Randomized trial of sildenafil for the treatment of erectile dysfunction in spinal cord injury. Sildenafil Study Group.

Erectile dysfunction is a common complication of spinal cord injury. This double-blind, placebo-controlled, two-way crossover study assessed the efficacy and safety of oral sildenafil in men with erectile dysfunction caused by traumatic spinal cord injury. A total of 178 men (mean age, 38 years) received placebo or sildenafil 1 hour before sexual activity for 6 weeks; after a 2-week washout period, the men received the alternate treatment for 6 weeks. The 50-mg starting dose could be adjusted to 100 or 25 mg based on efficacy and tolerability. Efficacy was assessed by using global efficacy questions, the International Index of Erectile Function (IIEF), and a patient log of erectile activity. Of 143 men with residual erectile function at baseline, 111 (78%) reported improved erections and preferred sildenafil to placebo. For all men (including those who reported no residual erectile function at baseline), 127 of 168 (76%) reported improved erections and preferred sildenafil to placebo. For all men, 132 of 166 (80%) reported that sildenafil improved sexual intercourse compared with 17 of 166 men (10%) reporting improvement with placebo. IIEF questions assessing the ability to achieve and maintain erections and satisfaction with sexual intercourse demonstrated significant improvement with sildenafil. Sildenafil was well tolerated, with a low rate of discontinuation because of treatment-related adverse events (2% vs 1% for placebo). Oral sildenafil is an effective and well-tolerated treatment for erectile dysfunction caused by spinal cord injury.     

Measuring seating pressure,area, and asymmetry in persons with spinal cord injury

The goal of this study was to measure characteristics of seat loading in manual wheelchair users with complete spinal cord injury (SCI). Pressure distribution on the seating area of 25 adult males with SCI and eight non-injured adult males was measured in a relaxed and an upright posture on a standardized hard surface. Subjects with SCI were also tested in their wheelchairs. Maximum pressure, contact area, area of the highest pressure, and three asymmetry indices were compared. Subjects with SCI have higher pressure distributed over a smaller area, have a much smaller contact area, and distribute the loading more asymmetrically than non-injured subjects. Upright posture only corrects for some loading problems, while the wheelchair corrects for more loading parameters. Routine clinical seat loading evaluation may lead to improved chair and cushion selection for patients with SCI and may even alert clinicians to patients at high risk for complications due to high or unbalanced loads.     

Rehabilitation engineering

Abstracts

Rehabilitation engineering     

In-vitro fertilization and intracytoplasmic sperm injection in the treatment of infertility after testicular cancer

Treatment of testicular cancer (TC) may cause infertility due to reduced sperm quality with or without an ejaculation problem. In cases of anejaculation or retrograde ejaculation, spermatozoa can be obtained by transrectal electroejaculation (TE) or testicular sperm extraction (TESE) and used for in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). In this study, 15 out of 17 couples evaluated for infertility after TC, underwent a total of 21 treatment cycles, resulting in 18 embryo transfers. Spermatozoa were obtained by TE in 16 cycles, by masturbation in three cycles and by TESE in one. In one cycle no spermatozoa were found using TESE. Fertilization and cleavage was achieved by IVF in seven cycles and ICSI in 11 cycles; average fertilization rates of 57 and 55% respectively were observed. Twelve clinical pregnancies occurred, of which 11 have been delivered or are ongoing. The ongoing pregnancy rate was 57% per cycle. These results show that infertility after testicular cancer can be treated effectively with IVF and that ICSI even permits treatment of patients who have severe oligozoospermia.      

The prevalence of neuropathic pain after non-traumatic spinal cord lesion

STUDY DESIGN: Retrospective register study. OBJECTIVE: To investigate the predictive value of the following parameters for the development of neuropathic pain after non-traumatic spinal cord lesion: that is age at onset of spinal cord disease, gender, completeness of lesion, level of lesion, and aetiology. SETTING: A unit for patients with post-acute traumatic and non-traumatic spinal cord lesions in the greater area of Stockholm, Sweden. METHOD: All patients with non-traumatic spinal cord lesions visiting the unit between 1995 and 2000 were classified according to the following: that is neuropathic pain at or below lesion level according to IASP criteria, age at time of the onset of the spinal cord symptoms, injury level, complete/incomplete injury, and aetiology. Results were analysed with chi(2) - analysis and logistic regression. RESULTS: In total, 38% had neuropathic pain, 15% had pain predominantly at the level of lesion, and 23% predominantly below the level of lesion. Of those with pain, 67% reported that the pain affected daily life. Women reported neuropathic pain below the level of lesion more often (40%) than men (13%). The prevalence was particularly high (64%) for patients with malignant spinal cord diseases. Neither age at onset of the spinal cord symptoms, nor complete/incomplete injury nor injury level had significant influence on the prevalence. CONCLUSION: Neuropathic pain is common among patients with acquired non-traumatic spinal cord lesions regardless of aetiology, often causing severe problems in daily life.     

Semen retrieval and analysis in men with myelomeningocele

The introduction of advanced assisted reproduction technologies (ART) has created opportunities for the treatment of infertility among patients with myelomeningocele (MMC). The aim of this study was to assess the possibility of semen retrieval and to analyse the semen quality in men with MMC. Nine men, aged 22 to 39 with MMC participated in the study. Two participants were able to achieve unassisted ejaculation. Vibratory stimulation was unsuccessfully attempted in the remaining seven participants who then underwent electroejaculation under general anaesthesia. In total, enough spermatozoa for intracytoplasmic spermatozoa injection were retrieved from five participants. In four cases, no spermatozoa were observed in the ejaculates. Testicular biopsies, however, revealed spermatogenesis, and thus a reproductive potential, in one of these men. Therefore, in six of the nine men with MMC, fatherhood seemed possible with modern ART, despite the semen quality generally being very poor.     

Prevalence of postpartum depression and anxiety among women with spinal cord injury

Objective: To examine the prevalence of postpartum depression (PPD) and postpartum anxiety (PPA) in mothers with spinal cord injury (SCI).Design: Retrospective, cross-sectional study.Setting: Online multi-national study.Participants: We surveyed an international sample of 102 women who gave birth following cervical SCI (C1–C8, n = 30), upper thoracic SCI (T1–T6, n = 12) or lower level SCI (T7 & below, n = 60). Participants were primarily from Canada and Sweden, and mean age at childbirth was 30 ± 6 years.Outcome Measures: Subscales from the Pregnancy Risk Assessment Monitoring System (PRAMS) were used to measure PPD (PRAMS-3D) and PPA (PRAMS-2A).Results: PPD and PPA were most prevalent in women with cervical SCI, followed by upper thoracic SCI then lower SCI. Self-reported PPD was more prevalent than clinically diagnosed PPD in women with cervical SCI (P = 0.03) and upper thoracic SCI (P = 0.03). With cervical SCI, 75% of women diagnosed with MDD before pregnancy scored >9 on the PRAMS PPD subscale, indicating clinically relevant PPD. However, only 10% were diagnosed with PPD. Of women with lower SCI diagnosed with MDD before pregnancy, 25% had a clinically relevant score for self-reported PPD; 7% were diagnosed.Conclusions: This is currently the largest study examining PPD and PPA after SCI. Clinicians should be aware that mothers with SCI (particularly high-level SCI) may have increased risk of PPD and PPA. PPD is poorly understood in women with SCI and may even be underdiagnosed. SCI-related risk factors for PPD and PPA should be explored.     

Sitting balance and effects of kayak training in paraplegics.

OBJECTIVES: The objectives of this study were to evaluate biomechanical variables related to balance control in sitting, and the effects of kayak training, in individuals with spinal cord injury. SUBJECTS: Twelve individuals with spinal cord injury were investigated before and after an 8-week training period in open sea kayaking, and 12 able-bodied subjects, who did not train, served as controls. METHODS: Standard deviation and mean velocity of centre of pressure displacement, and median frequency of centre of pressure acceleration were measured in quiet sitting in a special chair mounted on a force plate. RESULTS: All variables differed between the group with spinal cord injury, before training, and the controls; standard deviation being higher and mean velocity and median frequency lower in individuals with spinal cord injury. A significant training effect was seen only as a lowering of median frequency. CONCLUSION: The results indicate that individuals with spinal cord injury may have acquired and consolidated an alternative strategy for balance control in quiet sitting allowing for only limited further adaptation even with such a vigorous training stimulus as kayaking.