A systematic review of clinical studies on electrical stimulation therapy for patients with neurogenic bowel dysfunction after spinal cord injury

Spinal cord stimulation: Beyond pain management

INTRODUCTION

The gate control theory of pain was the starting point of the development of spinal cord stimulation (SCS). We describe the indications for the treatment in pain management and other uses not related to pain.

DEVELOPMENT

There are currently several paradigms for SCS: tonic, burst, and high frequency. The main difference lies in the presence of paraesthesias. SCS is most beneficial for treating neuropathic pain. Patients with failed back surgery syndrome show the best response rates, although a considerable reduction in pain is also observed in patients with complex regional pain syndrome, diabetic neuropathy, radiculopathy, and low back pain without previous surgery. Phantom pain or pain related to cardiovascular or peripheral vascular disease may improve, although there is a lack of robust evidence supporting generalisation of its use. SCS also improves cancer-related pain, although research on this issue is scarce. Non-pain-related indications for SCS are movement disorders, spasticity, and sequelae of spinal cord injury. The main limiting factors for the use of SCS are mechanical complications and the cost of the treatment.

CONCLUSION

In its 50-year history, SCS has progressed enormously. The perfection of hardware and software may improve its effectiveness and reduce the rate of complications. Indications for SCS could include other diseases, and its use could be expanded, if the costs of the technology are reduced.

Effect of transcutaneous abdominal electrical stimulation in people with constipation due to spinal cord injuries: a pilot study

OBJECTIVE

To evaluate the effect of abdominal electrical stimulation (EE) on bowel movement frequency and feces consistency and expelled amount in people with constipation due to spinal cord injuries (SCI).

METHOD

This is an experimental, crossover, randomized pilot study with two treatment groups: conventional intestinal rehabilitation and conventional rehabilitation associated with EE via 8- and 20-Hz Functional Electrical Stimulation (FES) of the abdominal muscles. Both groups were followed for two weeks with daily 30-minute EE sessions. Participants were hospitalized in a rehabilitation institute in the municipality of São Paulo. Data were analyzed using descriptive and inferential statistics.

RESULTS

This study included 10 people with SCI, of which most were male (70%), with a mean age of 39 years (SD = 16.37). EE, associated with conventional treatment, was more effective in increasing defecation frequency (p = 0.029) and amount of feces expelled (p = 0.031).

CONCLUSION

Abdominal EE, associated with conventional treatment, helped to increase defecation frequency and amount of feces expelled in people with constipation due to SCI. This pilot study will serve as the basis for a future clinical trial with greater sampling and statistical evidence.

Rapid priority setting exercise on faecal incontinence for Cochrane Incontinence

Objective

This rapid priority setting exercise aimed to identify, expand, prioritise and explore stakeholder (patients, carers and healthcare practitioners) topic uncertainties on faecal incontinence (FI).

Design

An evidence gap map (EGM) was produced to give a visual overview of emerging trial evidence; existing systematic review-level evidence and FI stakeholder topic uncertainties derived from a survey. This EGM was used in a knowledge exchange workshop that promoted group discussions leading to the prioritisation and exploration of FI stakeholder identified topic uncertainties.

Results

Overall, a mismatch between the existing and emerging evidence and key FI stakeholder topic uncertainties was found. The prioritised topic uncertainties identified in the workshop were as follows: psychological support; lifestyle interventions; long-term effects of living with FI; education; constipation and the cultural impact of FI. When these six prioritised topic uncertainties were explored in more depth, the following themes were identified: education; impact and burden of living with FI; psychological support; healthcare service improvements and inconsistencies; the stigma of FI; treatments and management; culturally appropriate management and technology and its accessibility.

Conclusions

Topic uncertainties identified were broad and wide ranging even after prioritisation. More research is required to unpick the themes emerging from the in-depth discussion and explore these further to achieve a consensus on deliverable research questions.

Factors associated with neuropathic pain in Colombian patients with spinal cord injury of traumatic origin: case-control study

STUDY DESIGN

Case-control study.

OBJECTIVES

To identify factors associated with neuropathic pain (NP) in patients with spinal cord injury of traumatic origin (TSCI).

SETTING

University Hospital of Valle, Cali, Colombia.

METHODS

Study participants were individuals with diagnosis of TSCI who visited a trauma referral center from January 1st, 2016, to December 31st, 2016. Information was retrospectively extracted from the Hospital's Spinal Cord Injury registry and patients' medical records. Cases were defined as patients with NP and controls were those without NP. The exposure of interest was intentional injuries. Individuals were matched by age and stratified into 11 groups of ±3 years each.

RESULTS

We found 164 participants with an average age of 34 ± 13 years, of whom 95.1% were male, and 53.6% had NP. Neurogenic bladder and bowel occurred in 94.3% of NP patients. Cause of injury was not associated with NP. Older injuries were protective for NP (>10 years since injury OR = 0.10, 95% CI = 0.03-0.37, p < 0.0001) and neurogenic bladder and bowel were found as risk factors (OR = 5.89, 95% CI = 1.84-18.88; p = 0.003).

CONCLUSIONS

Our study uniquely shows time since injury as a protective factor for NP and neurogenic bladder and bowel as a risk factor, while violence was not found associated. This could help guide the scope of future research about NP secondary to SCI.

Spinal cord stimulation research in the restoration of motor, sensory and autonomic function for individuals living with spinal cord injuries: A scoping review

OBJECTIVE

To describe the status of spinal cord stimulation (SCS) research for the improvement of motor, sensory and autonomic function for individuals living with a spinal cord injury (SCI).

DATA SOURCES

This scoping review identified original research published prior to March 31, 2021, via literature searches using Medline, EMBASE, PubMed, Science Direct, CINAHL, Sport Discus, Web of Science, as well as a targeted search for well-known principal investigators. Search terms included permutations of "spinal cord stimulation", "epidural spinal cord stimulation", "transcutaneous spinal cord stimulation", "magnetic spinal cord stimulation" and "neuromodulation".

STUDY SELECTION

Studies were included if they: 1) were in English, 2) presented original research on humans living with a SCI, and 3) investigated at least one of the three forms of SCS.

DATA EXTRACTION

Extracted data included: authors, publication year, participant characteristics, purpose, study design, stimulation (device, location, parameters,) primary outcomes, and adverse events.

DATA SYNTHESIS

As a scoping review the extracted data was tabulated and presented descriptively. Themes and gaps in the literature were identified and reported. Of the 5,754 articles screened, 103 articles were included (55 epidural, 36 transcutaneous and 12 magnetic). The primary research design was a case study or series with only a single randomized clinical trial. Motor recovery was the most common primary outcome for epidural and transcutaneous SCS studies whereas bowel and bladder outcomes were most common for magnetic. Seventy percent of the studies included 10 or fewer participants, and 18 articles documented at least one adverse event. Incomplete stimulation parameter descriptions were noted across many studies. No articles mentioned direct engagement of consumers or advocacy groups.

CONCLUSION

This review identified a need for more robust study designs, larger sample sizes, comparative studies, improved reporting of stimulation parameters, adverse event data, and alignment of outcomes with the priorities of the SCI community.

The Effect of Non-invasive Spinal Cord Stimulation on Anorectal Function in Individuals With Spinal Cord Injury: A Case Series

Spinal cord injury (SCI) is a devastating condition that impacts multiple organ systems. Neurogenic bowel dysfunction (NBD) frequently occurs after a SCI leading to reduced sensation of bowel fullness and bowel movement often leading to constipation or fecal incontinence. Spinal Neuromodulation has been proven to be a successful modality to improve sensorimotor and autonomic function in patients with spinal cord injuries. The pilot data presented here represents the first demonstration of using spinal neuromodulation to activate the anorectal regions of patients with spinal cord injuries and the acute and chronic effects of stimulation. We observed that spinal stimulation induces contractions as well as changes in sensation and pressure profiles along the length of the anorectal region. In addition, we present a case report of a patient with a SCI and the beneficial effect of spinal neuromodulation on the patient’s bowel program.

Efeito da eletroestimulação abdominal transcutânea no quadro de constipação em pessoas com lesão medular: estudo piloto

RESUMO Objetivo: Avaliar o efeito da eletroestimulação (EE) abdominal sobre a frequência de evacuações, a consistência e a quantidade de fezes em pessoas com constipação decorrente da lesão medular (LM). Método: Estudo piloto experimental do tipo crossover-randomizado em dois grupos de tratamento: convencional de reabilitação intestinal e convencional associado à EE com Functional Electrical Stimulation (FES) de 8 e 20 Hz aplicados na musculatura abdominal. Ambos os grupos em seguimento por duas semanas, com 30 minutos de sessão diária de EE. Os participantes estavam internados em um instituto de reabilitação da cidade de São Paulo. Os dados foram analisados por meio de estatística descritiva e inferencial. Resultados: Participaram do estudo 10 pessoas com LM, a maioria do sexo masculino (70%), com média de idade de 39 anos (DP = 16,37). A EE, associada ao tratamento convencional, mostrou-se mais eficaz no aumento da frequência evacuatória (p = 0,029) e na quantidade de fezes (p = 0,031). Conclusão: A EE abdominal associada ao tratamento convencional auxiliou no aumento da frequência evacuatória e na quantidade de fezes no quadro de constipação em pessoas com LM. Este estudo piloto servirá como base para um futuro ensaio clínico com maior amostragem e comprovação estatística.

[The paraplegic patient-Characteristics of diagnostics and treatment in visceral surgery]

BACKGROUND

Patients with paraplegia develop syndrome-specific complications relevant to visceral surgery, which occur in the context of the acute spinal shock or as a consequence of the progressive neurogenic bowel dysfunction (NBD) with the formation of an elongated colon and/or megacolon. Moreover, acute abdominal emergencies, such as acute appendicitis, cholecystitis, diverticulitis and ileus images, pose particular challenges for the clinician when the clinical signs are atypical or even absent. The expansion of indications for obesity surgery to include patients with a paraplegic syndrome, whose independence and quality of life can be impaired due to the restricted mobility, especially by obesity, is becoming increasingly more important.

OBJECTIVE

This article provides an overview of the special requirements and aspects in the treatment of this special patient collective and to show the evidence of paraplegia-specific visceral surgery treatment.

MATERIAL AND METHODS

Targeted literature search in Medline and Cochrane library (German and English, 1985-2020).

RESULTS AND CONCLUSION

The clinical treatment of paraplegic patients requires in-depth knowledge of the pathophysiological changes at the different height of the paraplegia (upper versus lower motor neuron) and the phase of the disease (spinal shock versus long-term course). Missing or atypical clinical symptoms of acute diseases delay a quick diagnosis and make early diagnosis essential. The evidence for surgical treatment of the acute and chronic consequences of NBD is based on small retrospective series and case reports, as is that for special indications such as obesity surgery.

Electric field stimulation for tissue engineering applications

Electric fields are involved in numerous physiological processes, including directional embryonic development and wound healing following injury. To study these processes in vitro and/or to harness electric field stimulation as a biophysical environmental cue for organised tissue engineering strategies various electric field stimulation systems have been developed. These systems are overall similar in design and have been shown to influence morphology, orientation, migration and phenotype of several different cell types. This review discusses different electric field stimulation setups and their effect on cell response.

Electroacupuncture at Zusanli (ST36) Repairs Interstitial Cells of Cajal and Upregulates c-Kit Expression in Rats with SCI-Induced Neurogenic Bowel Dysfunction

Background

Electroacupuncture (EA) could improve colonic transit activity in rats with neurogenic bowel dysfunction (NBD) caused by spinal cord injury (SCI). The function of interstitial cells of Cajal (ICCs) and c-Kit expression may play essential roles in this process. Material and Methods. Thirty-six Sprague Dawley rats were randomized to the sham group, the SCI group, or the SCI + EA group (bilateral Zusanli, 30 min/day, 14 days). Changes in the ultrastructural morphology of ICCs were observed. The c-Kit expression on different levels was analyzed by immunohistochemistry, Western blotting, and RT-qPCR, respectively.

Results

Abnormal morphology of ICCs and downregulation of the c-Kit expression occurred after SCI. While the number of ICCs was increased, the ultrastructural morphology was improved significantly in EA rats. They also showed better improvement in c-Kit expression at both protein and gene levels.

Conclusion

Abnormal ICCs in colon tissues and the downregulated expression of c-Kit could be observed after SCI. EA at Zusanli (ST36) could improve the colon function by repairing the morphology and increasing the number of ICCs and upregulating c-Kit expression.

Rehabilitation of neurogenic bladder and bowel after spinal cord injury

Neurogenic bladder and bowel refers to the dysfunction of bladder and bowel caused by neurogenic etiology. Spinal cord injury is a major cause of this dysfunction, which seriously affects the injured person’s quality of life. The injury causes not only motor weakness of abdominal and perineal muscles, but also sensory changes and autonomic dysfunction of bladder and bowel. Spinal cord injuries involve multiple systems, and thus affect the normal functioning of the bowel and bladder in several ways: difficulty in urination and defecation, frequent or infrequent voiding, decrease of the sensation of fullness, incontinence, autonomic dysreflexia, perineal hygiene, deterioration of renal function, fecal impaction, psychological burden, etc. Thus, this review aims to provide updated practical guidance for the evaluation and management of neurogenic bowel and bladder by the clinicians who want to provide better care for their patients. Management of neurogenic bowel and bladder starts with carefully recording the patient’s history, including their bowel habits prior to the spinal injury. In general, evaluation of the neurogenic bladder requires more clinical tests than for the neurogenic bowel. The patients’ problems can be alleviated by adopting various measures: proper daily water and food intake, simultaneous pharmacologic treatments for the bowel and bladder, physiologic reflexes, bladder catheterization, rectal irrigation, surgical measures, etc. Priority should be given to the management of the neurogenic bladder with clean intermittent catheterization and decompression of the bladder pressure, and management of the neurogenic bowel by pharmacological treatment.

Treatments in neurogenic bowel dysfunctions: evidence reviews and clinical recommendations in adults

INTRODUCTION

Neurogenic bowel dysfunction (NBD) is an impairment of defecation control due to any nervous system lesion negatively affecting physical health status and quality of life. We aimed at systematically assessing all available evidence on NBD treatment in adults and providing clinical management guidance and recommendations.

EVIDENCE ACQUISITION

PICOs and questions (N.=7) were identified by an expert panel. We searched for and retrieved evidence from the PUBMED and EMBASE databases, limited to the English language and the Western countries context, related to any type of setting and published from 2009 to 2019. Health effects, patient values, preferences and resource use were assessed. Of all, only RCTs, observational studies and systematic reviews on adult population (≥18 years) were analyzed. The study was conducted according to PRISMA guidelines and Cochrane recommendations. The effect size, if possible, was calculated for the interpretation of the outcomes, and evidence was assessed through the GRADE method.

EVIDENCE SYNTHESIS

Thirty-one studies were included in our qualitative synthesis. Evidence is generally scarce. Most of the outcomes are narratively described and therefore defined by imprecision. Besides, most of the included studies are affected by risk of bias. Digital stimulation was found to be effective in short term follow-up. The pharmacological treatment choice, combined or alone, needs to be balanced case by case considering clinical history, setting of use and bowel management protocol. According to only one RCT supporting evidence mainly in persons affected by spinal cord injury (SCI), trans-anal irrigation (TAI) improves QoL and patient independency with a significant reduction of time spent for defecation and daily bowel program. History of urinary infections predicts the choice of using TAI. Patient-reported efficacy of colostomy alone or in combination with other surgeries appears evident in terms of patient's satisfaction and QoL over time. Nonetheless, perioperative and late complications can occur and may result in reduced acceptability over time.

CONCLUSIONS

Evidence is somehow weak and mainly reported in SCI. The systematic use of assistive interventions does not reduce the need of conservative or invasive approaches. Studies are needed on the role of bowel management in protecting patients from complications secondary to NBD in long term follow-ups.

Efficacy of neural stem cell transplantation for the treatment of patients with spinal cord injury: A protocol of systematic review and meta-analysis

BACKGROUND

The aim of this study is to evaluate the efficacy of neural stem cell transplantation (NSCT) for the treatment of patients with spinal cord injury (SCI).

METHODS

All potential randomized controlled trials (RCTs) on NSCT in the treatment of patients with SCI will be searched from the following electronic databases: Cochrane Library, MEDILINE, EMBASE, Web of Science, Scopus, CBM, WANGFANG, and CNKI. We will search all electronic databases from their initiation to the January 31, 2020 in spite of language and publication date. Two contributors will independently select studies from all searched literatures, extract data from included trials, and evaluate study quality for all eligible RCTs using Cochrane risk of bias tool, respectively. Any confusion will be resolved by consulting contributor and a consensus will be reached. We will utilize RevMan 5.3 software to pool the data and to conduct the data analysis.

RESULTS

This study will summarize the most recent RCTs to investigate the efficacy and safety of NSCT in the treatment of patients with SCI.

CONCLUSION

This study will provide evidence to assess the efficacy and safety of NSCT in the treatment of patients with SCI at evidence-based medicine level.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020173792.

Partners in Crime: NGF and BDNF in Visceral Dysfunction

Neurotrophins (NTs), particularly Nerve Growth Factor (NGF) and Brain-Derived Neurotrophic Factor (BDNF), have attracted increasing attention in the context of visceral function for some years. Here, we examined the current literature and presented a thorough review of the subject. After initial studies linking of NGF to cystitis, it is now well-established that this neurotrophin (NT) is a key modulator of bladder pathologies, including Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) and Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS. NGF is upregulated in bladder tissue and its blockade results in major improvements on urodynamic parameters and pain. Further studies expanded showed that NGF is also an intervenient in other visceral dysfunctions such as endometriosis and Irritable Bowel Syndrome (IBS). More recently, BDNF was also shown to play an important role in the same visceral dysfunctions, suggesting that both NTs are determinant factors in visceral pathophysiological mechanisms. Manipulation of NGF and BDNF improves visceral function and reduce pain, suggesting that clinical modulation of these NTs may be important; however, much is still to be investigated before this step is taken. Another active area of research is centered on urinary NGF and BDNF. Several studies show that both NTs can be found in the urine of patients with visceral dysfunction in much higher concentration than in healthy individuals, suggesting that they could be used as potential biomarkers. However, there are still technical difficulties to be overcome, including the lack of a large multicentre placebo-controlled studies to prove the relevance of urinary NTs as clinical biomarkers.