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Smith DB. Postganglionic cholinergic collaterals drive pathological sympathetic hyperactivity. J Physiol 2024. [PMID: 39151130 DOI: 10.1113/jp287251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 08/07/2024] [Indexed: 08/18/2024] Open
Affiliation(s)
- Donovan Bernard Smith
- Departments of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute, Hotchkiss Brain Institute, RESTORE.network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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2
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Solinsky R, Singer W. Autonomic dysreflexia with relative tachycardia: Potential physiologic pathways for this head scratching clinical finding. PM R 2024. [PMID: 39126312 DOI: 10.1002/pmrj.13247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 08/12/2024]
Affiliation(s)
- Ryan Solinsky
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Wolfgang Singer
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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3
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Zhang Z, Su J, Tang J, Chung L, Page JC, Winter CC, Liu Y, Kegeles E, Conti S, Zhang Y, Biundo J, Chalif JI, Hua CY, Yang Z, Yao X, Yang Y, Chen S, Schwab JM, Wang KH, Chen C, Prerau MJ, He Z. Spinal projecting neurons in rostral ventromedial medulla co-regulate motor and sympathetic tone. Cell 2024; 187:3427-3444.e21. [PMID: 38733990 PMCID: PMC11193620 DOI: 10.1016/j.cell.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/27/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
Many behaviors require the coordinated actions of somatic and autonomic functions. However, the underlying mechanisms remain elusive. By opto-stimulating different populations of descending spinal projecting neurons (SPNs) in anesthetized mice, we show that stimulation of excitatory SPNs in the rostral ventromedial medulla (rVMM) resulted in a simultaneous increase in somatomotor and sympathetic activities. Conversely, opto-stimulation of rVMM inhibitory SPNs decreased both activities. Anatomically, these SPNs innervate both sympathetic preganglionic neurons and motor-related regions in the spinal cord. Fiber-photometry recording indicated that the activities of rVMM SPNs correlate with different levels of muscle and sympathetic tone during distinct arousal states. Inhibiting rVMM excitatory SPNs reduced basal muscle and sympathetic tone, impairing locomotion initiation and high-speed performance. In contrast, silencing the inhibitory population abolished muscle atonia and sympathetic hypoactivity during rapid eye movement (REM) sleep. Together, these results identify rVMM SPNs as descending spinal projecting pathways controlling the tone of both the somatomotor and sympathetic systems.
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Affiliation(s)
- Zicong Zhang
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Junfeng Su
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jing Tang
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Leeyup Chung
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jessica C Page
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Carla C Winter
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA; Harvard/MIT MD-PhD Program, Harvard Medical School, Boston, MA, USA
| | - Yuchu Liu
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Evgenii Kegeles
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA; PhD Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA, USA
| | - Sara Conti
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Yu Zhang
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jason Biundo
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Joshua I Chalif
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Charles Y Hua
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Zhiyun Yang
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Xue Yao
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Yang Yang
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Shuqiang Chen
- Graduate Program for Neuroscience, Boston University, Boston, MA, USA
| | - Jan M Schwab
- Belford Center for Spinal Cord Injury, The Ohio State University, Columbus, OH, USA; Departments of Neurology and Neuroscience, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Kuan Hong Wang
- Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, USA
| | - Chinfei Chen
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Michael J Prerau
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Zhigang He
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA; Department of Neurology and Ophthalmology, Harvard Medical School, Boston, MA, USA.
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Sartori AM, Kessler TM, Castro-Díaz DM, de Keijzer P, Del Popolo G, Ecclestone H, Frings D, Groen J, Hamid R, Karsenty G, Musco S, Padilla-Fernández B, Pannek J, Schouten N, van der Vorm A, Blok BFM. Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology. Eur Urol 2024; 85:543-555. [PMID: 38594103 DOI: 10.1016/j.eururo.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/14/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND OBJECTIVE Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology. METHODS A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data. KEY FINDINGS AND LIMITATIONS Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients. CONCLUSIONS AND CLINICAL IMPLICATIONS The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients. PATIENT SUMMARY Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.
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Affiliation(s)
- Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Harvard Medical School, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - David M Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Peter de Keijzer
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Giulio Del Popolo
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | | | - Dennis Frings
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rizwan Hamid
- Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, UK
| | - Gilles Karsenty
- Department of Urology, Aix Marseille University, Marseille, France
| | - Stefania Musco
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Jürgen Pannek
- Neuro-Urology Department, Swiss Paraplegic Center, Nottwil, Switzerland; Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Natasha Schouten
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | | | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
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Lyakhovetskii V, Shkorbatova P, Gorskii O, Musienko P. Forward Stepping Evoked by Transvertebral Stimulation in the Decerebrate Cat. Neuromodulation 2024; 27:625-635. [PMID: 36567242 PMCID: PMC10569082 DOI: 10.1016/j.neurom.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Implantation of stimulating electrodes into the basement of the vertebral spinous process allows the electrodes to be quickly and stably fixed relative to the spinal cord. Using this approach, we have previously shown the selectivity of rat muscle activation during transvertebral stimulation (TS). In this work, we investigated the TS to induce forward stepping of the cat's hindlimbs in comparison with epidural stimulation (ES). MATERIALS AND METHODS TS was performed with an electrode placed in the VL3-VL6 vertebrae in five decerebrated cats. ES was performed on the same cats in L5-L7 segments. Kinematic parameters of stepping were recorded in addition to electromyographic activity of musculus (m.) iliopsoas (IP), m. tibialis anterior (TA), and m. gastrocnemius lateralis (GL) of both hindlimbs. RESULTS With VL3-VL4 TS, all five animals were capable of bipedal forward stepping, whereas VL5 and VL6 TS led to the forward stepping in 3 of 5 and 1 of 5 animals, respectively. Well-coordinated muscle activity led to a high level of intra- and interlimb coordination. Kinematic parameters of TS-induced stepping were similar to those obtained with ES. The TS of the VL3 vertebra causes the frequency lock with the integer multiple of the stimulation frequency. Similarly to the rat model, TS-evoked muscle responses were site specific. They were minimal during VL3 TS and were maximal during VL4-VL5 TS (IP) and VL5-VL6 TS (TA, GL). CONCLUSIONS The obtained results support hypotheses about the location of the central pattern generators in the upper lumbar spinal segments. The proposed approach of electrode placement is surgically easier to perform than is ES. This approach is useful for studying site-specific neuromodulation of the spinal sensorimotor networks and for investigating new strategies of locomotor recovery in animal models.
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Affiliation(s)
| | - Polina Shkorbatova
- Pavlov Institute of Physiology Russian Academy of Sciences, St Petersburg, Russia; Institute of Translational Biomedicine, Saint Petersburg State University, St Petersburg, Russia; Department of Neurobiology, Sirius University, Sirius, Sochi, Russia
| | - Oleg Gorskii
- Pavlov Institute of Physiology Russian Academy of Sciences, St Petersburg, Russia; Institute of Translational Biomedicine, Saint Petersburg State University, St Petersburg, Russia
| | - Pavel Musienko
- Pavlov Institute of Physiology Russian Academy of Sciences, St Petersburg, Russia; Institute of Translational Biomedicine, Saint Petersburg State University, St Petersburg, Russia; National University of Science and Technology "MISIS," Moscow, Russia.
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6
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Ehler J, Sakowitz OW, Harnisch LO, Michels P. [Specialized Concepts for the Management of Severe Neurotrauma]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:368-384. [PMID: 38914079 DOI: 10.1055/a-2156-6790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
Neurotrauma results from violence on structures of the central or peripheral nervous system and is a clinically common disease entity with high relevance for patients' long-term outcome. The application of evidence-based diagnostic and therapeutic concepts aims to minimize secondary injury and thus to improve treatment outcome. This article describes the current management of the two main injury patterns of neurotrauma - traumatic brain and spinal cord injury.
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Dolbow DR, Bersch I, Gorgey AS, Davis GM. The Clinical Management of Electrical Stimulation Therapies in the Rehabilitation of Individuals with Spinal Cord Injuries. J Clin Med 2024; 13:2995. [PMID: 38792536 PMCID: PMC11122106 DOI: 10.3390/jcm13102995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/09/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Background: People with spinal cord injuries (SCIs) often have trouble remaining active because of paralysis. In the past, exercise recommendations focused on the non-paralyzed muscles in the arms, which provides limited benefits. However, recent studies show that electrical stimulation can help engage the paralyzed extremities, expanding the available muscle mass for exercise. Methods: The authors provide an evidence-based approach using expertise from diverse fields, supplemented by evidence from key studies toward the management of electrical stimulation therapies in individuals with SCIs. Literature searches were performed separately using the PubMed, Medline, and Google Scholar search engines. The keywords used for the searches included functional electrical stimulation cycling, hybrid cycling, neuromuscular electrical stimulation exercise, spinal cord injury, cardiovascular health, metabolic health, muscle strength, muscle mass, bone mass, upper limb treatment, diagnostic and prognostic use of functional electrical stimulation, tetraplegic hands, and hand deformities after SCI. The authors recently presented this information in a workshop at a major rehabilitation conference. Additional information beyond what was presented at the workshop was added for the writing of this paper. Results: Functional electrical stimulation (FES) cycling can improve aerobic fitness and reduce the risk of cardiovascular and metabolic diseases. The evidence indicates that while both FES leg cycling and neuromuscular electrical stimulation (NMES) resistance training can increase muscle strength and mass, NMES resistance training has been shown to be more effective for producing muscle hypertrophy in individual muscle groups. The response to the electrical stimulation of muscles can also help in the diagnosis and prognosis of hand dysfunction after tetraplegia. Conclusions: Electrical stimulation activities are safe and effective methods for exercise and testing for motor neuron lesions in individuals with SCIs and other paralytic or paretic conditions. They should be considered part of a comprehensive rehabilitation program in diagnosing, prognosing, and treating individuals with SCIs to improve function, physical activity, and overall health.
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Affiliation(s)
- David R. Dolbow
- Physical Therapy Program, College of Osteopathic Medicine, William Carey University, 710 William Carey Parkway, Hattiesburg, MS 39401, USA
| | - Ines Bersch
- International FES Centre®, Swiss Paraplegia Centre, CH-6207 Nottwil, Switzerland
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, VA 23249, USA;
| | - Glen M. Davis
- Discipline of Exercise and Sport Sciences, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
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Lana JF, Navani A, Jeyaraman M, Santos N, Pires L, Santos GS, Rodrigues IJ, Santos D, Mosaner T, Azzini G, da Fonseca LF, de Macedo AP, Huber SC, de Moraes Ferreira Jorge D, Purita J. Sacral Bioneuromodulation: The Role of Bone Marrow Aspirate in Spinal Cord Injuries. Bioengineering (Basel) 2024; 11:461. [PMID: 38790327 PMCID: PMC11118755 DOI: 10.3390/bioengineering11050461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Spinal cord injury (SCI) represents a severe trauma to the nervous system, leading to significant neurological damage, chronic inflammation, and persistent neuropathic pain. Current treatments, including pharmacotherapy, immobilization, physical therapy, and surgical interventions, often fall short in fully addressing the underlying pathophysiology and resultant disabilities. Emerging research in the field of regenerative medicine has introduced innovative approaches such as autologous orthobiologic therapies, with bone marrow aspirate (BMA) being particularly notable for its regenerative and anti-inflammatory properties. This review focuses on the potential of BMA to modulate inflammatory pathways, enhance tissue regeneration, and restore neurological function disrupted by SCI. We hypothesize that BMA's bioactive components may stimulate reparative processes at the cellular level, particularly when applied at strategic sites like the sacral hiatus to influence lumbar centers and higher neurological structures. By exploring the mechanisms through which BMA influences spinal repair, this review aims to establish a foundation for its application in clinical settings, potentially offering a transformative approach to SCI management that extends beyond symptomatic relief to promoting functional recovery.
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Affiliation(s)
- José Fábio Lana
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Clinical Research, Anna Vitória Lana Institute (IAVL), Indaiatuba 13334-170, SP, Brazil
- Medical School, Max Planck University Center (UniMAX), Indaiatuba 13343-060, SP, Brazil
| | - Annu Navani
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Medical School, Max Planck University Center (UniMAX), Indaiatuba 13343-060, SP, Brazil
- Comprehensive Spine & Sports Center, Campbell, CA 95008, USA
| | - Madhan Jeyaraman
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Department of Orthopaedics, ACS Medical College and Hospital, Chennai 600077, Tamil Nadu, India
| | - Napoliane Santos
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Luyddy Pires
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Gabriel Silva Santos
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Izair Jefthé Rodrigues
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Douglas Santos
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Tomas Mosaner
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Gabriel Azzini
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Lucas Furtado da Fonseca
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Medical School, Federal University of São Paulo (UNIFESP), São Paulo 04024-002, SP, Brazil
| | - Alex Pontes de Macedo
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Stephany Cares Huber
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Daniel de Moraes Ferreira Jorge
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Joseph Purita
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Medical School, Max Planck University Center (UniMAX), Indaiatuba 13343-060, SP, Brazil
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9
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Higano JD, Burns K, Smith G, Solinsky R. Why do different people with Spinal Cord Injury have differing severity of symptoms with Autonomic Dysreflexia? Exploring relationships of vascular alpha-1 adrenoreceptor and baroreflex sensitivity after SCI. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.02.24306772. [PMID: 38746296 PMCID: PMC11092739 DOI: 10.1101/2024.05.02.24306772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Introduction Individuals with spinal cord injury (SCI) commonly have autonomic dysreflexia (AD) with increased sympathetic activity. After SCI, individuals have decreased baroreflex sensitivity and increased vascular responsiveness. Objective To evalate relationship between baroreflex and blood vessel sensitivity with autonomic dysreflexia symptoms. Design Case control. Setting Tertiary academic center. Patients 14 individuals with SCI, 17 matched uninjured controls. Interventions All participants quantified AD symptoms using the Autonomic Dysfunction Following SCI (ADFSCI)-AD survey. Participants received three intravenous phenylephrine boluses, reproducibly increasing systolic blood pressure (SBP) 15-40 mmHg. Continuous heart rate (R-R interval, ECG), beat-to-beat blood pressures (finapres), and popliteal artery flow velocity were recorded. Vascular responsiveness (α1 adrenoreceptor sensitivity) and heart rate responsiveness to increased SBP (baroreflex sensitivity) were calculated. Main outcome measures Baroreflex sensitivity after increased SBP; Vascular responsiveness through quantified mean arterial pressure (MAP) 2-minute area under the curve and change in vascular resistance. Results SCI and control cohorts were well-matched with mean age 31.9 and 29.6 years (p=0.41), 21.4% and 17.6% female respectively. Baseline MAP (p=0.83) and R-R interval (p=0.39) were similar. ADFSCI-AD scores were higher following SCI (27.9+/-22.9 vs 4.2+/-2.9 in controls, p=0.002).To quantify SBP response, MAP area under the curve was normalized to dose/bodyweight. Individuals with SCI had significantly larger responses (0.26+/-0.19 mmHg*s/kg*ug) than controls (0.06+/-0.06 mmHg*s/kg*ug, p=0.002). Similarly, leg vascular resistance increased after SCI (24% vs 6% to a normalized dose, p=0.007). Baroreflex sensitivity was significantly lower after SCI (15.0+/-8.3 vs 23.7+/-9.3 ms/mmHg, p=0.01). ADFSCI-AD subscore had no meaningful correlation with vascular responsiveness (R2=0.008) or baroreflex sensitivity (R2=0.092) after SCI. Conclusions While this confirms smaller previous studies suggesting increased α1 adrenoreceptor sensitivity and lower baroreflex sensitivity in individuals with SCI, these differences lacked correlation to increased symptoms of AD. Further research into physiologic mechanisms to explain why some individuals with SCI develop symptoms is needed.
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Calderón-Juárez M, Miller T, Samejima S, Shackleton C, Malik RN, Sachdeva R, Dorey TW, Krassioukov AV. Heart Rate Variability-Based Prediction of Autonomic Dysreflexia After Spinal Cord Injury. J Neurotrauma 2024; 41:1172-1180. [PMID: 38214089 DOI: 10.1089/neu.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Autonomic dysreflexia (AD) is a common autonomic complication of spinal cord injury (SCI) characterized by a sudden increase is blood pressure triggered by peripheral stimulation, such as bladder distention. Iatrogenic AD events often occur during various medical procedures including urodynamic assessments (UDSs) used to evaluate lower urinary tract (LUT) function in individuals with SCI. To date, there are no established clinical practices that would allow early detection of the development of episodes of AD. Heart rate variability (HRV) is a reliable and non-invasive metric for evaluating autonomic regulation of the cardiovascular system, with demonstrated utility in people with SCI during UDSs. We aim to provide a comprehensive evaluation of cardiovascular function during UDS-induced AD using ultra-short-term HRV analysis and identify changes in cardiovascular dynamics to predict the onset of AD. We assessed cardiovascular data in a total of 24 participants with sensorimotor complete SCI above T6 (17 males, 7 females, median age = 43 [36-50] years) who experienced AD during UDS. We used continuous electrocardiographic recordings to evaluate HRV in 60 sec overlapping windows during filling cystometry. The mean of "normal-to-normal" heartbeats (meanNN), its standard deviation (SDNN), and the root mean square of successive differences (RMSSD) were calculated and used in all subsequent analyses. We found that SDNN and RMSSD diminished during the early phase of bladder filling and sharply increased during AD. Using the lowest point of statistical variability in heart rate (i.e., SDNN), we were able to predict AD events within 240 sec (percentile 25-percentile 75: 172-339 sec) before the first systolic blood pressure peak after AD onset (sensitivity = 0.667; specificity = 0.875). Our results indicated a temporary increase in sympathetic activity during the early phase of bladder filling, which is followed by an increase in parasympathetic outflow to the heart when AD occurs. These findings have significant clinical implications that extend beyond the context of UDS and demonstrate the importance of identifying early changes in HRV in order to accurately predict AD episodes in people living with SCI.
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Affiliation(s)
- Martín Calderón-Juárez
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tiev Miller
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Soshi Samejima
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Claire Shackleton
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raza N Malik
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tristan W Dorey
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada
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11
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Yang P, Bian ZQ, Song ZB, Yang CY, Wang L, Yao ZX. Dominant mechanism in spinal cord injury-induced immunodeficiency syndrome (SCI-IDS): sympathetic hyperreflexia. Rev Neurosci 2024; 35:259-269. [PMID: 37889575 DOI: 10.1515/revneuro-2023-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023]
Abstract
Clinical studies have shown that individuals with spinal cord injury (SCI) are particularly susceptible to infectious diseases, resulting in a syndrome called SCI-induced immunodeficiency syndrome (SCI-IDS), which is the leading cause of death after SCI. It is believed that SCI-IDS is associated with exaggerated activation of sympathetic preganglionic neurons (SPNs). After SCI, disruption of bulbospinal projections from the medulla oblongata C1 neurons to the SPNs results in the loss of sympathetic inhibitory modulation from the brain and brainstem and the occurrence of abnormally high levels of spinal sympathetic reflexes (SSR), named sympathetic hyperreflexia. As the post-injury survival time lengthens, mass recruitment and anomalous sprouting of excitatory interneurons within the spinal cord result in increased SSR excitability, resulting in an excess sympathetic output that disrupts the immune response. Therefore, we first analyze the structural underpinnings of the spinal cord-sympathetic nervous system-immune system after SCI, then demonstrate the progress in highlighting mechanisms of SCI-IDS focusing on norepinephrine (NE)/Beta 2-adrenergic receptor (β2-AR) signal pathways, and summarize recent preclinical studies examining potential means such as regulating SSR and inhibiting β2-AR signal pathways to improve immune function after SCI. Finally, we present research perspectives such as to promote the effective regeneration of C1 neurons to rebuild the connection of C1 neurons with SPNs, to regulate excitable or inhibitory interneurons, and specifically to target β2-AR signal pathways to re-establish neuroimmune balance. These will help us design effective strategies to reverse post-SCI sympathetic hyperreflexia and improve the overall quality of life for individuals with SCI.
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Affiliation(s)
- Ping Yang
- Department of Neurobiology, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Zhi-Qun Bian
- Department of Orthopedics, The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Zhen-Bo Song
- Department of Physiology, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Cheng-Ying Yang
- Department of Immunology, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Li Wang
- Department of Immunology, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Zhong-Xiang Yao
- Department of Physiology, Army Medical University (Third Military Medical University), Chongqing 400038, China
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Trbovich M, Wu Y, Romo T, Koek W, Kellogg D. Mechanistic involvement of noradrenergic neuronal neurotransmitter release in cutaneous vasoconstriction during autonomic dysreflexia in persons with spinal cord injury. Auton Neurosci 2024; 252:103154. [PMID: 38330594 PMCID: PMC11304048 DOI: 10.1016/j.autneu.2024.103154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/22/2023] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Autonomic dysreflexia (AD) is a potentially life-threatening consequence in high (above T6) spinal cord injury that involves multiple incompletely understood mechanisms. While peripheral arteriolar vasoconstriction, which controls systemic vascular resistance, is documented to be pronounced during AD, the pathophysiological neurovascular junction mechanisms of this vasoconstriction are undefined. One hypothesized mechanism is increased neuronal release of norepinephrine and co-transmitters. We tested this by examining the effects of blockade of pre-synaptic neural release of norepinephrine and co-transmitters on cutaneous vasoconstriction during AD, using a novel non-invasive technique; bretylium (BT) iontophoresis followed by skin blood flow measurements via laser doppler flowmetry (LDF). METHODS Bretylium, a sympathetic neuronal blocking agent (blocks release of norepinephrine and co-transmitters) was applied iontophoretically to the skin of a sensate (arm) and insensate (leg) area in 8 males with motor complete tetraplegia. An nearby untreated site served as control (CON). Cutaneous vascular conductance (CVC) was measured (CVC = LDF/mean arterial pressure) at normotension before AD was elicited by bladder stimulation. The percent drop in CVC values from pre-AD vs. AD was compared among BT and CON sites in sensate and insensate areas. RESULTS There was a significant effect of treatment but no significant effect of limb/sensation or interaction of limb x treatment on CVC. The percent drop in CVC between BT and CON treated sites was 25.7±1.75 vs. 39.4±0.87, respectively (P = 0.004). CONCLUSION Bretylium attenuates, but does not fully abolish vasoconstriction during AD. This suggests release of norepinephrine and cotransmitters from cutaneous sympathetic nerves is involved in cutaneous vasoconstriction during AD.
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Affiliation(s)
- Michelle Trbovich
- Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio Audie L. Murphy Memorial Veterans Affairs Hospital, San Antonio, TX, United States of America; South Texas Veteran's Health Care System, San Antonio, TX, United States of America.
| | - Yubo Wu
- South Texas Veteran's Health Care System, San Antonio, TX, United States of America
| | - Terry Romo
- Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio Audie L. Murphy Memorial Veterans Affairs Hospital, San Antonio, TX, United States of America; South Texas Veteran's Health Care System, San Antonio, TX, United States of America
| | - Wouker Koek
- Department of Cell Systems and Anatomy, University of Texas Health Science Center, San Antonio, United States of America
| | - Dean Kellogg
- Department of Medicine, University of TX Health Science Center, San Antonio, United States of America; Geriatric Research Education and Clinical Center and Dept of Medicine, University of Texas Health Science Center, San Antonio, United States of America; South Texas Veteran's Health Care System, San Antonio, TX, United States of America
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13
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Grau JW, Hudson KE, Johnston DT, Partipilo SR. Updating perspectives on spinal cord function: motor coordination, timing, relational processing, and memory below the brain. Front Syst Neurosci 2024; 18:1184597. [PMID: 38444825 PMCID: PMC10912355 DOI: 10.3389/fnsys.2024.1184597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024] Open
Abstract
Those studying neural systems within the brain have historically assumed that lower-level processes in the spinal cord act in a mechanical manner, to relay afferent signals and execute motor commands. From this view, abstracting temporal and environmental relations is the province of the brain. Here we review work conducted over the last 50 years that challenges this perspective, demonstrating that mechanisms within the spinal cord can organize coordinated behavior (stepping), induce a lasting change in how pain (nociceptive) signals are processed, abstract stimulus-stimulus (Pavlovian) and response-outcome (instrumental) relations, and infer whether stimuli occur in a random or regular manner. The mechanisms that underlie these processes depend upon signal pathways (e.g., NMDA receptor mediated plasticity) analogous to those implicated in brain-dependent learning and memory. New data show that spinal cord injury (SCI) can enable plasticity within the spinal cord by reducing the inhibitory effect of GABA. It is suggested that the signals relayed to the brain may contain information about environmental relations and that spinal cord systems can coordinate action in response to descending signals from the brain. We further suggest that the study of stimulus processing, learning, memory, and cognitive-like processing in the spinal cord can inform our views of brain function, providing an attractive model system. Most importantly, the work has revealed new avenues of treatment for those that have suffered a SCI.
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Affiliation(s)
- James W. Grau
- Lab of Dr. James Grau, Department of Psychological and Brain Sciences, Cellular and Behavioral Neuroscience, Texas A&M University, College Station, TX, United States
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14
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Calderón-Juárez M, Samejima S, Rempel L, Sachdeva R, Krassioukov A. Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations. World J Urol 2024; 42:80. [PMID: 38358540 DOI: 10.1007/s00345-024-04781-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD. METHODS After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.
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Affiliation(s)
- Martín Calderón-Juárez
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Soshi Samejima
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Lucas Rempel
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Rahul Sachdeva
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Andrei Krassioukov
- International Collaboration On Repair Discoveries, Faculty of Medicine, The University of British Columbia, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
- Division of Physical Medicine and Rehabilitation, Department of Medicine, The University of British Columbia, Vancouver, Canada.
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada.
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Pancholi S, Everett TH, Duerstock BS. Advancing spinal cord injury care through non-invasive autonomic dysreflexia detection with AI. Sci Rep 2024; 14:3439. [PMID: 38341453 PMCID: PMC10858945 DOI: 10.1038/s41598-024-53718-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/04/2024] [Indexed: 02/12/2024] Open
Abstract
This paper presents an AI-powered solution for detecting and monitoring Autonomic Dysreflexia (AD) in individuals with spinal cord injuries. Current AD detection methods are limited, lacking non-invasive monitoring systems. We propose a model that combines skin nerve activity (SKNA) signals with a deep neural network (DNN) architecture to overcome this limitation. The DNN is trained on a meticulously curated dataset obtained through controlled colorectal distension, inducing AD events in rats with spinal cord surgery above the T6 level. The proposed system achieves an impressive average classification accuracy of 93.9% ± 2.5%, ensuring accurate AD identification with high precision (95.2% ± 2.1%). It demonstrates a balanced performance with an average F1 score of 94.4% ± 1.8%, indicating a harmonious balance between precision and recall. Additionally, the system exhibits a low average false-negative rate of 4.8% ± 1.6%, minimizing the misclassification of non-AD cases. The robustness and generalizability of the system are validated on unseen data, maintaining high accuracy, F1 score, and a low false-negative rate. This AI-powered solution represents a significant advancement in non-invasive, real-time AD monitoring, with the potential to improve patient outcomes and enhance AD management in individuals with spinal cord injuries. This research contributes a promising solution to the critical healthcare challenge of AD detection and monitoring.
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Affiliation(s)
- Sidharth Pancholi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
| | - Thomas H Everett
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, IU School of Medicine, Indianapolis, USA
| | - Bradley S Duerstock
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA.
- School of Industrial Engineering, Purdue University, West Lafayette, USA.
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16
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Wiles MD, Benson I, Edwards L, Miller R, Tait F, Wynn-Hebden A. Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence. Anaesthesia 2024; 79:193-202. [PMID: 38088443 DOI: 10.1111/anae.16198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/11/2024]
Abstract
Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.
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Affiliation(s)
- M D Wiles
- Academic Department of Anaesthesia and Peri-operative Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - I Benson
- National Spinal Injuries Centre, Buckinghamshire Hospitals NHS Trust, Stoke Mandeville, UK
| | - L Edwards
- University of Nottingham, Nottingham, UK
| | - R Miller
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - F Tait
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - A Wynn-Hebden
- Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust, Leicester, UK
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Vu PD, Conselman C, Hernandez I, Francisco GE. Headaches in Spinal Cord Injury: A Differential Diagnosis. Am J Phys Med Rehabil 2024; 103:e15-e17. [PMID: 37903598 DOI: 10.1097/phm.0000000000002360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Affiliation(s)
- Peter D Vu
- From the McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (PDV, CC, IH, GEF); and TIRR Memorial Hermann, Houston, Texas (PDV, IH, GEF)
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Izzy S. Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:53-72. [PMID: 38330472 PMCID: PMC10869103 DOI: 10.1212/con.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article provides a review of the initial clinical and radiologic evaluation and treatment of patients with traumatic spinal cord injuries. It specifically highlights essential knowledge for neurologists who encounter patients with these complex injuries. LATEST DEVELOPMENTS There has been improvement in the care of patients with traumatic spinal cord injuries, particularly in the prehospital evaluation, approach for immediate immobilization, standardized spinal clearance, efficient triage, and transportation of appropriate patients to traumatic spinal cord injury specialized centers. Advancements in spinal instrumentation have improved the surgical management of spinal fractures and the ability to manage patients with spinal mechanical instability. The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours of traumatic spinal cord injuries, regardless of the severity or location of the injury. There is no evidence that supports the use of neuroprotective treatments to improve outcomes in patients with traumatic spinal cord injuries. The administration of high-dose methylprednisolone, which is associated with significant systemic adverse effects, is strongly discouraged. Early and delayed mortality rates continue to be high in patients with traumatic spinal cord injuries, and survivors often confront substantial long-term physical and functional impairments. Whereas the exploration of neuroregenerative approaches, such as stem cell transplantation, is underway, these methods remain largely investigational. Further research is still necessary to advance the functional recovery of patients with traumatic spinal cord injuries. ESSENTIAL POINTS Traumatic spinal cord injury is a complex and devastating condition that leads to long-term neurologic deficits with profound physical, social, and vocational implications, resulting in a diminished quality of life, particularly for severely affected patients. The initial management of traumatic spinal cord injuries demands comprehensive interdisciplinary care to address the potentially catastrophic multisystem effects. Ongoing endeavors are focused on optimizing and customizing initial management approaches and developing effective therapies for neuroprotection and neuroregeneration to enhance long-term functional recovery.
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Mashola MK, Korkie E, Mothabeng DJ. Pain medication misuse in the South African spinal cord injury context. Health SA 2024; 29:2377. [PMID: 38322368 PMCID: PMC10839206 DOI: 10.4102/hsag.v29i0.2377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 10/31/2023] [Indexed: 02/08/2024] Open
Abstract
Background Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce. Aim To determine PMM and the associated factors in PWSCI. Setting Homes of community-dwelling manual wheelchair users with SCI in South Africa. Methods Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance. Results Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively). Conclusion Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose. Contribution This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.
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Affiliation(s)
- Mokgadi K Mashola
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Elzette Korkie
- Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Diphale J Mothabeng
- Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Benitez-Albiter A, Anderson CP, Jones M, Park SS, Layec G, Park SY. Contributing Factors to Endothelial Dysfunction in Individuals with Spinal Cord Injuries. Pulse (Basel) 2024; 12:49-57. [PMID: 39022560 PMCID: PMC11250044 DOI: 10.1159/000539199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background Patients with spinal cord injuries (SCIs) are at a greater risk for the development of cardiovascular diseases (CVDs) than able-bodied individuals due to the high risk of endothelial dysfunction. Summary For instance, patients with SCIs lose autonomic control of the heart and vasculature, which results in severe fluctuations in blood pressure. These oscillations between hypotension and hypertension have been shown to damage blood vessel endothelial cells and may contribute to the development of atherosclerosis. Furthermore, the loss of skeletal muscle control results in skeletal muscle atrophy and inward remodeling of the conduit arteries. It has been shown that blood vessels in the legs are chronically exposed to high shear, while the aorta experiences chronically low shear. These alterations to shear forces may adversely impact endothelial vasodilatory capacity and promote inflammatory signaling and leukocyte adherence. Additionally, microvascular endothelial vasodilatory capacity is impaired in patients with an SCI, and this may precede changes in conduit artery endothelial function. Finally, due to immobility and a loss of skeletal muscle mass, patients with SCIs have a higher risk of metabolic disorders, inflammation, and oxidative stress. Key Messages Collectively, these factors may impair endothelium-dependent vasodilatory capacity, promote leukocyte adhesion and infiltration, promote the peroxidation of lipids, and ultimately support the development of atherosclerosis. Therefore, future interventions to prevent CVDs in patients with SCIs should focus on the management of endothelial health to prevent endothelial dysfunction and atherosclerosis.
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Affiliation(s)
| | - Cody P. Anderson
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA
| | - Matthew Jones
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA
| | - Sang-Seo Park
- Department of Physiology, Kyung Hee University, Seoul, Republic of Korea
| | - Gwenael Layec
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Song-Young Park
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, USA
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21
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Ji W, Nightingale TE, Zhao F, Fritz NE, Phillips AA, Sisto SA, Nash MS, Badr MS, Wecht JM, Mateika JH, Panza GS. The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI. Arch Phys Med Rehabil 2024; 105:166-176. [PMID: 37625532 DOI: 10.1016/j.apmr.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/25/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023]
Abstract
A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.
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Affiliation(s)
- Wenjie Ji
- Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Tom E Nightingale
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK; Centre for Trauma Science Research, University of Birmingham, Birmingham, UK; International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
| | - Fei Zhao
- Department of Health Care Sciences, Program of Occupational Therapy, Wayne State University, Detroit, MI; John D. Dingell VA Medical Center, Research and Development, Detroit, MI
| | - Nora E Fritz
- Department of Health Care Sciences, Program of Physical Therapy, Detroit, MI; Department of Neurology, Wayne State University, Detroit, MI
| | - Aaron A Phillips
- Department of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular institute, Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada; RESTORE.network, University of Calgary, Calgary, AB, Canad
| | - Sue Ann Sisto
- Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Mark S Nash
- Department of Neurological Surgery, Physical Medicine & Rehabilitation Physical Therapy, Miami, FL; Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Research and Development, Detroit, MI; Departments of Physiology and Internal Medicine, Wayne State University, Detroit, MI
| | - Jill M Wecht
- James J Peters VA Medical Center, Department of Spinal Cord Injury Research, Bronx, NY; Icahn School of Medicine Mount Sinai, Departments of Rehabilitation and Human Performance, and Medicine Performance, and Medicine, New York, NY
| | - Jason H Mateika
- John D. Dingell VA Medical Center, Research and Development, Detroit, MI; Departments of Physiology and Internal Medicine, Wayne State University, Detroit, MI
| | - Gino S Panza
- Department of Health Care Sciences, Program of Occupational Therapy, Wayne State University, Detroit, MI; John D. Dingell VA Medical Center, Research and Development, Detroit, MI.
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22
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Visagan R, Kearney S, Blex C, Serdani-Neuhaus L, Kopp MA, Schwab JM, Zoumprouli A, Papadopoulos MC, Saadoun S. Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord. J Neurotrauma 2023; 40:2680-2693. [PMID: 37476968 PMCID: PMC11265769 DOI: 10.1089/neu.2023.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.
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Affiliation(s)
- Ravindran Visagan
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
| | - Siobhan Kearney
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
- Neuro Anesthesia and Neuro Intensive Care Unit, St. George's Hospital, London, United Kingdom
| | - Christian Blex
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leonarda Serdani-Neuhaus
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel A. Kopp
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan M. Schwab
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
- The Belford Center for Spinal Cord Injury, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
- Departments of Neurology, Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus, Ohio, USA
| | - Argyro Zoumprouli
- Neuro Anesthesia and Neuro Intensive Care Unit, St. George's Hospital, London, United Kingdom
| | | | - Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
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23
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Chen RY, Chang HS, Huang HC, Hsueh YH, Tu YK, Lee KZ. Comorbidity of cardiorespiratory and locomotor dysfunction following cervical spinal cord injury in the rat. J Appl Physiol (1985) 2023; 135:1268-1283. [PMID: 37855033 DOI: 10.1152/japplphysiol.00473.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023] Open
Abstract
Cervical spinal cord injury interrupts supraspinal pathways innervating thoracic sympathetic preganglionic neurons and results in cardiovascular dysfunction. Both respiratory and locomotor functions were also impaired due to damages of motoneuron pools controlling respiratory and forelimb muscles, respectively. However, no study has investigated autonomic and somatic motor functions in the same animal model. The present study aimed to establish a cervical spinal cord injury model to evaluate cardiorespiratory response and locomotor activity in unanesthetized rats. Cardiovascular response and respiratory behavior following laminectomy or cervical spinal contusion were measured using noninvasive blood pressure analyzer and plethysmography systems, respectively. Locomotor activity was evaluated by an open-field test and a locomotor rating scale. The results demonstrated that mean arterial blood pressure and heart rate were significantly reduced in contused rats compared with uninjured rats at the acute injured stage. Tidal volume was also significantly reduced during the acute and subchronic stages. Moreover, locomotor function was severely impaired, evidenced by decreasing moving ability and locomotor rating scores from the acute to chronic injured stages. Retrograde neurotracer results revealed that cervical spinal cord injury caused a reduction in number of phrenic and triceps motoneurons. Immunofluorescence staining revealed a significant attenuation of serotonergic, noradrenergic, glutamatergic, and GABAergic fibers innervating the thoracic sympathetic preganglionic neurons in chronically contused rats. These results revealed the pathological mechanism underlying the comorbidity of cardiorespiratory and locomotor dysfunction following cervical spinal cord injury. We proposed that this animal model can be used to evaluate the therapeutic efficacy of potential strategies to improve different physiological functions.NEW & NOTEWORTHY The present study establishes a preclinical rodent model to comprehensively investigate physiological functions under unanesthetized condition following cervical spinal cord contusion. The results demonstrated that cervical spinal cord contusion is associated with impairments in cardiovascular, respiratory, and locomotor function. Respiratory and forelimb motoneurons and neurochemical innervations of sympathetic preganglionic neurons were damaged following injury. This animal model can be used to evaluate the therapeutic efficacy of potential strategies to improve different physiological functions.
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Affiliation(s)
- Rui-Yi Chen
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Hsiao-Sen Chang
- Department of Orthopedic Surgery, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Hsien-Chang Huang
- Department of Orthopedic Surgery, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Yu-Huan Hsueh
- Department of Orthopedic Surgery, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedic Surgery, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Kun-Ze Lee
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung, Taiwan
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24
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Smith L, Weber G. Differentiating essential hypertension from autonomic dysreflexia: a case report. Spinal Cord Ser Cases 2023; 9:51. [PMID: 37884525 PMCID: PMC10603167 DOI: 10.1038/s41394-023-00607-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION Autonomic dysreflexia (AD), a condition of critically raised blood pressure, is a severe complication of spinal cord injury. Primary (essential) hypertension may present with similar blood pressure levels to AD, though the causes, pathophysiology, presentation and treatment will differ. CASE PRESENTATION We report a case of a 74-year-old patient with a C1 spinal injury, who developed primary (essential) hypertension during her rehabilitation phase of care, requiring extensive investigations for autonomic dysreflexia. Despite this, no underlying cause was found; essential hypertension was subsequently confirmed with 24-hour ambulatory blood pressure monitoring. Treatment with an ACE inhibitor was introduced to good effect. DISCUSSION Essential hypertension can affect patients with spinal injury, even though most patients with higher level injuries (particularly cervical spinal cord injuries) are expected to have low resting baseline hypotension. Relevant features of this are presented within this case; a set of criteria to differentiate essential hypertension from autonomic dysreflexia are also proposed.
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Affiliation(s)
- Leon Smith
- Spinal Injuries Unit, Royal Rehabilitation Centre Sydney, Morrison Ave, Putney, 2112, NSW, Australia.
| | - Gerard Weber
- Spinal Injuries Unit, Royal Rehabilitation Centre Sydney, Morrison Ave, Putney, 2112, NSW, Australia
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25
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Ebrahimi H, Maroufi SF, Abdollahzadegan S, Rahimi-Movaghar V. Clinical Practice Guideline Development for Autonomic Dysreflexia in Spinal Cord Injury. Med J Islam Repub Iran 2023; 37:109. [PMID: 38145189 PMCID: PMC10744198 DOI: 10.47176/mjiri.37.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Indexed: 12/26/2023] Open
Abstract
Background Autonomic Dysreflexia (AD) is a crucial emergency complication of cervical and upper thoracic spinal cord injury (SCI). Although there are several treatment options for AD, unfortunately, there is no consensus on the treatment of AD.This study aimed to present Clinical Practice Guidelines (CPG) development for AD in SCI in different conditions. Methods The project was carried out by an executive team of general practitioners and neurosurgeons. A national multidisciplinary panel of experts performed the decision-making step, which consisted of deciding on the final list of recommendations and articulating novel recommendations regarding the infrastructure and fundamental elements necessary for managing patients suffering from AD. Four appraisers evaluated the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tools. Results A total of 575 articles were found after searching different databases. After the primary screening, title, abstract, and full-text screening were performed, which yielded 9 records. Five were excluded after the AGREE II evaluation. The source guidelines' recommendations were tabulated as possible scenarios for 15 patient/population, intervention, comparison, and outcomes clinical questions. Based on the expert panel's opinion, all the recommendations were adaptable. Finally, the suggestions were transformed into a protocol for managing patients suffering from autonomic dysreflexia. Conclusion This guideline presented the treatment and pharmacotherapy of autonomic dysreflexia. However, the treatment is being updated. We suggest more educational multimedia for health care professionals, primarily in the emergency department.
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Affiliation(s)
- Hannan Ebrahimi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences,
Tehran, Iran
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran
University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences,
Tehran, Iran
| | - Shayan Abdollahzadegan
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences,
Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences,
Tehran, Iran
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran
University of Medical Sciences, Tehran, Iran
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran
- Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran
- Spine Program, University of Toronto, Toronto, Canada
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26
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Guízar-Sahagún G, Grijalva I, Franco-Bourland RE, Madrazo I. Aging with spinal cord injury: A narrative review of consequences and challenges. Ageing Res Rev 2023; 90:102020. [PMID: 37487887 DOI: 10.1016/j.arr.2023.102020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023]
Abstract
Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.
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Affiliation(s)
- Gabriel Guízar-Sahagún
- Research Unit for Neurological Diseases, Instituto Mexicano del Seguro Social, 4430 Calzada de Tlalpan, Mexico City, Mexico.
| | - Israel Grijalva
- Research Unit for Neurological Diseases, Instituto Mexicano del Seguro Social, 4430 Calzada de Tlalpan, Mexico City, Mexico
| | - Rebecca E Franco-Bourland
- Department of Biochemistry, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, 289 Calzada México-Xochimilco, Mexico City, Mexico
| | - Ignacio Madrazo
- Research Unit for Neurological Diseases, Instituto Mexicano del Seguro Social, 4430 Calzada de Tlalpan, Mexico City, Mexico
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27
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Futch BG, Kouam RW, Ugiliweneza B, Harrop J, Kurpad S, Foster N, Than K, Crutcher C, Goodwin CR, Tator C, Shaffrey CI, Aarabi B, Fehlings M, Neal CJ, Guest J, Abd-El-Barr MM. Demographics, Mechanism of Injury, and Outcomes for Acute Upper and Lower Cervical Spinal Cord Injuries: An Analysis of 470 Patients in the Prospective, Multi-Center, North American Clinical Trials Network Registry. J Neurotrauma 2023; 40:1918-1927. [PMID: 36852492 DOI: 10.1089/neu.2022.0407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
There is a paucity of data comparing the demographics, mechanism of injury, and outcomes of upper versus lower cervical spinal cord injuries (cSCI). The study objective was to define different clinical manifestations of cSCI. Data were collected prospectively through centers of the North American Clinical Trials Network (NACTN). Data was collected on 470 patients (21% women, mean age 50 years). Cervical vertebral level was analyzed as an ordinal variable to determine a natural demarcation to classify upper versus lower cSCI. For continuous variable analysis, falls were associated with C3 more than C4 vertebral level injuries (60% vs. 42%; p = 0.0126), while motor vehicle accidents were associated with C4 more than C3 (40% vs. 29%; p = 0.0962). Motor International Standards for Neurological Classification of Spinal Cord Injury scores also demonstrated a natural demarcation between C3 and C4, with C3 having higher median American Spinal Injury Association (ASIA) motor scores (40 [4-73] vs. 11 [3-59], p = 0.0227). There were no differences when comparing C2 to C3 nor C4 to C5. Given the significant differences seen between C3 and C4, but not C2 and C3 nor C4 and C5, upper cSCI was designated as C1-C3, and lower cSCI was designated as C4-C7. Compared with a lower cSCI, patients with an upper cSCI were more likely to have a fall as their mechanism of injury (54% vs. 36%; p = 0.0072). Patients with an ASIA C cSCI were likely to have an upper cervical injury: 23% vs. 11% (p = 0.0226). Additionally, patients with an upper cSCI were more likely to have diabetes prior to injury: 37% versus 22%, respectively (p = 0.0084). Lower cSCI were more likely injured through sports (19% vs. 8%, p = 0.0171) and present with ASIA A (42% vs. 25%, p = 0.0186) neurological grade. Patients with lower cSCI were also significantly more likely to have complications such as shock, pulmonary embolism, and pleural effusion. In conclusion, there appears to be a natural demarcation of injury type between C3 and C4. Upper cSCI (C1-C3) was more associated with falls and diabetes, whereas lower cSCI (C4-C7) was more associated with sports, worse ASIA scores, and more complications. Further research will be needed to understand the mechanistic and biological differences between these two groups and whether different treatments may be appropriate for each of these groups.
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Affiliation(s)
| | - Romaric Waguia Kouam
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina, USA
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, Louisville, Kentucky, USA
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - James Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Shekar Kurpad
- Neuroscience Institute. The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Norah Foster
- Department of Orthopedic Surgery, Premier Health, Centerville Ohio, USA
| | - Khoi Than
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Clifford Crutcher
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Maryland, USA
| | - Michael Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Chris J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - James Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
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28
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Cunha NSC, Malvea A, Sadat S, Ibrahim GM, Fehlings MG. Pediatric Spinal Cord Injury: A Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1456. [PMID: 37761417 PMCID: PMC10530251 DOI: 10.3390/children10091456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.
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Affiliation(s)
| | - Anahita Malvea
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON M5T 2S8, Canada;
| | - Sarah Sadat
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - George M. Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada;
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON M5T 2S8, Canada;
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
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29
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Michael FM, Patel SP, Bachstetter AD, Rabchevsky AG. Proinflammatory and Immunomodulatory Gene and Protein Expression Patterns in Spinal Cord and Spleen Following Acute and Chronic High Thoracic Injury. J Inflamm Res 2023; 16:3341-3349. [PMID: 37576153 PMCID: PMC10423003 DOI: 10.2147/jir.s417435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction In addition to paralysis and loss of sensation, high-level spinal cord injury (SCI) causes sympathetic dysfunction that can lead to autonomic dysreflexia (AD) and chronic immune suppression involving splenic leukopenia. Evidence has shown that treatment with either gabapentin or blockade of TNFα mitigates maladaptive plasticity and the underlying hemodynamic dysfunction, spleen atrophy, and immune dysfunction associated with AD. Because significant improvements long term was noted following treatments only during acute stages of recovery, we sought to systematically examine changes in proinflammatory and immunomodulatory cytokines to ascertain the reason. Methods Adult female Wistar rats underwent complete T4 spinal transection before euthanasia at systematic intervals from 3 days to 8 weeks after injury. Using qRT-PCR and meso scale discovery (MSD) assays, the gene and protein expression of TNFα and IFNγ in the spleen, upper thoracic (T4-9) and lumbosacral (L5-S6) spinal cords were analyzed. Results We found that spleen atrophy occurs in a biphasic manner compared to naïve controls, with significant decreases in the spleen mass noted at 3 days and 8 weeks after injury. Splenic TNFα mRNA and protein levels did not change significantly over time, while IFNγ gene expression dipped acutely with trends for increased protein levels at more chronic time points. TNFα protein increased significantly only in thoracic spinal cord segments from 3 to 14 days post-injury. IFNγ mRNA and protein levels remained unelevated in injured spinal cords over time, with trends for increased protein levels at 2 and 8 weeks in the lumbosacral segments. Discussion Novel temporal-spatial cytokine expression profiles reveal that TNFα protein levels are increased solely in upper thoracic segments after high thoracic SCI, while IFNγ remains unaltered. Splenic leukopenia and latent systemic immunosuppression are not associated with altered TNFα or IFNγ expression in the spleen or spinal cord.
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Affiliation(s)
- Felicia M Michael
- Department of Physiology, University of Kentucky, Lexington, KY, 40536-0509, USA
- Spinal Cord & Brain Injury Research Center (SCoBIRC); University of Kentucky, Lexington, KY, 40536-0509, USA
| | - Samir P Patel
- Department of Physiology, University of Kentucky, Lexington, KY, 40536-0509, USA
- Spinal Cord & Brain Injury Research Center (SCoBIRC); University of Kentucky, Lexington, KY, 40536-0509, USA
| | - Adam D Bachstetter
- Spinal Cord & Brain Injury Research Center (SCoBIRC); University of Kentucky, Lexington, KY, 40536-0509, USA
- Department of Neuroscience, University of Kentucky, Lexington, KY, 40536-0509, USA
| | - Alexander G Rabchevsky
- Department of Physiology, University of Kentucky, Lexington, KY, 40536-0509, USA
- Spinal Cord & Brain Injury Research Center (SCoBIRC); University of Kentucky, Lexington, KY, 40536-0509, USA
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30
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Miller RR, Tso MM, Rimok J, Smith DB. Collateral connectivity of the sympathetic nervous system. J Physiol 2023; 601:3443-3444. [PMID: 37190919 DOI: 10.1113/jp284933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- Ryan R Miller
- Departments of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute, Hotchkiss Brain Institute, RESTORE.network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcus M Tso
- Departments of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute, Hotchkiss Brain Institute, RESTORE.network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julien Rimok
- Departments of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute, Hotchkiss Brain Institute, RESTORE.network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Donovan B Smith
- Departments of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute, Hotchkiss Brain Institute, RESTORE.network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Torres RD, Rashed H, Mathur P, Castillo C, Abell T, Terson de Paleville DGL. Autogenic biofeedback training improves autonomic responses in a participant with cervical motor complete spinal cord injury- case report. Spinal Cord Ser Cases 2023; 9:31. [PMID: 37438337 PMCID: PMC10338546 DOI: 10.1038/s41394-023-00593-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023] Open
Abstract
STUDY DESIGN Single-subject case design OBJECTIVE: To evaluate the Autogenic Feedback Training Exercise (AFTE) on autonomic nervous system responses. INTRODUCTION AFTE combines specific autogenic exercises with biofeedback of multiple physiological responses. Originally developed by the National Aeronautics and Space Administration (NASA), AFTE is used to improve post-flight orthostatic intolerance and motion sickness in astronauts. Individuals with cervical or upper thoracic spinal cord injury (SCI) often present symptoms of autonomic dysfunction similar to astronauts. We hypothesize that AFTE challenges nervous system baroreflex, gastric and vascular responses often impaired after SCI. METHODS Using a modified AFTE protocol, we trained a hypotensive female participant with cervical motor complete (C5/6-AIS A) SCI, and a male non-injured control participant (NI) and measured blood pressure (BP), heart rate (HR), gastric electrical activity, and microvascular blood volume before, during and after AFTE. The participants were instructed to complete breathing and imagery exercises to help facilitate relaxation. Subsequently, they were instructed to use stressful imagery and breathing exercises during arousal trials. RESULTS Both participants completed 8 sessions of approximately 45 min each. Microvascular blood volume decreased 23% (SCI) and 54% (NI) from the beginning to the end of the stimulation cycles. The participant with SCI became progressively more normotensive and improved levels of gastric electrical activity, while the NI participant's changes in HR, gastric electrical activity, and BP were negligible. CONCLUSIONS AFTE may offer a novel non-pharmacologic intervention to minimize symptoms of dysautonomia in people with SCI.
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Affiliation(s)
- Rachel D Torres
- Interdisciplinary Program in Translational Neuroscience, University of Louisville, Louisville, KY, USA
| | - Hani Rashed
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prateek Mathur
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA
| | - Camilo Castillo
- Division of Physical Medicine and Rehabilitation, University of Louisville, Louisville, KY, USA
| | - Thomas Abell
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA
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Miller T, Lange D, Kizhakkedathu JN, Yu K, Felix D, Samejima S, Shackleton C, Malik RN, Sachdeva R, Walter M, Krassioukov AV. The Microbiological Burden of Short-Term Catheter Reuse in Individuals with Spinal Cord Injury: A Prospective Study. Biomedicines 2023; 11:1929. [PMID: 37509568 PMCID: PMC10377649 DOI: 10.3390/biomedicines11071929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Despite the risk of developing catheter-associated urinary tract infections (CAUTI), catheter reuse is common among people with spinal cord injury (SCI). This study examined the microbiological burden and catheter surface changes associated with short-term reuse. Ten individuals with chronic SCI reused their catheters over 3 days. Urine and catheter swab cultures were collected daily for analysis. Scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS) analyses were used to assess catheter surface changes. Catheter swab cultures showed no growth after 48 h (47.8%), skin flora (28.9%), mixed flora (17.8%), or bacterial growth (5.5%). Asymptomatic bacteriuria was found for most participants at baseline (n = 9) and all at follow-up (n = 10). Urine samples contained Escherichia coli (58%), Klebsiella pneumoniae (30%), Enterococcus faecalis (26%), Acinetobacter calcoaceticus-baumannii (10%), Pseudomonas aeruginosa (6%) or Proteus vulgaris (2%). Most urine cultures showed resistance to one or more antibiotics (62%). SEM images demonstrated structural damage, biofilm and/or bacteria on all reused catheter surfaces. XPS analyses also confirmed the deposition of bacterial biofilm on reused catheters. Catheter surface changes and the presence of antibiotic-resistant bacteria were evident following short-term reuse, which may increase susceptibility to CAUTI in individuals with SCI despite asymptomatic bacteriuria.
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Affiliation(s)
- Tiev Miller
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Dirk Lange
- Department of Urologic Sciences, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- The Stone Centre at Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Centre for Blood Research, Life Science Institute, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- The School of Biomedical Engineering, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Kai Yu
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Centre for Blood Research, Life Science Institute, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Demian Felix
- Department of Urologic Sciences, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- The Stone Centre at Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Soshi Samejima
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Claire Shackleton
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Raza N Malik
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
| | - Matthias Walter
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Department of Urology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC V6T 1Z3, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC V5Z 2G9, Canada
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Fallahi MS, Azadnajafabad S, Maroufi SF, Pour-Rashidi A, Khorasanizadeh M, Sattari SA, Faramarzi S, Slavin KV. Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation. World Neurosurg 2023; 174:11-24. [PMID: 36858292 DOI: 10.1016/j.wneu.2023.02.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023]
Abstract
Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.
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Affiliation(s)
- Mohammad Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Azadnajafabad
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Pour-Rashidi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sina Faramarzi
- School of Biological Sciences, University of California, Irvine, Irvine, California, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
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Wang Y, Yi H, Song Y. miRNA Therapy in Laboratory Models of Acute Spinal Cord Injury in Rodents: A Meta-analysis. Cell Mol Neurobiol 2023; 43:1147-1161. [PMID: 35648313 DOI: 10.1007/s10571-022-01235-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 05/18/2022] [Indexed: 11/28/2022]
Abstract
miRNA therapy is popularly investigated in treating acute spinal cord injury (SCI) and offers a significant prospect for the treatment of acute SCI. We aimed to provide pre-clinical validations of miRNA in the treatment of SCI. A systematic search of EMBASE, PubMed, Web of Science, the Cochrane Library, and Scopus databases was performed. Rats, which were the most used animals (70%, n = 46 articles), receiving miRNA therapy got prominent recovery in SCI models [BBB score, SMD 3.90, 95% CI 3.08-4.73, p < 0.01]. Locomotor function of fore and hind limbs in SCI mice receiving miRNA therapy (30%, n = 19 articles) [grip strength, SMD 3.22, 95% CI 2.14-4.26; p < 0.01; BBB score, SMD 3.47, 95% CI 2.38-4.56, p < 0.01; BMS, SMD 2.27, 95% CI 1.34-3.20, p < 0.01] also recovered better than mice in control group. Then, we conducted the subgroup analysis and did find that high-quality articles trended to report non-therapeutic effect of miRNA. Furtherly, we analyzed 46 miRNAs, including 9 miRNA families (miR-21-5p/34a-3p/124-3p/126-3p/223-3p/543-3p/30-3p/136-3p/15-5p), among which miR-30-3p/136-3p/15-5p family were not effective in recovering locomotor function of rats. Conclusively, miRNAs are curative drugs for SCI, however, appropriate miRNA carrier and which miRNA is the most efficacious for SCI should be furtherly investigated.
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Affiliation(s)
- Yang Wang
- Department of Orthopedics, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong Pharmaceutical University, No. 19 Nonglinxia Road, Yuexiu District, Guangzhou, Guangdong Province, China.
| | - Hanxiao Yi
- Department of Radiotherapy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, China
| | - Yancheng Song
- Department of Orthopedics, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong Pharmaceutical University, No. 19 Nonglinxia Road, Yuexiu District, Guangzhou, Guangdong Province, China
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Boakye M, Ball T, Dietz N, Sharma M, Angeli C, Rejc E, Kirshblum S, Forrest G, Arnold FW, Harkema S. Spinal cord epidural stimulation for motor and autonomic function recovery after chronic spinal cord injury: A case series and technical note. Surg Neurol Int 2023; 14:87. [PMID: 37025529 PMCID: PMC10070319 DOI: 10.25259/sni_1074_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/14/2023] [Indexed: 03/19/2023] Open
Abstract
Background:
Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series (n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES.
Methods:
This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2–3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively.
Results:
Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met (n = 9) or exceeded (n = 8) their expectations, and 100% would undergo the operation again.
Conclusion:
scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES’s role in SCI patients.
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Affiliation(s)
- Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Tyler Ball
- Department of Neurosurgery, Vanderbilt University, Nashville,
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Claudia Angeli
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Enrico Rejc
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Steven Kirshblum
- Department of Physical Medicine Rehabilitation, Rutgers, Newark, New Jersey,
| | - Gail Forrest
- Department of Physical Medicine Rehabilitation, Rutgers, Newark, New Jersey,
| | - Forest W. Arnold
- Department of Infectious Diseases, University of Louisville, Louisville, United States
| | - Susan Harkema
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
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36
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Nakata T, Shibasaki M, Nishimura Y, Kinoshita T, Hashizaki T, Kamijo YI, Kouda K, Umemoto Y, Tajima F. Quantification of catecholamine neurotransmitters released from cutaneous vasoconstrictor nerve endings in men with cervical spinal cord injury. Am J Physiol Regul Integr Comp Physiol 2023; 324:R345-R352. [PMID: 36693170 DOI: 10.1152/ajpregu.00063.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Control of cutaneous circulation is critically important to maintain thermoregulation, especially in individuals with cervical spinal cord injury (CSCI) who have no or less central thermoregulatory drive. However, the peripheral vasoconstrictor mechanism and capability have not been fully investigated after CSCI. Post- and presynaptic sensitivities of the cutaneous vasoconstrictor system were investigated in 8 CSCI and 7 sedentary able-bodied (AB) men using an intradermal microdialysis technique. Eight doses of norepinephrine (NE, 10-8 to 10-1 M) and five doses of tyramine (TY, 10-8, 10-5 to 10-2 M) were administered into the anterior right and left thigh, respectively. Endogenous catecholamines, noradrenaline, and dopamine, collected at the TY site, were determined by high-performance liquid chromatography with electrochemical detection. Regardless of vasoconstrictor agents, cutaneous vascular conductance decreased dose-dependently and responsiveness was similar between the groups (NE: Group P = 0.255, Dose P = 0.014; TY: Group P = 0.468, Dose P < 0.001), whereas the highest dose of each drug induced cutaneous vasodilation. Administration of TY promoted the release of noradrenaline and dopamine in both groups. Notably, the amount of noradrenaline released was similar between the groups (P = 0.819), although the concentration of dopamine was significantly greater in individuals with CSCI than in AB individuals (P = 0.004). These results suggest that both vasoconstrictor responsiveness and neural functions are maintained after CSCI, and dopamine in the skin is likely to induce cutaneous vasodilation.
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Affiliation(s)
- Tomonori Nakata
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Yukihide Nishimura
- Department of Rehabilitation Medicine, Iwate Medical University, Wakayama, Japan
| | - Tokio Kinoshita
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan.,Division of Rehabilitation, Wakayama Medical University Hospital, Wakayama, Japan
| | - Takamasa Hashizaki
- Division of Rehabilitation, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yoshi-Ichiro Kamijo
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan.,Department of Rehabilitation Medicine, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Ken Kouda
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasunori Umemoto
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Fumihiro Tajima
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
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Sachdeva R, Hosseinzadeh A, Rizzardo A, Maharaj A, Berger M, Krassioukov A. No pain, no strain: Targin® mitigates pain and constipation following spinal cord injury. Ann Clin Transl Neurol 2023; 10:453-458. [PMID: 36692221 PMCID: PMC10014000 DOI: 10.1002/acn3.51734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/30/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Opioids effectively reduce chronic pain, but present significant side effects including opioid-induced constipation. Oxycodone/naloxone decreases pain and constipation in cancer patients, however its effect on spinal cord injury population remains understudied. METHODS We assessed whether oxycodone/naloxone reduces pain, constipation, and severity of autonomic dysreflexia in an individual with spinal cord injury. A 55-year-old male with C5 lesion presented with chief complaint of chronic pain received 5/2.5 mg and 20/10 mg oxycodone/naloxone for 6 and 2 weeks, respectively. RESULTS Oxycodone/naloxone improved pain, bowel function, and autonomic dysreflexia severity. INTERPRETATION Oxycodone/naloxone was effective in managing chronic pain and constipation in the studied case.
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Affiliation(s)
- Rahul Sachdeva
- International Collaboration on Repair Discoveries, University of British Columbia, British Columbia, Vancouver, Canada
| | - Ali Hosseinzadeh
- International Collaboration on Repair Discoveries, University of British Columbia, British Columbia, Vancouver, Canada
| | - Aaron Rizzardo
- Department of Medicine, Division of Community Internal Medicine, University of British Columbia, British Columbia, Vancouver, Canada
| | - Andrea Maharaj
- International Collaboration on Repair Discoveries, University of British Columbia, British Columbia, Vancouver, Canada
| | - Michael Berger
- International Collaboration on Repair Discoveries, University of British Columbia, British Columbia, Vancouver, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, British Columbia, Vancouver, Canada
| | - Andrei Krassioukov
- International Collaboration on Repair Discoveries, University of British Columbia, British Columbia, Vancouver, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, British Columbia, Vancouver, Canada.,Spinal Cord Program, GF Strong Rehabilitation Centre, University of British Columbia, British Columbia, Vancouver, Canada
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Simulation- vs. Didactic-Based Learning for Rehabilitation Nurses Caring for Patients With Autonomic Dysreflexia. Rehabil Nurs 2023; 48:56-62. [PMID: 36792955 DOI: 10.1097/rnj.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE Autonomic dysreflexia (AD) is associated with spinal cord injury, manifesting in symptoms of high blood pressure, bradycardia, headache, diaphoresis, and anxiety. Nurses often manage these symptoms; thus, nursing knowledge of AD is crucial. The purpose of this study was to improve AD nursing knowledge while exploring differences between simulation and didactic learning in nurse education. DESIGN AND METHODS This prospective pilot study used two types of learning (simulation vs. didactic) to determine if one was superior to the other regarding nursing knowledge of AD. Nurses were given a pretest, randomized to simulation or didactic learning, and then given a posttest 3 months later. RESULTS Thirty nurses were enrolled in this study. Seventy-seven percent of nurses held a BSN degree with an average of 15.75 years in nursing. The mean knowledge scores for AD at baseline for the control (13.9 [2.4]) and intervention (15.5 [2.9]) groups were not statistically different ( p = .1118). The mean knowledge scores for AD after either didactic- or simulation-based education for the control (15.5 [4.4]) and intervention (16.5 [3.4]) groups were not statistically different ( p = .5204). CLINICAL RELEVANCE Autonomic dysreflexia is a critical clinical diagnosis that requires prompt nursing intervention to prevent threatening consequences. This study focused on how different methods of education best benefited AD knowledge acquisition and how simulation versus didactic learning impacts overall nursing education. CONCLUSIONS As a whole, providing nurses with AD education was helpful in improving their understanding of the syndrome. However, our data suggest that both didactic and simulation are equally effective methods to increase AD knowledge.
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Chow PM, Kuo HC. Botulinum Toxin A Injection for Autonomic Dysreflexia-Detrusor Injection or Urethral Sphincter Injection? Toxins (Basel) 2023; 15:toxins15020108. [PMID: 36828422 PMCID: PMC9961697 DOI: 10.3390/toxins15020108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 01/27/2023] Open
Abstract
Spinal cord injuries (SCI) have a profound impact on autonomic systems, sometimes resulting in multi-organ dysfunction, including of the neurogenic bladder. Autonomic dysreflexia (AD) is commonly seen in patients with SCI above T6 when the injured cord develops a deregulated sympathetic reflex, which can be induced by bladder sensation and can cause hypertensive crisis. While intravesical injection of botulinum toxin A (Botox) is a standard therapy for neurogenic detrusor overactivity, the role of Botox for AD has rarely been described. This study reviewed the medical records of SCI patients who reported AD and received either detrusor or urethral sphincter injection with Botox. The primary endpoint is the subjective improvement of AD. The secondary endpoint is a change in videourodynamic parameters before and after Botox injection. A total of 200 patients were enrolled for analysis. There were 125 (62.5%) patients in the detrusor injection group, and 75 (37.5%) in the urethral sphincter injection group. There were 79 (63.2%) patients in the detrusor injection group and 43 (57.3%) in the urethral sphincter injection group reporting moderate or marked improvement. Detrusor injection leads to a greater improvement in AD, probably because of decreased detrusor pressure and increased compliance after Botox injection. Urethral sphincter injection appears to have a modest effect on AD, despite general improvements in the voiding parameters of videourodynamic study.
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Affiliation(s)
- Po-Ming Chow
- Department of Urology, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei 100225, Taiwan
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, 707, Sec. 3, Chung-Yang Rd., Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-3-856-1825
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Quercetin Derivatives in Combating Spinal Cord Injury: A Mechanistic and Systematic Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12121960. [PMID: 36556325 PMCID: PMC9783198 DOI: 10.3390/life12121960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
Abstract
Spinal cord injury (SCI) possesses a complicated etiology. There is no FDA-approved treatment for SCI, and the majority of current interventions focus on reducing symptoms. During SCI, inflammation, oxidative stress, apoptosis, and autophagy are behind the secondary phase of SCI and cause serious consequences. It urges the need for providing multi-targeting agents, that possess lower side effects and higher efficacy. The plant secondary metabolites are multi-targeting agents and seem to provide new roads in combating diseases. Flavonoids are phytochemicals of continual interest to scientists in combating neurodegenerative diseases (NDDs). Flavonoids are being studied for their biological and pharmacological effects, particularly as antioxidants, anti-inflammatory agents, anti-apoptotic, and autophagy regulators. Quercetin is one of the most well-known flavonols known for its preventative and therapeutic properties. It is a naturally occurring bioactive flavonoid that has recently received a lot of attention for its beneficial effects on NDDs. Several preclinical evidence demonstrated its neuroprotective effects. In this systematic review, we aimed at providing the biological activities of quercetin and related derivatives against SCI. Detailed neuroprotective mechanisms of quercetin derivatives are also highlighted in combating SCI.
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Zhang C, Gao R, Zhou R, Chen H, Liu C, Zhu T, Chen C. The emerging power and promise of non-coding RNAs in chronic pain. Front Mol Neurosci 2022; 15:1037929. [PMID: 36407760 PMCID: PMC9668864 DOI: 10.3389/fnmol.2022.1037929] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/07/2022] [Indexed: 08/26/2023] Open
Abstract
Chronic pain (CP) is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage lasting longer than 3 months. CP is the main reason why people seek medical care and exerts an enormous economic burden. Genome-wide expression analysis has revealed that diverse essential genetic elements are altered in CP patients. Although many possible mechanisms of CP have been revealed, we are still unable to meet all the analgesic needs of patients. In recent years, non-coding RNAs (ncRNAs) have been shown to play essential roles in peripheral neuropathy and axon regeneration, which is associated with CP occurrence and development. Multiple key ncRNAs have been identified in animal models of CP, such as microRNA-30c-5p, ciRS-7, and lncRNA MRAK009713. This review highlights different kinds of ncRNAs in the regulation of CP, which provides a more comprehensive understanding of the pathogenesis of the disease. It mainly focuses on the contributions of miRNAs, circRNAs, and lncRNAs to CP, specifically peripheral neuropathic pain (NP), diabetic NP, central NP associated with spinal cord injury, complex regional pain syndrome, inflammatory pain, and cancer-induced pain. In addition, we summarize some potential ncRNAs as novel biomarkers for CP and its complications. With an in-depth understanding of the mechanism of CP, ncRNAs may provide novel insight into CP and could become new therapeutic targets in the future.
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Affiliation(s)
- Changteng Zhang
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Gao
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruihao Zhou
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hai Chen
- Department of Respiratory and Critical Care Medicine, West China Medical School/West China Hospital, Sichuan University, Chengdu, China
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Changliang Liu
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chan Chen
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Suresh S, Everett TH, Shi R, Duerstock BS. Automatic Detection and Characterization of Autonomic Dysreflexia Using Multi-Modal Non-Invasive Sensing and Neural Networks. Neurotrauma Rep 2022; 3:501-510. [DOI: 10.1089/neur.2022.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shruthi Suresh
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Thomas H. Everett
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Riyi Shi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
- Center for Paralysis Research, West Lafayette, Indiana, USA
- Department of Basic Medical Sciences, West Lafayette, Indiana, USA
| | - Bradley S. Duerstock
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
- Center for Paralysis Research, West Lafayette, Indiana, USA
- School of Industrial Engineering, West Lafayette, Indiana, USA
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Sherwin E, King C, Hasen H, May S. Single-dose intravesical amikacin instillation for pyocystis in a patient with autonomic dysreflexia: A case report. J Spinal Cord Med 2022; 45:965-968. [PMID: 33983103 PMCID: PMC9661977 DOI: 10.1080/10790268.2021.1922832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
CONTEXT Pyocystis is an infection of the epithelium of the bladder and a frequent complication of anuria. Patients with spinal cord injury (SCI) at the sixth thoracic vertebra (T6) or higher are at a greater risk for autonomic dysreflexia (AD), which can be induced by infections such as pyocystis. Cases of pyocystis treatment with aminoglycoside instillations have been reported in the literature. FINDINGS We describe the case of a 59-year-old male with T1 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A complete paraplegia, status post bilateral nephrectomy with recurrent episodes of AD suspected to be caused by pyocystis related to anuria. A bladder specimen culture grew Escherichia coli susceptible to amikacin with a minimum inhibitory concentration (MIC) of ≤ 8 mg/L. In the setting of anuria and with concern that intravenous antibiotics would not adequately reach the site of infection, we chose to treat the patient with a single-dose intravesical instillation of amikacin 25 mg/100 mL left to dwell for approximately 2 h. A repeat bladder culture showed no colonies. The patient remained stable with no episodes of AD and no signs or symptoms of infection one month following treatment. CONCLUSION The purpose of this case report is to add to the current literature on intravesical aminoglycoside instillations for pyocystis to aid clinicians in treating future cases, as well as to highlight pyocystis as a potential cause of AD in SCI patients with anuria.
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Affiliation(s)
- Erin Sherwin
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA,Correspondence to: Erin Sherwin, Science Center College of Pharmacy, University of Tennessee Health, 700 South 19th Street, Birmingham, AL35233, USA; Ph: (205) 933-8101 ext. 6401.
| | - Cynthia King
- Veteran’s Affairs Medical Center, Memphis, Tennessee,USA
| | - Howard Hasen
- Veteran’s Affairs Medical Center, Memphis, Tennessee,USA
| | - Shari May
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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44
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Increased Prevalence of Blood Pressure Instability Over Twenty-Four Hours in Chronic Spinal Cord Injury. Neurotrauma Rep 2022; 3:522-533. [DOI: 10.1089/neur.2022.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Mercado J, Ruiz A, Parsh B. Autonomic dysreflexia: Recognition and intervention. Nursing 2022; 52:10. [PMID: 36129497 DOI: 10.1097/01.nurse.0000872424.15581.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Julianne Mercado
- Julianne Mercado and Amanda Ruiz are RNs who graduated from the Sacramento State School of Nursing. Bridget Parsh is a professor at the California State University of Sacramento and a member of the Nursing2022 editorial board
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Thøgersen MB, Mohammadi M, Gull MA, Bengtson SH, Kobbelgaard FV, Bentsen B, Khan BYA, Severinsen KE, Bai S, Bak T, Moeslund TB, Kanstrup AM, Andreasen Struijk LNS. User Based Development and Test of the EXOTIC Exoskeleton: Empowering Individuals with Tetraplegia Using a Compact, Versatile, 5-DoF Upper Limb Exoskeleton Controlled through Intelligent Semi-Automated Shared Tongue Control. SENSORS (BASEL, SWITZERLAND) 2022; 22:6919. [PMID: 36146260 PMCID: PMC9502221 DOI: 10.3390/s22186919] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
This paper presents the EXOTIC- a novel assistive upper limb exoskeleton for individuals with complete functional tetraplegia that provides an unprecedented level of versatility and control. The current literature on exoskeletons mainly focuses on the basic technical aspects of exoskeleton design and control while the context in which these exoskeletons should function is less or not prioritized even though it poses important technical requirements. We considered all sources of design requirements, from the basic technical functions to the real-world practical application. The EXOTIC features: (1) a compact, safe, wheelchair-mountable, easy to don and doff exoskeleton capable of facilitating multiple highly desired activities of daily living for individuals with tetraplegia; (2) a semi-automated computer vision guidance system that can be enabled by the user when relevant; (3) a tongue control interface allowing for full, volitional, and continuous control over all possible motions of the exoskeleton. The EXOTIC was tested on ten able-bodied individuals and three users with tetraplegia caused by spinal cord injury. During the tests the EXOTIC succeeded in fully assisting tasks such as drinking and picking up snacks, even for users with complete functional tetraplegia and the need for a ventilator. The users confirmed the usability of the EXOTIC.
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Affiliation(s)
- Mikkel Berg Thøgersen
- Center for Rehabilitation Robotics, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
| | - Mostafa Mohammadi
- Center for Rehabilitation Robotics, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
| | - Muhammad Ahsan Gull
- Department of Materials and Production Technology, Aalborg University, 9220 Aalborg, Denmark
| | - Stefan Hein Bengtson
- Visual Analysis and Perception (VAP) Lab, Department of Architecture, Design, and Media Technology, Aalborg University, 9000 Aalborg, Denmark
| | | | - Bo Bentsen
- Center for Rehabilitation Robotics, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
| | - Benjamin Yamin Ali Khan
- Spinal Cord Injury Centre of Western Denmark, Viborg Regional Hospital, 8800 Viborg, Denmark
| | - Kåre Eg Severinsen
- Spinal Cord Injury Centre of Western Denmark, Viborg Regional Hospital, 8800 Viborg, Denmark
| | - Shaoping Bai
- Department of Materials and Production Technology, Aalborg University, 9220 Aalborg, Denmark
| | - Thomas Bak
- Department of Electronic Systems, Aalborg University, 9220 Aalborg, Denmark
| | - Thomas Baltzer Moeslund
- Visual Analysis and Perception (VAP) Lab, Department of Architecture, Design, and Media Technology, Aalborg University, 9000 Aalborg, Denmark
| | | | - Lotte N. S. Andreasen Struijk
- Center for Rehabilitation Robotics, Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
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Drotleff N, Jansen O, Weckwerth C, Aach M, Schildhauer TA, Waydhas C, Hamsen U. Pilot study: advanced haemodynamic monitoring after acute spinal cord injury-Keep the pressure up? BMC Anesthesiol 2022; 22:277. [PMID: 36050640 PMCID: PMC9434085 DOI: 10.1186/s12871-022-01806-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the use of vasopressors to maintain haemodynamic goals after acute spinal cord injury (SCI) is still recommended, evidence regarding the target values and possible risks of this practice is limited, and data on haemodynamic parameters unaffected by catecholamines are rare. In this pilot study, we show the haemodynamic profile of patients with acute SCI mainly unaffected by vasopressor use and other factors that influence the cardiovascular system. METHODS From March 2018 to March 2020, we conducted a prospective, single-centre pilot study of 30 patients with acute SCI. Factors that could affect the cardiocirculatory system other than SCI (sepsis, pre-existing heart disease or multiple trauma) led to exclusion. A total of 417 measurements were performed using the PiCCO™ system. RESULTS The mean systemic vascular resistance index (SVRI, 1447.23 ± 324.71 dyn*s*cm-5*m2), mean central venous pressure (CVP, 10.69 ± 3.16) and mean global end-diastolic volume index (GEDVI, 801.79 ± 158.95 ml/m2) deviated from the reference range, while the mean cardiac index (CI), mean stroke volume index (SVI), mean arterial pressure (MAP), and mean heart rate (HR) were within the reference range, as indicated in the literature. A mixed model analysis showed a significant negative relationship between norepinephrine treatment and MAP (83.97 vs. 73.69 mmHg, p < 0.001), SVRI (1463.40 vs. 1332.14 dyn*s*cm-5*m2, p = 0.001) and GEDVI (808.89 vs. 759.39 ml/m2, p = 0.001). CONCLUSION These findings could lead to an adaptation of the target range for SVRI and MAP in patients with acute SCI and therefore reduce the use of vasopressors.
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Affiliation(s)
- Niklas Drotleff
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany.
| | - Oliver Jansen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | | | - Mirko Aach
- Department of Spinal Cord Injury, BG University Hospital Bergmannsheil, Bochum, Germany
| | | | - Christian Waydhas
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany.,Medical Faculty of the University of Duisburg-Essen, Essen, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
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Bauermann A, Costa E Silva ADA, Figueiredo F, Koury JC. Bioelectrical impedance vector analysis and body composition in cervical spinal cord injury: A pilot study. Front Nutr 2022; 9:935128. [PMID: 35978958 PMCID: PMC9376375 DOI: 10.3389/fnut.2022.935128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Body composition assessment in cervical spinal cord injury (c-SCI) individuals is important to monitor the fat free-mass (FFM) loss, due to immobilization, or gain, due to exercise practice. Single frequency bioelectrical impedance analysis (SF-BIA) is low in cost, simple and easy. Objectives The aims of this study are: to evaluate the concordance between the FFM values obtained using dual X-ray absorptiometry (DXA) and the three SF-BIA previous predictive equations; and to test the applicability of the bioelectrical impedance vector analysis (BIVA). Methods Twenty-three c-SCI males were divided into two groups: Physically active (PA; n = 13; at least 150 min/week) and non-active individuals (NPA) and were assessed by DXA and SF-BIA simultaneously. Results FFM values were similar between groups PA and NPA. Considering all participants, FFM values obtained by Kocina and Heyward (>11%) and Sun (<15.4%) predictive equations were different when compared to DXA (p < 0.01). However, Buchholz's et al. predictive equation showed FFM values similar to DXA, but presented poor concordance (<7%, p = 0.99; concordance coefficient = 0.85). BIVA showed consistency in ellipse distribution using FFM obtained using Buchholz et al. predictive equation. Conclusions The use of non-specific BIA equations can lead to misinterpretation in FFM values in male c-SCI individuals. Predictive equations for this group need to be developed.
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Affiliation(s)
- Andreia Bauermann
- Graduate Program in Human Movement Sciences, Federal University of Pará, Belém, Pará, Brazil.,Brazilian Paralympic Academy, São Paulo, Brazil
| | - Anselmo de Athayde Costa E Silva
- Graduate Program in Human Movement Sciences, Federal University of Pará, Belém, Pará, Brazil.,Brazilian Paralympic Academy, São Paulo, Brazil
| | | | - Josely Correa Koury
- Nutrition Institute, Rio de Janeiro State University, Rio de Janeiro, Brazil
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Miget G, Tan E, Pericolini M, Chesnel C, Haddad R, Turmel N, Amarenco G, Hentzen C. The Neurogenic Bowel Dysfunction score (NBD) is not suitable for patients with multiple sclerosis. Spinal Cord 2022; 60:1130-1135. [PMID: 35859189 DOI: 10.1038/s41393-022-00837-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Bowel and anorectal dysfunctions are common in patients with multiple sclerosis (pwMS). The use of validated questionnaires is recommended in the initial assessment and patient's follow-up. The Neurogenic Bowel Dysfunction (NBD) score is the most used questionnaire but has been developed in spinal cord injured patients and has never been validated in other neurological diseases. We aimed to assess NBD's relevance in pwMS. SETTINGS Monocentric study in a tertiary neuro-urology department. METHODS A retrospective study in pwMS consulting for the first time in our department, that fulfilled the NBD questionnaire between 2010 and 2021 was performed. Qualitative and quantitative answers for each question were analyzed. Content validity and internal consistency were evaluated. RESULTS One hundred thirty-five pwMS (mean age 47.1, 58% of women) fulfilled the NBD questionnaire. Mean NBD score was 6.0 (SD 6.1) and 75% of patients had a score <9. Content validity analysis revealed 4 items not appropriate, 1 item with irrelevant calibration, and omission of some treatment widely used in pwMS. Internal consistency was appreciated with Cronbach's alpha = 0.48 IC 95% [0.31; 0.6]. CONCLUSION NBD questionnaire lacks content validity and presents a weak internal consistency in pwMS. A specific questionnaire is therefore required in pwMS to optimize bowel management and follow-up.
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Affiliation(s)
- Gabriel Miget
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France. .,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France.
| | - Eliane Tan
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France
| | - Martina Pericolini
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France.,Urology Department, Policlinico Tor Vergata, Università Degli Studi di Roma "Tor Vergata", 00133, Rome, Italy
| | - Camille Chesnel
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France
| | - Rebecca Haddad
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France
| | - Nicolas Turmel
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France
| | - Gérard Amarenco
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France
| | - Claire Hentzen
- GRC 01, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, 75020, Paris, France.,Department of Neuro-urology, Tenon Hospital, AP-HP, 4, Rue de la Chine, 75020, Paris, France
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Thomas AX, Riviello JJ, Davila-Williams D, Thomas SP, Erklauer JC, Bauer DF, Cokley JA. Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children. Curr Treat Options Neurol 2022; 24:285-304. [PMID: 35702419 PMCID: PMC9184374 DOI: 10.1007/s11940-022-00720-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available. Recent Findings Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment. Summary Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.
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Affiliation(s)
- Ajay X. Thomas
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX USA
| | - James J. Riviello
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Daniel Davila-Williams
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Sruthi P. Thomas
- Division of Pediatric Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Jennifer C. Erklauer
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - David F. Bauer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Jon A. Cokley
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Department of Pharmacy, Baylor College of Medicine, Houston, TX USA
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