Are oxybutynin and trospium efficacious in the treatment of detrusor overactivity in spinal cord injury patients?

OBJECTIVES

To evaluate the efficacy of anticholinergic agents in the treatment of neurogenic overactive bladder (NOAB) and neurogenic detrusor overactivity (NDO) in spinal cord injury (SCI) patients on clean intermittent catheterisation (CIC).

METHODS

Chronic suprasacral SCI patients on CIC presenting with at least one urinary leakage a day were included. Urodynamics and voiding diaries were performed at baseline and 1 month follow-up. In case of NDO at baseline, an anticholinergic drug was prescribed.

RESULTS

The 231 SCI patients presented with one to five urinary leakages per day (mean 2.1). Urodynamics showed NDO in all patients. A new anticholinergic treatment was started in all, either in monotherapy (134 patients) or in association with the existing anticholinergic drug (oxybutynin+trospium bitherapy, 97 patients). The mean maximum bladder capacity significantly increased from 225 to 441 ml, and the mean involuntary detrusor contractions (IDC) significantly decreased from 67 to 41 cm H2O. Only 75 SCI patients (32%) were fully continent. However, 25 out of these 75 patients showed persistent NDO, with amplitudes of IDC above 40 cm H2O in 12 patients. Incontinence was still found in 156 SCI patients (67%), with an average of 1,2 leakages a day. In 100 patients, amplitudes of IDC remained above 40 cm H2O. There was no statistical difference between patients on anticholinergic monotherapy or bitherapy at follow-up.

CONCLUSION

Anticholinergic treatment is not always satisfactory in terms of control of NDO and rarely allows full continence. Urodynamic follow-up is mandatory in all patients, even in those showing clinical continence.

[Assessment of functional abilities, handicap and quality of life in patients with spinal cord injuries]

OBJECTIVES

A literature review of the methods of evaluating function, handicap and quality of life in patients with spinal cord injuries.

METHODS

The literature review was based on the available French and English articles published since 1990 in 3 databases: MEDLINE, Pascal and Embase.

RESULTS

The literature is dominated by descriptions of tools for evaluating functional limitations in motor deficiencies. Such descriptions involve the validation of generic tools for patients with spinal cord injuries or of specific tools during the evaluation of a particular intervention such as surgery of the tetraplegic hand or adaptation of technical help.

CONCLUSION

The tools to assess patients with spinal-cord injuries are sufficiently numerous and varied to allow us to evaluate physical, functional and psychosocial dimensions. Rigorous methodological validation is continuously at the base of those proposed tools and thus reinforces our choice to use them. Unfortunately, few evaluation tools for patients with spinal cord injuries have been published, translated into French and validated.

Transcutaneous electric nerve stimulation reduces neglect-related postural instability after stroke

OBJECTIVE

To test the existence of a neglect-related component of postural imbalance in some stroke patients to determine whether neglect patients (1) show worse postural control compared with nonneglect patients and healthy subjects and (2) have latent postural capacities that could be unmasked by an appropriate somatosensory manipulation.

DESIGN

Intervention study with and without transcutaneous electric nerve stimulation (TENS).

SETTING

Rehabilitation center research laboratory.

PARTICIPANTS

Twenty-two stroke patients (mean age, 58.3 +/- 2.5yr; average days since stroke, 83.2d) and 14 age-matched healthy subjects. Stroke patients were subdivided into 3 groups: 6 with spatial neglect and 16 without (8 with left lesion, 8 with right lesion).

INTERVENTIONS

All participants were subjected to a dynamic balance task, performed while sitting for 8 seconds on a laterally rocking platform. Seated on this mobile support, they were asked to maintain actively an erect posture, sitting as still as possible. In patients, TENS was applied on the contralesional side of the neck during the postural task. An effective stimulation (intensity corresponding to the threshold of perception, TENS+) was compared with a placebo stimulation (.01 x threshold of perception, TENS-).

MAIN OUTCOME MEASURES

Postural performance in each trial was monitored by using 2 criteria: the number of aborted trials caused by loss of balance, and the angular dispersion of the support oscillations in roll. The latter criterion, which increased with body instability, was defined as 2 standard deviations of the angular distribution.

RESULTS

Patients showing neglect displayed pronounced postural instability compared with other patients and controls. Although dramatic postural instability in the neglect patients was spectacularly and systematically reduced with TENS, no effect was observed in patients without neglect.

CONCLUSION

This is among the first studies to provide clinical evidence supporting the "postural body scheme" concept.

The polymodal sensory cortex is crucial for controlling lateral postural stability: evidence from stroke patients

In modern literature, internal models are considered as a general neural process for resolving sensory ambiguities, synthesising information from disparate sensory modalities, and combining efferent and afferent information. The polymodal sensory cortex, especially the temporoparietal junction (TPJ), is thought to be a nodal point of the network underlying these properties. According to this view, a pronounced disruption of the TPJ functioning should dramatically impair body balance. Surprisingly, little attention has been paid to this possible relationship, which was the subject of investigation in this study. Twenty-two brain-damaged patients and 14 healthy subjects were subjected to a self-regulated lateral balance task, performed while sitting for 8 s on a rocking platform. Their lateral body balance was analysed both with and without vision (darkness). Support displacements in the frontal plane were recorded by means of an accelerometer. Two criteria were taken into account to evaluate body stability in each trial: the number of aborted trials due to balance loss and the angular dispersion of the supporting surface. Lesions involving the temporoparietal junction were found to markedly increase body instability, both with and without vision. Therefore, the temporoparietal junction plays a pivotal role in lateral body stabilisation, irrespective of the sensory condition in which the task is performed. This suggests that body stability is controlled throughout internal model(s).

Biased postural vertical in humans with hemispheric cerebral lesions

This study was aimed at demonstrating the existence of a biased postural vertical in humans with a recent cerebral lesion. The postural vertical of patients and controls was analysed comparatively using a self-regulated balancing task, performed in sitting posture. Patients displayed a quite constant (19/22) contralesional tilt of the postural vertical (mean -2.6 degrees), varying with the severity of their spatial neglect and hemianaethesia. Eight of them showed a pathological contralesional bias (mean -5.5 degrees) as compared to normals. This result indicates an asymmetric process of somatic graviceptive information due to some cerebral lesions. When patients were subjected to a transcutaneous electrical stimulation applied onto the contralesional side of the neck, body verticality was especially improved in those who showed a pathological bias in the postural vertical. This effect could thus be due to a reduced distortion in the egocentric co-ordinate system for spatial information processing.

[Esophageal pH measurement in newborn infants under 1,700 gms]

Esophageal pH was systematically recorded for 3 hours in 30 neonates under 1,700 g, of which 18 were under assisted ventilation. Gastric acid secretion occurs early. Varying degrees of gastroesophageal reflux were observed in 21 neonates. Positioning in the prone position at 30 degrees allowed for the disappearance of reflux in 19 and an improvement in the remaining 2. We recommend the adoption of this position in all premature infants including those under assisted ventilation.

[Intensive care in acute hemorrhagic pancreatitis. Hemodynamic aspects]

Hemodynamic monitoring by a balloon flotation catheter was done in eight patients suffering from acute hemorrhagic pancreatitis. This syndrome associates hypovolemia and circulatory failure. These two factors are enhanced by the "pulmonary pancreatic syndrome" which produces hypoxemia. Thus positive end expiratory pressure ventilation must be employed and could worsen circulation failure. Dobutamine may help to better hemodynamic conditions.