Motor and autonomic concomitant health improvements with neuromodulation and exercise (MACHINE) training: a randomised controlled trial in individuals with spinal cord injury.

INTRODUCTION: Motor and autonomic dysfunctions are widespread among people with spinal cord injury (SCI), leading to poor health and reduced quality of life. Exercise interventions, such as locomotor training (LT), can promote sensorimotor and autonomic recovery post SCI. Recently, breakthroughs in SCI research have reported beneficial effects of electrical spinal cord stimulation (SCS) on motor and autonomic functions. Despite literature supporting the independent benefits of transcutaneous SCS (TSCS) and LT, the effect of pairing TSCS with LT is unknown. These therapies are non-invasive, customisable and have the potential to simultaneously benefit both sensorimotor and autonomic functions. The aim of this study is to assess the effects of LT paired with TSCS in people with chronic SCI on outcomes of sensorimotor and autonomic function. METHODS AND ANALYSIS: Twelve eligible participants with chronic (>1 year) motor-complete SCI, at or above the sixth thoracic segment, will be enrolled in this single-blinded, randomised sham-controlled trial. Participants will undergo mapping for optimisation of stimulation parameters and baseline assessments of motor and autonomic functions. Participants will then be randomly assigned to either LT+TSCS or LT+Sham stimulation for 12 weeks, after which postintervention assessments will be performed to determine the effect of TSCS on motor and autonomic functions. The primary outcome of interest is attempted voluntary muscle activation using surface electromyography. The secondary outcomes relate to sensorimotor function, cardiovascular function, pelvic organ function and health-related quality of life. Statistical analysis will be performed using two-way repeated measures Analysis of variance (ANOVAs) or Kruskal-Wallis and Cohen's effect sizes. ETHICS AND DISSEMINATION: This study has been approved after full ethical review by the University of British Columbia's Research Ethics Board. The stimulator used in this trial has received Investigation Testing Authorisation from Health Canada. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars. TRIAL REGISTRATION NUMBER: NCT04726059.

Breastfeeding Before and After Spinal Cord Injury: A Case Report of a Mother With C6 Tetraplegia.

INTRODUCTION: Although lactation dysfunction and breastfeeding difficulties after spinal cord injury have been previously reported, there is still a lack of research on the specific challenges and aspects that require more support. This unique case of a mother with C6 tetraplegia details her breastfeeding experience before and after spinal cord injury. MAIN ISSUE: A 23-year-old woman with a 20-month-old daughter sustained a motor and sensory complete traumatic spinal cord injury in a motor-vehicle crash while she was 6 months pregnant with her second child. This resulted in complete absence of sensory function below the level of injury (including the breast) and limited hand function. In comparison with her breastfeeding experience before injury, after injury she experienced decreased milk production, absence of the milk ejection reflex, and impaired ability to pick up, hold, and position her infant. MANAGEMENT: Care aides and family members assisted this mother with picking up, positioning, and latching her infant. She also utilized alternative breastfeeding positions, nursing pillows, and wedges. Domperidone was suggested by her physiatrist to increase milk production but ultimately was not used as there were no concerns with her infant's growth or development. CONCLUSION: Breastfeeding as a recently injured mother while undergoing intensive post-injury rehabilitation was challenging. Her second child developed well and was breastfed for 3 months compared to her first child (9 months). Breastfeeding was possible for this mother after spinal cord injury, in part due to previous experience successfully breastfeeding her first child, assistance from care personnel, and nursing aids.

Inter-Rater Reliability of the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury.

The autonomic nervous system can be profoundly affected after spinal cord injury (SCI). Despite its importance to quality of life, autonomic function is rarely systematically assessed in the clinical setting. The International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) is an assessment designed to determine which autonomic functions are intact, impaired, or lost after SCI. The psychometric properties of the ISAFSCI have not yet been reported. The objective of this study was to describe the inter-rater reliability of the ISAFSCI. Participants with chronic traumatic SCI (greater than 1 year) able to remain on the same medications for the study period and communicate clearly with the assessor were recruited for the study. A standard protocol minimized variation between the sites. During the first assessment, neurologic examination (ISNCSCI) was performed and ISAFSCI completed. After 10-14 days, the ISAFSCI was repeated. Inter-rater reliability was calculated using percentage agreement, kappa, and weighted kappa statistics. Participants (n = 48) had an average age of 45 ± 12 years. Forty-one (85.4%) were male, 38 (79.2%) had a SCI at or above the T6 level, 24 (50.0%) had a complete SCI. Inter-rater reliability within the general autonomic component was moderate with kappa values ranging 0.41-0.6 (p < 0.05). Within the Lower Urinary Tract, Bowel, and Sexual Function component, agreement was good-strong with weighted kappa values 0.62-0.88 (p < 0.05). Given the results, we conclude that the ISAFSCI can be considered to have at least moderate and up to strong inter-rater reliability, especially in the bladder, bowel, and sexual function component of the assessment.

Selective alpha adrenergic antagonist reduces severity of transient hypertension during sexual stimulation after spinal cord injury.

On a daily basis, the majority of those with high-level spinal cord injury have autonomic dysreflexia, which describes a life-threatening episode of transient extreme hypertension (i.e., as high as 300 mm Hg) as many as 90% of people living with this condition. Unfortunately, ejaculation is a major initiating factor for autonomic dysreflexia, which discourages sexual activity. In order to obtain a sperm specimen, or for initial assessment of fertility, penile vibrostimulation is clinically performed. Nifedipine, a selective calcium channel blocker, is the most commonly prescribed pharmaceutical for a priori management of autonomic dysreflexia secondary to ejaculation or other causes; however, it is limited because of its potential exacerbation of low resting pressure, which also affects this population. The present study examined the effect of a short-acting selective α1 antagonist (prazosin) on autonomic dysreflexia severity using a randomized placebo trial during medically supervised penile vibrostimulation in six males with cervical spinal cord injury. Beat-by-beat blood pressure and heart rate were recorded throughout penile vibrostimulation during placebo and prazosin-treated days. The increase in systolic blood pressure was mitigated during vibrostimulation in subjects administered prazosin as compared with those administered placebo (+140±19 mm Hg vs. +96±14 mmHg; p<0.05). On average, the peak in systolic blood pressure was 46 mm Hg lower during penile vibrostimulation when patients were administered prazosin (p<0.05), whereas resting blood pressure was not affected. Prazosin appears to be effective at reducing the severity of autonomic dysreflexia during sexual stimulation in patients with spinal cord injury, without exacerbating resting hypotension in high-level spinal cord injury.

The development of a sensory substitution system for the sexual rehabilitation of men with chronic spinal cord injury.

INTRODUCTION: Sexual health is often severely impacted after spinal cord injury (SCI). Current research has primarily addressed male erection and fertility, when in fact pleasure and orgasm are top priorities for functional recovery. Sensory substitution technology operates by communicating input from a lost sensory pathway to another intact sensory modality. It was hypothesized that through training and neuroplasticity, mapped tongue sensations would be interpreted as sensory perceptions arising from insensate genitalia, and improve the sexual experience. AIM: To report the development of a sensory substitution system for the sexual rehabilitation of men with chronic SCI. METHODS: Subjects performed sexual self-stimulation while using a novel sensory substitution device that mapped the stroking motion of the hand to a congruous flow of electrocutaneous sensations on the tongue. MAIN OUTCOME MEASURES: Three questionnaires, along with structured interviews, were used to rate the perceived sexual sensations following each training session. RESULTS: Subjects completed 20 sessions over approximately 8 weeks of training. Each subject reported an increased level of sexual pleasure soon after training with the device. Each subject also reported specific perceptions of cutaneous-like sensations below their lesion that matched their hand motion. Later sessions, while remaining pleasurable and interesting, were inconsistent, and no subject reported an orgasmic feeling during a session. The subjects were all interested in continuing training with the device at home, if possible, in the future. CONCLUSIONS: This study is the first to show that sensory substitution is a possible therapeutic avenue for sexual rehabilitation in people lacking normal genital sexual sensations. However more research, for instance on frequency and duration of training, is needed in order to induce functional lasting neuroplasticity. In the near term, SCI rehabilitation should more fully address sexuality and the role of neuroplasticity for promoting the maximal potential for sexual pleasure and orgasm.

Canadian male sexual health council survey to assess prevalence and treatment of premature ejaculation in Canada.

INTRODUCTION: This study evaluated the prevalence of complaints of premature ejaculation (PE) among a cross-sectional sample of Canadian males and their partners. AIM: It sought to quantify measures of behavior and attitudes as they relate to PE. It evaluated the level of patient knowledge, physician engagement, and patient satisfaction with treatment options for PE, a common sexual complaint. It also explored the patient and partner-reported impacts on quality of life and well-being. MAIN OUTCOME MEASURE: The main outcome measure for the study was the statistical analysis of data on different facets of PE and associated factors from a comprehensive population-based survey conducted in Canada. METHODS: A web-based survey was carried out among adults in Canada (phase 1, N = 3,816) followed by a focused telephone interview in phase 2 for those who met the criteria for PE (phase 2, N = 1,636). Men were classified as having PE based on self-report of low or absent control over ejaculation, irrespective of the duration of the ejaculation time, resulting in distress for them or their sexual partner or both, or reporting that they "climaxed too soon". RESULTS: The prevalence of PE in the survey, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-III criteria, ranged from 16% to 24% depending on the definition of PE utilized, and did not vary significantly with age. Ninety percent of those with a determination of PE in this survey had not discussed alternatives to prolong time to ejaculation with a physician, pointing to gaps in patient/physician communication around sexual health. CONCLUSIONS: PE is a prevalent sexual problem that poses special challenges to clinicians and causes considerable burden to Canadian men and their partners. There remains a stigma associated with PE, resulting in the existence of significant barriers to obtaining assistance from physicians for this problem. The majority of those interviewed who sought and received treatment have not been satisfied with the results.

Incidence of autonomic dysreflexia and silent autonomic dysreflexia in men with spinal cord injury undergoing sperm retrieval: implications for clinical practice.

BACKGROUND/OBJECTIVE: To determine the incidence of symptomatic autonomic dysreflexia (AD) and asymptomatic autonomic dysreflexia (silent AD) in men with spinal cord injury (SCI) undergoing sperm retrieval procedures. DESIGN: Descriptive study. METHODS: Thirteen men underwent cardiovascular monitoring during vibrostimulation (or self-stimulation) to the point of ejaculation. Cardiovascular results were compared with objective and subjective signs of AD to determine the incidence of symptomatic and silent AD. Past history and knowledge of AD were correlated to participants' experience of AD in the clinical setting. OUTCOME MEASURES: Change in diastolic and systolic blood pressure is the primary outcome data that will be compared to AD history and data from each participant's questionnaire. RESULTS: Twelve of the 13 men experienced a rise in blood pressure consistent with AD (defined as an increase in blood pressure > 20 mmHg). Men with incomplete tetraplegia were able to identify symptoms associated with AD, and those with complete tetraplegia did not experience symptoms. Eleven of the 13 men knew that sexual activity could cause AD; however, only 2 of the 13 men acknowledged a history of AD with sexual activity and/or ejaculation. CONCLUSIONS: Symptomatic and silent AD occur frequently during sperm retrieval in men with SCI above T6. Knowledge and past history of AD are not accurate indicators of who will experience AD with sexual activity and/or ejaculation.

Problems of sexual function after spinal cord injury.

Sex is a legitimate and fundamental need in humans. Substantial changes to both the autonomic and somatic nervous system occur after spinal cord injury, and result in altered sexual function and fertility potential. This chapter provides a clinical overview of the main sexual and reproductive concerns and priorities men and women face after spinal cord injury. Besides genital functioning, other autonomic functions affect sexuality, such as bladder and bowel function, cardiovascular control and temperature regulation. These interlinked autonomic functions are presented in their impact on sexuality. The mind-body interaction and spinal feedback loops are discussed. It is proposed that human sexuality after spinal cord injury can be a model for investigating integrated autonomic function. Recent research on the measurement of cardiovascular parameters during vibrostimulation and ejaculation demonstrates the discordance between objective and subjective signs of autonomic dysreflexia. It is hoped that health care professionals and researchers will become motivated to attend to the unmet sexual health care needs of this population.

Autonomic dysreflexia during sperm retrieval in spinal cord injury: influence of lesion level and sildenafil citrate.

Autonomic dysreflexia (AD) can occur during penile vibratory stimulation in men with spinal cord injury, but this is variable, and the association with lesion level is unclear. The purpose of this study was to characterize the cardiovascular responses to penile vibratory stimulation in men with spinal cord injury. We hypothesized that those with cervical injuries would demonstrate a greater degree of AD compared with men with thoracic injuries. We also questioned whether the rise in blood pressure could be attenuated by sildenafil citrate. Participants were classified as having cervical (n = 8) or thoracic (n = 5) injuries. While in a supine position, subjects were instrumented with an ECG, and arterial blood pressure was determined beat by beat. Subjects reported to the laboratory twice and received an oral dose of sildenafil citrate (25-100 mg) or no medication. Penile vibratory stimulation was performed using a handheld vibrator to the point of ejaculation. At ejaculation during the nonmedicated trials, the cervical group had a significant decrease in heart rate (-5-10 beats/min) and increase in mean arterial blood pressure (+70-90 mmHg) relative to resting conditions, whereas the thoracic group had significant increases in both heart rate (+8-15 beats/min) and mean arterial pressure (+25-30 mmHg). Sildenafil citrate had no effect on the change in heart rate or mean arterial pressure in either group. In summary, men with cervical injuries had more pronounced AD during penile vibratory stimulation than men with thoracic injuries. Administration of sildenafil citrate had no effect on heart rate or blood pressure during penile vibratory stimulation in men with spinal cord injury.