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STUDY DESIGN: Secondary analysis of a randomised controlled trial. OBJECTIVES: Our primary study showed that increasing inspiratory muscle strength with training in people with chronic (>1 year) tetraplegia corresponded with reduced sensations of breathlessness when inspiration was loaded. This study investigated whether respiratory muscle training also affected the respiratory sensations for load detection and magnitude perception. SETTING: Independent research institute in Sydney, Australia. METHODS: Thirty-two adults with chronic tetraplegia participated in a 6-week, supervised training protocol. The active group trained the inspiratory muscles through progressive threshold loading. The sham group performed the same protocol with a fixed threshold load (3.6 cmH2O). Primary measures were load detection threshold and perceived magnitudes of six suprathreshold loads reported using the modified Borg scale. RESULTS: Maximal inspiratory pressure (PImax) increased by 32% (95% CI, 18-45) in the active group with no change in the sham group (p = 0.51). The training intervention did not affect detection thresholds in the active (p = 0.24) or sham (p = 0.77) group, with similar overall decreases in Borg rating of 0.83 (95% CI, 0.49-1.17) in active and 0.72 (95% CI, 0.32-1.12) in sham group. Increased inspiratory muscle strength reduced slope magnitude between Borg rating and peak inspiratory pressure (p = 0.003), but not when pressure was divided by PImax to reflect contraction intensity (p = 0.92). CONCLUSIONS: Training reduces the sensitivity of load sensations for a given change in pressure but not for a given change in contraction intensity.
Assuntos
Traumatismos da Medula Espinal , Adulto , Humanos , Traumatismos da Medula Espinal/complicações , Exercícios Respiratórios , Academias e Institutos , Quadriplegia , SensaçãoRESUMO
STUDY DESIGN: An international multi-centred, double-blinded, randomised sham-controlled trial (eWALK). OBJECTIVE: To determine the effect of 12 weeks of transcutaneous spinal stimulation (TSS) combined with locomotor training on walking ability in people with spinal cord injury (SCI). SETTING: Dedicated SCI research centres in Australia, Spain, USA and Scotland. METHODS: Fifty community-dwelling individuals with chronic SCI will be recruited. Participants will be eligible if they have bilateral motor levels between T1 and T11, a reproducible lower limb muscle contraction in at least one muscle group, and a Walking Index for SCI II (WISCI II) between 1 and 6. Eligible participants will be randomised to one of two groups, either the active stimulation group or the sham stimulation group. Participants allocated to the stimulation group will receive TSS combined with locomotor training for three 30-min sessions a week for 12 weeks. The locomotor sessions will include walking on a treadmill and overground. Participants allocated to the sham stimulation group will receive the same locomotor training combined with sham stimulation. The primary outcome will be walking ability with stimulation using the WISCI II. Secondary outcomes will record sensation, strength, spasticity, bowel function and quality of life. TRIAL REGISTRATION: ANZCTR.org.au identifier ACTRN12620001241921.
Assuntos
Traumatismos da Medula Espinal , Estimulação da Medula Espinal , Humanos , Modalidades de Fisioterapia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Traumatismos da Medula Espinal/complicações , Caminhada/fisiologiaRESUMO
BACKGROUND: Respiratory complications remain a leading cause of morbidity and mortality in people with acute and chronic tetraplegia. Respiratory muscle weakness following spinal cord injury-induced tetraplegia impairs lung function and the ability to cough. In particular, inspiratory muscle strength has been identified as the best predictor of the likelihood of developing pneumonia in individuals with tetraplegia. We hypothesised that 6 weeks of progressive respiratory muscle training (RMT) increases respiratory muscle strength with improvements in lung function, quality of life and respiratory health. METHODS: Sixty-two adults with tetraplegia participated in a double-blind randomised controlled trial. Active or sham RMT was performed twice daily for 6 weeks. Inspiratory muscle strength, measured as maximal inspiratory pressure (PImax) was the primary outcome. Secondary outcomes included lung function, quality of life and respiratory health. Between-group comparisons were obtained with linear models adjusting for baseline values of the outcomes. RESULTS: After 6 weeks, there was a greater improvement in PImax in the active group than in the sham group (mean difference 11.5 cmH2O (95% CI 5.6 to 17.4), p<0.001) and respiratory symptoms were reduced (St George Respiratory Questionnaire mean difference 10.3 points (0.01-20.65), p=0.046). Significant improvements were observed in quality of life (EuroQol-Five Dimensional Visual Analogue Scale 14.9 points (1.9-27.9), p=0.023) and perceived breathlessness (Borg score 0.64 (0.11-1.17), p=0.021). There were no significant improvements in other measures of respiratory function (p=0.126-0.979). CONCLUSIONS: Progressive RMT increases inspiratory muscle strength in people with tetraplegia, by a magnitude which is likely to be clinically significant. Measurement of baseline PImax and provision of RMT to at-risk individuals may reduce respiratory complications after tetraplegia. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN 12612000929808).
Assuntos
Exercícios Respiratórios , Quadriplegia/fisiopatologia , Quadriplegia/reabilitação , Músculos Respiratórios/fisiopatologia , Adulto , Idoso , Método Duplo-Cego , Dispneia/etiologia , Feminino , Humanos , Inalação , Pulmão/fisiopatologia , Masculino , Pressões Respiratórias Máximas , Pessoa de Meia-Idade , Força Muscular , Quadriplegia/complicações , Qualidade de Vida , Avaliação de SintomasRESUMO
BACKGROUND: Expiratory muscle weakness leads to difficult ventilator weaning. Maintaining their activity with functional electrical stimulation (FES) may improve outcome. We studied feasibility of breath-synchronized expiratory population muscle FES in a mixed ICU population ("Holland study") and pooled data with our previous work ("Australian study") to estimate potential clinical effects in a larger group. METHODS: Holland: Patients with a contractile response to FES received active or sham expiratory muscle FES (30 min, twice daily, 5 days/week until weaned). Main endpoints were feasibility (e.g., patient recruitment, treatment compliance, stimulation intensity) and safety. Pooled: Data on respiratory muscle thickness and ventilation duration from the Holland and Australian studies were combined (N = 40) in order to estimate potential effect size. Plasma cytokines (day 0, 3) were analyzed to study the effects of FES on systemic inflammation. RESULTS: Holland: A total of 272 sessions were performed (active/sham: 169/103) in 20 patients (N = active/sham: 10/10) with a total treatment compliance rate of 91.1%. No FES-related serious adverse events were reported. Pooled: On day 3, there was a between-group difference (N = active/sham: 7/12) in total abdominal expiratory muscle thickness favoring the active group [treatment difference (95% confidence interval); 2.25 (0.34, 4.16) mm, P = 0.02] but not on day 5. Plasma cytokine levels indicated that early FES did not induce systemic inflammation. Using a survival analysis approach for the total study population, median ventilation duration and ICU length of stay were 10 versus 52 (P = 0.07), and 12 versus 54 (P = 0.03) days for the active versus sham group. Median ventilation duration of patients that were successfully extubated was 8.5 [5.6-12.2] versus 10.5 [5.3-25.6] days (P = 0.60) for the active (N = 16) versus sham (N = 10) group, and median ICU length of stay was 10.5 [8.0-14.5] versus 14.0 [9.0-19.5] days (P = 0.36) for those active (N = 16) versus sham (N = 8) patients that were extubated and discharged alive from the ICU. During ICU stay, 3/20 patients died in the active group versus 8/20 in the sham group (P = 0.16). CONCLUSION: Expiratory muscle FES is feasible in selected ICU patients and might be a promising technique within a respiratory muscle-protective ventilation strategy. The next step is to study the effects on weaning and ventilator liberation outcome. TRIAL REGISTRATION: ClinicalTrials.gov, ID NCT03453944. Registered 05 March 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03453944 .
Assuntos
Estimulação Elétrica/métodos , Músculos Respiratórios/inervação , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estimulação Elétrica/instrumentação , Estudos de Viabilidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Medicare/estatística & dados numéricos , Medicare/tendências , Modelos de Riscos Proporcionais , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Músculos Respiratórios/fisiopatologia , Estudos Retrospectivos , Estados UnidosRESUMO
STUDY DESIGN: A multi-centred, single-blinded randomised controlled trial. OBJECTIVES: To determine the effect of 10,000 voluntary contractions over 8 weeks on the strength of very weak muscles in people with spinal cord injury (SCI). SETTINGS: Seven hospitals in Australia and Asia. METHODS: One hundred and twenty people with recent SCI undergoing inpatient rehabilitation were randomised to either a Treatment or Control Group. One major muscle group from an upper or lower limb was selected if the muscle had grade 1 or grade 2 strength on a standard six-point manual muscle test. Participants allocated to the Treatment Group performed 10,000 isolated contractions of the selected muscle group, as well as usual care in 48 sessions over 8 weeks. Participants allocated to the Control Group received usual care alone. Participants were assessed at baseline and 8 weeks by a blinded assessor. The primary outcome was voluntary muscle strength on a 13-point manual muscle test. There were three secondary outcomes capturing therapists' and participants' perceptions of strength and function. RESULTS: The mean between-group difference of voluntary strength at 8 weeks was 0.4/13 points (95% confidence interval -0.5 to 1.4) in favour of the Treatment Group. There were no notable between-group differences on any secondary outcome. CONCLUSION: Ten thousand isolated contractions of very weak muscles in people with SCI over 8 weeks has either no or a very small effect on voluntary strength.
Assuntos
Contração Muscular , Força Muscular , Debilidade Muscular/reabilitação , Músculo Esquelético , Avaliação de Resultados em Cuidados de Saúde , Traumatismos da Medula Espinal/reabilitação , Adulto , Ásia , Austrália , Terapia por Exercício/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Força Muscular/fisiologia , Debilidade Muscular/etiologia , Músculo Esquelético/fisiopatologia , Método Simples-Cego , Traumatismos da Medula Espinal/complicaçõesRESUMO
BACKGROUND: For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay. METHODS: Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor. RESULTS: Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group. CONCLUSIONS: Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.
Assuntos
Estimulação Elétrica/métodos , Desmame do Respirador/instrumentação , APACHE , Adulto , Idoso , Estado Terminal/epidemiologia , Estado Terminal/terapia , Método Duplo-Cego , Estimulação Elétrica/instrumentação , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Reto do Abdome/irrigação sanguínea , Reto do Abdome/fisiopatologia , Desmame do Respirador/métodos , Desmame do Respirador/normasRESUMO
STUDY DESIGN: Randomised, controlled, crossover study. OBJECTIVES: Paired corticospinal-motoneuronal stimulation (PCMS) involves repeatedly pairing stimuli to corticospinal neurones and motoneurones to induce changes in corticospinal transmission. Here, we examined whether PCMS could enhance maximal voluntary elbow flexion in people with cervical spinal cord injury. SETTING: Neuroscience Research Australia, Sydney, Australia. METHODS: PCMS comprised 100 pairs of transcranial magnetic and electrical peripheral nerve stimulation (0.1 Hz), timed so corticospinal potentials arrived at corticospinal-motoneuronal synapses 1.5 ms before antidromic motoneuronal potentials. On two separate days, sets of five maximal elbow flexions were performed by 11 individuals with weak elbow flexors post C4 or C5 spinal cord injury before and after PCMS or control (100 peripheral nerve stimuli) conditioning. During contractions, supramaximal biceps brachii stimulation elicited superimposed twitches, which were expressed as a proportion of resting twitches to give maximal voluntary activation. Maximal torque and electromyographic activity were also assessed. RESULTS: Baseline median (range) maximal torque was 11 Nm (6-41 Nm) and voluntary activation was 92% (62-99%). Linear mixed modelling revealed no significant differences between PCMS and control protocols after conditioning (maximal torque: p = 0.87, superimposed twitch: p = 0.87, resting twitch: p = 0.44, voluntary activation: p = 0.36, biceps EMG: p = 0.25, brachioradialis EMG: 0.67). CONCLUSIONS: Possible explanations for the lack of effect include a potential ceiling effect for voluntary activation, or that PCMS may be less effective for elbow flexors than distal muscles. Despite results, previous studies suggest that PCMS is worthy of further investigation.
Assuntos
Articulação do Cotovelo/fisiologia , Potencial Evocado Motor/fisiologia , Córtex Motor/fisiologia , Tratos Piramidais/fisiologia , Traumatismos da Medula Espinal/terapia , Estimulação Magnética Transcraniana/métodos , Adulto , Estudos Cross-Over , Articulação do Cotovelo/inervação , Estimulação Elétrica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurônios Motores/fisiologia , Músculo Esquelético/fisiologia , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/fisiopatologia , Adulto JovemRESUMO
STUDY DESIGN: Randomised double-blind factorial-design placebo-controlled trial. OBJECTIVE: Urinary tract infections (UTIs) are common in people with spinal cord injury (SCI). UTIs are increasingly difficult to treat due to emergence of multi-resistant organisms. Probiotics are efficacious in preventing UTIs in post-menopausal women. We aimed to determine whether probiotic therapy with Lactobacillus reuteri RC-14+Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG+Bifidobacterium BB-12 (LGG-BB12) are effective in preventing UTI in people with SCI. SETTING: Spinal units in New South Wales, Australia with their rural affiliations. METHODS: We recruited 207 eligible participants with SCI and stable neurogenic bladder management. They were randomised to one of four arms: RC14-GR1+LGG-BB12, RC14-GR1+placebo, LGG-BB12+ placebo or double placebos for 6 months. Randomisation was stratified by bladder management type and inpatient or outpatient status. The primary outcome was time to occurrence of symptomatic UTI. RESULTS: Analysis was based on intention to treat. Participants randomised to RC14-GR1 had a similar risk of UTI as those not on RC14-GR1 (HR 0.67; 95% CI: 0.39-1.18; P = 0.17) after allowing for pre-specified covariates. Participants randomised to LGG-BB12 also had a similar risk of UTI as those not on LGG-BB12 (HR 1.29; 95% CI: 0.74-2.25; P = 0.37). Multivariable post hoc survival analysis for RC14-GR1 only vs. the other three groups showed a potential protective effect (HR 0.46; 95% CI: 0.21-0.99; P = 0.03), but this result would need to be confirmed before clinical application. CONCLUSION: In this RCT, there was no effect of RC14-GR1 or LGG-BB12 in preventing UTI in people with SCI.
Assuntos
Probióticos , Traumatismos da Medula Espinal/complicações , Infecções Urinárias/etiologia , Infecções Urinárias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
KEY POINTS: A cortical contribution to breathing, as indicated by a Bereitschaftspotential (BP) in averaged electroencephalographic signals, occurs in healthy individuals when external inspiratory loads are applied. Chronic obstructive pulmonary disease (COPD) is a condition where changes in the lung, chest wall and respiratory muscles produce an internal inspiratory load. These changes also occur in normal ageing, although to a lesser extent. In the present study, we determined whether BPs are present during quiet breathing and breathing with an external inspiratory load in COPD compared to age-matched and young healthy controls. We demonstrated that increased age, rather than COPD, is associated with a cortical contribution to quiet breathing. A cortical contribution to inspiratory loading is associated with more severe dyspnoea (i.e. the sensation of breathlessness). We propose that cortical mechanisms may be engaged to defend ventilation in ageing with dyspnoea as a consequence. ABSTRACT: A cortical contribution to breathing is determined by the presence of a Bereitschaftspotential, a low amplitude negativity in the averaged electroencephalographic (EEG) signal, which begins â¼1 s before inspiration. It occurs in healthy individuals when external inspiratory loads to breathing are applied. In chronic obstructive pulmonary disease (COPD), changes in the lung, chest wall and respiratory muscles produce an internal inspiratory load. We hypothesized that there would be a cortical contribution to quiet breathing in COPD and that a cortical contribution to breathing with an inspiratory load would be linked to dyspnoea, a major symptom of COPD. EEG activity was analysed in 14 participants with COPD (aged 57-84 years), 16 healthy age-matched (57-87 years) and 15 young (18-26 years) controls during quiet breathing and inspiratory loading. The presence of Bereitschaftspotentials, from ensemble averages of EEG epochs at Cz and FCz, were assessed by blinded assessors. Dyspnoea was rated using the Borg scale. The incidence of a cortical contribution to quiet breathing was significantly greater in participants with COPD (6/14) compared to the young (0/15) (P = 0.004) but not the age-matched controls (6/16) (P = 0.765). A cortical contribution to inspiratory loading was associated with higher Borg ratings (P = 0.007), with no effect of group (P = 0.242). The data show that increased age, rather than COPD, is associated with a cortical contribution to quiet breathing. A cortical contribution to inspiratory loading is associated with more severe dyspnoea. We propose that cortical mechanisms may be engaged to defend ventilation with dyspnoea as a consequence.
Assuntos
Potenciais Evocados , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Respiração , Músculos Respiratórios/fisiologia , Idoso , Idoso de 80 Anos ou mais , Envelhecimento , Dispneia , Eletromiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculos Respiratórios/inervação , Adulto JovemRESUMO
BACKGROUND: Neuropathic or neurogenic bladder describes a process of dysfunctional voiding as the result of injury in the brain, spinal cord or nerves innervating the bladder. People with neuropathic bladder, such as from spinal cord injury (SCI), are at significant risk of morbidity from urinary tract infections (UTI). Effective methods to prevent UTI in people with SCI have been sought for many years. Probiotics (micro-organisms that exert beneficial health effects in the host) have been recommended for bacterial interference of the urological tract to reduce colonisation by uropathogen and to manage the dual problems of infection and antibiotic resistance. OBJECTIVES: This review looked at the benefits and harms of probiotics in preventing symptomatic UTI in people with neuropathic bladder compared with placebo, no therapy, or non-antibiotic prophylaxis (cranberry juice, methenamine hippurate, topical oestrogen). SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register up to 10 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: All randomised controlled trials (RCTs), quasi-RCTs and cross-over RCTs looking at the use of probiotics for the prophylaxis of UTI in people with neuropathic bladders was considered for inclusion. Men, women and children of all ages with neuropathic bladders from neurological injury such as suprapontine, supra sacral and sacral aetiologies was included. All bladder management types, including reflex voiding, time voiding, indwelling and intermittent catheterization were eligible for this review.Studies comparing probiotics to placebo, no treatment or other non-antibiotic prophylaxis was included. Studies comparing probiotics with antibiotics or in combination with antibiotics were excluded. DATA COLLECTION AND ANALYSIS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI were planned for continuous outcomes. MAIN RESULTS: This review includes a total of three studies (one cross-over and two parallel RCTs) which involved 110 participants. All three studies looked at intravesical instillation of a low virulent Escherichia coli (E. coli) strain in reducing the risk of symptomatic UTI in participants with neuropathic bladder, predominantly from SCI. Two studies used the E. coli 83972 strain and one study used the E. coli HU2117 strain.We did not find any RCTs involving other probiotics or other routes of administration for preventing UTI in people with neuropathic bladder.There was consistency in definition of symptomatic UTI in all three studies. Symptoms that all studies considered were relevant to diagnose UTI were adequately defined. All three studies defined microbiological diagnosis of symptomatic UTI.Asymptomatic bacteriuria was not considered an outcome measure in any of the included studies; however it was defined in two studies to establish successful inoculation.It is uncertain if the risk of symptomatic UTI is reduced with bladder inoculation using E. coli because the certainty of the evidence is very low (3 studies, 110 participants: RR 0.32, 95% CI 0.08 to 1.19; I2 = 82%).Two studies reported adverse events. One study reported one episode of autonomic dysreflexia. One study reported three symptomatic UTI occurring in two patients, and two studies mentioned the absence of septicaemia and pyelonephritis. Intravesical instillation was reported as "generally safe". One study reported high attrition rates in participants due to the need to adhere to strict instillation protocols.The overall quality of the studies was poor. All three studies had high risk of attrition bias due to failure of an intention-to-treat analysis which undermines the randomisation process and weakened the results of the studies. All three studies also had high risk of reporting bias. AUTHORS' CONCLUSIONS: In this review, there were no studies identified addressing oral probiotics in preventing UTI in people with neuropathic bladder. It is uncertain if the risk of symptomatic UTI is reduced in people with neuropathic bladders via intravesical instillation of non-pathogenic E. coli as data were derived from small studies with high risk of bias.Although very minimal levels of harm was reported with this procedure, due to variable success rates, the need for strict adherence to instillation protocols together with high attrition rates in these studies, it is doubtful bladder instillation will be a widely accepted intervention in its current form.It is recommended that further appropriately powered RCTs with more robust methodological reporting be carried out.
Assuntos
Escherichia coli , Probióticos/uso terapêutico , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/prevenção & controle , Adulto , Criança , Feminino , Humanos , Masculino , Probióticos/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Urinary tract infections [UTIs] are very common in people with Spinal Cord Injury [SCI]. UTIs are increasingly difficult and expensive to treat as the organisms that cause them become more antibiotic resistant. Among the SCI population, there is a high rate of multi-resistant organism [MRO] colonisation. Non-antibiotic prevention strategies are needed to prevent UTI without increasing resistance. Probiotics have been reported to be beneficial in preventing UTIs in post-menopausal women in several in vivo and in vitro studies. The main aim of this study is to determine whether probiotic therapy with combinations of Lactobacillus reuteri RC-14 + Lactobacillus rhamnosus GR-1 [RC14-GR1] and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 [LGG-BB12] are effective in preventing UTI in people with SCI compared to placebo. METHOD: This is a multi-site randomised double-blind double-dummy placebo-controlled factorial design study conducted in New South Wales, Australia. All participants have a neurogenic bladder as a result of spinal injury. Recruitment started in April 2011. Participants are randomised to one of four arms, designed for factorial analysis of LGG-BB12 and/or RC14-GR1 v Placebo. This involves 24 weeks of daily oral treatment with RC14-GR1 + LGG-BB12, RC14-GR1 + placebo, LGG-BB12 + placebo or two placebo capsules. Randomisation is stratified by bladder management type and inpatient status. Participants are assessed at baseline, three months and six months for Short Form Health Survey [SF-36], microbiological swabs of rectum, nose and groin; urine culture and urinary catheters for subjects with indwelling catheters. A bowel questionnaire is administered at baseline and three months to assess effect of probiotics on bowel function. The primary outcome is time from randomisation to occurrence of symptomatic UTI. The secondary outcomes are change of MRO status and bowel function, quality of life and cost-effectiveness of probiotics in persons with SCI. The primary outcome will be analysed using survival analysis of factorial groups, with Cox regression modelling to test the effect of each treatment while allowing for the other, assuming no interaction effect. Hazard ratios and Kaplan-Meier survival curves will be used to summarise results. DISCUSSION: If these probiotics are shown to be effective in preventing UTI and MRO colonisation, they would be a very attractive alternative for UTI prophylaxis and for combating the increasing rate of antibiotic resistance after SCI. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry [ ACTRN 12610000512022 ]. Date of registration: 21 June 2010.
Assuntos
Probióticos/uso terapêutico , Traumatismos da Medula Espinal/complicações , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/prevenção & controle , Bifidobacterium , Método Duplo-Cego , Humanos , Estimativa de Kaplan-Meier , Limosilactobacillus reuteri , Lacticaseibacillus rhamnosus , New South Wales , Modelos de Riscos Proporcionais , Infecções Urinárias/etiologiaRESUMO
STUDY DESIGN/SETTING: Secondary analysis. OBJECTIVES: To compare the change in maximal inspiratory pressure (PImax) over the first 4 weeks of two different inspiratory muscle training (IMT) protocols and explore if either method is more effective for people with spinal cord injury. METHODS: Data originated from two published studies. Participants completed flow-resistive IMT (F-IMT) at 80% daily PImax, 7 days/week (supervised weekly), or threshold IMT (T-IMT) at 30-80% weekly PImax, twice-daily, 5 days/week (supervised every session). Seven participants from each trial were matched by training adherence, level of spinal cord injury, impairment grade (A-C), and height. Differences between F-IMT and T-IMT groups in training intensity, breaths taken, inspiratory work, and the change in the PImax from baseline at the end of week four were analysed. RESULTS: Over 4 weeks, there was no difference in the change in PImax between groups (Absolute change in PImax (cmH2O): p = 0.456, Percent change in PImax relative to baseline: p = 0.128). F-IMT participants trained at a higher intensity (median: 77 vs 22 cmH2O, p = 0.001 and 80% baseline vs 61% baseline, p = 0.038) but took fewer breaths (840 vs 1404 breaths, p = 0.017) than T-IMT participants. Inspiratory work was similar between groups (64,789 vs 65,910 (% PImax × number of breaths), p = 0.535). CONCLUSIONS: Our findings support both methods of IMT as the change in PImax and inspiratory work were similar between groups. However, daily high-intensity F-IMT with intermittent supervision, required fewer breaths and less participant and therapist time. Future studies should examine optimal dosage and supervision required to achieve increased PImax.
Assuntos
Músculos Respiratórios , Traumatismos da Medula Espinal , Humanos , Modalidades de Fisioterapia , Músculos Respiratórios/fisiologia , Terapia Respiratória/métodosRESUMO
Transcutaneous spinal cord stimulation (TSS) is purported to improve motor function in people after spinal cord injury (SCI). However, several methodology aspects are yet to be explored. We investigated whether stimulation configuration affected the intensity needed to elicit spinally evoked motor responses (sEMR) in four lower limb muscles bilaterally. Also, since stimulation intensity for therapeutic TSS (i.e., trains of stimulation, typically delivered at 15-50 Hz) is sometimes based on the single-pulse threshold intensity, we compared these two stimulation types. In non-SCI participants (n = 9) and participants with a SCI (n = 9), three different electrode configurations (cathode-anode); L1-midline (below the umbilicus), T11-midline and L1-ASIS (anterior superior iliac spine; non-SCI only) were compared for the sEMR threshold intensity using single pulses or trains of stimulation which were recorded in the vastus medialis, medial hamstring, tibialis anterior, medial gastrocnemius muscles. In non-SCI participants, the L1-midline configuration showed lower sEMR thresholds compared to T11-midline (p = 0.002) and L1-ASIS (p < 0.001). There was no difference between T11-midline and L1-midline for participants with SCI (p = 0.245). Spinally evoked motor response thresholds were ~13% lower during trains of stimulation compared to single pulses in non-SCI participants (p < 0.001), but not in participants with SCI (p = 0.101). With trains of stimulation, threshold intensities were slightly lower and the incidence of sEMR was considerably lower. Overall, stimulation threshold intensities were generally lower with the L1-midline electrode configuration and is therefore preferred. While single-pulse threshold intensities may overestimate threshold intensities for therapeutic TSS, tolerance to trains of stimulation will be the limiting factor in most cases.
Assuntos
Traumatismos da Medula Espinal , Estimulação da Medula Espinal , Humanos , Traumatismos da Medula Espinal/terapia , Músculo Esquelético/fisiologia , Músculo Quadríceps , Estimulação da Medula Espinal/métodos , EletrodosRESUMO
This study investigated sensations of breathing following tetraplegia. Fifteen people with chronic tetraplegia and fifteen healthy able-bodied controls matched for age, sex, height, and weight participated. Sensations of breathing were quantified by determining the threshold for detecting an added resistance during inspiration. In a separate task, the perceived magnitudes of six suprathreshold resistive loads were determined with a modified Borg scale. The detection threshold of 0.34 cmH2O/L/s [standard deviation (SD) 0.14] in the tetraplegia group was higher than the 0.23 cmH2O/L/s (SD 0.10) threshold for able-bodied controls (P = 0.004). Both participant groups perceived larger loads to be more effortful, with the Borg effort rating increasing linearly with the peak inspiratory pressure generated at each load. The relationship between Borg effort rating and peak inspiratory pressure was steeper in participants with tetraplegia than in able-bodied controls (P = 0.001), but there was no difference when pressure was divided by maximal inspiratory pressure (P = 0.95). Despite a higher detection threshold, the findings suggest that the perceived magnitude of a suprathreshold inspiratory load is not impaired in chronic tetraplegia and that load magnitude perception is related to the maximal, and not absolute, inspiratory muscle force.NEW & NOTEWORTHY Sensations of breathing are thought to be impaired following chronic tetraplegia. The detection threshold for an added resistive load during inspiration was higher in people with tetraplegia than in healthy able-bodied participants. However, for inspiratory loads above the detection threshold, the perceived magnitude of a resistive load as a function of the peak inspiratory pressure was greater in tetraplegia. Load magnitude perception was comparable between participant groups when peak pressure was divided by maximal inspiratory pressure.
Assuntos
Respiração , Sensação , Humanos , Testes de Função Respiratória , Quadriplegia , Percepção/fisiologia , Resistência das Vias RespiratóriasRESUMO
In healthy individuals, loading inspiratory muscles by brief inspiratory occlusion produces a short-latency inhibitory reflex (IR) in the electromyographic (EMG) activity of scalene and diaphragm muscles. This IR may play a protective role to prevent aspiration and airway collapse during sleep. In people with motor and sensory complete cervical spinal cord injury (cSCI), who were able to breathe independently, this IR was predominantly absent. Here, we investigated the reflex response to brief airway occlusion in 16 participants with sensory incomplete cSCI [American spinal injury association impairment scale (AIS) score B or C]. Surface EMG was recorded from scalene muscles and the lateral chest wall (overlying diaphragm). The airway occlusion evoked a small change in mouth pressure resembling a physiological occlusion. The short-latency IR was present in 10 (63%) sensory incomplete cSCI participants; significantly higher than the IR incidence observed in complete cSCI participants in our previous study (14%; P = 0.003). When present, mean IR latency across all muscles was 58 ms (range 29-79 ms), and mean rectified EMG amplitude decreased to 37% preocclusion levels. Participants without an IR had untreated severe obstructive sleep apnea (OSA), in contrast to those with an IR, who had either had no, mild, or treated OSA (P = 0.002). Insufficient power did not allow statistical comparison between IR presence or absence and participant clinical characteristics. In conclusion, spared sensory connections or intersegmental connections may be necessary to generate the IR. Future studies to establish whether IR presence is related to respiratory morbidity in the tetraplegic population are required.NEW & NOTEWORTHY Individuals with incomplete cSCI were tested for the presence of a short latency reflex inhibition of inspiratory muscles, by brief airway occlusion. The reflex was 4.5 times more prevalent in this group compared with those with complete cSCI and is similar to the incidence in able-bodied people. Participants without this reflex all had untreated severe OSA, in contrast to those with an IR, who either had no, mild, or treated OSA. This work reveals novel differences in the reflex control of inspiratory muscles across the cSCI population.
Assuntos
Medula Cervical , Humanos , Reflexo , MúsculosRESUMO
Altered neural processing and increased respiratory sensations have been reported in chronic obstructive pulmonary disease (COPD) as larger respiratory-related evoked potentials (RREPs), but the effect of healthy-aging has not been considered adequately. We tested RREPs evoked by brief airway occlusions in 10 participants with moderate-to-severe COPD, 11 age-matched controls (AMC) and 14 young controls (YC), with similar airway occlusion pressure stimuli across groups. Mean age was 76 years for COPD and AMC groups, and 30 years for the YC group. Occlusion intensity and unpleasantness was rated using the modified Borg scale, and anxiety rated using the Hospital Anxiety and Depression Scale. There was no difference in RREP peak amplitudes across groups, except for the N1 peak, which was significantly greater in the YC group than the COPD and AMC groups (p = 0.011). The latencies of P1, P2 and P3 occurred later in COPD versus YC (p < 0.05). P3 latency occurred later in AMC than YC (p = 0.024). COPD and AMC groups had similar Borg ratings for occlusion intensity (3.0 (0.5, 3.5) [Median (IQR)] and 3.0 (3.0, 3.0), respectively; p = 0.476) and occlusion unpleasantness (1.3 (0.1, 3.4) and 1.0 (0.75, 2.0), respectively; p = 0.702). The COPD group had a higher anxiety score than AMC group (p = 0.013). A higher N1 amplitude suggests the YC group had higher cognitive processing of respiratory inputs than the COPD and AMC groups. Both COPD and AMC groups showed delayed neural responses to the airway occlusion, which may indicate impaired processing of respiratory sensory inputs in COPD and healthy aging.
Assuntos
Obstrução das Vias Respiratórias , Envelhecimento Saudável , Doença Pulmonar Obstrutiva Crônica , Humanos , Idoso , Sistema Respiratório , Taxa Respiratória , Potenciais EvocadosRESUMO
Background: People with a spinal cord injury (SCI) have a high rate of bowel-related morbidity, even compared with people with other neurological disorders. These complications lower quality of life and place a financial burden on the health system. A noninvasive intervention that improves the bowel function of people with an SCI should reduce morbidity, improve quality of life, and lead to cost savings for health care providers. Objectives: To investigate the effectiveness of noninvasive abdominal functional electrical stimulation (FES) for improving bowel function in people with a chronic SCI. Methods: A prospective, double-blinded, 1:1 randomized, placebo-controlled intervention trial will be conducted with 80 adults with chronic SCI (>12 months since injury) above T8 single neurological level. The intervention will be a 45-minute abdominal FES (or placebo) session, 3 days per week, for 6 weeks. Main Study Parameters/Endpoints: Primary endpoint is whole gut transit time before and after 6 weeks of abdominal FES. Secondary endpoints measured before and after 6 weeks of abdominal FES are (1) colonic transit time; (2) quality of life (EQ-5D-5L); (3) participant-reported bowel function (International SCI Bowel Function Basic Data Set Questionnaire and visual analogue scale); (4) respiratory function (forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximal expiratory pressure); (5) bladder symptoms (Neurogenic Bladder Symptom Score); (6) daily bowel management diary; and (7) unplanned hospital visits. Conclusion: Safety data will be collected, and a cost utility analysis using quality of life scores will be performed. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000386831.
Assuntos
Traumatismos da Medula Espinal , Adulto , Humanos , Qualidade de Vida , Estudos Prospectivos , Austrália , Estimulação Elétrica , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Brief airway occlusion produces a potent reflex inhibition of inspiratory muscles that is thought to protect against aspiration. Its duration is prolonged in asthma and obstructive sleep apnea. We assessed this inhibitory reflex (IR) in chronic obstructive pulmonary disease (COPD). Reflex responses to brief (250 ms) inspiratory occlusions were measured in 18 participants with moderate to severe COPD (age 73 ± 11 yr) and 17 healthy age-matched controls (age 72 ± 6 yr). We compared the incidence and properties of the IR between groups. Median eupneic preocclusion electromyographic activity was higher in the COPD group than controls (9.4 µV vs. 5.2 µV, P = 0.001). Incidence of the short-latency IR was higher in the COPD group compared with controls (15 participants vs. 7 participants, P = 0.010). IR duration for scalenes was similar for the COPD and control groups [73 ± 37 ms (means ± SD) and 90 ± 50 ms, respectively] as was the magnitude of inhibition. IRs in the diaphragm were not detected in the controls but were present in 9 participants of the COPD group (P = 0.001). The higher incidence of the IR in the COPD group than in the age-matched controls may reflect the increased inspiratory neural drive in the COPD group. This higher drive counteracts changes in chest wall and lung mechanics. However, when present, the reflex was similar in size and duration in the two groups. The relation between the IR in COPD and swallowing function could be assessed.NEW & NOTEWORTHY A potent short-latency reflex inhibition of inspiratory muscles produced by airway occlusion was tested in people with COPD and age-matched controls. The reflex was more prevalent in COPD, presumably due to an increased neural drive to breathe. When present, the reflex was similar in duration in the two groups, longer than historical data for younger control groups. The work reveals novel differences in reflex control of inspiratory muscles due to aging as well as COPD.
Assuntos
Obstrução das Vias Respiratórias , Doença Pulmonar Obstrutiva Crônica , Apneia Obstrutiva do Sono , Idoso , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade , Reflexo , Músculos RespiratóriosRESUMO
BACKGROUND: Swallowing disorders occur in COPD, but little is known about tongue strength and mastication. This is the first assessment in COPD of tongue strength and a test of mastication and swallowing solids (TOMASS). METHODS: Anterior tongue strength measures were obtained in 18 people with COPD, aged 73±11â years (mean±sd), and 19 healthy age-matched controls, aged 72±6â years. Swallowing dynamics were assessed using an eating assessment tool (EAT-10), timed water swallow test (TWST), and TOMASS. Swallowing measures were compared to an inhibitory reflex (IR) in the inspiratory muscles to airway occlusion (recorded previously in the same participants). RESULTS: Tongue strength was similar between COPD and controls (p=0.715). Self-assessed scores of dysphagia EAT-10 were higher (p=0.024) and swallowing times were prolonged for liquids (p=0.022) and solids (p=0.003) in the COPD group. During TWST, â¼30% of COPD group showed clinical signs of airway invasion (cough and wet voice), but none in the control group. For solids, the COPD group had â¼40% greater number of chews (p=0.004), and twofold-higher number of swallows (p=0.0496). Respiratory rate was 50% higher in COPD group than controls (p <0.001). The presence of an IR was not related to better swallowing outcomes, but signs of airway invasion were associated with a delayed IR. CONCLUSION: Dysphagia in stable COPD is not due to impaired anterior tongue strength, but rather swallowing-breathing discoordination. To address dysphagia, aspiration and acute exacerbations in COPD, therapeutic targets to improve swallowing dynamics could be investigated further.