Botulinum toxin therapy for neurogenic detrusor hyperactivity versus augmentation enterocystoplasty: impact on the quality of life of patients with SCI.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To compare quality of life (QoL) in patients with spinal cord injury (SCI) who underwent overactive detrusor treatment by botulinum toxin (BT) versus augmentation cystoplasty (AC). SETTING: France. METHODS: Prospective and descriptive study: Patients with a refractory overactive bladder due to SCI treated by at least two successive injections of BT or by AC. QoL was assessed using Qualiveen-30 (Q30). Clinical data and urodynamic parameters were collected. RESULTS: Thirty patients were included between March 2013 and March 2014: 14 in arm 1 (BT injections) and 16 in arm 2 (AC). Mean postoperative time after AC was 9.94 years. Mean BT injections already performed was 6.36. Qol was significantly lower in arm 1-Q30 score 1.625 versus arm 2-Q30 score 1.077 (P=0.037). Continence control was significantly higher in arm 2. Fourteen patients were completely continent (87.5%) in arm 2, whereas only 6 (42.3%) were continent in arm 1 (P=0.0187). Urinary infection, reflux, diverticula and stones were almost at a similar occurrence level. CONCLUSIONS: QoL was found to be higher with an AC compared with BT injections. Long-time intervals between two injections and advantages specific to AC might explain in part these findings.

Neural and muscular mechanisms of electrically induced fatigue in patients with spinal cord injury.

STUDY DESIGN: Intervention study. OBJECTIVES: The present study aimed at examining whether spinal and/or peripheral alterations are in the origin of neuromuscular fatigue development induced by intermittent neuromuscular electrical stimulation (NMES) in subjects with complete spinal cord injury (SCI). SETTING: Neurological Rehabilitation Center CMN Propara, Montpellier, France. METHODS: Thirteen volunteers with complete SCI participated in the study. The right triceps surae muscle was fatigued using a 30-Hz NMES protocol (2 s ON-2 s OFF) composed of three series of five trains. Spinal excitability (assessed by the H-reflex), muscle excitability (assessed by the M-wave), muscle contractile properties (assessed by mechanical response parameters) and torque evoked by NMES were tested before and after each five-train series. RESULTS: NMES-evoked torque significantly decreased throughout the protocol (P<0.001). This decrease was accompanied by a significant increase in M-wave amplitude (P<0.001), whereas H-reflex and the Hmax/Mmax ratio were not significantly modified. The amplitude of the mechanical response was significantly decreased at the end of the protocol (P<0.05). CONCLUSION: The results indicate significant fatigue development, which was attributed to impaired cross-bridge force-generating capacity, without modification of spinal excitability nor muscle excitability.

Evaluating self-reported pressure ulcer prevention measures in persons with spinal cord injury using the revised Skin Management Needs Assessment Checklist: reliability study.

STUDY DESIGN: Cross-cultural adaptation and reliability study. OBJECTIVE: To translate, evaluate the reliability and cross-culturally adapt the Skin Management Needs Assessment Checklist (SMnac), a questionnaire evaluating the knowledge on pressure ulcer (PU) prevention measures in persons with spinal cord injury (SCI). SUBJECTS: 138 persons with SCI, mean age 45.9 years, mean time since injury 94 months. MATERIAL AND METHOD: The study was carried out in two stages. First, the questionnaire went through a forward-backward translation process and was cross-culturally adapted, according to a validated methodology for self-reported measures. Then, the test-retest reliability was evaluated on a population of persons with SCI. RESULTS: The standardized back-translation and cross-cultural adaptation led to the revised Smack grid, with the addition of seven items representing an update of PU prevention measures. The reliability was excellent (intraclass correlation coefficient: 0.899). CONCLUSION: The revised SMnac is an adaptation of the SMnac, including therapeutic education frameworks and the latest PU prevention practices. It appears to be a reliable tool for assessing the knowledge and benefits of PU prevention in persons with SCI. Further studies are needed to explore its validity and responsiveness to change.

Pressure ulcer risk factors in persons with spinal cord injury part 2: the chronic stage.

INTRODUCTION: Pressure ulcers (PUs) are a common complication following spinal cord injury (SCI). Prevalence for persons in the chronic SCI stage varies between 15 and 30%. The risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed for designing an SCI-specific assessment tool. The first results seem quite disappointing, probably because of the level of evidence of the risk factors used. OBJECTIVE: To determine PU risk factors correlated to the chronic stage of SCI. MATERIALS AND METHODS: Systematic review of the literature. RESULTS: There are several PU risk factors for chronic SCI stage: socio-demographics, neurological, medical or behavioral. The level of evidence varies: it is quite high for the socio-demographics and neurological factors and low for behavioral factors. DISCUSSION AND CONCLUSION: Behavioral risk factors (relieving the pressure, careful skin monitoring, smoking) are probably the ones for which a preventive strategy can be established. It is important to develop specific assessment tools for these behavioral risk factors to determine their relevance and evaluate the effect of therapeutic educational programs on persons with SCI.

A new 3D center of mass control approach for FES-assisted standing: First experimental evaluation with a humanoid robot.

This paper proposes a new control framework to restore the coordination between upper (functional) and lower (paralyzed) limbs in the context of functional electrical stimulation in completely paraplegic individuals. A kinematic decoupling between the lower and upper limbs controls the 3D whole-body center of mass location and the relative foot positions by acting only on the lower-limb joints. The upper limbs are free to move under voluntary control, and are seen as a perturbation for the lower limbs. An experimental validation of this paradigm using a humanoid robot demonstrates the real-time applicability and robustness of the method. Different scenarios mimicking the motion of a healthy subject are investigated. The proposed method can maintain bipedal balance and track the desired center of mass trajectories under movement disturbances of the upper limbs with an error inferior to 0.01 m under any conditions.

[Assessment of functional abilities, handicap and quality of life in patients with spinal cord injuries]. / Evaluation des aptitudes fonctionnelles, du handicap et de la qualité de vie chez le blessé médullaire.

OBJECTIVES: A literature review of the methods of evaluating function, handicap and quality of life in patients with spinal cord injuries. METHODS: The literature review was based on the available French and English articles published since 1990 in 3 databases: MEDLINE, Pascal and Embase. RESULTS: The literature is dominated by descriptions of tools for evaluating functional limitations in motor deficiencies. Such descriptions involve the validation of generic tools for patients with spinal cord injuries or of specific tools during the evaluation of a particular intervention such as surgery of the tetraplegic hand or adaptation of technical help. CONCLUSION: The tools to assess patients with spinal-cord injuries are sufficiently numerous and varied to allow us to evaluate physical, functional and psychosocial dimensions. Rigorous methodological validation is continuously at the base of those proposed tools and thus reinforces our choice to use them. Unfortunately, few evaluation tools for patients with spinal cord injuries have been published, translated into French and validated.

[Critical review of the evaluation of the results of upper limb functional surgery in tetraplegia since 50 years]. / Analyse critique des modalités d'évaluation des résultats de la chirurgie fonctionnelle du membre supérieur tétraplégique. Revue de la littérature sur les 50 dernières années.

OBJECTIVE: To study the methods of assessment of upper limb functional surgery in the literature. METHODS: The literature review relating to the years 1950-2002 was carried out with three data bases: Medline, Pascal, Embase. This review also involved a thorough study of non-indexed references. RESULTS: Although many instruments or tests are used to assess outcome after surgery, their reliability, validity and responsiveness have not been adequately proven. Methodology appears to be the major failing of the various scales used to assess these patients. The conceptual models underlying the evaluation are all too often unspecified. There is a lack of pertinence of the selected tasks for tetraplegics. There is limited documentation of the guiding framework or conceptualisation. Furthermore, the process of item selection is often unknown. Scales or instruments are also deemed to be too insensitive to document the small but meaningful functional gains made by tetraplegics after functional surgery. CONCLUSION: To answer the need for a specific assessment tool for tetraplegics who undergo functional surgery, we have developed a national, multicenter, prospective and longitudinal study based on two concepts: the first concept is related to Life Habits that are the activities of daily living and social roles recognised by the socio-cultural context of a person according to age, sex and social and personal identity. They include activities that should be accomplished on a daily basis (nutrition, fitness, personal care, communication, mobility, etc.). Life Habits presenting a significant level of disruption can create handicap situations. The second concept is in relation with Motor Capacities that correspond to the abilities of a patient to perform basic and functional tasks regardless of contextual factors (environmental and personal factors).

[Validation of the motor capacities scale: a specific evaluation of manual abilities in tetraplegics who undergo functional surgery of the upper limbs]. / Validation d'une grille de capacités motrices du tétraplégique opéré du ou des membres supérieurs.

OBJECTIVE: Metrological investigation to develop a motor capacities scale (MCS) specifically designed for tetraplegics who undergo a functional surgery of upper limbs. METHODS: From diverse sources-review of literature, discussion with patients and therapists-, 328 daily life activities were compiled. Eighty of them were identified as motor capacities and correspond to basic and functional tasks performed by tetraplegics independently of contextual and environmental factors. Because of the absence of a reference test, a process of validation was required. In the preliminary study, patients and occupational therapists were asked to criticize the pertinence of the study. In the pilot study, patients were assessed on the basis of a protocol. Feasibility of the evaluation was also studied. The intermediate study was focused on the interrater reproducibility. The prefinal study aimed at assessing construct validity. In the final study, the external structure of the scale and responsiveness to change provided by functional surgery were analyzed. RESULTS: The preliminary and pilot studies revealed the good acceptability of the scale by both the patients and the therapists. Face and content validity were enhanced by the multidisciplinary and multicenter approach. Global reproducibility was found to be excellent (intraclass correlation coefficient = 0.99). MCS was correlated with the Sollerman test, the functional independence measure (FIM), the ASIA motor score, dynamometric scores of Jamar and Preston. No correlation was found with the interval since the onset of the tetraplegia, the educational level and the age at the time of the evaluation. A factorial analysis was performed in 125 patients (146 observations) and revealed one main dimension that appears to reflect manual abilities. Responsiveness to change was important regarding the short time following surgery. The final version of the MCS comprises 31 items classified in six functional categories: transfers, positioning on a Bobath's couch, positioning in a wheelchair, locomotion, motor capacities of spatial exploration and motor capacities for grasping and gripping. CONCLUSION: The MCS displays satisfactory metrological properties: a good apparent and content validity, an excellent reproducibility and a good construct validity. The data showed that sensitivity to change was good enough to consider the MCS as a valid means of assessment of the effectiveness of upper limb functional surgery in tetraplegics.

[Functional surgery of upper limb in tetraplegics since 50 years]. / Evolution de la prise en charge chirurgicale du membre supérieur tétraplégique depuis 50 ans.

OBJECTIVE: Development of upper limb functional surgery in tetraplegics in the last 50 years. METHODS: The literature review relating to the years 1950-2002 was carried out with 3 data bases: Medline, Pascal, Embase. This review also involved a thorough study of non-indexed references. RESULTS: A large number of surgical procedures are described. Two priorities are stressed by the authors: safety of these procedures and duration of postoperative immobilization. CONCLUSION: This review of literature shows that the prospects for restoring upper limb function in tetraplegics are greater than ever, offering a larger number of patients the possibility to increase their independence in daily life. Functional surgery remains, nevertheless, demanding in terms of length of immobilization and presupposes requiring a multidisciplinary approach requiring rehabilitation teams to be up to date with surgical procedures.

Physical and rehabilitation medicine (PRM) care pathways: "spinal cord injury".

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. The patients after spinal cord injury are divided into five categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.

[Acute traumatic spinal cord injuries: Epidemiology and prospects]. / Les lésions médullaires traumatiques : épidémiologie et perspectives.

OBJECTIVE: Specify the epidemiological data on the acute spinal cord injuries and define a group of patients that could benefit from cellular transplantation therapy designed with the aim of repair and regeneration of damaged spinal cord tissues. MATERIAL AND METHODS: Five years monocentric (Gui-de-Chauliac Hospital, Montpellier, France) retrospective analysis of patients suffering from spinal cord injury (SCI). Spinal cord injured-patients, defined as sensory-motor complete, underwent a clinical evaluation following American Spinal Injury Association (ASIA) and functional type 2 Spinal Cord Independence Measure (SCIM2) scorings as well as radiological evaluation through spinal cord magnetic resonance imaging (MRI). RESULTS: One hundred and fifty-seven medical records were reviewed and we selected and re-examined 20 patients with complete thoracic spinal cord lesion. Clinical and radiological evaluations of these patients demonstrated, in 75 % of the cases, an absence of clinical progression after a mean of 49months. Radiological abnormalities were constantly present in the initial (at the admission to hospital) and control (re-evaluation) MRI and no reliable predictive criteria of prognosis had been found. DISCUSSION/CONCLUSION: We compare our results to the literature and discuss advantages and limits of cellular transplantation strategies for these patients.

Therapeutic education in persons with spinal cord injury: a review of the literature.

INTRODUCTION: Therapeutic education is an integrant part of the physical medicine and rehabilitation care of persons with spinal cord injury. It is often conducted in an empirical manner. The objective of this literature review was to evaluate the state of the art regarding the evaluations and therapeutic education programs for persons with spinal cord injury. MATERIAL AND METHOD: Systematic review of the literature with Medline and Cochrane Library databases from 1966 to 2009. RESULTS: The main areas of interest, for the evaluations found in the literature, focused on clinical variables, patients' knowledge, health behaviors, functional independence and quality of life but also psychological dimensions such as health locus of control, representations, abilities to resolve problems and self-perceived efficacy. Ten clinical studies were retained for analysis. These clinical studies were built around various health and educational models. An impact was highlighted on clinical variables (pressure ulcer, urinary tract infection), knowledge, quality of life and psychological criteria (depression, self-perceived efficacy, coping and problem solving strategies). DISCUSSION AND CONCLUSION: The global level of evidence on the effects of therapeutic education in persons with spinal cord injury is low because of the number of studies and their low statistical power and requires additional studies. However, the analysis of the literature allows for discussing the organization of therapeutic education in clinical practice.

Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: technique and results.

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

Chronic neuropathic pain in spinal cord injury patients: what relevant additional clinical exams should be performed?

OBJECTIVE: Study the indications and level of evidence of clinical exams that might be relevant in exploring the causes of neuropathic pain in spinal cord injury patients. METHOD: Literature review from three databases: PubMed, Embase, Pascal. RESULTS: Disparity and heterogeneity of the answers given by the attendees to the experts conference of the French Society of Physical Medicine and Rehabilitation (SOFMER) and the physicians surveyed via the SOFMER website. These results corroborate the shortage of available data on this topic in the literature. From this analysis, we can however validate spinal MRI imaging as a mandatory exam for the diagnosis of post-traumatic syringomyelia (cystic myelopathy) - this exam can even be considered a Gold Standard. Furthermore, we can also recommend using electrodiagnostic studies for compressive neuropathies. However, it is not possible to validate the relevance of additional clinical exams for radicular pain, segmental deafferentation pain, central deafferentation pain as well as Complex Regional Pain Syndrome (CRPS) type 1; for these types of pain we can only formulate experts recommendations in light of the dearth of available data on the subject. CONCLUSION: For the neuropathic pain of spinal cord injury patients' additional clinical exams should be used in the framework of an etiological diagnosis.

Chronic neuropathic pain in spinal cord injury patients: what is the impact of social and environmental factors on care management?

OBJECTIVE: In order to refine therapeutic strategies for spinal cord injury (SCI) patients with chronic neuropathic pain, it appears essential to assess the impact of socioenvironmental factors on the onset of pain or its chronic nature. The aim of this article is to answer the following question regarding these factors: is there any evidence that managing these social and environmental factors could have a positive impact on the treatment of chronic neuropathic pain in SCI patients? METHODOLOGY: The English keywords were: Chronic neuropathic pain in spinal cord injury/human/adult and rehabilitation; functional independence; community integration; family support; employment; social environment; social support; life satisfaction; quality of life. RESULTS: Thirty-four articles were selected, the data extracted from the literature highlighted several socioenvironmental factors that could have a potential impact on the onset of neuropathic pain in spinal cord injury patients. CONCLUSION: It was impossible to directly answer this question based on the literature review only. Nonetheless, some socioenvironmental factors can be considered as potential triggering factors for the onset of chronic pain in spinal cord injury patients, i.e. a low degree of independence (C), low socioeconomic status (B), unemployment (B), and family and friends with a "negative attitude" (C).

The chronic neuropathic pain of spinal cord injury: which efficiency of neuropathic stimulation?

OBJECTIVE: Determine the efficacy of spinal cord stimulation (SCS) for treating neuropathic pain in spinal cord injury (SCI) patients. MATERIAL AND METHODS: We proceeded with a data analysis of the French and English medical literature with the following keywords: chronic neuropathic pain, spinal cord stimulation. The quality of every selected article was analyzed according to criteria established by the French National Health Authority (HAS). RESULTS: Eighty-three articles were read, 27 of them report clinical studies on SCS on at least one SCI patient. No article had a level of proof lower than 4. CONCLUSION: There is no significant level of proof to recommend the use of this technique in this indication. Conducting further studies, either physiological or clinical, could help to promote this technique with very minor adverse effects in an indication which, to this day, has no gold standard.

What are the risk factors of occurence and chronicity of neuropathic pain in spinal cord injury patients?

OBJECTIVE: Analyze the epidemiological data on neuropathic pain in spinal cord injury patients and determine the risk factors for its occurrence and chronicity. METHOD: Review and analysis of the literature. RESULTS: Epidemiological data report that 40% of spinal cord injury (SCI) patients suffer from neuropathic pain and 40% of these patients report an intense neuropathic pain. Some factors do not seem to be predictive for the onset of neuropathic pain: the level of injury, complete or incomplete injury, the existence of an initial surgery, sex. However, old age at the time of injury, bullet injury as the cause of trauma, early onset of pain in the weeks following the injury, their initial nature, intensity and continuous pain, as well as associated symptoms all appear to be negative prognostic factors. CONCLUSION: Neuropathic pain in SCI patients is a major issue, its determining factors still need to be evaluated properly by refining the epidemiological data.

What is the efficacy of physical therapeutics for treating neuropathic pain in spinal cord injury patients?

OBJECTIVE: Evaluate the place and level of proof of physical therapeutics for treating neuropathic pain in spinal cord injury (SCI) patients. METHOD: Literature review from three databases: PubMed, Embase, Pascal. The following keywords were selected: chronic neuropathic pain/non-pharmacological treatment; transcutaneous electrical nerve stimulation, physiotherapy, acupuncture, physical therapy, transcranial magnetic stimulation, heat therapy, ice therapy, cold therapy, massage, ultrasound, alternative treatment, complementary treatment, occupational therapy. The articles were analyzed using the double-reading mode. RESULTS: Three techniques emerge from the literature: magnetic or electrical transcranial stimulation, transcutaneous electrical nerve stimulation and acupuncture. Even though the first method is not easily accessible on a daily basis it is the one that yields the most promising results validated by Grade B studies. Healthcare professionals remain faithful to pain-relieving transcutaneous neurostimulation for both segmental neuropathic pain and below-level central neuropathic pain. Acupuncture is advocated by Canadian teams and could offer some interesting options; however, to this day, it does not have the methodological support and framework required to validate its efficacy. All other physical therapies are used in a random way. Only below-level massages are advocated by the patients themselves. CONCLUSION: To this day, no study can validate the integration of physical therapy as part of the array of therapeutics used for treating neuropathic pain in SCI patients. In the future, it will require controlled and randomized therapeutic studies on homogenous groups of SCI patients, to control the various confusion factors.

Chronic neuropathic pain of spinal cord injury: what is the effectiveness of psychocomportemental management?

OBJECTIVES: To determine the efficacy of treating neuropathic pain in spinal cord injury (SCI) patients by psychological, cognitive or behavioral therapies and suggest recommendations for clinical practices. MATERIAL AND METHOD: The methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts. RESULTS: Due to the dearth of literature on the subject only one study is found, evaluating the efficacy of these therapies on neuropathic pain but not on the chronic neuropathic pain of SCI patients. The results show a greater efficacy on the associated symptoms: anxiety and depression level, sleep disorders, rather than the pain itself. CONCLUSION: There is no scientific evidence for validating this type of pain management care. However, the high level of evidence of the articles studying the efficacy of these therapies in patients with chronic pain suggest that it could be applied to SCI patients. These techniques must be developed in France and further studies should be conducted on SCI patients affected by neuropathic pain.