Rehabilitation care of patients with neurogenic bladder after spinal cord injury: A literature review

Electric Stimulation Combined with Biomaterials for Repairing Spinal Cord Injury

Spinal cord injury (SCI) is a central nervous system (CNS) disease with a high disability rate, and reconstructing motor function after SCI remains a global challenge. Recent advancements in rehabilitation and regenerative medicine offer new approaches to SCI repair. Electrical stimulation has been shown to alter cell membrane charge distribution, generating action potentials, and affecting cell behavior. This method aids axon regeneration and neurotrophic factor upregulation, crucial for nerve repair. Biomaterials, used as scaffolds or coatings in cell culture and tissue engineering, enhance cell proliferation, migration, differentiation, and tissue regeneration. Electroactive biomaterials combined with electrical stimulation show promise in regenerating nerve, heart, and bone tissues. In this paper, different types of electrical stimulation and biomaterials applied to SCI are described, and the current application and research progress of electrical stimulation combined with biomaterials in the treatment of SCI are described, as well as the future prospects and challenges.

Latent classes analysis and associated factors of knowledge of intermittent catheterization in neurogenic bladder management among medical staff

Previous studies have demonstrated that intermittent catheterization (IC) is an effective management strategy for neurogenic bladder (NB), but the knowledge of medical staff in this field remains under-researched. This cross-sectional study aimed to explore the profile of medical staff's knowledge regarding IC in NB management and its associated factors. In August 2023, we conducted a convenience sampling survey involving 207 eligible medical staff from high-prevalence departments of NB at a tertiary general hospital in Nanchong, Southwest China. Data analysis was performed using latent class analysis (LCA) and logistic regression analysis. The results showed that respondents' knowledge of IC in NB management scored 10.27 ± 2.89 (maximum possible score of 16). The LCA identified two distinct profiles: a high knowledge group (57.97%) and a low knowledge group (42.03%). Logistic regression revealed that individuals with a college degree or above (OR = 2.15, 95% CI 1.14-4.07), those focusing on NB management (OR = 4.07, 95% CI 2.21-7.49), and those who received relevant training (OR = 2.81, 95% CI 1.57-5.02) were more likely to be in the high level group. Additionally, variations in knowledge profiles were observed across different departments. These findings indicate a need to enhance medical staff's understanding of IC in NB management in high-prevalence departments of NB, with targeted training programs as a potential solution. Notably, the use of convenience sampling and a single-center design in this study may constrain the generalizability of these findings, necessitating multicenter validation studies in the future.

Enhanced BDNF and ROS in Mucosa of Lower Motor Neuron Lesioned Dog Bladder Following Somatic Motor Nerve Transfer

Neurotrophic factors and reactive oxygen species (ROS) modulate neuronal plasticity. In a model of a lower motor neuron lesioned bladder, somatic nerve transfer was used as a reinnervation strategy. Levels of neurotrophins, ROS, and TNF-α in bladder mucosa and muscle layers collected from three groups of adult female dogs: (1) Decentralized, via bilateral transection of coccygeal and sacral spinal roots, lumbar 7 dorsal roots, and hypogastric nerves, then 6-21 mo recovery; (2) reinnervated (ObNT-Reinn), after similar decentralization for 12 mo, then bilateral obturator-to-vesical nerve transfer and 8-12 mo recovery; and (3) Controls. In mucosa, BDNF and ROS levels were highest in ObNT-Reinn bladders, GDNF and TNF-α levels were restored to Control levels in ObNT-Reinn bladders (lowest in Decentralized). NT-3 and ARTN were lower in ObNT-Reinn and Decentralized bladders versus Controls. In muscle, ROS was lower in ObNT-Reinn muscle versus Controls. BDNF mucosa levels correlated with bladder axonal density and detrusor layer thickness; and GDNF mucosal correlated with bladder contraction after vesical or transferred obturator nerve electrical stimulation, as did BDNF and GDNF muscle levels. The increased BDNF and GDNF in bladders that underwent somatic nerve transfer with subsequent recovery suggest that BDNF and GDNF may help promote the reestablishment of bladder innervation.

Activation of the Nrf2 Signaling Pathway by Tetrahydroberberine Suppresses Ferroptosis and Enhances Functional Recovery Following Spinal Cord Injury

Recent research has identified ferroptosis, a newly recognized form of programmed cell death, is a crucial factor in spinal cord injury (SCI). Tetrahydroberberine (THB) is a tetrahydroisoquinoline alkaloid derived from the tuber of the poppy family plant, Corydalis, which is recognized for its antioxidant and neuroprotective properties. Despite these attributes, the potential protective effects of THB against SCI are yet to be thoroughly investigated. Therefore, the aim of this study was to elucidate the protective effects and underlying mechanisms of action of THB in SCI. A mouse model of SCI was used for the in vivo experiments. Functional recovery was evaluated using the Basso Mouse Scale (BMS), footprint analysis, and hematoxylin and eosin (HE), Masson's trichrome, and Nissl staining. Lipid peroxidation was quantified using malondialdehyde (MDA), glutathione (GSH), and superoxide dismutase (SOD). The expression levels of the nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway and ferroptosis markers were analyzed using western blot (WB) and immunofluorescence (IF) staining. To further elucidate the mechanism through which THB inhibits ferroptosis, an in vitro ferroptosis model was established in PC12 cells using RSL3, a known ferroptosis activator. THB markedly improved tissue and motor function restoration in mice post-SCI, with the BMS score increasing by approximately 50% compared with that in the control group. Lipid peroxidation assays revealed that THB significantly reduced MDA levels and increased GSH and SOD levels. Both in vivo and in vitro experiments demonstrated that THB significantly activated the Nrf2 pathway and inhibited ferroptosis in mice and in PC12 cells. This protective effect was reversed by the Nrf2 inhibitor, ML385, as evidenced by suppression of the Nrf2 pathway, increased lipid peroxidation, and elevated ferroptosis levels. Our in vivo and in vitro experiments indicate that THB promotes functional recovery after SCI by activating the Nrf2 signaling pathway, which attenuates lipid peroxidation and suppresses ferroptosis, thereby contributing to neuronal survival. Our findings contribute to a more comprehensive understanding of how THB exerts its recovery effects in SCI and demonstrate the potential of THB as a novel therapeutic strategy for the clinical management of SCI.

Clamping Catheter Versus Free Drainage for Patients With Neurogenic Bladder With Indwelling Urinary Catheter: A Meta-Analysis

Background: In the clinical setting, individuals with neurogenic bladder dysfunction commonly utilize indwelling urinary catheters for urinary management. The comparative efficacy of catheter clamping versus continuous free drainage in this patient population is yet to be established. This meta-analysis aims to explore the efficacy and safety of catheter clamping versus natural drainage in patients with neurogenic bladder, to provide evidence to support the treatment and nursing care of these patients. Methods: Two researchers conducted a literature search in Clinicaltrials et al. databases for Randomized Controlled Trials (RCTs) comparing clamping of the catheter to free drainage in patients with neurogenic bladder who have indwelling urinary catheters. The RCT bias risk assessment tool recommended by the Cochrane Handbook was used for quality assessment. RevMan 5.3 software were used for meta-analysis. Results: A total of 8 RCTs involving 772 patients with neurogenic bladder were enrolled. Catheter clamping significantly increased the volume of first urination in patients [MD = 52.86, 95%CI (42.30, 63.41), p < .001]. The difference in time to first urination [SMD = 0.10, 95%CI (-0.68, 0.89), p = .80], residual urine volume [MD = -5.18, 95%CI (-17.27, 6.90), p = .40], incidence of urinary retention [MD = 1.07, 95%CI (0.30, 3.87), p = .92], the incidence of urinary tract infection [RR = 1.38, 95%CI (0.64, 2.97), p = .42] between the catheter clamping group and the natural drainage group were not statistically significant. The results of Egger's regression analysis indicated no evidence of statistical publication bias. Conclusion: In light of the existing body of evidence, the routine practice of catheter clamping in catheterized patients with neurogenic bladder is not recommended.

Induction of Neural Differentiation and Protection by a Novel Slow-Release Nanoparticle Estrogen Construct in a Rat Model of Spinal Cord Injury

Spinal cord injury (SCI) is a complex debilitating condition leading to permanent life-long neurological deficits. Estrogen (E2) treatment is known to be neuroprotectant in SCI. This hormone is highly pleiotropic and has been shown to decrease apoptosis, modulate calcium signaling, regulate growth factor expression, act as an anti-inflammatory, and drive angiogenesis. These beneficial effects were found in our earlier study at the low dose of 10 µg/kg E2 in rats. However, the dose remains non-physiologic, which poses a safety hurdle for clinical use. Thus, we recently devised/constructed a fast release nanoparticle (NP) estrogen embedded (FNP-E2) construct and tested a focal delivery system in a contused SCI rat model which showed protection in the short run. In the current study, we have developed a novel slow-release NP estrogen (SNP-E2) delivery system that shows sustained release of E2 in the injured spinal cord and no systemic exposure in the host. The study of E2 release and kinetics of this SNP-E2 construct in vitro and in vivo supported this claim. Delivery of E2 to the injured spinal cord via this approach reduced inflammation and gliosis, and induced microglial differentiation of M1 to M2 in rats after SCI. Analysis of spinal cord samples showed improved myelination and survival signals (AKT) as demonstrated by western blot analysis. SNP-E2 treatment also induced astrocytic differentiation into neuron-like (MAP2/NeuN) cells, supported the survival of oligodendrocyte precursor cells (OPC), and improved bladder and locomotor function in rats following SCI. These data suggest that this novel delivery strategy of SNP-E2 to the injured spinal cord may provide a safe and effective therapeutic approach to treat individuals suffering from SCI.

Evaluating Neurogenic Bladder Management in Palestinian Healthcare: A Qualitative Study

BACKGROUND

Neurogenic bladder (NB) is a prevalent urologic condition significantly impacting the health and quality of life of affected individuals. The condition, often resulting from various etiologies such as spinal cord injuries and multiple sclerosis, leads to severe life problems, including pain and impaired physical, mental, social, and emotional functioning. This study aims to explore the medical practices of urologists in the diagnosis, management, and care of NB patients within the Palestinian healthcare context, highlighting the absence of a unified treatment protocol and the reliance on private clinics for care.

METHODS

An exploratory qualitative study design was employed, adhering to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Structured interviews were conducted with 14 urologists and two urology residents across eight different cities in Palestine, including 10 governmental hospitals, two private hospitals, one university hospital, and one charity hospital. Fourteen doctors had private outpatient clinics alongside their work in hospitals. A questionnaire developed by the authors was delivered to specialists and residents to understand the evaluation, management, follow-up practices, and challenges faced in treating NB patients. The study focused on the diagnostic processes, treatment modalities, complications management, and the impact of the lack of standardized protocols on patient care. Our qualitative study consists of six major themes, each theme consisting of multiple sub-themes and different participant responses: (1) diagnosis and follow-up of NB patients; (2) general issues in the management of NB; (3) evaluation and follow-up of upper and lower urinary system function in NB patients; (4) urinary tract infections associated with NB disease and how to deal with it; (5) opinions and future attitudes in the treatment of NB patients; (6) NB in patients with multiple sclerosis.

RESULTS

The study found that urodynamic studies are crucial in NB diagnosis, yet there is no unified management protocol, leading to varied practices. Most participants preferred the American Urological Association (AUA) guidelines in the absence of Palestinian protocols. Six major themes emerged, including diagnosis and follow-up challenges, general issues in NB management, evaluation and follow-up of urinary system function, urinary tract infections management, opinions on future treatment directions, and specific considerations for NB patients with multiple sclerosis.

CONCLUSIONS

The study highlights the need for a unified, standardized protocol for the management of NB patients in Palestine. The reliance on international guidelines, primarily the AUA protocols, underscores the gap in local healthcare policies. The findings call for the establishment of national guidelines and enhanced resources for the effective management of NB, aiming to improve patient outcomes and quality of life.

Acute ampakines increase voiding function and coordination in a rat model of SCI

Neurogenic bladder dysfunction causes urological complications and reduces the quality of life in persons with spinal cord injury (SCI). Glutamatergic signaling via AMPA receptors is fundamentally important to the neural circuits controlling bladder voiding. Ampakines are positive allosteric modulators of AMPA receptors that can enhance the function of glutamatergic neural circuits after SCI. We hypothesized that ampakines can acutely stimulate bladder voiding that has been impaired due to thoracic contusion SCI. Adult female Sprague-Dawley rats received a unilateral contusion of the T9 spinal cord (n = 10). Bladder function (cystometry) and coordination with the external urethral sphincter (EUS) were assessed 5 d post-SCI under urethane anesthesia. Data were compared to responses in spinal-intact rats (n = 8). The 'low-impact' ampakine CX1739 (5, 10, or 15 mg/kg) or vehicle (2-hydroxypropyl-beta-cyclodextrin [HPCD]) was administered intravenously. The HPCD vehicle had no discernible impact on voiding. In contrast, following CX1739, the pressure threshold for inducing bladder contraction, voided volume, and the interval between bladder contractions were significantly reduced. These responses occurred in a dose-dependent manner. We conclude that modulating AMPA receptor function using ampakines can rapidly improve bladder-voiding capability at subacute time points following contusion SCI. These results may provide a new and translatable method for therapeutic targeting of bladder dysfunction acutely after SCI.

Rehabilitation approach and results of using the biofeedback method (GIGER MD device) in children with neurogenic bladder

Background

GIGER MD device applies a biofeedback method through stimulated coordinated rhythmic and dynamic movements of the trunk and extremities in an anti-gravity position, thus helping to regain lost motor functions.

Methods

In this article, the performance of the GIGER MD device was evaluated in 36 children with neurogenic bladder measuring gait speed, voiding bladder capacity, deviation from the age-adjusted bladder capacity (measured using the Koff scale), and urinary incontinence.

Results

Children using the GIGER MD device had an increase in voiding bladder capacity (33.79%, median volume increase of 50 ml) with a subsequent median decrease in median age-adjusted bladder capacity by 45.50% (median deviation before was 36% vs. 16% after treatment). The number of urinary incontinence episodes also reduced by 55.57% (7-3 episodes per day), and the 20-meter motor gait speed increased by 14.26% (from 23 to 19 s).

Conclusion

Children who follow the GIGER MD therapy regularly for a period of 6 months show that CNS functional damage can be significantly improved.