Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows: Management of Blood Pressure, Sweating, and Temperature Dysfunction

[Invasive neurostimulation in neuro-urology: state of the art]

Modulation or stimulation of the nerves supplying the lower urinary tract is a possible treatment option for dysfunction of the lower urinary tract, pelvic floor and rectum if conservative or minimally invasive treatment approaches fail. This overview shows the possibilities and limitations of sacral neuromodulation, sacral deafferentation with sacral anterior root stimulation and conus deafferentation.Sacral neuromodulation (SNM) is a procedure for the treatment of refractory pelvic floor dysfunction of various origins (idiopathic, neurogenic or post-operative), such as overactive bladder, non-obstructive retention and faecal incontinence. A particular advantage of SNM is the possibility of prior test stimulation with a high prognostic value. The procedure is minimally invasive, reversible and associated with relatively low morbidity rates.Following the introduction of MRI-compatible SNM systems, there has been renewed interest in the treatment of neurogenic bladder dysfunction. A recent meta-analysis reports similar success rates as in the idiopathic patient population.Sacral deafferentation with implantation of a sacral anterior root stimulator (SARS/SDAF) is an excellent therapeutic option for patients with spinal cord injury, which can significantly improve the quality of life of those affected and, in addition to treating neurogenic lower urinary tract dysfunction, can also have a positive effect on neurogenic bowel dysfunction, neurogenic sexual dysfunction or autonomic dysreflexia. If conservative or minimally invasive treatment fails, it is crucial for the success of this procedure to consider SDAF/SARS at an early stage in order to avoid irreversible organic damage.Conus deafferentation (KDAF) is a less invasive surgical treatment option for patients with spinal cord injury for whom sacral deafferentation would be indicated but who would not benefit from the simultaneous implantation of a sacral anterior root stimulator. In principle, these patients also have the option of being subsequently treated with an extradural implant and thus utilising the advantages of anterior root stimulation. Indications for KDAF are autonomic dysreflexia, therapy-refractory detrusor overactivity, recurrent urinary tract infections, urinary incontinence and spasticity triggered by detrusor overactivity. With KDAF, we have a safe and efficient procedure with great potential for improving the spectrum of paraplegiological and neuro-urological treatment.

Effects of two external cooling strategies on physiological and perceptual responses of athletes with tetraplegia during and after exercise in the heat

Athletes with tetraplegia may experience marked hyperthermia while exercising under environmental heat stress due to their limited ability to dissipate heat through evaporative means. This study investigated the effectiveness of two external cooling strategies (i.e., spraying water onto the body surface or using a cooling vest) on physiological and perceptual variables in tetraplegic athletes during and after an aerobic exercise session in a hot environment. Nine male wheelchair rugby players performed an incremental test to determine their maximum aerobic power output. After that, they were subjected to three experimental trials in a counter-balanced order: control (CON, no body cooling), cooling vest (CV), and water spraying (WS). During these trials, they performed 30 min of a submaximal exercise (at 65% of their maximum aerobic power) inside an environmental chamber set to maintain the dry-bulb temperature at 32 °C. The following variables were recorded at regular intervals during the exercise and for an additional 30 min following the exertion (i.e., post-exercise recovery) with the participants also exposed to 32 °C: body core temperature (TCORE), skin temperature (TSKIN), heart rate (HR), rating of perceived exertion (RPE), thermal comfort (TC), and thermal sensation (TS). While exercising in CON conditions, the tetraplegic athletes had the expected increases in TCORE, TSKIN, HR, RPE, and TC and TS scores. HR, TC, and TS decreased gradually toward pre-exercise values after the exercise, whereas TCORE and TSKIN remained stable at higher values. Using a cooling vest decreased the temperature measured only on the chest and reduced the scores of RPE, TC, and TS during and after exercise but did not influence the other physiological responses of the tetraplegic athletes. In contrast, spraying water onto the athletes' body surface attenuated the exercise-induced increase in TSKIN, led to lower HR values during recovery, and was also associated with better perception during and after exercise. We conclude that water spraying is more effective than the cooling vest in attenuating physiological strain induced by exercise-heat stress. However, although both external cooling strategies do not influence exercise hyperthermia, they improve the athletes' thermal perception and reduce perceived exertion.

Mapping the Iceberg of Autonomic Recovery: Mechanistic Underpinnings of Neuromodulation following Spinal Cord Injury

Spinal cord injury leads to disruption in autonomic control resulting in cardiovascular, bowel, and lower urinary tract dysfunctions, all of which significantly reduce health-related quality of life. Although spinal cord stimulation shows promise for promoting autonomic recovery, the underlying mechanisms are unclear. Based on current preclinical and clinical evidence, this narrative review provides the most plausible mechanisms underlying the effects of spinal cord stimulation for autonomic recovery, including activation of the somatoautonomic reflex and induction of neuroplastic changes in the spinal cord. Areas where evidence is limited are highlighted in an effort to guide the scientific community to further explore these mechanisms and advance the clinical translation of spinal cord stimulation for autonomic recovery.

Evidence-based recommendations for the rehabilitation and management of the ageing population with spinal cord injury: a systematic review of clinical practice guidelines

INTRODUCTION

The intersection of ageing and spinal cord injury (SCI) is of global concern. Two scenarios have been described: 1) "SCI with ageing," an increase in the average age of SCI onset, and 2) "ageing with SCI," an increase in post-injury life expectancy. These scenarios entail complex health care and rehabilitation needs due to the accumulation of comorbidities, ageing-related and SCI-induced physiological changes, and post-SCI secondary health conditions. We systematically reviewed Clinical Practice Guidelines (CPGs) with the objective of identifying the extent to which SCI CPGs include recommendations for the rehabilitation and management of people who are "ageing with SCI" or who have acquired an "SCI with ageing". We termed these as "ageing-related recommendations". We also aimed to describe them and identify gaps.

EVIDENCE ACQUISITION

We searched PubMed (NCBI), CINAHL Complete (EBSCOhost) and Embase (Elsevier) for relevant CPGs between 28 December 2022 and 5 January 2023. Included CPGs were evidence-based and had at least one ageing-related recommendation for SCI rehabilitation and management. We used the two core sets of the International Classification of Functioning, Disability and Health (ICF) to identify gaps.

EVIDENCE SYNTHESIS

Only 16 (30%) of the 52 identified CPGs included ageing-related recommendations. Most were recent US or European publications and lacked specific chapters on ageing. These CPGs included 40 ageing-related recommendations, mostly "strong" but based on "low" to "very low" quality of evidence. The overall quality of the development process was low and did not consider the values and preferences of stakeholders and patients. Common topics included cardiovascular, bone, metabolic, bowel, bladder, and skin health. The recommendations could be linked to 30 ICF categories which represented only 18% of the ICF categories included in the comprehensive versions of two ICF Core Sets. Key gaps were found in mobility, interpersonal interactions, and relationships, neuromusculoskeletal and movement-related, mental, sensory and pain functions.

CONCLUSIONS

There is a notable lack of high-quality ageing-related recommendations for SCI management and rehabilitation. Future research should prioritize the generation of high-quality evidence to develop age-sensitive CPGs. Future SCI CPGs need to address the complex challenges at the interface of ageing and SCI, considering patient and stakeholder preferences.

Lowering blood pressure by exercise: investigating the effect of sweating

High blood pressure (hypertension), is a common medical condition, affecting millions of people and is associated with significant health risks. Exercise has been suggested to manage hypertension by inducing sweating and the corresponding loss of sodium and water from the body.Thus, a variety of epidemiological and clinical studies have been conducted to investigate the relationship between sweating and exercise-induced blood pressure reduction and its impacts on hypertension. The mechanisms underlying exercise-induced blood pressure reduction are complex and still not fully understood. However, several pathways have been suggested, including the loss of sodium and water through sweat, a decrease in peripheral resistance, and an improvement in endothelial function in the blood vessels. The decrease in sodium and water content in the body associated with sweating may result in a reduction in blood volume and thus a decrease in blood pressure. Moreover, the reduction in peripheral resistance is thought to be mediated by the activation of the nitric oxide synthase pathway and the release of vasodilators such as prostacyclin and bradykinin, which lead to vasodilation and, thus, a reduction in blood pressure. In conclusion, exercise-induced sweating and consequent sodium and water loss appear to be a reliable biological link to the blood pressure-reducing effects of exercise in hypertensive individuals. Additionally, the mechanisms underlying exercise-induced blood pressure reduction are complex and involve several biological pathways in the cardiovascular system. Therefore, understanding the role of sweat production in blood pressure management is important for developing effective exercise interventions to prevent and manage hypertension.

Motherhood after Spinal Cord Injury: Breastfeeding, Autonomic Dysreflexia, and Psychosocial Health: Clinical Practice Guidelines

The World Health Organization (WHO) recommends that children be breastfed exclusively for the first 6 months of age. This recommendation may prove challenging for women with spinal cord injury (SCI) who face unique challenges and barriers to breastfeeding due to the impact of SCI on mobility and physiology. Tailored provision of care from health care professionals (HCPs) is important in helping women navigate these potential barriers. Yet, HCPs often lack the confidence and SCI-specific knowledge to meet the needs of mothers with SCI. An international panel of clinicians, researchers, consultants, and women with lived experience was formed to create an accessible resource that can address this gap. A comprehensive survey on breastfeeding complications, challenges, resources, and quality of life of mothers with SCI was conducted, along with an environmental scan to evaluate existing postpartum guidelines and assess their relevance and usability as recommendations for breastfeeding after SCI. Building on this work, this article provides evidence-based recommendations for HCPs, including but not limited to general practitioners, obstetricians, pediatricians, physiatrists, lactation consultants, nurses, midwives, occupational therapists, and physiotherapists who work with prospective and current mothers with SCI.

Lived Experiences of Sexuality and Sexual Functioning in Males with SCI: A Mixed-Methods Study

Background

Sexual dysfunction is highly prevalent in males with spinal cord injury (SCI) and has been recognized to be a key recovery priority.

Objectives

This cross-sectional, mixed-methods study aimed to investigate the major themes linked to sexual functioning in males with chronic (>1 year) SCI.

Methods

Twenty male participants with SCI, aged 25 to 59 years, completed validated questionnaires exploring sexual function/satisfaction and health-related quality of life and a semi-structured interview with an experienced sexual medicine physician. Sex hormone concentrations and metabolic biomarkers, along with body composition and habitual physical activity levels, were assessed. Interview recordings were transcribed and thematic analysis performed using combined COM-B (Capability, Opportunity, Motivation, and Behavior) and biopsychosocial models to identify and organize major contributors and barriers to sexual functioning.

Results

Metabolic and hormonal biomarkers largely fell within normal physiological ranges despite reduced sexual functioning reported in our cohort (19/20 participants reported some degree of erectile dysfunction). Qualitative analysis of interview transcripts revealed 24 themes. Adaptability was important for improving sexual satisfaction. Attraction and attentiveness to sex and partners remained stable over time, while the desire for intimacy increased post injury. Sexual social norms, and comparisons to the able-bodied population, provided challenges for sexual activity and partnership. Environmental concerns regarding access to sexual health resources and accessible physical spaces during intimacy were relevant. Mood disorders and general life stressors negatively impacted sexual desire, while physical activity encouraged sexual activity.

Conclusion

By considering a holistic view of sexuality in males with SCI, we identified key contributors and barriers to sexual functioning for the cohort studied.

The Clinical Management of Electrical Stimulation Therapies in the Rehabilitation of Individuals with Spinal Cord Injuries

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.

Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations

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.

From Toxin to Treatment: A Narrative Review on the Use of Botulinum Toxin for Autonomic Dysfunction

Since its regulatory approval over a half-century ago, botulinum toxin has evolved from one of the most potent neurotoxins known to becoming routinely adopted in clinical practice. Botulinum toxin, a highly potent neurotoxin produced by Clostridium botulinum, can cause botulism illness, characterized by widespread muscle weakness due to inhibition of acetylcholine transmission at neuromuscular junctions. The observation of botulinum toxin's anticholinergic properties led to the investigation of its potential benefits for conditions with an underlying etiology of cholinergic transmission, including autonomic nervous system dysfunction. These conditions range from disorders of the integument to gastrointestinal and urinary systems. Several formulations of botulinum toxin have been developed and tested over time, significantly increasing the availability of this treatment for appropriate clinical use. Despite the accelerated and expanded use of botulinum toxin, there lacks an updated comprehensive review on its therapeutic use, particularly to treat autonomic dysfunction. This narrative review provides an overview of the effect of botulinum toxin in the treatment of autonomic dysfunction and summarizes the different formulations and dosages most widely studied, while highlighting reported outcomes and the occurrence of any adverse events.

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence

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.

Autonomic Dysreflexia in Spinal Cord Injury: Mechanisms and Prospective Therapeutic Targets

High-level spinal cord injury (SCI) often results in cardiovascular dysfunction, especially the development of autonomic dysreflexia. This disorder, characterized as an episode of hypertension accompanied by bradycardia in response to visceral or somatic stimuli, causes substantial discomfort and potentially life-threatening symptoms. The neural mechanisms underlying this dysautonomia include a loss of supraspinal control to spinal sympathetic neurons, maladaptive plasticity of sensory inputs and propriospinal interneurons, and excessive discharge of sympathetic preganglionic neurons. While neural control of cardiovascular function is largely disrupted after SCI, the renin-angiotensin system (RAS), which mediates blood pressure through hormonal mechanisms, is up-regulated after injury. Whether the RAS engages in autonomic dysreflexia, however, is still controversial. Regarding therapeutics, transplantation of embryonic presympathetic neurons, collected from the brainstem or more specific raphe regions, into the injured spinal cord may reestablish supraspinal regulation of sympathetic activity for cardiovascular improvement. This treatment reduces the occurrence of spontaneous autonomic dysreflexia and the severity of artificially triggered dysreflexic responses in rodent SCI models. Though transplanting early-stage neurons improves neural regulation of blood pressure, hormonal regulation remains high and baroreflex dysfunction persists. Therefore, cell transplantation combined with selected RAS inhibition may enhance neuroendocrine homeostasis for cardiovascular recovery after SCI.

Obstructive sleep apnoea triggering autonomic dysreflexia: Isn't it time for sleep studies to be routine in SCI?

Autonomic dysreflexia is a known complication after spinal cord injury. It is defined as a reflexive increase in blood pressure as a result of a painful or irritating stimulus below the level of the lesion. Although commonly caused by stimuli from the bladder, other rare triggers are still being described. Herein, we present a case with autonomic dysreflexia triggered by obstructive sleep apnoea. A 43-year-old smoker suffered a spinal cord injury after a road traffic accident secondary to multiple cervical spine vertebrae fractures. He presented to our rehabilitation centre 6 months post-injury as a case of complete spinal cord injury with C4 neurological level. Autonomic dysfunction in the form of autonomic dysreflexia was occurring on a daily basis. After exclusion of known inciting factors, it was noticed that early morning episodes of autonomic dysreflexia were persistent. He was also reporting daytime fatigue and sleepiness and multiple night-time awakenings. Therefore, work up for sleep apnoea was done. A diagnosis of moderate obstructive sleep apnoea was made. With continuous positive airway pressure treatment, his daily early morning episodes of autonomic dysreflexia settled. This case illustrates the importance of the pattern of blood pressure elevation to pinpoint specific triggers of autonomic dysreflexia.

"Meet the patient" session: a strategy to teach medical students about autonomic dysfunction after spinal cord injury

Dysregulation of the autonomic nervous system is an important long-term consequence of spinal cord injury (SCI). Yet, there is a scarcity of teaching resources about this topic for preclinical medical students. Given the association of SCI sequelae with emergency complications and mortality, it is imperative to equip medical students with the ability to recognize them. We designed a "Meet the Patient" (MTP) session with the primary goal to enhance student learning about SCI sequelae by interacting with patients and listening to real-life stories. The session primarily focused on recognizing triggers and symptoms of autonomic dysreflexia (AD) and discussing the loss of bowel and bladder control, while providing opportunities to learn more about living with SCI from patients' real-life experiences. During the MTP session, patients living with SCI discussed their experience with AD, neurogenic bowel and bladder, and spasticity, among other SCI sequelae. We evaluated the outcomes of the MTP session by assessing numerical performance in questions related to the session (post-session quiz and final exam) and students' satisfaction (post-session survey) in two subsequent academic years. The numerical performance in SCI-questions was high for both academic years (and higher than national average for the final exam question), indicating adequate acquisition of knowledge. Satisfaction with the session was high, with most students indicating that the session helped them consolidate their knowledge about the topic.

Differentiating essential hypertension from autonomic dysreflexia: a case report

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.

Clinical Practice Guideline Development for Autonomic Dysreflexia in Spinal Cord Injury

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.

Spinal Cord Stimulation Prevents Autonomic Dysreflexia in Individuals with Spinal Cord Injury: A Case Series

Spinal cord injury (SCI) results in severe cardiovascular dysfunction due to the disruption of supraspinal control. Autonomic dysreflexia (AD), an uncontrolled rise in blood pressure in response to peripheral stimuli including common bowel routine, digital anorectal stimulation (DARS), reduces the quality of life, and increases morbidity and mortality. Recently, spinal cord stimulation (SCS) has emerged as a potential intervention to mitigate unstable blood pressure following SCI. The objective of this case series was to test the real-time effect of epidural SCS (eSCS) at the lumbosacral spinal cord, the most common implant location, on mitigating AD in individuals with SCI. We recruited three individuals with cervical and upper thoracic motor-complete SCI who have an implanted epidural stimulator. We demonstrated that eSCS can reduce the elevation in blood pressure and prevent DARS-induced AD. The blood pressure variability analysis indicated that eSCS potentially reduced vascular sympathetic nervous system activity during DARS, compared to without eSCS. This case series provides evidence to support the use of eSCS to prevent AD episodes during routine bowel procedures, improving the quality of life for individuals with SCI and potentially reducing cardiovascular risks.

Primary Care in the Spinal Cord Injury Population: Things to Consider in the Ongoing Discussion

Purpose of Review

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population.

Findings

Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population.

Summary

Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

Transcutaneous spinal stimulation in patients with intrathecal baclofen pump delivery system: A preliminary safety study

Objective

To determine the effect of transcutaneous spinal stimulation (TSS) on an implanted intrathecal baclofen (ITB) pump in persons with traumatic spinal cord injury (SCI).

Design

Prospective clinical trial.

Participants

Five individuals with chronic traumatic SCI, >18 years of age, and an anteriorly implanted Medtronic SynchroMed™ II ITB pump delivery system.

Intervention

Transcutaneous spinal stimulation trials with cathode at T11/12, with pump interrogation before, during and after stimulation.

Results

There was no evidence of any effect of the TSS in regards to disruption of the ITB pump delivery mechanism. Communication interference with the interrogator to the pump occurred often during stimulation for log transmission most likely secondary to the electromagnetic interference from the stimulation. One individual had elevated blood pressure at the end of the trial, suspected to be unrelated to the spinal stimulation.

Conclusion

Based upon this pilot study, further TSS studies including persons with an implanted Medtronic SynchroMed™ II ITB pump can be considered when stimulating at the low thoracic spine, although communication with the programmer during the stimulation may be affected.

Rectal Application of Lidocaine Reduces the Severity of Autonomic Dysreflexia following Experimental Spinal Cord Injury

Spinal cord injury (SCI) results in devastating cardiovascular dysfunction. Noxious stimuli from the rectum during bowel routine often trigger life-threatening blood pressure surges, termed autonomic dysreflexia (AD). Rectal application of anesthetic lidocaine jelly has been recommended during bowel care to reduce AD severity by mitigating sensory input. However, clinical studies have reported contradicting evidence. We performed a pre-clinical study on the efficacy of rectal lidocaine in a standardized rodent T3 transection model. We found that 2% and 10% lidocaine significantly reduced AD severity by 32% and 50%, respectively, compared with control (p < 0.0001). Our pre-clinical experiments support the current recommendation of rectal lidocaine application during bowel care.

Neurogenic Bowel and Management after Spinal Cord Injury: A Narrative Review

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

Pressure Injuries and Management after Spinal Cord Injury

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.

Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.

Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review

The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1–L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.

Concomitant Brain Injury and Spinal Cord Injury Management Strategies: A Narrative Review

Spinal cord injury (SCI) is a catastrophic event with multiple comorbidities including spastic paralysis, sensory loss, autonomic dysfunction with sympathetic blunting, neurogenic orthostatic hypotension, neurogenic restrictive and obstructive lung disease, neuropathic pain, spasticity, neurogenic bladder, neurogenic bowel, immobilization hypercalcemia, osteopenia/osteoporosis, neurogenic obesity, and metabolic dysfunction. Cervical and thoracic SCI is all too often accompanied by traumatic brain injury (TBI), which carries its own set of comorbidities including headaches, seizures, paroxysmal sympathetic hyperactivity, aphasia, dysphagia, cognitive dysfunction, memory loss, agitation/anxiety, spasticity, bladder and bowel incontinence, and heterotopic ossification. This manuscript will review the etiology and epidemiology of dual diagnoses, assessment of both entities, and discuss some of the most common comorbidities and management strategies to optimize functional recovery.

Targeting bladder function with network-specific epidural stimulation after chronic spinal cord injury

Profound dysfunctional reorganization of spinal networks and extensive loss of functional continuity after spinal cord injury (SCI) has not precluded individuals from achieving coordinated voluntary activity and gaining multi-systemic autonomic control. Bladder function is enhanced by approaches, such as spinal cord epidural stimulation (scES) that modulates and strengthens spared circuitry, even in cases of clinically complete SCI. It is unknown whether scES parameters specifically configured for modulating the activity of the lower urinary tract (LUT) could improve both bladder storage and emptying. Functional bladder mapping studies, conducted during filling cystometry, identified specific scES parameters that improved bladder compliance, while maintaining stable blood pressure, and enabled the initiation of voiding in seven individuals with motor complete SCI. Using high-resolution magnetic resonance imaging and finite element modeling, specific neuroanatomical structures responsible for modulating bladder function were identified and plotted as heat maps. Data from this pilot clinical trial indicate that scES neuromodulation that targets bladder compliance reduces incidences of urinary incontinence and provides a means for mitigating autonomic dysreflexia associated with bladder distention. The ability to initiate voiding with targeted scES is a key step towards regaining volitional control of LUT function, advancing the application and adaptability of scES for autonomic function.

Pediatric Spina Bifida and Spinal Cord Injury

Pediatric spina bifida (SB) and spinal cord injury (SCI) are unfortunately common in our society, and their unique findings and comorbidities warrant special consideration. This manuscript will discuss the epidemiology, pathophysiology, prevention, and management strategies for children growing and developing with these unique neuromuscular disorders. Growth and development of the maturing child places them at high risk of spinal cord tethering, syringomyelia, ascending paralysis, pressure injuries, and orthopedic abnormalities that must be addressed frequently and judiciously. Similarly, proper neurogenic bladder and neurogenic bowel management is essential not just for medical safety, but also for optimal psychosocial integration into the child’s expanding social circle.

Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury

Urinary incontinence is common after spinal cord injury (SCI) due to loss of supraspinal coordination and unabated reflexes in both autonomic and somatic nervous systems; if unchecked, these disturbances can become life-threatening. This manuscript will review normal anatomy and physiology of the urinary system and discuss pathophysiology secondary to SCI. This includes a discussion of autonomic dysreflexia, as well as its diagnosis and management. The kidneys and the ureters, representing the upper urinary tract system, can be at risk related to dyssynergy between the urethral sphincters and high pressures that lead to potential vesicoureteral reflux, urinary tract infections, and calculi associated with neurogenic lower urinary tract dysfunction (NLUTD). Recent guidelines for diagnosis, evaluation, treatment and follow up of the neurogenic bladder will be reviewed and options provided for risk stratification and management. Mechanical, pharmacological, neurolysis and surgical management will be discussed.

Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel

INTRODUCTION

Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care.

METHODS

Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80).

CONCLUSION

There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.

Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview

INTRODUCTION

Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process.

METHODS

The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool.

RESULTS

The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo.

CONCLUSION

The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.