Five-year follow-up of persons with brain injury entering the French vocational and social rehabilitation programme UEROS: Return-to-work, life satisfaction, psychosocial and community integration.

BACKGROUND: Social and vocational reintegration of persons with brain injury is an important element in their rehabilitation. AIMS: To evaluate the 5-year outcome of persons with brain injury included in 2008 in the Aquitaine Unit for Evaluation, Training and Social and Vocational Counselling programme (UEROS). METHOD: 57 persons with brain injury were recruited from those who completed the 2008 UEROS programme. Five years later, an interview was done to assess family and vocational status, autonomy and life satisfaction. These results were compared with those from persons completing the 1997-1999 programme. RESULTS: The typical person entered the 2008 UEROS programme 6 years after a severe brain injury (42%) and was male, single and 35 years. At the 5-year follow-up, more persons lived with a partner (+23%) and lived in their own home (+21%). 47% were working vs 11% on entering the programme. Approximately half were satisfied or very satisfied with their quality of life. Having a job in 2013 was associated with a high education level, less cognitive sequelae, having a job in 2008 and no health condition. CONCLUSIONS: The UEROS programme is effective with regard to return-to-work and improvement of autonomy in persons with brain injury, irrespective of length of time from injury.

The evaluation of behavioural changes in brain-injured patients: SOFMER recommendations for clinical practice.

UNLABELLED: Behavioural changes are the main cause of difficulties in interpersonal relationships and social integration among traumatic brain injury (TBI) patients. The Société française de médecine physique et réadaptation (SOFMER) decided to develop recommendations for the treatment and care provision for these problem under the auspices of the French health authority, the Haute Autorité de la santé (HAS). Assessment of behaviour is essential to describe, understand and define situations, assess any change and suggest lines for intervention. The relationship of these behavioural changes with the brain lesion is likewise of crucial importance in legal and forensic expertise. AIMS: Using a literature review and expert opinions, the aim was to define the optimal conditions for the collection of data on behavioural changes in individuals having sustained brain trauma, to identify the situations in which they arise, to review the instruments available, and to suggest lines of intervention. METHODS: A literature search identified 981 articles, among which 122 on the target subject were selected and analysed in detail and confronted with the experience of professionals and user representatives. A first draft of the recommendations was produced by the working group, and then submitted to a review group for opinions and complements. RESULTS: The literature on this subject is heterogeneous, and presents low levels of evidence. No article enabled the development of recommendations above the "expert opinion" level. After prior clarification of the aims of the evaluation, it is recommended first to carefully describe the changes in behaviour, from patient and third-person narratives, and where possible from direct observations. The information enabling the description of the phenomena occurring should be collected by different individuals (multi-source evaluation): the patient, his or her close circle, and professionals with different training backgrounds (multidisciplinary evaluation). The analysis of triggering or associated factors requires an assessment of cognitive functions and any neurological pathology (seizures). After confrontation and synthesis, the information should be completed using one or several behavioural scales, which provide objectivity and reproducibility. The main generic and specific scales are presented, with their advantages, drawbacks and validation references. The group did not wish to recommend any one of them in particular. CONCLUSION: The evaluation of behavioural changes is essential, since without it a therapeutic strategy and appropriate orientation cannot be implemented. The emphasis should be put on contextualised, multi-source and multidisciplinary evaluation, including validated behavioural scales. In this area, nevertheless, evaluation is still restricted by several methodological limitations. Further research is needed to improve the standardisation of data collection and the psychometric properties of the instruments. A European harmonisation of these procedures is also greatly needed.

Psychotherapeutic follow up of out patients with traumatic brain injury: preliminary results of an individual neurosystemic approach.

UNLABELLED: Psychotherapy for affective/behaviour disorders after traumatic brain injury (TBI) remains complex and controversial. The neuro-systemic approach aims at broadening the scope in order to look at behaviour impairments in context of both patient's cognitive impairments and family dysfunctioning. OBJECTIVE: To report a preliminary report of a neuro-systemic psychotherapy for patients with TBI. PATIENTS AND METHODS: All patients with affective/behaviour disorders referred to the same physician experienced in the neuro-systemic approach were consecutively included from 2003 to 2007. We performed a retrospective analysis of an at least 1-year psychotherapy regarding the evolution of the following symptoms: depressive mood, anxiety, bipolar impairment, psychosis, hostility, apathy, loss of control, and addictive behaviours as defined by the DSM IV. Results were considered very good when all impairments resolved, good when at least one symptom resolved, medium when at least one symptom improved, and bad when no improvement occurred, or the patient stopped the therapy by himself. RESULTS: Forty-seven patients, 35 men and 12 women, with a mean age of 33.4 years, were included. Most suffered a severe TBI (mean Glasgow coma score: 6.4) 11 years on average before the inclusion. At the date of the study, 11 patients (23%) had a poor outcome, 23 (48%) suffered Moderate disability and 13 (27%) had a Good recovery on the GOS scale. All therapy sessions were performed by the same physician, with 10 sessions on average during 13.5 months. Results were classified very good in six cases (13%), good in 18 others (38%), medium in 10 patients (21%) and bad in 13 cases (27%). We observed a significant improvement of affective disorders, namely anxiety (P<0.001) depressive mood (P<0.001) and hostility (P<0.01). However, bipolar symptomatology, apathy, loss of control and addictive disorders did not improve. DISCUSSION/CONCLUSION: From our best knowledge, this is the first clinical report of neuro-systemic psychotherapy for affective/behaviour disturbances in TBI patients. This kind of therapy was shown to be feasible, with a high rate of compliance (72%). Psycho-affective disorders and hostility were shown to be more sensitive to therapy than other behaviour impairments. These preliminary findings have to be confirmed by prospective trials on broader samples of patients.

Are family-centred principles, functional goal setting and transition planning evident in therapy services for children with cerebral palsy?

BACKGROUND: Family-centred service, functional goal setting and co-ordination of a child's move between programmes are important concepts of rehabilitation services for children with cerebral palsy identified in the literature. We examined whether these three concepts could be objectively identified in programmes providing services to children with cerebral palsy in Alberta, Canada. METHODS: Programme managers (n= 37) and occupational and physical therapists (n= 54) representing 59 programmes participated in individual 1-h semi-structured interviews. Thirty-nine parents participated in eleven focus groups or two individual interviews. Evidence of family-centred values in mission statements and advisory boards was evaluated. Therapists were asked to identify three concepts of family-centred service and to complete the Measures of Process of Care for Service Providers. Therapists also identified therapy goals for children based on clinical case scenarios. The goals were coded using the components of the International Classification of Functioning Disability and Health. Programme managers and therapists discussed the processes in their programmes for goal setting and for preparing children and their families for their transition to other programmes. Parents reflected on their experiences with their child's rehabilitation related to family-centredness, goal setting and co-ordination between programmes. RESULTS: All respondents expressed commitment to the three concepts, but objective indicators of family-centred processes were lacking in many programmes. In most programmes, the processes to implement the three concepts were informal rather than standardized. Both families and therapists reported limited access to general information regarding community supports. CONCLUSION: Lack of formal processes for delivery of family-centred service, goal-setting and co-ordination between children's programmes may result in inequitable opportunities for families to participate in their children's rehabilitation despite attending the same programme. Standardized programme processes and policies may provide a starting point to ensure that all families have equitable opportunities to participate in their child's rehabilitation programme.

Right spatial neglect after left hemisphere stroke: qualitative and quantitative study.

OBJECTIVES: Comparatively little research has been conducted on right neglect after left brain damage. The authors sought to assess contralateral neglect in subacute left hemisphere stroke patients using a comprehensive test battery validated in a large control group after right hemisphere stroke. METHODS: Seventy-eight left hemisphere stroke patients were assessed. The test battery included a preliminary assessment of anosognosia and visual extinction, a clinical assessment of gaze orientation and personal neglect, and paper-and-pencil tests of spatial neglect in the peripersonal space. Only nonverbal tests were used. RESULTS: Drawing and cancellation tasks revealed neglect in 10 to 13% of patients. The combined battery was more sensitive than any single test alone. A total of 43.5% of patients showed some degree of neglect on at least one measure. Anatomic analyses showed that neglect was more common and severe when the posterior association cortex was damaged. CONCLUSIONS: The frequency of occurrence of right neglect was, as expected, much lower than that reported in a study using the same assessment battery in right brain damage stroke patients. Nevertheless, neglect was found in a substantial proportion of patients at a subacute stage, suggesting that it should be considered in the rehabilitation planning of left brain damage stroke patients.

[Functional prognosis of paraplegia due to cord ischemia: a retrospective study of 23 patients]. / Pronostic fonctionnel des paraplégies par ischémie médullaire: étude rétrospective de 23 cas.

The functional prognosis of spinal cord infarct is not well known, complicating care of patients suffering from ischemic paraplegia. The aim of this study was to evaluate the clinical and functional outcome of patients with spinal cord infarct treated in rehabilitation centers in order to identify factors influencing functional outcome. We studied cases of non-trauma-related paraplegia treated between 1992 and 1999. Spinal compression and infectious and inflammatory myelopathy were excluded. Age, gender, cardiovascular risk factors, initial and final clinical findings according to the American Spinal Injury Association (ASIA/IMSOP) criteria, MRI findings, and initial urodynamic findings were analyzed. Two groups were identified regarding extension of the spinal cord infarct to the cone or not. Assessment of functional outcome was based on the Frankel classification, ambulatory ability, wheelchair use, and bladder control. Cases of spinal cord infarct were then classified according to extension to the cone or not, determined on the basis of initial clinical, MRI, and urodynamic findings. Twenty-three patients (19 males and 4 females) were selected for analysis. Mean age was 54 years, with no mortality during the follow-up period. At discharge, the group of nine patients whose infarct had not extended to the medullary cone had a significantly better motor recovery using the ASIA motor score (p<0.01). Patients whose infarct did not extend to the cone used wheelchairs less often, were more often in Frankel class D (p<0.05), and had normal bladder control more often (p<0.05) than patients whose infarct extended to the cone. Lack of extension to the medullary cone appeared to be a factor predictive of better functional outcome.

The Tetrafigap Survey on the long-term outcome of tetraplegic spinal cord injured persons: Part III. Medical complications and associated factors.

STUDY DESIGN: To study the short- and long-term medical complications encountered in tetraplegic spinal cord injured persons (TSCI) and to give prominence to both the medical and socio-economic factors with which they are respectively associated. METHODS: The Tetrafigap Study is a multicentre epidemiological survey carried out using self-administered questionnaires studying the global long-term outcome of TSCI patients after the initial phase of rehabilitation. RESULTS: The data for 1668 patients were analyzed. The rate of rehospitalizations was 74.4% with on average three stays per patient and as reported causes, in descending order: urinary complications, systematic follow-up, pressure sores, respiratory complications, contractures, bowel complications, pains and secondary fractures of the lower limbs. At the time of the survey, 84.7% of patients mentioned awkward contractures, 73.8% pains, 55.9% embarrassing urinary leakage and 14.1% pressure sores. With regard to persons suffering from complete motor lesion, urinary complications and pressure sores were more frequently reported, whereas for persons suffering from incomplete motor lesions, awkward contractures and pains were more frequent. In the elderly, pains were more often mentioned, and pressure sores and pain were also the most common in patients coming from lower socio-professional status. Contractures and pain decreased with time. All these complications but pressure sores and pain are statistically interrelated. CONCLUSION: The medical complications of spinal cord injured persons are frequent, they are linked to biological, psychological and environmental factors, and are interrelated. Therefore, seeking mid- and long-term risk factors must be given priority in order to better adapt attempts at increasing secondary prevention.

Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke.

OBJECTIVES: The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of spatial neglect after stroke. The aim of this study was to assess the sensitivity of different tests of neglect after right hemisphere stroke. METHODS: Two hundred and six subacute right hemisphere stroke patients were given a test battery including a preliminary assessment of anosognosia and of visual extinction, a clinical assessment of gaze orientation and of personal neglect, and paper and pencil tests of spatial neglect in the peripersonal space. Patients were compared with a previously reported control group. A subgroup of patients (n=69) received a behavioural assessment of neglect in daily life situations. RESULTS: The most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. About 85% of patients presented some degree of neglect on at least one measure. An important finding was that behavioural assessment of neglect in daily life was more sensitive than any other single measure of neglect. Behavioural neglect was considered as moderate to severe in 36% of cases. A factorial analysis revealed that paper and pencil tests were related to two underlying factors. Dissociations were found between extrapersonal neglect, personal neglect, anosognosia, and extinction. Anatomical analyses showed that neglect was more common and severe when the posterior association cortex was damaged. CONCLUSIONS: The automatic rightward orientation bias is the most sensitive clinical measure of neglect. Behavioural assessment is more sensitive than any single paper and pencil test. The results also support the assumption that neglect is a heterogeneous disorder.

Rehabilitation of postural disturbances of hemiplegic patients by using trunk control retraining during exploratory exercises.

OBJECTIVE: To assess use of the Bon Saint Côme device for axial postural rehabilitation in hemiplegic patients, a technique based on voluntary trunk control during exploratory retraining. DESIGN: A 3-month randomized controlled trial. SETTING: A public neurorehabilitation center. PATIENTS: Twenty consecutive hemiplegic patients with axial postural disturbance resulting from recent stroke were randomly assigned to a device group (DG) or control group (CG). The 2 groups of 10 patients were similar. INTERVENTION: For 1 month, the DG patients followed an experimental program for 1 hour daily and conventional neurorehabilitation for 1 hour daily, whereas CG patients had conventional neurorehabilitation for 2 hours daily. For the next 2 months, all 20 patients had conventional neurorehabilitation for 2 hours daily. MAIN OUTCOME MEASURES: Patients were assessed on days 0, 30, and 90 by using a battery of postural tests, gait evaluation, the Bells neglect test, and the FIM instrument. RESULTS: On day 30, postural and neglect tests improved significantly more in DG than in CG. The benefit remained at day 90. Gait improved earlier in DG than in CG. FIM scores improved equally. CONCLUSIONS: Voluntary trunk control retraining during spatial exploration with the Bon Saint Côme device appears to be a useful approach for rehabilitation of postural disorders in hemiplegic patients. Treatments designed to improve spatial cognition deficits probably enhance postural disorder recovery in hemiplegia.

[Presenting a battery for assessing spatial neglect. Norms and effects of age, educational level, sex, hand and laterality]. / Présentation d'une batterie de dépistage de la négligence spatiale. Normes et effets de l'âge, du niveau d'éducation, du sexe, de la main et de la latéralité.

The aim of this study was to build up a battery for assessing spatial neglect, then to analyse the norms and potential effects of age, education level, sex, hand used, and laterality. It was also to contribute evaluating the pseudoneglect phenomenon described by Heilman, which consists in a tendency of normal subjects to neglect the right peripersonal space. Tasks selected were presented to important groups of normal subjects, most often larger than 450. The battery comprised of a bell cancellation test, scene copy, clock drawing, two line bisection tasks, identification of overlapping figures, text reading, writing task, and the representational task of the France map. For each of them, different variables were selected, especially investigating the difference between performance in the right and the left hemispaces. This study allowed defining the threshold values (percentiles 5 and 95) for deciding of the pathological character of a patient performance. It also showed that the pseudoneglect phenomenon is more obvious in some tasks such as line bisection, and probably also in the representational task of the France map and writing. His importance and at times his side were influenced by the factors we studied, with between tasks differences, but also by the nature of the task to be performed, and especially his verbal component.

[Reiterated intravesical instillation of capsaicin in neurogenic detrusor hyperreflexia: a 5-years experience of 100 instillations]. / Capsaïcine intravésicale et hyperréflexie du détrusor. Expérience de 100 instillations sur une période de cinq ans.

INTRODUCTION: Capsaicin is a topic and specific C-fiber afferent neurotoxic. After spinal-cord injury, C-fiber afferent proliferate in the bladder mucosae and are involving in detrusor hyperreflexia AIM OF THE STUDY: To investigate middle-term efficacy and tolerance of intravesical instillation of capsaïcin in spinal-cord injured patients presenting severe urinary incontinence refractory to usual therapy due to detrusor hyperreflexia. METHODS: Thirty patients receveid a first intravesical instillation of 1mMol/L Capsaïcin solution in 30% alcohol. The efficacy (voiding diary, pads, quality of life, maximum cystometric capacity, maximum detrusor pressure, first and normal desire to void) and tolerance were evaluated before, 1 month and 3 months after each instillation, completed by anual cystoscopy. In patients who responded favorably to this instillation, repeated instillations were proposed when symptoms recurred. RESULTS: 25 patients (83.3%) were improved after the initial instillation (decrease of incontinence-frequency-urgency, best quality of life, rise on maximal cystometric capacity), since the 15(th) day and for 3.2 months. 76 reiterative instillations were performed in 22 patients (2 to 9 instillations per patient). 91.2% of them remained successfull, during an average period of 4.2 months. It does not appear loss of benefits after iterative instillations. Transient and moderate adverse effects followed 86% and 79% of the first and reiterated instillation (exacerbation of incontinence, supra-pubic pain). Two patients have presented a begnin and transient inflammatory cystitis after reiterated instillation. DISCUSSION-CONCLUSION: Intravesical instillation of capsaïcin are an effective treatment for incontinence and associated symptoms caused by neurogenic detrusor hyperactivity. Propositions to improve immediate tolerance are debated.

Fluoxetine in early poststroke depression: a double-blind placebo-controlled study.

BACKGROUND AND PURPOSE: Early poststroke depression (PSD) is a frequent and specific entity that impairs the rehabilitation and functional recovery of hemiplegic patients. This trial was designed to study the efficacy and tolerance of fluoxetine (FLX) in the treatment of early PSD. METHODS: This was a multicenter, double-blind, placebo-controlled study. Recent hemiplegic patients (<3 months) suffering from major depressive disorder (determined by International Classification of Diseases, 10th Revision, and Montgomery-Asberg Depression Rating Scale [MADRS] >19) were randomized to receive either 20 mg/d fluoxetine (FLX) or placebo for 6 weeks. Patients were evaluated by use of the Motricity Index, Mini-Mental State Examination, Functional Independence Measure, and MADRS. Statistical analysis was performed by using an intent-to-treat approach comparing the 2 groups at day 0 (baseline) and days 15, 30, and 45 (end point). RESULTS: Of 121 patients screened, 31 were included in the study, 16 in the FLX group and 15 in the placebo group. There were no significant differences in baseline characteristics among the 2 groups. The FLX-treated patients compared with placebo-treated patients demonstrated significant improvement in mean MADRS scores at end point (11.8+/-6. 7 [mean+/-SD] versus 18.7+/-10.0, respectively; P=0.05). FLX-treated patients compared with placebo-treated patients also demonstrated greater response rate (62.5% versus 33.3%, respectively) and greater mean decrease of MADRS (16.6 versus 8.4, respectively; P=0.02). There were no differences in motor, cognitive, or functional improvement and no significant side effects after FLX treatment, except for a patient with a moderate and transient increase of transaminases. CONCLUSIONS: FLX is an efficacious and well-tolerated treatment for early PSD. Further research is needed to evaluate the efficacy and safety of long-term treatment in this population.

Pharmacological therapy of spinal cord injury during the acute phase.

STUDY DESIGN: Prospective, randomized clinical trial. SETTING: France. OBJECTIVES: To evaluate the safety and effect on neurological outcome of nimodipine, methylprednisolone, or both versus no medical treatment in spinal-cord injury during the acute phase. METHOD: One hundred and six patients who had spinal trauma (including 48 with paraplegia and 58 with tetraplegia) were randomly separated into four groups: M=methylprednisolone (30 mg x kg(-1) over 1 h, followed by 5.4 mg x kg(-1) x h(-1) for 23 h), N=nimodipine (0.015 mg x kg(-1) x h(-1) for 2 h followed by 0.03 mg x kg(-1)h(-1) for 7 days), MN (both agents) or P (neither medication). Neurological assessment (ASIA score) was performed by a blinded senior neurologist before treatment and at 1-year follow-up. Early spinal decompression and stabilization was performed as soon as possible after injury. RESULTS: One hundred patients were reassessed at 1 year. Neurological improvement was seen in each group (P<0.0001), however no additional neurological benefit from treatment was observed. Infectious complications occurred more often in patients treated with M. Early surgery (49 patients underwent surgery within 8 h of their accident) did not influence the neurological outcome. The only predictor of the latter was the extent of the spinal injury (complete or incomplete lesion). CONCLUSION: The present study confirms the absence of benefit of pharmacological therapy in this indication. Because of the paucity of clinical studies that demonstrate the efficacy of pharmacological treatment in spinal injury during the acute phase, systematic use of pharmaceutical agents should be reconsidered.

Critical illness polyneuropathy. A 2-year follow-up study in 19 severe cases.

Critical illness polyneuropathy (CIP) is a reported cause of varying degrees of neuromuscular weakness in patients with multiple organ failure. Little is known concerning predictive factors of neurological recovery. The critical care conditions, neurological explorations and 2-year clinical follow-up of 19 patients who suffered from severe forms (quadriplegia or quadriparesis) of CIP were analyzed. Characteristics of patients who recovered clinically were compared with those of patients who did not. Two patients died within 2 months, 11 recovered completely, 4 remained quadriplegic and 2 remained quadriparetic. All patients suffered from sepsis, multiple organ dysfunction syndrome and a catabolic state before the onset of CIP. Outcome appears difficult to predict with clinical or electrophysiological data. Three parameters were significantly correlated with poor recovery: longer length of stay in the critical care unit, longer duration of sepsis and greater body weight loss. A relationship seems to exist between the severity of CIP and that of sepsis and its associated hypercatabolism. The favorable outcome usually attributed to CIP must be reconsidered. The authors recommend aggressive measures against sepsis to limit CIP and its sequelae.

[Intravesical instillations of capsaicin in urology: from pharmacological principles to therapeutic applications]. / Instillations intravésicales de capsaïcine en urologie. Des principes pharmacologiques aux applications thérapeutiques.

Capsaicin is a specific neurotoxin for type C nonmyelinated vesical afferent fibres involved in the transmission of nociceptive stimuli and reorganization of voiding reflexes in disease. The presence of afferents sensitive to vanilloid substances in the human bladder suggests the potential value of intravesical instillations of capsaicin in patients with symptoms of bladder hypersensitivity or bladder hyperactivity. Ten clinical trials document the efficacy and safety of vesical instillation of capsaicin in 200 patients with neurological or non-neurological lower urinary tract symptoms. The objective of this review is to analyse these various publications in order to define the indications and practical conditions of intravesical instillation of capsaicin. The value of intravesical capsaicin in neurogenic bladder hyperactivity has been clearly demonstrated. In non-neurological indications, the diversity of instillation protocols and the heterogeneity of the evaluation parameters complicate analysis of the results. Repeated low-dose capsaicin appears to be useful in bladder hyperactivity, but the value of capsaicin is uncertain in idiopathic detrusor instability. Transient adverse effects are almost systematically observed after intravesical capsaicin. The short-term and medium-term local histological safety appears to be satisfactory, but needs to be documented in the long-term.

Intravesical instillation of capsaicin in urology: A review of the literature.

OBJECTIVES: Interest in the intravesical instillation of capsaicin is growing among urologists. Its efficacy on detrusor hyperreflexia, hypersensitive bladder disorders and bladder pain has been reported in several studies. However, the lack of common evaluation parameters and the absence of consensus concerning a protocol of instillation hamper the interpretation of results. The purpose of this review is to better delineate the indications and optimum protocol for intravesical use of capsaicin. METHODS: Eight open and two placebo-controlled human clinical trials were analyzed. All 200 patients involved had lower urinary tract disorders. RESULTS: Clinical or urodynamic symptoms improved in 84.3% of the patients who received intravesical capsaicin for neurogenic hyperreflexic bladder, a significantly greater efficacy than that of placebo. Capsaicin may also be beneficial in patients who have non-neurogenic disorders. Whether or not the patients has a neurologic deficit, side effects appear during and in the period immediately following instillation. CONCLUSIONS: Intravesical capsaicin appears to be indicated in neurogenic hyperreflexic bladder, but is less effective against detrusor instability, hypersensitive bladder disorders or pelvic pain. The best instillation protocol and long-term tolerance remain to be established.

Capsaicin and neurogenic detrusor hyperreflexia: a double-blind placebo-controlled study in 20 patients with spinal cord lesions.

The aim of this study was to investigate the efficacy and tolerance of capsaicin, a neurotoxin for C-fiber afferents, applied intravesically in the treatment of detrusor hyperreflexia. Eleven male and nine female patients who had spinal cord lesions caused by multiple sclerosis (12) or trauma (eight) resulting in detrusor hyperreflexia with urge incontinence and pollakiuria were randomized to receive one intravesical instillation of either 30 mg capsaicin in 100 ml 30% ethanol or 100 ml 30% ethanol alone. The patients were evaluated clinically (voiding diary) and urodynamically (maximum cystometric capacity, maximum detrusor pressure, first and normal desire to void) before and 30 days after the instillation. On day 30, the 10 patients who received capsaicin had significant decreases in 24-h voiding frequency from 9.3+/-6.1 to 6.7+/-3.8 (P=0.016) and leakages from 3.9+/-1.6 to 0.6+/-0.8 (P=0.0008); their maximum cystometric capacity increased from 169+/-68 to 299+/-96 ml (P=0.01) and maximum detrusor pressure decreased from 77+/-24 to 53+/-27 cm H2O. There were no significant changes in the control group. In seven subjects in each group, instillation triggered immediate side effects (suprapubic pain, sensory urgency, flushes, hematuria, autonomic hyperreflexia) that resolved within 2 weeks. Intravesical capsaicin significantly improves clinical and urodynamic parameters of detrusor hyperreflexia in spinal cord-injured patients. Side effects are frequent, tolerable, and identical to those induced by 30% ethanol alone.

[Medical treatment of spinal cord injury in the acute stage]. / Traitement médicamenteux de la lésion médullaire traumatique au stade aigu.

OBJECTIVES: To evaluate the effect on neurologic outcome and the safety of nimodipine (N), methylprednisolone (M), or both (MN) versus no medical treatment (P) in spinal cord injury at the acute phase. STUDY DESIGN: Prospective, randomized clinical trial. PATIENTS: One hundred and six patients with a spinal trauma, including 48 with paraplegia and 58 with tetraplegia. METHOD: After eligibility, patients were randomly allocated in one of the following groups: M = methylprednisolone 30 mg.kg-1 over 1 hour, followed by 5.4 mg.kg-1.h-1 for 23 hours, N = nimodipine 0.015 mg.kg-1.h-1 over 2 hours followed by 0.03 mg.kg-1.h-1 for 7 days, MN or P. Neurologic assessment (ASIA score) was performed by a senior neurologist before treatment and at the 1-year follow-up. Early spinal decompression and stabilization was performed as soon as possible after injury. RESULTS: One hundred patients were reassessed at the 1-year follow-up. Neurologic improvement was seen in each group (P < 0.0001), however no neurologic benefit from treatment was observed. Infectious complications occurred more often in patients treated with M. Early surgery (49 patients), within the first 8 hours did not influence the neurologic outcome. The only predictor of the latter was the extent of the spinal injury (complete or incomplete lesion). CONCLUSION: Currently, no evidence of the benefit of medical treatment in this indication is existing. Because of the lack of clinical studies proving efficacy of pharmacological treatment in this specific pathology, a systematic use of medications cannot be recommended.