Energy expenditure in people with motor-complete paraplegia.

This corrects the article DOI: 10.1038/ajg.2017.27.

Energy expenditure in people with motor-complete paraplegia.

STUDY DESIGN: The present descriptive clinical and laboratory study is cross-sectional in design. OBJECTIVES: The primary aim is to describe and compare resting energy expenditure (REE) and energy expenditure (EE) during different standardized sedentary, non-exercise and exercise activities in people with motor-complete paraplegia (Th7 to Th12.). A secondary aim was to compare men and women. METHODS: Thirty-eight adults (10 women) with SCI, T7-T12 AIS A-B, were recruited. All the data were collected through indirect calorimetry. REE was measured in supine for 30 min after 8 h of overnight fasting. Activity energy expenditure (AEE) for activities was measured for seven minutes during sedentary, non-exercise physical activity (NEPA) and exercise activities. RESULTS: AEE increased four to eight times when engaging in NEPA compared to that in sedentary activities. Men had significantly higher resting oxygen uptake compared to women, 0.19 vs 0.15 l min-1 (P=0.005), REE per 24 h, 1286 vs 1030 kcal (P=0.003) and EE during weight-bearing activities. However, these became nonsignificant after adjustment for body weight and speed of movement, with a mean resting oxygen uptake of 2.47 ml O2 per kg min-1 for the whole group (women 2.43 and men 2.57 ml O2 kg-1 min-1, P=0.49). CONCLUSIONS: NEPA increases AEE up to eight times compared to sedentary activities. Gender differences in oxygen uptake during both rest and weight-bearing activities were diminished after adjustment for body weight. The mean resting oxygen uptake for the whole group was 2.47 ml O2 kg-1 min-1. These results highlight the importance, especially of NEPA, for increasing total daily EE in the target population.

Outcomes after acute traumatic spinal cord injury in Botswana: from admission to discharge.

STUDY DESIGN: Prospective follow-up study. OBJECTIVES: To increase the knowledge regarding clinical and functional outcomes after traumatic spinal cord injuries (TSCI) in a resource-constrained setting. A special focus was placed on secondary complications such as pressure ulcers. SETTING: The national referral hospital in Gaborone, Botswana. METHODS: The study included all patients admitted with an acute TSCI during a 2-year period (n=39). Data collection was conducted at the time of discharge, and clinical characteristics, length of stay and pressure ulcers were analysed using descriptive and inferential statistics. RESULTS: Completeness of injury and presence of pressure ulcers were the factors found to significantly prolong hospitalization, which was 5 months (median). One patient died before discharge and one was discharged to rehabilitation in South Africa; all other patients were living with close or distant family members after discharge. Patients were supplied with electrical or manual active wheelchairs. Self-catheterization or suprapubic catheters were the main methods for bladder management, and ano-rectal stimulation to manage the bowel. Pressure ulcers, urinary tract infections and pain were the most frequent complications during in-patient care. CONCLUSIONS: Rehabilitation of patients with TSCI in Botswana has been going through big changes, and new rehabilitation objectives, such as techniques used for the management of bladder and bowel dysfunctions and the provision of technical aids, have been implemented, which likely can contribute to an overall improvement in the outcomes. However, basic care at the general wards is still lagging behind, causing high rates of pressure ulcers that significantly extend hospitalization periods.

Outcomes 2 years after traumatic spinal cord injury in Botswana: a follow-up study.

STUDY DESIGN: Prospective follow-up study. OBJECTIVES: To identify indicators leading to compliance with yearly controls (YCs) and to describe the clinical and functional outcomes 2 years after traumatic spinal cord injury (SCI). SETTING: The national SCI rehabilitation centre in Botswana. METHODS: Included in the study were all people who were admitted with a traumatic SCI during a 2-year period and survived to be discharged (n=38). Data were collected at the YCs and included demographic characteristics and clinical and functional outcomes. Comparisons were made between those who did or did not attend YCs and between those who did or did not develop pressure ulcers (PUs). RESULTS: The follow-up rate was 71% (27/38) with higher attendance among those with complete injuries and those with secondary complications, especially pain. Age, gender, distance to the centre and education did not affect the follow-up rate. Self-catheterisation and suprapubic catheter were the preferred methods to manage neurogenic bladder dysfunction. Despite high rates of PUs (48%) and urinary tract infections (UTIs; 41%), no death had occurred during the follow-up period. Furthermore, one-third had resumed work. CONCLUSION: Despite high rates of UTIs and PUs developed in the home environment, this study showed a high survival rate 2 years after traumatic SCI, which might be explained by the establishment of a specialised SCI unit and the high follow-up rate. In addition, the continuing contact with the SCI staff might have facilitated the relatively high return-to-work rate. Long-term follow-up seems possible even in resource-constrained settings with clearly stated objectives, transport, dedicated staff and well-educated patients and families.

Concerns about falling in wheelchair users with spinal cord injury--validation of the Swedish version of the spinal cord injury falls concern scale.

OBJECTIVE: Translation of the Spinal Cord Injury Falls Concern Scale (SCI-FCS); validation and investigation of psychometric properties. DESIGN: Translation, adaptation and validation study. SUBJECTS/PATIENTS: Eighty-seven wheelchair users with chronic SCI attending follow-up at Rehab Station Stockholm/Spinalis, Sweden. METHODS: The SCI-FCS was translated to Swedish and culturally adapted according to guidelines. Construct validity was examined with the Mann-Whitney U-test, and psychometric properties with factor and Rasch analysis. RESULTS: Participants generally reported low levels of concerns about falling. Participants with higher SCI-FCS scores also reported fear of falling, had been injured for a shorter time, reported symptoms of depression, anxiety and fatigue, and were unable to get up from the ground independently. Falls with or without injury the previous year, age, level of injury, sex and sitting balance did not differentiate the level of SCI-FCS score. The median SCI-FCS score was 21 (range 16-64). Cronbachs alpha (0.95), factor and Rasch analysis showed similar results of the Swedish as of the original version. CONCLUSION: The Swedish SCI-FCS showed high internal consistency and similar measurement properties and structure as the original version. It showed discriminant ability for fear of falling, time since injury, symptoms of depression or anxiety, fatigue and ability to get up from the ground but not for age, gender or falls. Persons with shorter time since injury, psychological concerns, fatigue and decreased mobility were more concerned about falling. In a clinical setting, the SCI-FCS might help identifying issues to address to reduce the concerns about falling.

Traumatic spinal cord injury in Botswana: characteristics, aetiology and mortality.

STUDY DESIGN: Descriptive study with a cross-sectional design. OBJECTIVES: To describe the epidemiology of traumatic spinal cord injuries (TSCIs) in Botswana, with a specific focus on road traffic crashes (RTC). SETTING: Main public referral hospital, Gaborone, Botswana. METHOD: Two samples were included. Sample one described the epidemiology and included patients admitted during a 2-year period with acute TSCI. Sample two included only patients with TSCI due to RTC. RESULTS: Annual incidence was 13 per million population. Epidemiology of TSCI: 49 patients were included, 71% male, age ranging from 4 to 81 years, 80% ⩽ 45 years. Tetraplegia was more common than paraplegia (59/41%), and 39% had C1-C4 level of injury. The main cause of TSCI was RTC (68%), followed by assault (16%) and falls (10%). Mortality was 20%, where all, but one, had tetraplegia (18%). Median time from injury to spinal surgery was 12 days, with longer time for women, 16 days compared with 8 for men. Burst tire was the primary cause of RTC resulting in a TSCI, followed by hitting animals on the road. The majority had been passengers and 72% were involved in single crashes. CONCLUSION: The most common cause for TSCI was RTC, followed by assault. In-hospital mortality was high and the waiting period from the time of accident to spinal surgery was long, especially for women. The aetiology and high mortality of TSCI in Botswana indicate that improvements in roadway safety and medical care may decrease the TSCI incidence and mortality.

25 years or more after spinal cord injury: clinical conditions of individuals in the Florence and Stockholm areas.

SETTING: Retrospective analysis and retrospective follow-up. INTRODUCTION: Spinal cord injury (SCI) patients have today a nearly normal lifespan. Avoidance of medical complications is key to this end. The aim of the study was to analyse health in individuals surviving 25 years or more after traumatic SCI in Stockholm and Florence, and compare medical complications. METHODS: Data from the databases of the Spinal Unit of Florence and from the Spinalis, Stockholm were analysed. Patients included were C2-L 2, American Spinal Cord Association (ASIA) Impairment Scale (AIS) A-C, and ≥25 years post traumatic SCI. Patients underwent a thorough neurological and general examination, and were interviewed about medical events during those years. Analysed data include: gender, age at injury, current age, neurological level, AIS, cause of injury, presence of neuropathic pain (NP), and spasticity and medical complications. RESULTS: A total of 66 Italian patients and 74 Swedish patients were included. The only statistical difference between the groups was cause of injury due to falls was higher in the Florence group (P<0.01). Male/female ratio was 4:1. Traffic accidents were the most common cause of injury. In all, 60% were paraplegics. Pressure ulcers (PU) occurred in nearly 60% and 32% experienced NP. Respiratory complications (RC) occurred in 25% among tetraplegics. Neurological deterioration occurred in 14%. CONCLUSION: PU, bony fractures, spasticity and NP are important problems after SCI. RC are of clinical importance in the tetraplegics. Complications occur during all periods after injury. Many patients are otherwise healthy 25 years or more after SCI.

Sildenafil in women with sexual arousal disorder following spinal cord injury.

STUDY DESIGN: Double-blind, placebo-controlled, flexible-dose study. OBJECTIVE: To evaluate the efficacy, safety and tolerability of oral sildenafil in women with female sexual arousal disorder as a result of SCI (paraplegia/tetraplegia). SETTING: The study was conducted at clinical practice sites in North America (n =23), 11 European countries (n =23), Australia (n =4) and South Africa (n =2). METHODS: 129 women were randomized and treated with sildenafil or matching placebo. A 4-week baseline period was followed by 12 weeks of treatment, which could be increased from 50 to 100 mg or decreased to 25 mg once during the treatment period, depending on efficacy and tolerability. By use of an event log, sexual activity was monitored between screening and the end of treatment. The Sexual Function Questionnaire, the Sexual Quality of Life Questionnaire-Female, a global efficacy question and Sexual Distress Question were also assessed. RESULTS: Sildenafil-treated women and placebo-treated women had an increase in their percentage of sexual activities throughout the course of the study, with no statistically significant difference between groups in the percentage of successful sexual activities at end of treatment versus baseline. There were also no statistically significant differences between sildenafil- and placebo-treated women on the aforementioned measures. The most common adverse events included headache and vasodilatation. CONCLUSION: The results of this study are similar to other reports regarding a lack of clinically meaningful benefit of sildenafil in other populations of women. SPONSORSHIP: This study was sponsored by Pfizer Inc.

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.

Quality of sleep in individuals with spinal cord injury: a comparison between patients with and without pain.

STUDY DESIGN: A cross-sectional descriptive study of self-reported quality of sleep in individuals with a spinal cord injury (SCI). OBJECTIVES: To assess and describe subjective quality of sleep in patients with SCI, with and without pain. SETTING: Spinalis SCI unit, Stockholm, Sweden. METHODS: A total of 230 patients with an SCI were mailed a questionnaire containing queries about pain intensities, pain unpleasantness, mood, and sleep quality (Basic Nordic Sleep Questionnaire) to assess quality of sleep in patients with SCI with and without pain. RESULTS: Of the 192 questionnaires that were returned (response rate 83.4%), 191 were analysed. Patients were divided into three groups: (1) those who reported no pain (n=50), (2) those who reported intermittent pain (n=42), and (3) those who suffered from continuous pain (n=99). Patients suffering from continuous pain rated pain intensity and unpleasantness significantly higher than those who only suffered from intermittent pain. The group with continuous pain also reported the poorest quality of sleep and the highest ratings of anxiety and depression of the three groups. Anxiety, together with pain intensity and depression, were the main predictors for poor sleep quality. CONCLUSIONS: Poor subjective sleep quality was associated with higher ratings of pain intensity, anxiety, and depression. It is possible that melatonin serves as a modulator of these different aspects.

Neuropathic pain after traumatic spinal cord injury--relations to gender, spinal level, completeness, and age at the time of injury.

STUDY DESIGN: Retrospective register study. OBJECTIVE: To investigate the predictive value of age at the time of injury, gender, level of injury, and completeness of injury for the development of at level and below level neuropathic pain. SETTING: "Spinalis", a postacute spinal cord injury (SCI) outpatient clinic, serving the greater Stockholm area (Sweden). METHOD: All patients who visited the clinic in 1995-2000 (402 patients) for the first time were examined. The following items were selected: at-level and below-level neuropathic pain according to the International Association for the Study of Pain (IASP) criteria, age at the time of injury, gender, level of injury according to ASIA, and completeness of injury. Mean time of 6 years after the injury. Results were analysed with chi(2) analysis and logistic regression. RESULTS: Of all patients examined, 13% had at level pain and 27% had below level pain. Neuropathic pain was less than half as frequent (26%) in the group aged less than 20 years at the time of injury as in the oldest group (58%). The increasing trend was mainly due to below-level pain up to 39 years of age, and due to at-level pain at ages 40 and above at the time of injury. No correlation was observed to gender, level of injury or completeness of injury, except for below level pain, which was associated with complete injury. CONCLUSION: The results show that neuropathic pain after SCI is common and occurs much more often in patients injured at higher ages. This indicates the importance of neuroanalgetic intervention, in particular for patients injured in higher ages.

Clinical evaluation of seating in persons with complete thoracic spinal cord injury.

STUDY DESIGN: Consecutive male patients studied with photographic measurement of a combination of clinical methods. OBJECTIVES: To describe seating in individuals with complete thoracic spinal cord injury (SCI) by using a combination of clinical methods. SETTING: Spinalis SCI unit, Stockholm, Sweden. METHODS: Wheelchair specifications were documented. Measurements of posture from photographs in 30 male subjects with complete thoracic SCI, sitting in a relaxed and an upright position on a standardized surface and in a wheelchair were calculated. A comparison was made between positions and seating surfaces. An examiner's classification of lower trunk position in wheelchair was compared to subjects' evaluations. SCI subjects reported sitting support, satisfaction, and wishes for improvement. RESULTS: Most SCI subjects used similar wheelchair specifications. None of the backrests were custom designed. Relatively small differences were found between the relaxed and upright position in the wheelchair regarding measurements of posture and according to the examiner's classification of the lower trunk position. Only 13/30 SCI subjects were sitting with the lower trunk centered relative to the backrest in the upright position. The examiner's classification and the subjects' evaluation of asymmetric sitting were not always in agreement. Only 12/30 SCI subjects were satisfied with their way of sitting. CONCLUSION: Current wheelchair specifications and adjustments seem to inhibit a postural correction towards upright sitting and fail to provide sufficient lateral support. Findings indicate an inability for SCI subjects to vary their sitting position in a wheelchair to a large extent. Both an examiner's classification and subjects' evaluation of asymmetric sitting are necessary to obtain a sufficient knowledge base for subsequent adjustment. By using methods regarding different aspects of seating, a more comprehensive view of seating was achieved. The combination of clinical methods seems to be useful in order to describe seating in individuals with complete thoracic SCI.

Gender related differences in pain in spinal cord injured individuals.

STUDY DESIGN: Out of a population of 456 patients with spinal cord injuries (SCI), 130 having pain were selected after matching, based on gender, age, American Spinal Injury Association (ASIA) impairment grade and level of lesion. OBJECTIVE: To investigate whether gender differences with regard to pain perception and prevalence exist in a population of patients following spinal cord injury. SETTING: Spinalis SCI Unit (out-patient clinic), Stockholm, Sweden. METHOD: 130 patients suffering from pain were assessed over a 12-month period in a yearly health control. RESULTS: SCI women had a higher prevalence of nociceptive pain than men and their use of analgesics was greater. However, no differences between the sexes could be seen regarding pain and localization, onset, distribution, factors affecting pain, number of painful body regions, pain descriptors, ratings of pain intensities or in pain and life satisfaction. CONCLUSION: This study showed that SCI men and women describe their pain very similarly. However, SCI women had a higher prevalence of nociceptive pain than men and their use of opiates and non-steroid anti-inflammatory drugs (NSAIDs) was greater.

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.

Quality of life in patients with spinal cord injury receiving Viagra (sildenafil citrate) for the treatment of erectile dysfunction.

STUDY DESIGN: A multicenter, randomized, double-blind, placebo-controlled, flexible-dose, two-way crossover study conducted June 1996 through January 1997. OBJECTIVES: To evaluate the effect of sildenafil citrate (VIAGRA(R)) on the quality of life (QoL) of men with erectile dysfunction (ED) caused by spinal cord injury (SCI). SETTING: Study centers in Australia, Belgium, France, Germany, Norway, Sweden and the United Kingdom. METHODS: Questions 13 and 14 of the 15-item International Index of Erectile Function (IIEF) addressed QoL issues directly related to ED in 178 men with SCI. A 5-item questionnaire addressing concerns that men had about their erection problems was also used to evaluate the impact of ED on QoL. Several commonly used psychometric instruments, including the Medical Outcomes Survey (MOS) Short Form-12, Psychological General Well-Being Index, and MOS Family Survey, assessed general QoL issues. RESULTS: Significant improvements were seen for overall satisfaction with sex life (IIEF Q13), sexual relationship with partner (IIEF Q14), and concerns about erectile problems (P<0.0001). Improvements were reported in scores for the generic QoL parameters of mental health, well-being, depression, and anxiety (P<0.05 sildenafil versus placebo). CONCLUSION: Treatment with sildenafil can significantly improve key QoL parameters in men with ED caused by SCI. SPONSORSHIP: This study was funded by Pfizer Inc. Spinal Cord (2000) 38, 363 - 370.

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.

Obstructive sleep apneas in relation to severity of cervical spinal cord injury.

Thirty-three subjects (28 men, five women) with complete or incomplete cervical cord injury representing a wide range of neurological impairment were investigated with regard to the prevalence of Obstructive Sleep Apnea (OSA). The relation between OSA and neurological function, respiratory capacity, body mass index and symptoms associated with OSA were studied. Overnight sleep recordings employed combined oximetry and respiratory movement monitoring. Pulmonary function tests included static and dynamic spirometry, maximal static inspiratory and expiratory pressures at the mouth. The subjects answered a questionnaire concerning sleep quality and tiredness. The prevalence of OSA was 15% (5/33) in this nonobese cervical cord injury study population. Nine percent of the subjects (3/33) fulfilled the criteria for obstructive sleep apnea syndrome, but daytime sleepiness or fatigue were also common in subjects without OSA. There was an inverse correlation between oxygen desaturation index and American Spinal Injury Association (ASIA) motor score in the subjects with complete injury, while there was no such correlation in the whole study group. There were significant correlations between maximal inspiratory and expiratory pressures and vital capacity and between ASIA motor score and vital capacity.

Simultaneous Ashworth measurements and electromyographic recordings in tetraplegic patients.

OBJECTIVE: A recent prevalence study of 353 spinal cord injured (SCI) individuals in the greater Stockholm area showed problematic spasticity in 30% of this population. To treat spasticity, the evaluation becomes crucial. The modified Ashworth scale (MAS) is the clinically most-used scale to grade degree of spasticity. This study evaluated whether the MAS correlated with electromyographic (EMG) recordings of muscle activity. STUDY DESIGN: This cross-sectional study was performed at an outpatient clinic that has the responsibility to do a standardized, yearly follow-up of all SCI patients in the greater Stockholm area. Thirty-eight SCI individuals met the inclusion criteria; 15 of the 38 were randomly selected for the study. They were all motor-complete tetraplegic men; mean age was 33 years and mean time since injury was 9 years. Spasticity evaluation was performed by flexing and extending the knees during simultaneous EMG recordings and MAS assessment of the thigh muscle activity. RESULTS: Eighty percent of the individual EMG recordings correlated significantly with the corresponding Ashworth measurements. The spastic resistance, as measured both clinically and electromyographically, was stronger and lasted longer during extension than flexion movements. Spearman coefficients for correlation of quantitative spasticity measures with MAS grades were calculated. EMG and clinical measures of spasticity were more closely correlated for flexion movements. Among EMG parameters, duration of movement-associated electrical activity invariably correlated significantly with the MAS grades (p < .05). Furthermore, Ashworth measurements of movement-associated spasticity showed a positive correlation with the EMG parameters mean, peak, and start to peak of electrical activity. Each increasing grade on the MAS corresponded to increasing myoelectric activity levels for each movement. CONCLUSION: EMG parameters were significantly positively correlated with simultaneous MAS measurements of the spastic muscle contraction. The Ashworth scale may therefore accurately reflect the movement-provoked spasticity in motor-complete tetraplegic patients.