Spinal Cord Injury Center Research Articles

Cost-Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries

ObjectiveTo estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs). DesignCost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI. SettingSCI centers in the Veterans Health Administration. ParticipantsSubjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76). InterventionA vocational rehabilitation program of SE for veterans with SCI. Main Outcome MeasuresCosts and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities. ResultsAverage cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care. ConclusionsAn intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.

Comparing Multicomponent Interventions to Improve Skin Care Behaviors and Prevent Recurrence in Veterans Hospitalized for Severe Pressure Ulcers

ObjectiveTo compare a multicomponent motivational interviewing (MI)/self-management (SM) intervention with a multicomponent education intervention to improve skin-protective behaviors and prevent skin worsening in veterans with spinal cord injury (SCI) hospitalized for severe pressure ulcers (PrUs). DesignSingle-blinded, prospective, randomized controlled trial. SettingSix Veterans Affairs SCI centers. ParticipantsVeterans admitted for a severe (stage III/IV) PrU were followed up to 6 months postdischarge. InterventionTelephone-based individual MI counseling plus SM skills group (SM+MI; n=71) versus an active control group of telephone-based individual educational counseling plus group education (n=72). Main Outcome MeasuresSelf-reported skin-protective behaviors, objective skin worsening. ResultsIntention-to-treat analyses found nonsignificant increases in skin behaviors in the SM+MI versus education control intervention arms at 3 and 6 months. The difference in behaviors used between SM+MI and education control intervention participants was 4.6% (95% confidence interval [CI], −11.3 to 2.7) (0–3mo) and 3.0% (95% CI, –8.7 to 3.9) (0–6mo). High rates of skin worsening were observed (n=74, 51.7%), usually within 3 months postdischarge and most frequently within the month postdischarge. Skin worsening, skin-related visits, and readmissions did not differ by study arm. Study limitations are presented. ConclusionsFor persons with chronic SCI and severe PrUs, complicated by multiple comorbidities, a primary focus on improving patient behavior is likely insufficient to address the complex problem of PrUs in SCI. More health care systems–level changes such as collaborative care may be needed to reduce PrU recurrence, especially in this era in which many people are discharged from the hospital unhealed or with little sitting tolerance.

Missed signs of autonomic dysreflexia in a tetraplegic patient after incorrect placement of urethral Foley catheter: a case report

BackgroundAutonomic dysreflexia is poorly recognised outside of spinal cord injury centres, and may result in adverse outcomes including mortality from delayed diagnosis and treatment. We present a spinal cord injury patient, who developed autonomic dysreflexia following incorrect placement of urethral Foley catheter. Health professionals failed to recognise signs and symptoms of autonomic dysreflexia as well as its significance in this tetraplegic patient.Case presentationA tetraplegic patient started sweating profusely following insertion of a Foley catheter per urethra. The catheter was draining urine; there was no bypassing, no bleeding per urethra, and no haematuria. Patient’s wife, who had been looking after her tetraplegic husband for more than forty years, told the health professionals that the catheter might have been placed incorrectly but her concerns were ignored. Ultrasound scan of urinary tract revealed no urinary calculi, no hydronephrosis. The balloon of Foley catheter was not seen in urinary bladder but this finding was not recognised by radiologist and spinal cord physician. Patient continued to sweat profusely; therefore, CT of pelvis was performed, but there was a delay of ten days. CT revealed the balloon of Foley catheter in the over-stretched prostate-membranous urethra; the tip of catheter was not located within the urinary bladder but was lying distal to bladder neck. Flexible cystoscopy was performed and Foley catheter was inserted into the bladder over a guide wire. The intensity of sweating decreased; noxious stimuli arising from traumatised urethra might take a long while to settle.ConclusionInserting a catheter in a tetraplegic patient should be carried out by a senior health professional, who is familiar with spasm of bladder neck which occurs frequently in tetraplegic patients. Facilities for urgent CT scan should be available to check the position of Foley catheter in spinal cord injury patients when a patient manifests signs and symptoms of autonomic dysreflexia following insertion of a urethral catheter. When an isolated symptom such as flushing or sweating is noticed in a tetraplegic patient, doctors should seek out other signs/symptoms of autonomic dysreflexia.

Expectations, Worries and Wishes: The Challenges of Returning to Home after Initial Hospital Rehabilitation for Traumatic Spinal Cord Injury

Literature highlights the barriers and problems that individuals who sustain traumatic spinal cord injury (TSCI) meet when they attempt to resume everyday life after hospital rehabilitation. However, what do patients think about before returning home, and what should professionals encourage patients to address while the patient is hospitalized in order to balance the patient’s expectations and to reveal what is of importance to the patient. This qualitative study explores the expectations, wishes and worries patients have before they return home after hospital rehabilitation due to TSCI. Eight Danish residents aged 25-75 years, admitted for initial rehabilitation at the Spinal Cord Injury Center of Western Denmark, participated in an individual interview before returning home. The transcribed interviews were analyzed according to inductive content analysis. Transversal analyses revealed four categories of barriers and problems: “facing uncertainty when leaving the rehabilitation center and peers”, “hoping to get back to work and safe economy”, “needing understanding from the community”, and “relying on resilience of significant others”. These categories were combined into one major theme: “relations”. The findings indicate that there is a need for professionals to address patients´ close relations and to initiate dialog with patients and their families on how SCI may impact close relations in order to promote a good life on new terms.

The Beginning of a New Life Following Traumatic Spinal Cord Injury- Patient�s Experiences One Month Post-Discharge

Introduction: Studies show that individuals having suffered traumatic spinal cord injury (TSCI) are challenged by barriers and problems in their transition from hospital rehabilitation to home. This study aims to explore patients’ first-hand experiences of returning home and to compare their post-discharge experiences with their pre-discharge expectations. Method: A qualitative follow-up study using inductive contents analysis. One month post-discharge, we re-interviewed seven Danish TSCI-patients, admitted for initial rehabilitation at the Spinal Cord Injury Centre of Western Denmark. Findings: We identified two categories from the interviews: “The body as a fatiguing time-consumer causing dependence”, “The need for timely cooperation and collaboration”. The transversal analyses revealed the overall theme “Timing” highlighting the experiences of returning home. Conclusion: Patients´ early post-discharge period is complicated by lack of timing in establishing training possibilities and providing equipment needed. This has consequences for the individual in terms of setbacks, and it imposes a burden on the patient, partner and close family. Hope of further progress was dominant, while delays threaten this hope for progress. In order to promote a smooth and safe return to home timing seems of crucial importance.

A randomized controlled trial of venlafaxine XR for major depressive disorder after spinal cord injury: Methods and lessons learned

Context/objectiveWe describe the rationale, design, methods, and lessons learned conducting a treatment trial for major depressive disorder (MDD) or dysthymia in people with spinal cord injury (SCI).DesignA multi-site, double-blind, randomized (1:1) placebo controlled trial of venlafaxine XR for MDD or dysthymia. Subjects were block randomized and stratified by site, lifetime history of substance dependence, and prior history of MDD.SettingSix SCI centers throughout the United States.ParticipantsAcross participating centers, 2536 subjects were screened and 133 were enrolled into the trial. Subjects were 18–64 years old and at least 1 month post-SCI.InterventionsTwelve-week trial of venlafaxine XR versus placebo using a flexible titration schedule.Outcome measuresThe primary outcome was improvement in depression severity at 12 weeks. The secondary outcome was improvement in pain.ResultsThis article includes study methods, modifications prompted by a formative review process, preliminary data on the study sample and lessons learned. We describe common methodological and operational challenges conducting multi-site trials and how we addressed them. Challenges included study organization and decision making, staff training, obtaining human subjects approval, standardization of measurement and treatment, data and safety monitoring, subject screening and recruitment, unblinding and continuity of care, database management, and data analysis.ConclusionsThe methodological and operational challenges we faced and the lessons we learned may provide useful information for researchers who aim to conduct clinical trials, especially in the area of medical treatment of depression in people with SCI.

Is undernutrition risk associated with an adverse clinical outcome in spinal cord-injured patients admitted to a spinal centre?

To evaluate whether undernutrition risk measured using the Spinal Nutrition Screening Tool (SNST) and the Malnutrition Universal Screening Tool (MUST) is associated with worse clinical outcomes in respect of length of in-patient hospital stay (LOS) and mortality in the 12 months after admission to a spinal cord injuries (SCIs) centre. A multicentre, prospective, cross-sectional observational study was conducted in four UK SCI centres (SCICs). A total of 150 SCI patients (aged 18-88 years (median: 44 years), 30.7% females) were studied between July 2009 and March 2010. LOS and mortality 12 months after admission to the SCIC was monitored. Multivariate regression analysis was used to identify unique predictors of the variance of LOS. The patients initially undernourished or at risk of undernutrition (44.6%) had a significantly longer LOS (median (days): 129 vs 85, P=0.012) and greater 12-month mortality (% deceased: 9.2% vs 1.4%, P=0.036). In addition, serum albumin and new admission to an SCIC were identified as independent predictors for long LOS. The present study suggests that undernutrition risk, as identified by the SNST, is associated with adverse clinical outcomes. Nutritional screening should be helpful in improving clinical outcomes if it promotes more appropriate and effective nutritional intervention.

Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders.

Management of the neurogenic bladder has the primary objectives of maintaining continence, ensuring low bladder pressure (to avoid renal damage) and avoiding or minimising infection. Options include intermittent urethral catheterisation, indwelling urethral or suprapubic catheterisation, timed voiding, use of external catheter (for men), drug treatment, augmentation cystoplasty and urinary diversion. The primary objective was to determine the effects of different methods of managing long-term voiding problems (persisting after three months) with catheters in patients with neurogenic bladder.Specific hypotheses to be addressed included:1. that intermittent catheterisation is better than indwelling catheterisation;2. that indwelling urethral catheterisation is better than suprapubic catheterisation;3. that external (sheath) catheters are better than indwelling or intermittent urethral catheters;4. that external (sheath) catheters are better than suprapubic catheters;5. that intermittent catheterisation is better than timed voiding. We searched the Cochrane Incontinence Group Specialised Register (searched 3 July 2013), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearched journals and conference proceedings. We sought additional trials from other sources such as the reference lists of relevant articles and by contacting consultants in Spinal Cord Injury Centres throughout the United Kingdom. All randomised and quasi-randomised controlled trials comparing methods of using catheters to manage urinary voiding in people with neurogenic bladder. Abstracts were independently inspected by the reviewers and full papers were obtained where necessary. Approximately 400 studies were scrutinised. No trials were found that met the inclusion criteria, and five studies were excluded from the review. Despite a comprehensive search no evidence from randomised or quasi-randomised controlled trials was found. It was not possible to draw any conclusions regarding the use of different types of catheter in managing the neurogenic bladder.

Nutritional supplement usage in patients admitted to a spinal cord injury center

ObjectivesTo (1) assess food intake; (2) establish the prevalence of dietary supplement usage and its associated cost (oral nutritional supplements (ONS); vitamin and mineral supplements (VMS)) and; (3) identify the characteristics of nutritional supplement users among patients admitted to a spinal cord injury (SCI) center.Study designA single center survey.MethodsStandardized questionnaires were used to collect demographic information, food consumption over a 24-hour period, and the use of nutritional supplements. Multivariate logistic regression was used to determine the characteristics of dietary supplement usage and those using them.ResultsSeventy-three patients with SCI completed and returned the questionnaires (69.5% response rate). From 67 questionnaires with food intake data, 21 patients (31.3%) consumed three full meals a day. Nine of the full 73 patients (12.3%) received artificial nutritional support, 14 of 73 (19.1%) received ONS, 34 of 73 (46.5%) received VMS, and 31 of 73 (42.4%) required assistance in order to eat. The three supplements most often prescribed were multivitamins (19.1%), vitamins B (17.8%), and vitamin D (13.6%). VMS use was associated with age (years: >60 vs. ≤60: 62.1 vs. 34.1%, P = 0.019), nutrition risk (Spinal Nutrition Screening Tool (≥11 vs. <11: 65.7 vs. 28.9%, P = 0.001), and serum albumin concentration (<35 vs. ≥35 g/l: 59.6 vs. 16%, P < 0.01). Patients at nutrition risk were found to consume more ONS than the lower risk group (28.5 vs. 10.5%, P = 0.05). The expenditures on ONS and VMS were higher in the group at greater nutritional risk (£1878.3 vs. £914.3, P = 0.005).ConclusionThe use of nutritional supplements is common in patients with SCI, particularly in older adults and patients with poor nutritional state. However, the present study identified only small numbers of patients consuming all of their hospital meals, which may well contribute to undernutrition risk. Given that a high proportion of patients with SCI require assistance to eat, we suggest that further efforts focus on the feasibility of providing feeding assistants, and on reviewing the nature of the hospital menu.

P 105. Efficacy of Anodal transcranial direct current stimulation in rehabilitation of motor hand function in chronic incomplete spinal cord injury may depend on sensory impairment: A pilot study

Impairment of motor function in Spinal cord injury (SCI) is associated with reduction in the excitability of motor cortical (M1) representations to muscles ( Freund et al., 2011 ), while recovery is associated with representational plasticity ( Jurkiewicz et al., 2010 ). Noninvasive brain stimulation (NBS) such as anodal transcranial direct current stimulation (atDCS) increases M1 excitability, and has beneficial effects on retention of motor skill training in both the healthy and chronic stroke survivor ( Bastani and Jaberzadeh, 2012 ). However, sensory impairment may independently predict limits of recovery of functional independence ( Kirshblum and O’Connor, 1998 ). This pilot study included incomplete tetraplegic spinal cord injured patients to examine whether the covariate of sensory impairment might account for the possible after effects of atDCS applied during simulated rehabilitation. 8 consenting right-handed outpatients at the London Spinal Cord Injury Centre, with partial impairment of non-dominant hand function (American Spinal Injury Association Impairment Scale (AIS) motor level C5-C7, C-D) were randomly allocated to ACTIVE or SHAM groups in a single-blinded RCT pilot study. Pre-assessment included standardised AIS scoring of upper limb sensory sparing (PINPRICK scoring). Subjects carried out practise of a novel, inclusive manual upper limb motor skill rehabilitation task (MSRT) developed to deliver the novel Task Productivity Rate (TPR) univariate skill measure derived from direct sampling of movement time and target accuracy. 45 min continuous, repetitive MSRT training was applied from naïve baseline state on 3 consecutive days, with follow-up measures 7 days afterwards, during the first 20 min of which received either 20 min ACTIVE anodal tDCS (1 mA, 0.029 mA/cm 2 ) or a SHAM dosage to the non-dominant M1. TPR was obtained from the first 15 min of practise in each session. Repeated measures ANOVA with covariate of PINPRICK scoring as measure of sensory impairment (ANCOVA) were applied to normalised data, with independent t -tests at the follow-up session. The ACTIVE group retained a mean TPR improvement of 42% compared to 7% by SHAM which showed a non-significant trend to benefit of ACTIVE stimulation at follow-up t (6) = 2.24, p = 0.066. ANCOVA revealed significant ( p < 0.05) main effect of ACTIVE stimulation F (1,5) = 12.9, interaction with practise time ( F (3,15) = 3.4, and between-groups effect at follow-up t (6) = 3.16, p = 0.025, r = 0.625. PINPRICK was a significant independent factor F (1,5) = 6.9, which remained stable over time F (3,15) = 0.97, p = 0.43. The independent factors did not interact (confirmatory ANCOVA F (1,4) = 0.52, p = 0.5). Adjunctive application of atDCS to M1 during rehabilitation may have imparted a lasting benefit compared to rehabilitation activity alone. But the covariate of sensory impairment (Pinprick score) independently modulated skill learning and retention scores. Because atDCS did not mitigate the negative effects of sensory impairment on skill acquisition, it is possible that atDCS boosts recovery of motor activation via un-masking of existing M1 connections rather than enhancing motor memory formation necessary for skills uptake (Reis and Fritsch, 2011) .

Examination and measurement of coping among adolescents with spinal cord injury

Cross-sectional survey. To describe coping strategy use in adolescents with spinal cord injury (SCI), to explore the underlying factor structure of a measure of coping among adolescents with SCI and to assess relationships between coping and psychosocial outcomes. Multiple pediatric SCI centers in the United States. One hundred and eighty-two participants aged 13-17 years who experienced an SCI completed measures including the Kidcope, Children's Depression Inventory, Revised Children's Manifest Anxiety Scale and the Pediatric Quality of Life Inventory. Participants reported that cognitive restructuring and resignation are the most used coping strategies, whereas social support, emotional regulation (calming) and cognitive restructuring are the most effective coping strategies. An exploratory factor analysis revealed that a three-factor solution provided the most parsimonious model for the relationships between the different coping strategies. However, only one of the three factors had acceptable internal consistency. This factor comprised escape-oriented coping strategies or an avoidant approach to coping with the sequelae of SCI. After controlling for demographic/injury-related factors, higher scores on the escape-oriented factor were associated with the lower quality of life and higher levels of depression and anxiety symptomatology. Escape-oriented coping is associated with maladaptive psychosocial outcomes in adolescents with SCI. These adolescents report that active coping strategies are most effective in reducing SCI-related distress. Coping strategy use may mediate psychosocial outcomes in adolescents with SCI and represent an intervention target in adolescents who overly rely on escape-oriented coping.

Current Practice of Methylprednisolone Administration for Acute Spinal Cord Injury in Germany

Written mail-out survey. To determine current practice in high-dose methylprednisolone succinate (MPSS) administration for treatment of acute spinal cord injury (SCI) in Germany. Reanalysis of the National Acute Spinal Cord Injury Studies (NASCIS) resulted in criticism of the use of high-dose MPSS for treatment of acute SCI. Subsequently, SCI treatment guidelines were revised leading to a reduction in MPSS use across North America. The impact of these revisions on SCI treatment in Germany is not known. A questionnaire was sent to all trauma, orthopedic and neurosurgical departments of German university centers, affiliated teaching hospitals, and specialized SCI care centers. Survey included 6 questions about the administration of MPSS after acute SCI. Three hundred seventy-two respondents completed the survey (response rate: 51% overall, 76% university hospitals, 85% specialized SCI care centers). Overall, 55% of departments that treat SCI prescribe MPSS. Among them, 73% are "frequent" users administering MPSS to more than 50% of their patients. Ten percent prescribe according to NASCIS I, 43% NASCIS II, 33% NASCIS III, and 13% "generic protocols." As justification for MPSS treatment, "effectiveness" ranked before "common practice" and "medicolegal reasons." "Specialized" SCI care centers differ in that (1) MPSS is administered less frequently, (2) NASCIS I doses are not used, and (3) during the past several years, practice patterns are more likely to have shifted away from the treatment of SCI with MPSS. About one-half of the institutions continue to prescribe MPSS in the setting of acute SCI. A need for further education in almost one-fourth of German departments treating acute SCI is demonstrated through responses indicating use of the outdated NASCIS I protocol, a "legal need" or "unchanged MPSS application during the last years." "Specialized" SCI centers are more likely to change their practice in accordance with evolving literature. 3.

A Prospective, Randomized, Crossover, Multicenter Study Comparing Quality of Life Using Compact versus Standard Catheters for Intermittent Self-Catheterization

Intermittent catheterization is the recommended standard treatment for neurogenic bladder dysfunction. However, standard intermittent catheters can be unwieldy, difficult to use and carry discreetly. This can influence patient ability to perform catheterization efficiently, discreetly and privately, therefore, affecting patient quality of life. We evaluated whether the discreet design of the compact catheter would improve quality of life in intermittent catheterization users compared with standard catheters. We performed a nonblinded, randomized, multicenter, 2-way crossover study with 2 treatment periods of 6 weeks ± 3 days. A total of 125 patients with neurogenic bladder dysfunction were included in the study from 17 study sites, including 7 in France, 3 each in Germany, Denmark and Sweden, and 1 in Norway. Quality of life was evaluated by the intermittent self-catheterization questionnaire. The difference in questionnaire scores between the compact catheter and standard hydrophilic coated catheters was analyzed using a mixed linear normal model. The intermittent catheterization questionnaire score increased significantly due to compact catheter use. We noted an estimated mean difference of 17.0 between the compact and standard intermittent catheters (p <0.001), corresponding to a 28% increase. The primary study results were further supported by the positive results of the secondary objective of preference, that is 63% of patients preferred the compact catheter. The discreet design of the compact catheter significantly improved patient quality of life related to intermittent self-catheterization.

Light touch and pin prick disparity in the International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI)

Retrospective review. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) assesses cutaneous sensibility through light touch (LT) and sharp-dull discrimination, referred to as pin prick (PP). This project aimed to confirm a tendency for LT to score higher than PP in SCI subjects and discuss possible reasons for such disparity. Single site cohort study, the London Spinal Cord Injury Centre, United Kingdom. A retrospective analysis of LT and PP scores of 99 spinal cord injury subjects at the time of discharge (median 5 months) from acute care and rehabilitation in the London Spinal Cord Injury Centre was conducted. Subjects were aged 10-88 years (median 44 years; 78 men, 74 traumatic, 25 non-traumatic). There were 40 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A, 7 B, 18 C and 34 D subjects. A disparity (P<0.001) was found between LT (64.5±3.2, mean±s.e.) and PP (54.7±2.9) AIS sensory scores. A similar difference in score (LT>PP) was registered both for traumatic and non-traumatic injury, but was greater for incomplete than for complete injury. Despite the difference, LT was well correlated with PP (R=0.87, P<0.001). Spinal segmental level of injury was determined more frequently by PP alone (43 of 99) than by LT (10 of 99) alone. The discrepancies between LT and PP could relate to the greater complexity of the PP test or a difference in the extent of injury to the posterior columns (LT) and spinothalamic (PP) tracts. Further interpretation would benefit from additional electrophysiological sensory tests.

One-year follow-up of Chinese people with spinal cord injury: A preliminary study

BackgroundA tertiary spinal cord injury (SCI) center was established in the northern region of Hong Kong, China and a multidisciplinary SCI rehabilitation program was developed to reintegrate patients into the community.ObjectiveTo investigate functional outcomes for Chinese people with SCI across a 1-year period.DesignLongitudinal prospective design.MethodsThirty community-dwelling participants with traumatic SCI were recruited. Functional status was measured using functional independence measure (FIM) on admission, upon discharge, 1-month, 3-month, 6-month, and 1-year post-discharge. Information on use of assistive devices and life role were also obtained.ResultsTwenty-three (76.67%) participants were men. Seventeen participants (10 with tetraplegia and 7 with paraplegia) were classified ASIA A, B, or C; 13 (7 with tetraplegia and 6 with paraplegia) were classified as ASIA D. Significant differences in FIM motor scores were only found between the tetraplegia group and three other diagnostic groups using Bonferroni post-hoc tests of repeated measure ANOVA (analysis of variance) (P < 0.05). Longitudinally, contrast tests of repeated measure ANOVA showed significant differences during the hospitalization period for all diagnostic groups. People in the ASIA D group showed significant functional improvement even after 1-year post-discharge (P < 0.05). At 1-year post-discharge, only two participants were engaged in either remunerative employment or academic pursuit.ConclusionDespite functional status improvement, few people with traumatic SCI were re-engaged in productive life role 1 year after discharge. Studies with longer follow-up would be beneficial.

Clinical usefulness of ultrasound assessment of detrusor wall thickness in patients with neurogenic lower urinary tract dysfunction due to spinal cord injury: urodynamics made easy?

To evaluate the clinical usefulness of sonographic measurement of detrusor wall thickness (DWT) for the prediction of risk factors in patients with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI). In a prospective study, 60 consecutive patients with NLUTD due to SCI presenting for routine urodynamic assessment at a specialized SCI center underwent additional measurement of DWT at varying bladder volumes. Results of urodynamic testing were classified into favorable and unfavorable. DWT at maximum capacity was used to calculate a possible cutoff value for favorable urodynamic results. Urodynamic results were favorable in 48 patients and unfavorable in 12 patients. A DWT of 0.97 mm or less can safely (sensitivity 91.7 %, specificity 63.0 %) be used as a cutoff point for the absence of risk factors for renal damage. According to our results, DWT may be useful as an additional risk assessment for renal damage in patients with NLUTD due to SCI. However, as other parameters required for bladder management, especially detrusor overactivity, cannot be evaluated by this technique, it cannot replace urodynamic testing.

Pain and Post-Traumatic Stress Disorder Symptoms During Inpatient Rehabilitation Among Operation Enduring Freedom/Operation Iraqi Freedom Veterans With Spinal Cord Injury

ObjectiveTo examine the frequency of post-traumatic stress disorder (PTSD) symptoms and pain, and how PTSD symptoms were associated with pain severity ratings and the longitudinal course of pain during inpatient rehabilitation for spinal cord injury (SCI) among veterans of the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts. DesignLongitudinal analysis of data gathered from electronic medical records. SettingSCI specialty care centers within the Department of Veterans Affairs. ParticipantsVeterans of the OEF/OIF conflicts (N=87) who received inpatient rehabilitation for SCI and disorders at Department of Veterans Affairs SCI centers between May 2003 and October 2009. InterventionsNot applicable. Main Outcome Measure(s)PTSD screening at start of rehabilitation and pain numeric rating scale measurements completed throughout rehabilitation. Cut-scores were used to categorize participants into 1 of 4 groups on the basis of scores at the start of rehabilitation: Pain and PTSD, Pain Alone, PTSD Alone, Neither Condition. ResultsComorbid pain and PTSD symptoms were more common than either condition alone, and nearly as common as not having either condition. Participants with pain at the start of rehabilitation (Pain and PTSD, Pain-Alone groups) showed declines in pain ratings over the course of rehabilitation. In contrast, participants in the PTSD-Alone group showed increasing pain over the course of rehabilitation. ConclusionsPain and PTSD symptoms may be more likely to manifest as comorbidities than as isolated conditions during inpatient rehabilitation. Assessment routines and care plans should be prepared with comorbidities as a foremost concern. It is advisable to screen for pain and PTSD at multiple time points during inpatient rehabilitation to detect new or emerging concerns.

The impact of stoma for bowel management after spinal cord injury

Multi-centre, retrospective self-report postal survey. To characterise spinal cord injured (SCI) individuals with a stoma, their stoma management and outcomes, to identify sources of information and support for decision making and to explore the impact of a stoma on life satisfaction. Five UK spinal cord injury centres. A study-specific questionnaire accompanied by self-concept, life satisfaction and mood measures, and three simple rating scales for satisfaction, impact and restriction on life were sent to all known ostomates at five participating centres. Respondents were 92 individuals, mean age 56 years, mean duration of injury 26 years, 91% with colostomy. Multiple sources of information were utilised in deciding on surgery; discussion with other SCI ostomates was important. Duration of bowel care, faecal incontinence, bowel-related autonomic dysreflexia, dietary manipulation and laxative use were all significantly reduced following surgery. Rectal mucous discharge was the most common and bothersome post-stoma problem. Satisfaction with stoma was high; provision of sufficient information preoperatively was important, those with ileostomy were more dependent and less satisfied. Life satisfaction and physical self-concept were both lower in this sample than in previously reported samples of SCI individuals without reported bowel difficulties or stoma. The findings of this study of self-selected respondents with a stoma for bowel management after SCI emphasised the benefits of stoma in selected individuals and the importance of timely intervention, the complexity of the associated decision-making and of preoperative counselling. The impact of bowel dysfunction on physical self-concept warrants investigation.

Sacral neuromodulation

BJU InternationalVolume 110, Issue 1 p. 146-159 Sacral neuromodulation Jens Wöllner, Jens Wöllner Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, Switzerland Department of Urology, University Medical Center, University of Mainz, GermanySearch for more papers by this authorChristian Hampel, Christian Hampel Department of Urology, University Medical Center, University of Mainz, GermanySearch for more papers by this authorThomas M. Kessler, Corresponding Author Thomas M. Kessler Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, SwitzerlandThomas M. Kessler, Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland. e-mail: [email protected]Search for more papers by this author Jens Wöllner, Jens Wöllner Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, Switzerland Department of Urology, University Medical Center, University of Mainz, GermanySearch for more papers by this authorChristian Hampel, Christian Hampel Department of Urology, University Medical Center, University of Mainz, GermanySearch for more papers by this authorThomas M. Kessler, Corresponding Author Thomas M. Kessler Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, SwitzerlandThomas M. Kessler, Neuro-Urology, Spinal Cord Injury Center and Research, University of Zürich, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland. e-mail: [email protected]Search for more papers by this author First published: 12 June 2012 https://doi.org/10.1111/j.1464-410X.2012.10906.xCitations: 28 ILLUSTRATIONS by STEPHAN SPITZER, http://www.spitzer-illustration.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume110, Issue1July 2012Pages 146-159 RelatedInformation

External Urethral Sphincter Pressure Measurement: An Accurate Method for the Diagnosis of Detrusor External Sphincter Dyssynergia?

BackgroundCombined pelvic floor electromyography (EMG) and videocystourethrography (VCUG) during urodynamic investigation are the most acceptable and widely agreed methods for diagnosing detrusor external sphincter dyssynergia (DESD). Theoretically, external urethral sphincter pressure (EUSP) measurement would provide enough information for the diagnosis of DESD and could simplify the urodynamic investigation replacing combined pelvic floor EMG and VCUG. Thus, we evaluated the diagnostic accuracy of EUSP measurement for DESD.Patients & MethodsA consecutive series of 72 patients (36 women, 36 men) with neurogenic lower urinary tract dysfunction able to void spontaneously was prospectively evaluated at a single university spinal cord injury center. Diagnosis of DESD using EUSP measurement (index test) versus combined pelvic floor EMG and VCUG (reference standard) was assessed according to the recommendations of the Standards for Reporting of Diagnostic Accuracy Initiative.ResultsUsing EUSP measurement (index test) and combined pelvic floor EMG and VCUR (reference standard), DESD was diagnosed in 10 (14%) and in 41 (57%) patients, respectively. More than half of the patients presented discordant diagnosis between the index test and the reference standard. Among 41 patients with DESD diagnosed by combined pelvic floor EMG and VCUR, EUSP measurement identified only 6 patients. EUSP measurement had a sensitivity of 15% (95% CI 5%–25%), specificity of 87% (95% CI 76%–98%), positive predictive value of 60% (95% CI 30%–90%), and negative predictive value of 56% (95% CI 44%–68%) for the diagnosis of DESD.ConclusionsFor diagnosis of DESD, EUSP measurement is inaccurate and cannot replace combined pelvic floor EMG and VCUR.