of adverse effects. Children who fail to respond to treatment or children suffering from side effects can profit from alternative treatment modalities including biofeedback programs, pelvic floor stimulation, or acupuncture.

[Biofeedback for urinary bladder dysfunctions in childhood. Indications, practice and the results of therapy]

In children, abnormal behavior during micturition, i.e. detrusor/sphincter dyscoordination, causes persistent voiding problems, urinary incontinence and/or recurrent urinary tract infections in up to 15% of cases. Contractions of the external urethral sphincter during micturition lead to functional subvesical obstruction. Nowadays, biofeedback training is the most suitable therapy. Biofeedback training for children is based on the assumption that relaxation and contraction of the urinary external sphincter is a habitual phenomenon and can be restored. With specially developed, computer-assisted biofeedback programs, sphincter contraction and relaxation can be transformed into acoustic or visual signals. Acoustic or optical feedback indicates relaxation and contraction control to the patient. The residual urine volume should subsequently be assessed. The results should be reviewed after each micturition. Poor compliance sometimes makes biofeedback training impossible. Further biofeedback training at home is a reasonable suggestion. Good results-a response rate of up to 90%-demonstrates that biofeedback training is successful in the treatment of detrusor-sphincter dyscoordination. After effective therapy, associated urinary tract infections and vesicoureterorenal reflux may disappear.

Intravesical therapy options for neurogenic detrusor overactivity

STUDY DESIGN

Review article.

SETTING

Neuro-Urology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.

OBJECTIVES

This review considers intravesical treatment options of neurogenic detrusor overactivity and discusses the underlying mechanism of action, clinical safety and efficacy, and the future trends.

METHODS

The available literature was reviewed using medline services.

RESULTS

Oral anticholinergic drugs are widely used to treat detrusor overactivity, but they are ineffective in some patients or cause systemic side effects such as blurred vision or dry mouth. As an alternative, topical therapy strategies have been suggested to achieve a profound inhibition of the overactive detrusor and to avoid high systemic drug levels. Currently available intravesical treatment options either act on the afferent arc of the reflex such as local anaesthetics or vanilloids or on the efferent cholinergic transmission to the detrusor muscle such as intravesical oxybutynin or botulinum toxin. Although an established and effective therapy, intravesical oxybutynin is not widely used. Evidence for clinical significance of intravesical atropine and local anaesthetic is missing. Intravesical capsaicin has been shown to improve clinical and urodynamic parameters, but cause pain in some patients. The intravesical instillation of resiniferatoxin and the injection of botulinum-A toxin into the detrusor muscle are promising new options; however, randomised placebo-controlled studies to prove their safety and efficacy are still missing.

CONCLUSION

Intravesical treatment strategies in patients with neurogenic detrusor overactivity may provide alternatives to established therapies such as oral anticholinergics. The selectivity of the intravesical treatment and the reduction or even the absence of side effects are major advantages of this topical approach.

Reversal of hypertonic co-contraction after bilateral pallidal stimulation in generalised dystonia: a clinical and electromyogram case study

In a patient of generalised dystonia treated with bilateral pallidal stimulation, serial surface EMGs recorded from the neck muscles during alternating head movements revealed progressive reduction in hypertonic activity and reversal of co-contraction to reciprocal contraction, which preceded clinical improvement.

Rehabilitation of partially edentulous patient with loss of vertical dimension

A case of rehabilitation of an edentulous patient with loss of vertical dimension is presented here. This patient presents with a Class III dental and skeletal malocclusion with an anterior cross-bite. The objective of this case report is to demonstrate that an accurate assessment of vertical dimension is necessary for good rehabilitation. The original vertical dimension was determined by a series of tests including, kinesiographic, electromyographic and transcutaneous electronic neural stimulation (TENS). Subsequently, the lost vertical dimension was re-established orthodontically. These examinations revealed a general hypertonicity of masticatory muscles due to the lost vertical dimension. Additionally, radiographs of the temporomandibular joint showed anteriorly displaced condyles. Following the completion of orthodontic treatment osseointegrated implants were placed to restore the dental arches.

Erste Ergebnisse der peripheren Neuromodulation nach Stoller (SANS) bei Blasenfunktionsst�rungen

PURPOSE

The Stoller peripheral neurostimulation (SANS) is a new therapeutic procedure for bladder dysfunction.

MATERIAL AND METHODS

Each of 11 patients (8 women, 3 men) underwent 12 SANS treatment sessions.

INDICATIONS

overactive bladder (5 patients), chronic nonobstructive urinary retention (3 patients) and pelvic pain (3 patients). Median follow-up was 3 months.

RESULTS

In 2 overactive bladder patients, the number of voids was reduced by at least 50%. In one patient with chronic retention, residual urine was temporarily decreased to <100 cc. 2 pelvic pain patients reported a slight improvement. In summary, 50% of the patients demonstrated a temporary response. Only 2 overactive bladder patients reported a permanent objective and subjective improvement. No complications were observed.

CONCLUSION

As the success rate was low and the procedure is time-consuming, we recommend the SANS procedure only in selected cases. We perform SANS treatment only in patients with overactive bladder refractory to conservative treatment. Prerequisites for a successful treatment is a high patient motivation.

Conditional stimulation of the dorsal penile/clitoral nerve may increase cystometric capacity in patients with spinal cord injury

AIMS

To investigate the feasibility of conditional short duration electrical stimulation of the penile/clitoral nerve as treatment for detrusor hyperreflexia, the present study was initiated.

METHODS

Ten patients with spinal cord injury, 4 women and 6 men, with lesions at different levels above the sacral micturition center had a standard cystometry performed. During a subsequent cystometry, conditional short duration electrical stimulation of the penile/clitoral nerve was performed as treatment for one or more detrusor hyperreflexic contractions.

RESULTS

In all patients, at least one contraction (mean, 7.8; range, 1-16 contractions) was inhibited by the stimulations. The mean cystometric capacity was increased significantly by conditional electrical stimulation, from 210 mL in the control cystometries to 349 mL in the stimulation cystometries (P=0.016). The maximal detrusor pressure during the first contraction in the control cystometries was mean 51 cm H(2)O, whereas the maximal pressure of the first contraction in the stimulation cystometries was reduced to mean 33 cm H(2)O (P=0.045).

CONCLUSIONS

The authors conclude that repeated conditional short duration electrical stimulation significantly increased cystometric capacity in patients with spinal cord injury. The increase was caused mainly by an inhibition of detrusor contractions. The need for a reliable technique for chronic bladder activity monitoring is emphasized, as it is a prerequisite for clinical application of this treatment modality.

The use of casts in the management of joint mobility and hypertonia following brain injury in adults: a systematic review

Many controversies exist regarding the practicality, the theoretical premises, and the supporting evidence for the use of casts in the management of joint hypomobility and hypertonia (ie, increase in joint resistance to passive movement resulting from hyperactivity of the stretch reflex and/or changes in the muscles and connective tissues). The purpose of this review was to determine current best practice for the use of casting in the rehabilitation of adults with brain injury. A systematic review was undertaken to find studies that quantified the effectiveness of casting in adults with brain injury. Thirteen articles that presented experimental or case report evidence on casting were analyzed using Sackett's levels of evidence and were examined for scientific rigor. A grade B recommendation is given for the use of casting to increase passive range of motion or to prevent its loss, and implications for further research are provided.

[Overactive bladder--which diagnosis investigations are necessary before initiating primary treatment?]

The symptom complex of frequency and urgency with or without urge incontinence is termed overactive bladder (OAB) according to the new definition by the International Continence Society. The background for this change in definition is the great economic and social importance of the disease, the rising costs in medicine, and the tendency to develop the simplest possible therapeutic strategies. Therapy consists of the administration of an anticholinergic/spasmolytic drug for at least 3 months. Although a great percentage of patients with OAB can be clinically identified, the required exclusion of "local pathologic and metabolic factors" calls for a minimal diagnostic program to come to fairly exact findings. This includes a detailed case history with standardized and evaluated questionnaires, a bladder diary, detailed clinical examination, urine analysis consisting of microscopic and microbiologic examination, uroflowmetry including measurement of residual urine, and examination of the kidneys and the upper urinary tract (determination of creatine and sonography). Minimally invasive tests to improve validity regarding obstruction and detrusor overactivity are being developed. These tests are intended to make an invasive pressure-flow study unnecessary. However, using the above-described minimal diagnostic program, one has to take into account that patients suffering from complaints without underlying idiopathic detrusor overactivity and with urgency/urge incontinence due to bladder outlet obstruction are referred for primary therapy with anticholinergic/antispastic drugs. In cases of neurologic signs, pathologic urinary findings, reduced urinary flow rate with residual urine, and problems of the upper urinary tract, further diagnostic studies are necessary. In any case, such patients need not undergo primary therapy on the basis of a clinical diagnosis. An ex iuvantibus therapy with anticholinergic drugs--even if limited to 3 months--is not acceptable if the diagnostic minimal program is not used.

[When is a urodynamic investigation indicated for overactive bladder?]

Overactive bladder (OAB) is generally not disease specific. Symptoms are frequency, nocturia, and urgency with or without urge incontinence. The prevalence of 16.6%, evaluated in six European countries, is surprisingly high. Causes for overactive bladder are an increase of sensory stimulation and/or a decrease of sensory threshold of the bladder or a disproportion between strength of afferent stimulation and central inhibition of micturition reflex resulting in detrusor overactivity. Overactive bladder is a symptom-based diagnosis. Urodynamics is an important diagnostic tool in daily routine. Urodynamics encompasses a spectrum of different techniques and is more than just cystometry. Simple cystometry or video cystometry should be carried out after evaluation with a frequency volume chart, flow rates, and residuals, mostly by ultrasound. Urodynamic observations should never be discussed separately but always together with history, symptoms, signs, and pathological findings. It is not necessary to perform a filling and voiding cystometry in each patient with symptoms and signs of overactive bladder. Indications for cystometry are prior to invasive therapy or where previous medical or surgical therapy has failed, after pelvic surgery or pelvic irradiation, in patients with signs or symptoms suggestive of an emptying disorder, in neurological disorders, or where there is any doubt about the diagnosis. Diagnostic evaluation of geriatric patients with overactive bladder can usually be accomplished with a basic assessment while invasive procedures should be the exception.

[Continuous bilateral sacral neuromodulation as a minimally invasive implantation technique in patients with functional bladder changes]

OBJECTIVE

Up to 50% of patients with bladder dysfunctions undergoing sacral neuromodulation treatment are non-responders. The most common treatment method today is the implantable neuromodulation system described by Tanagho and Schmidt; which allows unilateral sacral nerve stimulation. Our aim was to increase the number of responders and to improve the general efficiency of chronic sacral neuromodulation; therefore we have developed the bilateral electrode implantation by minimally invasive laminectomy.

METHODS

PNE-tests were carried out to assess which patients were likely to be good responders. Thirty patients (16 with detrusor instability, 14 with hypocontractile detrusors) were subjected to minimally invasive laminectomy and received implants of bilateral electrodes.

RESULTS

In those patients with a hyopcontractile detrusor, the level of residual urine of initially 350 ml was reduced to 58 ml, and the maximum detrusor pressure during micturition increased from initially 12 cMH2O to 34 cmH2O. In the other patient group with detrusor instability, the average number of incontinence incidences could be reduced from initially 7.2 to 1 per day, while the bladder capacity rose from 198 ml to 348 ml. The modulation effect did not show any signs of deteriorating in any of the patients. The follow-up period was 28 months on average.

CONCLUSIONS

Clinical experience has shown that optimal neuromodulation in patients with bladder dysfunction can be achieved by this new approach involving bilateral electrode implantation. Moreover, the laminectomy implantation method guarantees a minimum of invasive trauma and enables optimal placement and fixation of the electrode.

[Conservative and surgical therapy of urinary incontinence and bladder complaints in the man]

Treatment of incontinence and bladder complaints in the male should be directed to the cause whenever possible. Frequently, however, only symptomatic therapy is possible. Urge incontinence or overactive bladder due to obstruction should primarily be treated by eliminating the obstruction. Medical and surgical treatment methods are available for benign prostatic hyperplasia, bladder neck hypertrophy and prostatic cancer. In contrast, bladder neck sclerosis and uretheral strictures can only be treated surgically. Anticholinergics are primarily indicated if urge symptoms/incontinence persist after obstruction has been relieved or if urge incontinence occurs without obstruction. Seldom, in special cases injection of Botulinustoxin A or augmentation of the bladder may be indicated. Another possible cause of urge symptoms is urinary tract infection. This should be adequately treated according to resistance studies and the cause of the infection determined. In cases of overflow incontinence the infravesicle obstruction must be sought and treated. If limited detrusor contractability is the cause of overflow incontinence and the bladder cannot be emptied through pressmicturition, parasympathicometics may be of help. By insufficient effect, the procedure of intermittent self-catheterization must be taught. If this is not possible, the last resort is placement of a transuretheral or percutaneous catheter for continuous drainage. Stress incontinence is a rare complication in men, usually following prostatic surgery. It can be treated conservatively with pelvic floor training and alpha-adrenergic receptor agonists and if necessary surgically with submucosal collagen or silicon injections in the sphincter area or implantation of a sphincter prosthesis. Supravesicular urinary diversion is occasionally necessary after conservative and less invasive surgical measures have been exhausted and symptomatic suffering persists. Neurogenic disturbances in bladder capacity and/or emptying can be treated conservatively, medically, surgically or a combination of these depending upon the site of the lesion and the resulting urodynamic patterns.

Effects of subthalamic nucleus stimulation on urodynamic findings in patients with Parkinson's disease

PURPOSE

Although the effects of subthalamic nucleus stimulation on the control of motor symptoms in patients with Parkinson's disease have been demonstrated, to our knowledge there are no data on effects of this treatment on voiding. We evaluated differences in urodynamic findings in patients with Parkinson's disease during on and off subthalamic nucleus stimulation status.

MATERIALS AND METHODS

We evaluated 3 males and 2 females with Parkinson's disease. All patients had undergone surgical bilateral implantation of subthalamic nucleus electrodes 4 to 9 months before our observation. Urodynamic evaluation was performed during chronic subthalamic nucleus stimulation and 30 minutes after turning off the stimulators. Certain parameters were evaluated, including bladder compliance and capacity, first desire to void volume, bladder volume of appearance (reflex volume) and amplitude of detrusor hyperreflexic contractions, maximum flow, detrusor pressure at maximum flow and detrusor-sphincter coordination. Results were compared statistically.

RESULTS

Statistically significant differences in urodynamic data obtained during on and off subthalamic nucleus stimulation status were noted. In particular bladder capacity and reflex volume were increased for on status (median 320 versus 130 ml., p = 0.043 and 250 versus 110, p = 0.043, respectively). The amplitude of detrusor hyperreflexic contractions was decreased for on status but the difference was not significant (median 23 versus 37 cm. H2O, p = 0.223). No differences were noted in the other urodynamic parameters considered during the filling and voiding phases.

CONCLUSIONS

Our experience shows that subthalamic nucleus stimulation seems to be effective for decreasing detrusor hyperreflexia in Parkinson's disease cases. This finding confirms a role for basal ganglia in voiding control.

Clinical efficacy of tolterodine with or without a simplified pelvic floor exercise regimen

OBJECTIVES

To investigate whether the combination of tolterodine plus (Tp) a simple pelvic floor muscle exercise (PFME) program would provide improved treatment benefits compared with tolterodine alone (Ta) in patients with symptoms of overactive bladder (OAB).

METHODS

After a 1-2 week run-in period, 480 patients with symptoms of urinary frequency (> or =8 micturitions/24 hr), urgency, and urge incontinence (> or =1 episode/24 hr), were randomized to receive tolterodine 2 mg bid with or without a simple PFME program for 24 weeks in this multinational study. Treatment efficacy was assessed by comparing the change from baseline in 3-day micturition diary recordings.

RESULTS

After 24 weeks' treatment, in the Ta group the urgency episodes reduced from mean of 4.1 to 1.5 (83% reduction) while in the Tp group the urgency episodes reduced from 4.2 to 2.1 (78.7% reduction). Mean incontinence episodes per day decreased from 3.21 (standard deviation (SD) 3.4) to 0.95 (SD 1.9) in Ta group and from 3.44 (SD 3.4) to 1.25 (SD 2.7) in the Tp group. Similarly, the number of micturition/24 hr were significantly reduced, from 12.78 to 9.20 (27.3% reduction) in the Ta group and from 11.87 to 9.29 (23% reduction) in the Tp group. There was an improvement in the patients' perception of urinary symptoms in 85.9% of patients on Ta and 81.7% patients on Tp PFME. There were no statistically significant differences between the groups with regard to any of the outcome parameters.

CONCLUSIONS

Tolterodine therapy for 24 weeks results in significant improvement in urgency, frequency, and incontinence, however, no additional benefit was demonstrated for a simple PFME program.

[Intercavitary electrical stimulation of the gastrointestinal tract and mucosa with a stand-alone electric stimulator in the treatment of patients in the physicochemical stage of gallbladder disease]

The use of the SAE for the GIT and MC has a stimulating effect on the processes of bile production and secretion for patients with the physical and chemical stage of the gallstone disease. Over a short period of time the SAE for the GIT and MC normalizes the biliary tract motor functions removing the dissynergism of the biliary tract sphincter organ and restoring the sphincter motor functions. The SAE for the GIT and MC has a positive effect on major factors of bile concentration and components ratio aimed at the reduction of lithogenicity and its colloid stability improvement. The intracavitary electrical stimulation with the SAE for the GIT and MC both as a monotherapy and one of the complex anti-relapse methods is an efficient and simple method and has no side effects or complications. Therefore, it may be recommended for the treatment of patients with the physical and chemical stage of the gallstone disease.

Biofeedback therapy expedites the resolution of reflux in older children

PURPOSE

In older children the spontaneous resolution rate of low grade vesicoureteral reflux is low and currently its management is controversial in regard to surgery versus prophylaxis versus observation alone. Bladder dysfunction in children with neurogenic bladders and to a less declarative degree in neurologically intact children has a role in the etiology or persistence of reflux. We determine the impact of biofeedback therapy on neurologically intact children with vesicoureteral reflux and detrusor-sphincter dyssynergia.

MATERIALS AND METHODS

Vesicoureteral reflux was detected by voiding cystourethrography in children evaluated for urinary tract infections. Children with breakthrough infections or dysfunctional voiding based on history underwent uroflowmetry with concomitant patch electromyography of the external sphincter. Dyssynergia was defined as increased or steady electromyography activity during micturition. Biofeedback was initially performed weekly and the interval increased as indicated. The goals were to eliminate dyssynergia and reduce or eliminate post-void residual urine. Voiding cystourethrography was performed 1 year later to determine the status of the reflux. Ureteral reimplantation was performed during the period of biofeedback when indicated.

RESULTS

From February 1997 to March 2001, 25 children 6 to 10 years old (mean age 9) with vesicoureteral reflux and detrusor-sphincter dyssynergia were treated with biofeedback therapy. There were 31 units (5 bilateral) with reflux, which was grade I in 10, II in 15, III in 5 and IV in 1. Children underwent an average of 7 sessions of biofeedback (range 2 to 20). On followup voiding cystourethrography, vesicoureteral reflux resolved in 17 units (55%), grade improved in 5 (16%) and reflux remained unchanged in 9 (29%). All cured vesicoureteral reflux was grade I (8 cases) or II (9). Four children (5 renal units) underwent reimplantation. In cured children there were no breakthrough infections during or since therapy and post-void residual urine decreased from an average of 40% before to 10% after therapy. Symptoms of urgency, daytime wetting and hoarding of urine improved or were eliminated in all children with resolved vesicoureteral reflux.

CONCLUSIONS

Treating external detrusor-sphincter dyssynergia in older children with low grade vesicoureteral reflux, with biofeedback results in 1-year resolution rates that are considerably greater than historical resolution rates. External detrusor-sphincter dyssynergia should be screened for in children when surgery or discontinuation of chemoprophylaxis is considered so that biofeedback can be started.

Treatment of detrusor-sphincter dyssynergia by pudendal nerve block in patients with spinal cord injury

OBJECTIVE

To study the effects of pudendal nerve block with phenol on detrusor-sphincter dyssynergia in patients with spinal cord injury (SCI).

DESIGN

Before-after trial performed by using a consecutive sample.

SETTING

Rehabilitation hospital affiliated with a medical school.

PATIENTS

Twenty-two male SCI patients (mean age, 46.3+/-11.9y; mean duration postinjury, 2.7y) with voiding dysfunction resulting from external urethral sphincter hypertonicity.

INTERVENTION

Pudendal nerve block with 5% phenol solution under the guidance of electric stimulator.

MAIN OUTCOME MEASURES

Outcomes were measured using (1) postvoid residual volume, maximal detrusor pressure, leak point pressure, bladder volume at the first uninhibited contraction, maximal bladder capacity, and urethral pressure profile; (2) rectoanal rest and squeeze pressures; and (3) quality of life measures for urination, quantified by the Quality of Life Index (QLI). Changes in bowel habit or autonomic dysreflexia were recorded.

RESULTS

The mean decrease in postvoid residual volume was 242.8mL (mean decrease, 66%) after treatment (P<.001). The mean reduction in leak point pressure and maximal detrusor pressure were 37.1cmH(2)O and 43.3cmH(2)O, respectively (P<.05). The mean QLI significantly improved from -.74+/-.38 to.42+/-.47 (P<.001). The rectoanal pressures showed no significant difference. No complaints of fecal incontinence or other complications were noted after treatment.

CONCLUSION

Pudendal nerve block performed by using 5% phenol solution was safe, easy to perform, and effective as a treatment for detrusor-sphincter dyssynergia in selected patients with SCI.

Bladder injection of "naked" hSlo/pcDNA3 ameliorates detrusor hyperactivity in obstructed rats in vivo

The goal of these studies was to examine the potential utility of bladder instilled K+ channel gene therapy with hSlo cDNA (i.e., the maxi-K channel) to ameliorate bladder overactivity in a rat model of partial urinary outlet obstruction. Twenty-two female Sprague-Dawley rats were subjected to partial urethral (i.e., outlet) obstruction, with 17 sham-operated control rats run in parallel. After 6 wk of obstruction, suprapubic catheters were surgically placed in the dome of the bladder in all rats. Twelve obstructed rats received bladder instillation of 100 microg of hSlo/pcDNA in 1 ml PBS during catheterization, and another 10 obstructed rats received 1 ml PBS (7 rats) or 1 ml PBS containing pcDNA only (3 rats). Two days after surgery cystometry was performed on all animals to examine the characteristics of the micturition reflex in conscious and unrestrained rats. Obstruction was associated with a three- to fourfold increase in bladder weight and alterations in virtually every micturition parameter estimate. PBS-injected obstructed rats routinely displayed spontaneous bladder contractions between micturitions. In contrast, hSlo injection eliminated the obstruction-associated bladder hyperactivity, without detectably affecting any other cystometric parameter. Presumably, expression of hSlo in rat bladder functionally antagonizes the increased contractility normally observed in obstructed animals and thereby ameliorates bladder overactivity. These initial observations indicate a potential utility of gene therapy for urinary incontinence.

Managing incontinence due to detrusor instability

Urinary incontinence affects around 3.5 million people of all ages in the UK. For many, incontinence severely restricts their routine activities and damages their quality of life and self-esteem. In about one-third of women sufferers, and around a half of all men with incontinence, the cause is detrusor instability. This condition is characterised by involuntary bladder contractions or pressure rises during bladder filling, which result in a strong or uncontrollable urge to pass urine and, often, incontinence. Here, we consider a primary care-based approach to managing urinary incontinence in adults, concentrating on the medical management of detrusor instability.

[Treatment of dyskinetic disorders with tremor by lesioning and DBS of Vim]

OBJECTIVE

To explore the effect of stereotactic operation in treatment of dyskinetic disorders with tremor as the main symptom and to study the value of anatomic location and microelectrode functional location.

METHODS

Surgiplan system and microelectrode direction technique were used to locate the Vim, and then target lesioning and deep brain simulation (DBS) were performed in 22 patients with dyskinetic disorders with tremor. After the operation, a follow-up was conducted for 6 approximately 12 months.

RESULTS

After the operation, tremor disappeared in 21 patients and hypermyotonia was improved in 13 cases. During the follow-up tremor completely disappeared in 18 patients, including 3 cases treated with DBS, was markedly alleviated in 3 cases and was slightly improved in one case. Typical cell firing at tremor was recorded in 17 cases during the operation.

CONCLUSION

The surgiplan system and microelectrode recording technique play an important role in location of Vim. Accurate location is crucial for success of operation. The curative effect of DBS is similar as lesioning operation.

A crossover randomized trial of transcutaneous electrical nerve stimulation and oxybutynin in patients with detrusor instability

PURPOSE

Management of idiopathic detrusor instability is difficult in most patients mainly due to the lack of a complete understanding of the pathophysiology. Oxybutynin and transcutaneous electrical nerve stimulation have been used but to our knowledge no direct comparisons have been made.

MATERIALS AND METHODS

Patients with frequency, urgency, urge incontinence and proved detrusor instability were studied with urodynamics, quality of life instruments, and frequency and volume charts. Patients were randomized to transcutaneous electrical nerve stimulation or oxybutynin. After 6 weeks of treatment, they were reassessed and after a washout of 2 weeks, they were started on the second arm of treatment and reassessed 6 weeks later.

RESULTS

A total of 13 male and 30 female patients were studied. Functional capacity had increased and number of voids daily had decreased significantly compared with before treatment in both arms (p <0.005). There were significant improvements in symptom specific quality of life measures but no changes were found on the global Short Form 36 (SF-36) quality of life questionnaire. The volume to first desire to void and first unstable contraction had increased significantly with oxybutynin but not with transcutaneous electrical nerve stimulation. Of 23 patients 7 were stabilized with treatment, including 2 with oxybutynin only, 2 with either nerve stimulation or oxybutynin and the remaining 3 with only nerve stimulation. Total bladder capacity did not change significantly with either treatment but patients noticed side effects more commonly with oxybutynin.

CONCLUSIONS

Both treatments clearly improved subjective parameters. However, only oxybutynin showed significant improvements in objective urodynamic parameters. Transcutaneous electrical nerve stimulation can be used in patients who cannot take oxybutynin. Further studies are needed to show the long-term efficacy and cost analyses of nerve stimulation.