Understanding Therapeutic Benefits of Overground Bionic Ambulation: Exploratory Case Series in Persons With Chronic,Complete Spinal Cord Injury

Objective

To explore responses to overground bionic ambulation (OBA) training from an interdisciplinary perspective including key components of neuromuscular activation, exercise conditioning, mobility capacity, and neuropathic pain.

Design

Case series.

Setting

Academic research center.

Participants

Persons (N=3; 2 men, 1 woman) aged 26 to 38 years with complete spinal cord injury (SCI) (American Spinal Injury Association Impairment Scale grade A) between the levels of T1 and T10 for ≥1 year.

Intervention

OBA 3d/wk for 6 weeks.

Main Outcome Measures

To obtain a comprehensive understanding of responses to OBA, an array of measures were obtained while walking in the device, including walking speeds and distances, energy expenditure, exercise conditioning effects, and neuromuscular and cortical activity patterns. Changes in spasticity and pain severity related to OBA use were also assessed.

Results

With training, participants were able to achieve walking speeds and distances in the OBA device similar to those observed in persons with motor-incomplete SCI (10-m walk speed, .11–.33m/s; 2-min walk distance, 11–33m). The energy expenditure required for OBA was similar to walking in persons without disability (ie, 25%–41% of peak oxygen consumption). Subjects with lower soleus reflex excitability walked longer during training, but there was no change in the level or amount of muscle activity with training. There was no change in cortical activity patterns. Exercise conditioning effects were small or nonexistent. However, all participants reported an average reduction in pain severity over the study period ranging between −1.3 and 1.7 on a 0-to-6 numeric rating scale.

Conclusions

OBA training improved mobility in the OBA device without significant changes in exercise conditioning or in neuromuscular or cortical activity. However, pain severity was reduced and no severe adverse events were encountered during training. OBA therefore opens the possibility to reduce the common consequences of chronic, complete SCI such as reduced functional mobility and neuropathic pain.     

Increased Participation in Activities of Daily Living Is Associated With Lower Cholesterol Levels in People With Spinal Cord Injury

Hetz SP, Latimer AE, Martin Ginis KA, Buchholz AC, and the SHAPE-SCI Research Group. Increased participation in activities of daily living is associated with lower cholesterol levels in people with spinal cord injury.

Objective

To evaluate the relationships between activities of daily living (ADLs) participation and coronary heart disease (CHD) risk factors in people with spinal cord injury.

Design

Cross-sectional.

Setting

Community, university, hospital.

Participants

Participants (N=75) from the Study of Health and Activity in People With Spinal Cord Injury study (61 men, 14 women).

Interventions

Not applicable.

Main Outcome Measures

Physical Activity Recall Assessment for People With Spinal Cord Injury and CHD risk factor assessment including waist circumference, total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol, and triglycerides.

Results

Using generalized linear models, and controlling for leisure time physical activity and covariates, increased Mobility ADLs (transferring and wheeling) were associated with lower plasma total cholesterol and LDL. No other significant relationships emerged.

Conclusions

Mobility ADLs were associated with lower total cholesterol and LDL. However, neither Total ADLs nor Domestic ADLs were associated with CHD risk. Further investigation is needed to determine causality between Mobility ADLs and CHD risk.     

Short Versus Long Course of Antibiotics for Catheter-Associated Urinary Tract Infections in Patients With Spinal Cord Injury: A Randomized Controlled Noninferiority Trial

Objective

To assess the applicability of a short-course regimen of antibiotics for managing catheter-associated urinary tract infection (CA-UTI) in patients with spinal cord injury (SCI).

Design

Randomized, controlled, noninferiority trial.

Setting

Medical center.

Participants

Patients with SCI who had CA-UTI (N=61).

Interventions

Patients were randomized to receive either a 5-day regimen of antibiotics after catheter exchange (experimental group) or a 10-day regimen of antibiotics with catheter retention (control group). Noninferiority was prespecified with a margin of 10%.

Main Outcome Measure

Clinical cure at the end of therapy.

Results

Of the 61 patients enrolled in this study, 6 patients were excluded because of bacteremia or absence of urinary symptoms. All patients (100%) achieved clinical cure at the end of therapy. The rates of microbiologic response were 82.1% in the experimental group and 88.9% in the control group (upper boundary 95% confidence interval (CI) for difference, 26%). The rates of resolution of pyuria were 89.3% in the experimental group and 88.9% in the control group (upper boundary 95% CI for difference, 16%). Patients in the experimental group had higher rates of CA-UTI recurrence than the control group. The rates of new CA-UTI, diarrhea, and Clostridium difficile colitis were similar in the 2 treatment arms.

Conclusions

The primary endpoint of the study was met, indicating that the 5-day regimen with catheter exchange was noninferior to the 10-day regimen with catheter retention on the basis of clinical cure. Criteria for noninferiority on the basis of microbiologic response and resolution of pyuria were not met.     

A Randomized Controlled Trial on the Effects of Cycling With and Without Electrical Stimulation on Cardiorespiratory and Vascular Health in Children With Spinal Cord Injury

Johnston TE, Smith BT, Mulcahey MJ, Betz RR, Lauer RT. A randomized controlled trial on the effects of cycling with and without electrical stimulation on cardiorespiratory and vascular health in children with spinal cord injury.

Objective

To examine the cardiorespiratory/vascular effects of cycling with and without functional electrical stimulation (FES) in children with spinal cord injury (SCI).

Design

Randomized controlled trial.

Setting

Pediatric referral hospital.

Participants

Children with SCI (N=30), ages 5 to 13 years, with injury levels from C4 to T11, and American Spinal Injury Association grades A, B, or C.

Interventions

Children were randomly assigned to 1 of 3 groups: FES leg cycling exercise, passive leg cycling, or noncycling control group receiving electrical stimulation therapy. After receiving instruction on the use of the equipment, children exercised for 1 hour 3 times per week for 6 months at home with parental supervision.

Main Outcome Measures

Oxygen uptake (V̇o₂) during an incremental arm ergometry test, resting heart rate, forced vital capacity, and a fasting lipid profile.

Results

There were no differences (P>.05) between groups after 6 months of exercise when comparing pre- and postvalues. However, there were differences between groups for some variables when examining percent change. The FES cycling group showed an improvement (P=.035) in V̇o₂ (16.2%±25.0%) as compared with the passive cycling group (–28.7%±29.1%). For lipid levels, the electrical stimulation–only group showed declines (P=.032) in cholesterol levels (–17.1%±8.5%) as compared with the FES cycling group (4.4%±20.4%).

Conclusions

Cycling with FES led to gains in V̇o₂, whereas electrical stimulation alone led to improvements in cholesterol.     

Meta-Analysis of Botulinum Toxin A Detrusor Injections in the Treatment of Neurogenic Detrusor Overactivity After Spinal Cord Injury

Objective

To examine the effectiveness of botulinum toxin type A (BTX-A) on neurogenic detrusor overactivity (NDO) in individuals with spinal cord injury (SCI).

Data Sources

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to June 2012.

Study Selection

Trials examining the use of BTX-A injections into the detrusor wall in the treatment of NDO after SCI were included if (1) ≥50% of study sample comprised subjects post-SCI; (2) outcomes of interest were assessed before and after treatment with a single injection of BTX-A; and (3) the sample size was ≥3.

Data Extraction

A standardized mean difference ± SE (95% confidence interval) was calculated for at least 1 of the following outcomes in every study: postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, catheterization frequency, and maximum flow rate. Results from all studies were then pooled using a random-effects model. Treatment effect sizes were interpreted as small, >0.2; moderate, >0.5; or large, >0.8.

Data Synthesis

Fourteen studies representing data from 734 subjects were included. After BTX-A injection, large treatment effects were observed in postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, and catheterization frequency (P<.01). Rate of incontinence episodes was reduced from 23% to 1.31% after BTX-A treatment. No significant decrease in max flow rate was observed (P=.403).

Conclusions

Results of the meta-analysis indicate BTX-A is effective in treating NDO after SCI. The use of BTX-A was associated with a decrease in incontinence episodes, catheter use, and bladder pressures.     

Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study

OBJECTIVE: To describe, in a group of patients undergoing initial inpatient rehabilitation after nontraumatic spinal cord injury (SCI), the demographic characteristics, clinical features, and outcomes, with a focus on the functional status and disability. DESIGN: Retrospective data analysis, 3-year case series. SETTING: Tertiary medical unit specializing in nontraumatic SCI rehabilitation. PARTICIPANTS: Consecutive sample of 70 adult inpatient referrals with nontraumatic SCI undergoing initial inpatient rehabilitation. INTERVENTION: Chart review. MAIN OUTCOME MEASURES: Primary outcomes were demographic characteristics, clinical features, mortality, length of stay (LOS), neurologic classification, accommodation setting, support services, mobility, bladder and bowel continence, and FIM instrument scores. RESULTS: Forty-one patients (58.6%) were paraplegic incomplete, 23 (32.9%) were tetraplegic incomplete, and 6 (8.6%) were paraplegic complete. Eight patients (11.4%) died before hospital discharge. Of those who survived, 47 (75.8%) were discharged home, 11 (17.7%) were transferred to a nursing home, and 4 (6.4%) went elsewhere in the community. The geometric mean LOS was 55.8 days. Nine patients (14.5%) were discharged walking unaided, 27 (43.5%) were walking at least 10 m with a gait aid, and 26 (41.9%) were wheelchair dependent for mobility. Thirty patients (48.4%) were voiding on sensation, 7 (11.1%) used intermittent catheterization, 23 (37.2%) had an indwelling catheter, and 2 (2.8%) used reflex voiding. Eleven patients (17.7%) were fecally continent on sensation and 47 (75.8%) were fecally continent with a bowel program, 1 patient (1.6%) had a colostomy, and 3 patients (4.8%) were discharged fecally incontinent. The mean Rasch FIM motor score was 39.6 on admission and 58.7 at discharge (paired t test, t=-11.2; P<.000). CONCLUSIONS: Most nontraumatic SCI patients returned home with a good level of functioning regarding mobility, bladder, and bowel status, in comparison to other studies of patients with SCI. Patients' disability was usually significantly reduced during rehabilitation.