Neurogenic overactive bladder in spinal cord injury and multiple sclerosis: role of onabotulinumtoxinA.

People with neurogenic overactive bladder from either multiple sclerosis or spinal cord injury often suffer significant morbidity and decreased quality of life. Here we review the pathophysiology of neurogenic overactive bladder and the impact it can have on people with multiple sclerosis or spinal cord injury. We also address the various traditional treatment options and focus on the use of botulinum toxin A (specifically onabotulinumtoxinA) for this condition.

Positive and negative affect in individuals with spinal cord injuries.

STUDY DESIGN: Participants with spinal cord injuries (SCIs) and healthy controls completed standardized questionnaires assessing depression level, positive and negative affect, and personality traits. OBJECTIVES: To identify the specific characteristics of emotional experiences affected by spinal cord injury. SETTING: A Canadian rehabilitation center. Individuals with SCIs were recruited from a list of patients who had volunteered to participate in studies being conducted by the SCI clinic. Healthy controls were recruited from the community, but tested in the SCI clinic. METHODS: Thirty-six individuals with complete (ASIA A) SCIs and 36 age-, gender- and education-matched controls participated in this study. SCI participants were classified as cervical (C1-C7), upper thoracic (T1-T5) or lower thoracic/upper lumbar (T6-L2). All participants completed the Beck Depression Inventory, the Positive and Negative Affect Schedules, the NEO Neuroticism Questionnaire, and the harm avoidance scale of the Tridimensional Personality Questionnaire. Data were analyzed using independent-samples t-tests (when contrasting SCI and controls) and analysis of variance (when comparing across SCI groups). RESULTS: Participants with SCIs experienced significantly less positive affect than controls. The two groups did not differ in their experience of negative affect. Participants with SCIs also reported greater levels of depression. Depression scores improved with an increasing number of years post injury. CONCLUSION: Individuals with SCIs are characterized by specific emotional dysfunction related to the experience of positive emotions, rather than a tendency to ruminate on negative emotions. The results suggest that these individuals would benefit from rehabilitation programs that include training in positive psychology.

Measuring the effect of incremental angles of wheelchair tilt on interface pressure among individuals with spinal cord injury.

STUDY DESIGN: This study was a repeated measures study. OBJECTIVES: The objective was to systematically measure the relative reduction in interface pressure (IP) at the ischial tuberosities (IT) and sacrum through 10° increments of tilt in a manual wheelchair among individuals with motor complete spinal cord injury (SCI). SETTING: This study was carried out in Manitoba, Canada. METHODS: A total of 18 adults with ASIA A or B level of injury were recruited through an out-patient SCI clinic. Using a standardized protocol, participants were tilted in 10° increments between 0° and 50°, and IP readings were obtained at the IT and sacrum using pressure mapping technology. Relative pressure reduction from baseline was calculated and compared between tilt angles. RESULTS: Tilt angle had a highly significant effect on pressure reduction at the IT (P=0.000) and the cosine relationship between these variables was expressed as quadratic. Reduction in sacral pressure did not occur until 30° tilt, with increased loading at smaller tilt angles. Pressure reduction at the IT and sacrum was not significantly different for tetraplegic and paraplegic participants. CONCLUSION: Small tilt angles are more suitable for postural control than pressure management. A minimum tilt of 30° is required to initiate unloading the sacrum and to achieve a clinically important reduction in pressure at the IT. Larger tilt angles resulted in more substantial pressure reduction than previously reported. Tilt-in-space appears to have similar benefits for individuals with paraplegia and tetraplegia.

Research priorities for urological care following spinal cord injury: recommendations of an expert panel.

OBJECTIVE: A multidisciplinary panel of experts from Canada and the United States was convened by the Ontario Neurotrauma Foundation (ONF) to establish research priorities in the area of urological care following spinal cord injury (SCI). DESIGN: The panel reviewed a synthesis of published literature in five areas of urology, identified emerging opportunities in the private and public sector, and used a modified Delphi approach to reach consensus on priorities for funding. RESULTS: The panel recommendations included: clinical trials of the safety and efficacy of M3 receptor specific anti-muscarinic agents for bladder hyperactivity in SCI patients; development and testing of protocols for sacral nerve electrostimulation without sacral afferent neurectomy for management of micturition - including selective stimulation of sacral nerve fibers, high frequency blocking of the pudendal nerve to minimize the risk of urethral sphincter co-contraction and genital nerve stimulation for bladder inhibition and incontinence management; clinical trials of the efficacy and safety of intra-urethral valve catheters; trials of the efficacy of probiotics for bacterial interference i.e. to reduce colonization by uropathogens and manage the dual problems of infection and pathogen resistance to anti-microbials: innovations in the prevention or treatment of stone disease (ureteral, bladder and kidney). CONCLUSIONS: The recommendations form the strategic priorities of the ONF SCI grants program for Ontario-based investigators and their partnerships with out-of-province collaborators and organizations.

Intrathecal drug therapy using the Codman Model 3000 Constant Flow Implantable Infusion Pumps: experience with 17 cases.

OBJECTIVES: The objective of this study was to evaluate the accuracy, reliability, safety, and efficacy of the Codman Model 3000 Constant Flow Implantable Infusion Pump for intrathecal baclofen delivery as a therapeutic option for the treatment of severe spasticity. The distinctive features of this pump include a raised, easily palpable septum, a safety valve protecting the bolus pathway, no programmer needed, and no battery to fail. DESIGN: A total of 17 patients with spinal cord injury, multiple sclerosis, or cerebral palsy were implanted with this pump. The accuracy of the pump and drug treatment efficacy was determined at each visit and adjustments to the dosages were made as required. All the intrathecal drug delivery system complications were reviewed. RESULTS: The expected efficacy was achieved. The accuracy of the implanted pumps ranged from 90-97% (average 94%). There were no complications due to primary pump problems. The complications reported are similar to other implantable infusion devices and include dehiscence of the suture line, pressure ulcer development, formation of seroma, inversion of the pump, baclofen overdose, and catheter failures. CONCLUSION: The Codman Model 3000 Constant Flow Implantable Infusion Pump is an accurate, reliable, and convenient option for patients needing intrathecal baclofen therapy, with complications similar to other available pumps.

Congenital bilateral absence of the elbow flexors.

In this case report, a patient with bilateral congenital absence of the elbow flexors is described, which has not been described previously. The usual methods of tendon transfers after brachial plexus injury were not possible in this case because there were no biceps muscle tendons to which to attach. The method of moving the origin of the common extensor tendon proximally to have it function as an elbow flexor was successful and the patient obtained functional elbow flexion strength.

Wheelchair propulsion: descriptive comparison of hemiplegic and two-hand patterns during selected activities.

Most manual wheelchair users with hemiplegia use both the unaffected arm and leg to propel their wheelchairs. The objective of this study was to compare the wheelchair propulsion of subjects using the hemiplegic pattern (one arm and one leg) with subjects using two hands. In a case-controlled study in a kinesiologic laboratory, nine wheelchair users who used the hemiplegic pattern were compared with nine matched controls who used the two-handed pattern. Participants were tested for propelling and stopping the wheelchair, forward and backward, on a level surface and on a 5 degree incline. Video recording was used to assess deviation from the midline, foot slippage, the number of propulsive cycles, and the propelling velocity. Also, on the 5 degree incline, we noted the need for support when unlocking the wheel locks, instances of grabbing the side rail, or rollback between propulsions. The participants using the hemiplegic pattern when propelling up the incline deviated more to the hemiparetic side (P < 0.05), used more propulsive cycles per unit of distance (P < 0.01), were slower (P < 0.001), and used the side rail more often (P < 0.05). When propelling forward on level ground, the participants using the hemiplegic pattern were slower (P < 0.005). When stopping after moving backward down the incline, they were more likely to deviate to the unaffected side (P < 0.01). In conclusion, wheelchair users who use the hemiplegic pattern experience more difficulties than those using two hands, some of which may be amenable to improvements in wheelchair prescription and training.

Hip fracture in the elderly. An interdisciplinary team approach to rehabilitation.

The rising incidence of hip fractures in the elderly is a disturbing trend with serious health and socioeconomic consequences, including morbidity, loss of function, long-term institutionalization, and mortality. When preventive measures fail, the interdisciplinary healthcare team works together to provide operative treatment, reduce the risk of postoperative complications, and guide the patient through the recovery process. A team approach that ensures appropriate treatment, careful discharge planning, and coordinated rehabilitation can reduce the impact of the injury, speed recovery, and restore patient independence.

Transtibial prosthesis for a patient with Kaposi's sarcoma lesions on the residual limb.

A man with acquired immunodeficiency syndrome (AIDS) and widespread Kaposi's sarcoma (KS) presented with a transtibial amputation secondary to foot infection and intractable pain. Several open and draining KS lesions were present on the residual limb. There were two concerns: (1) prescribing a prosthesis to a person who likely had a limited future as a prosthetic user; and (2) how the lesions would tolerate pressure and shear forces in a prosthesis. There have been no previous reports of KS lesions of residual limbs. We prescribed a patellartendon-bearing prosthesis with supracondylar suspension. The lesions did not worsen with weight-bearing, and healed with concomitant treatment. The patient remains a functional ambulator 1 year after amputation. This case suggests that KS lesions can tolerate pressure and shear forces, which is important in considering prosthetic prescriptions as well as prescriptions of orthoses and other devices.