Exercise effect with the wheelchair aerobic fitness trainer on conditioning and metabolic function in disabled persons: a pilot study.

OBJECTIVE: To determine the effect of exercise with the wheelchair aerobic fitness trainer (WAFT) on anthropometric indices, conditioning, and endocrine and metabolic parameters in persons with lower extremity disability. DESIGN: Exercise sessions with the WAFT lasted 20 to 30 minutes for two to three sessions. SETTING: Tertiary-care Veterans Administration medical center. PARTICIPANTS: Twelve subjects (3 with quadriplegia, 7 with paraplegia, 1 with cerebrovascular accident, 1 with bilateral above-knee amputation). MAIN OUTCOME MEASURES: Anthropometric indices (heart rate, blood pressure, weight, oxygen utilization, body mass index, upper arm and abdominal circumference, arm power) and endocrine and metabolic parameters (fasting serum glucose, lipids, and thyroid function) were determined before and after 10 weeks of exercise with the WAFT. RESULTS: All patients noted improved feelings of well-being after training. Mean resting heart rate, upper arm fat area, and fasting serum cholesterol level decreased significantly. Peak oxygen consumption, midarm circumference, and free thyroxine index increased significantly with training. CONCLUSIONS: WAFT improves quality of life, conditioning, and endocrine-metabolic parameters in disabled persons.

Epidural spinal cord stimulation for the control of spasticity in spinal cord injury patients lacks long-term efficacy and is not cost-effective.

Epidural spinal cord stimulation has been used to decrease spasticity and spasms in spinal cord injury patients. However, the long-term benefits of this procedure have not been determined. We therefore conducted a retrospective study of the possible long-term efficacy of the epidural spinal cord stimulator for the relief of symptoms. Seventeen patients were identified who had undergone implantation of an epidural spinal stimulator. The total number of implantations in these seventeen patients was 24, (seven patients had undergone a second implantation) costing a total of $566,400. In only one of the patients was the epidural stimulator providing symptomatic relief. The epidural spinal cord stimulator lacks long-term efficacy for the relief of spasticity and pain and is not cost effective.

Extra pontine myelinolysis in a tetraplegic patient: case report.

Hyposmolar hyponatremia (serum sodium < 130 mmol/l) is a common phenomenon in the spinal cord injury (SCI) patient population and in most cases, it is of relatively little consequence. However, rapid correction or over correction of hyponatremia (a change in serum sodium > 25 mmol/l within 48 h) has been linked to Central Pontine Myelinolysis (CPM) and Extra Pontine Myelinolysis (EPM), usually along with other recognized predisposing factors. We report the first case of isolated Extra Pontine Myelinolysis in an SCI patient without any of the recognized predisposing factors, following correction of hyponatremia. The signs and symptoms of Extra Pontine Myelinolysis were not very remarkable in our patient because of prior spinal cord injury. The diagnosis was confirmed by the typical finding of myelinolysis in the basal ganglion region on MRI. Hyponatremia occurs frequently in the SCI patient population, thus placing them at increased risk for Extra Pontine Myelinolysis. Therefore, we emphasize the importance of watching for this entity during the management of hyponatremia in the SCI patient population and recommend the use of MRI scans to confirm the clinical diagnosis.

Profound hypotension in a tetraplegic patient following angiotensin-converting enzyme inhibitor lisinopril. Case report.

We present the case of a 60 year old C6 complete tetraplegic patient who developed profound hypotension following initiation of the angiotensin-converting enzyme inhibitor lisinopril to control blood pressure. Other causes of hypotension, such as myocardial infarction and sepsis was ruled out. Inhibition of the renin-angiotensin-aldosterone system was the probable cause of hypotension. This case demonstrates the critical importance of the renin-angiotensin-aldosterone axis in the maintenance of blood pressure in tetraplegic patients, who may lack input from the brain to sympathetic neurons, and therefore have increased reliance on the renin-angiotensin-aldosterone axis for the maintenance of blood pressure. Angiotensin-converting enzyme inhibitors should be avoided in tetraplegic patients, unless other treatment modalities are ineffective.

Prostatic fluid analysis in spinal-cord-injured patients with recurrent urinary tract infections.

OBJECTIVE: Recurrent urinary tract infections are common in spinal-cord-injured patients. Our study was designed to evaluate the association of bacteria colony counts, white blood cell (WBC) count, and antibody-coated bacteria analyzed in urethral and prostatic samples in hospitalized spinal-cord-injured patients with recurrent urinary tract infections. METHODS: Thirty-three patients were studied and 4 noninfected patients served as controls; 17 patients were paraplegic and 20 were quadriplegic. Mean patient age was 34.8 years and mean follow-up period was ninety-three days. During the surveillance period, 19 of the 33 patients had relapsing infections (same organism), while 14 had reinfections (new organism). A modified Foley catheter was used to seal the bladder neck, so that urethral and prostatic samples could be obtained. RESULTS: Bacteria colony counts and WBC counts did not correlate with relapsing infection. However, significantly more patients with relapsing infection (8/19) had antibody-coated bacteria in their prostatic fluid than patients with reinfection (1/13) (P < 0.05). CONCLUSIONS: The presence of antibody-coated bacteria in prostatic fluid is associated with relapsing urinary tract infections and not with reinfection.

Atrial natriuretic factor in spinal cord injury.

Atrial natriuretic factor (ANF) concentrations were determined in matched cervical (n = 6) and thoracic (n = 7) spinal cord injured subjects in comparison to control volunteers (n = 6). In the spinal cord injury groups sampling conditions were controlled for posture, time of day, smoking status, and dietary intake. There were no between groups differences relative to age, plasma renin activity, plasma aldosterone, plasma antidiuretic hormone, plasma osmolality, urine sodium or potassium excretion, or creatinine clearance. In comparison to ambulatory normals at comparable levels of sodium intake (14.4 +/- 4.8 ng/dL) both spinal cord injury groups exhibited elevated recumbent plasma aldosterone values 26.8 +/- 2.54 ng/dL (thoracic) and 20.9 +/- 4.38 ng/dL (cervical). Plasma ANF concentrations in thoracic cord injured subjects were 39.22 +/- 4.00 pg/mL and 119.5 +/- 33.40 pg/mL in cervical cord injured individuals, contrasting with normal control population values of 13.35 +/- 1.29 pg/mL. These data suggest that in the spinal cord injury state, there is either a failure of end organ response to ANF, or the ascendancy of counteracting hormonal and hemodynamic mechanisms over the effects of ANF.

Medical complications of spinal cord disease.

Spinal cord injury increases the risk of many life-threatening medical problems, including respiratory failure, pulmonary embolism, and renal failure. Respiratory failure results from paralysis of muscles of inspiration (which impairs oxygen transport to alveoli) and of expiration (which impairs cough and predisposes to pneumonia and atelectasis). Respiratory failure in patients with spinal cord injury can be prevented by proper positioning of the patient, training of ventilatory muscles, pulmonary toilet, and aggressive use of antibiotics and bronchodilators. When respiratory failure occurs, it can be managed by administration of oxygen, intubation, and mechanical ventilation, and in instances of paralysis of the diaphragm, by diaphragmatic pacing. The risk of deep vein thrombosis and pulmonary embolism in acute spinal cord disease is increased by the immobilization of the patient and abnormalities in clotting factors. Thrombotic disease in spinal cord disease can be prevented by intermittent calf compression and heparinization. If pulmonary embolism develops, the patient should be started on a regimen of warfarin for at least 3 months. If anticoagulation is contraindicated, a Greenfield filter can be placed. However, concurrent use of quad cough places the patient at increased risk for complications from the Greenfield filter. Chronic pyelonephritis and systemic amyloidosis are the most common causes of renal failure in the patient with spinal cord disease. Renal failure can be prevented by maintaining a low postvoid residual volume, avoidance of indwelling catheters, use of medications that are not nephrotoxic, and rapid treatment of infection. Hemodialysis and peritoneal dialysis can extend the life of the patient with spinal cord disease in whom renal failure develops, and successful use of renal transplantation has recently been reported.

Hyponatremia in spinal cord injury.

Hypoosmolar hyponatremia (serum Na+ less than 130 mmol/L) has proven a common and incompletely explained phenomenon in the spinal cord injured patient. When present, it has generally been preceded by excessive fluid intake and environmental/dietary factors which reversibly restrict free water excretion. We have attempted to more fully characterize the determinants of SCI-associated hyponatremia by retrospectively analyzing its features and treatment response in a series of 14 hyponatremic SCI patients. In most instances, hyponatremia could be attributed to uncontrolled fluid intake in the presence of an acute or semiacute illness and thus stimuli for non-osmotic releases of arginine vasopressin. Treatment measures generally included administration of 3% saline, with all patients recovering uneventfully from their episode of hyponatremia.

Pyomyositis in spinal cord injury patients.

Bacterial infections remain a major cause of morbidity and mortality among patients with longstanding spinal cord injury. Infection may occur in a number of different foci, often taxing the skill of the most accomplished diagnostician. Herein are described three patients with fever of unknown origin wherein extensive diagnostic workups ultimately led to the diagnosis of primary pyomyositis. These patients demonstrate the importance of repeated careful physician examination in determining the site of infection in patients with established sensorimotor deficits. Although primary pyomyositis is not a common occurrence in those with spinal cord injuries, it should be included as a potential cause of fever in this patient population.

Prostaglandin E2 excretion in spinal cord injury patients.

Hyponatremia has proven to be a common finding in spinal cord injured (SCI) patients. Mechanisms exist whereby SCI patients with either normal or impaired renal function may develop it. One such mechanism may be an impairment in prostaglandin (PGE2) excretion resulting in unopposed activity of antidiuretic hormone (ADH). Paired 24-hour urine collections for PGE2 were collected from SCI patients with varying degrees of renal dysfunction. There was a wide interpatient variability in the excretion of PGE2, with no significant correlation of PGE2 excretion in respect to either urine volume, urine sodium concentration, or the degree of renal dysfunction.