Midodrine in patients with spinal cord injury and anejaculation: A double-blind randomized placebo-controlled pilot study

OBJECTIVE

The objective of this study is to evaluate the efficacy of midodrine in the treatment of anejaculation in men with spinal cord injury (SCI).

STUDY DESIGN

Prospective, double-blind, randomized, placebo-controlled pilot study.

METHOD

Men with anejaculation associated with SCI (level of injury above T10) of more than 1 year in duration were approached. Those with no ejaculatory response to one penile vibratory stimulation (PVS) trial were assigned in a double-blind manner to one of the two following interventions once a week for a maximum of 3 weeks or until ejaculation occurred: oral administration of flexible midodrine (7.5-22.5 mg max) followed by PVS (group M), or oral administration of flexible sham-midodrine (placebo) followed by PVS (group P). Sociodemographic data, medical characteristics, and plasma desglymidodrine concentration were collected for all participants.

OUTCOME MEASURE

Ejaculation success rate in each group.

RESULTS

Among the 78 men approached, 23 participants (level of SCI: C4-T9) were randomized. Three participants abandoned the study and 20 completed the study; 10 were assigned to group M, 10 to group P. Ejaculation was reached for one participant of group M and for two participants of group P. Autonomic dysreflexia associated to PVS occurred in three patients.

CONCLUSION

In this small sample study, treatment of anejaculation after SCI with midodrine and PVS did not result in a better rate of antegrade ejaculation in 10 men than in 10 men treated with a placebo and PVS.

Transforaminal versus intra-articular facet corticosteroid injections for the treatment of cervical radiculopathy: a randomized, double-blind, controlled study

BACKGROUND AND PURPOSE

Transforaminal corticosteroid injections can be performed in the management of cervical radiculopathy but carry the risk of catastrophic complications. This study compares the efficacy of transforaminal and facet corticosteroid injections at 4 weeks' follow-up.

MATERIALS AND METHODS

We randomly assigned 56 subjects to receive CT-guided transforaminal (15 men, 13 women; mean age, 52 years; range, 28-72 years) or facet (8 men, 20 women; mean, 44 years; range, 26-60 years) injections. The primary outcome was pain severity rated on a Visual Analog Scale (0-100). Secondary outcomes were the Neck Disability Index and the Medication Quantitative Scale.

RESULTS

In the intention-to-treat and as-treated analyses, for a mean baseline score, facet injections demonstrated a significant pain score reduction of 45.3% (95% CI, 21.4-69.2) and 37.0% (95% CI, 9.2-64.7), while transforaminal injections showed a nonsignificant pain score reduction of 9.8% (95% CI, +11.5-31.2) and 17.8% (95% CI, +6.6-42.2). While facet injections demonstrated an improvement in the Neck Disability Index score of 24.3% (95% CI, +2.9-51.5) and 20.7% (95% CI, +6.2-47.6) as opposed to transforaminal injections of 9.6% (95% CI, +15.2-34.4) and 12.8% (95% CI, +11.2-36.7), the results were not statistically significant. Noninferiority of facet to transforaminal injections was demonstrated for baseline pain scores of ≤60, while noninferiority analysis was inconclusive for baseline pain scores of ≥80 and for the Neck Disability Index. Neither intervention showed a significant medication-intake score reduction with time.

CONCLUSIONS

Facet injections are effective for the treatment of cervical radiculopathy and represent a valid and safer alternative to transforaminal injections.

Treatment of infertility in 31 men with spinal cord injury

INTRODUCTION

The majority of men with a spinal cord injury (SCI) are infertile due to ejaculatory dysfunction and poor semen quality. The goal of this retrospective study is to present the outcomes of assisted reproductive technology (ART) in a group of couples with SCI male partners.

MATERIALS AND METHODS

A review was conducted of the records of 31 couples with SCI male partners who were treated at the Institut de réadaptation Gingras-Lindsay-de-Montréal, at PROCREA Cliniques or at a hospital center. A semen sample was obtained either by manual stimulation, penile vibratory stimulation, electroejaculation or testicular sperm extraction. ART technique was selected according to the sperm parameters.

RESULTS

The mean age of the men was 29 years (23-48) and of their female partners, 29 years (25-41). The average sperm count was 110.4 M/mL ± 16.2 M/mL and the average sperm motility rate was 12.3% ± 16.5%. Among the 10 couples treated with intravaginal insemination, 9 pregnancies occurred among 7 couples. No pregnancies resulted from intrauterine insemination (2 cases). Among the 18 couples treated with in vitro fertilization, 12 pregnancies were reported among 10 couples. The pregnancy rate/cycle was 43%. Following these ART techniques, the pregnancy rate reached 55%. Three pregnancies occurred from the use of donor sperm in 7 couples. Overall, 20 men with a SCI (64% of the group) became fathers to at least one child.

CONCLUSIONS

Fertility treatments are effective for couples with SCI male partners and secondary infertility.

Risk factors and prevention for spinal cord injury from diving in swimming pools and natural sites in Quebec, Canada: a 44-year study

BACKGROUND

Diving is the most frequent cause of spinal cord injury (SCI) from recreation and sport in Canada. This study was done to identify risk factors for SCI from diving in the province of Quebec.

METHODS

An interview survey was done for a target population of 203 subjects with a SCI from diving treated in the two specialized rehabilitation centers in Quebec during 1961-2004. Telephone interviews of consenting individuals were used to collect pertinent personal, equipment, and environmental factors for each incident.

RESULTS

Response was 44% (89/203); 92% were male and 85% <35 years old. Only 37% were aware prior to injury of the risk of SCI from diving, and only 33% had received water safety training. Swimming pools were the site of 51% (n=45) and natural bodies of water for 49% (n=44). 87% (n=39) of pools were single-unit home pools and 57% (n=26) above-ground. Depth indicators were absent for 100% of above-ground and 74% of in-ground pools. For SCI in in-ground pools, 63% resulted from striking the up-slope between deep and shallow ends. For dives at natural sites, a dock or wharf was the most frequent location, 36% (n=16). In 52% of pools and 79% of natural sites, depth was <1.4m (4.6ft). Signs prohibiting diving were absent in 96% of above-ground and 89% of in-ground pools. Alcohol was reported in 47% of SCIs.

INTERPRETATION

The target for prevention of diving SCI is male youths and young adults. Above-ground pools are too shallow and small for diving. Deep ends of many in-ground pools are excessively shallow and short since many SCIs resulted from striking the up-slope. Prevention of SCI from diving needs to focus on education of potential victims, pool vendors and manufacturers, and regulations for safety norms in private pools. Water safety should highlight diving as a high-risk activity, and emphasize that most home pools and natural sites are unsafe. Safer evidence-based pool designs and more effective warnings need to be implemented.

Estimated prevalence of obstructive sleep apnea-hypopnea syndrome after cervical cord injury

OBJECTIVES

To estimate the prevalence of obstructive sleep apnea-hypopnea syndrome (OSAHS) in patients with cervical cord injury and to identify predictive factors.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation center.

PARTICIPANTS

Forty-one adults with cervical cord injury of more than 6 months in duration.

INTERVENTIONS

Medical history, physical exam, and full in home overnight polysomnography were undertaken. Data were collected on characteristics of spinal cord injury, current medication, sleeping habits, daytime sleepiness, body mass index (BMI), and neck circumference.

MAIN OUTCOME MEASURE

Presence or absence of OSAHS as defined by the American Academy of Sleep Medicine criteria (1999).

RESULTS

Twenty-two (53%) patients (95% confidence interval [CI], 38.4%-68.9%) had OSAHS. Daytime sleepiness (odds ratio [OR], 41.1; 95% CI, 2.3-739.7; P=.02), BMI of 30 kg/m2 or higher (OR=17.2; 95% CI, 1.4-206.4; P=.03), and 3 or more awakenings during sleep (OR=34; 95% CI, 1.6-744.8; P=.03) were the best predictive factors of OSAHS obtained by a forward stepwise multiple logistic regression.

CONCLUSIONS

The estimated prevalence of OSAHS is high after cervical cord injury. OSAHS should be suspected, especially in patients with daytime sleepiness, obesity, and frequent awakenings during sleep.

Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a double-blind randomized controlled trial

OBJECTIVE

To assess the effects of acetic acid iontophoresis on the treatment of calcifying tendinitis of the shoulder.

DESIGN

Double-blind randomized controlled trial.

SETTING

Ambulatory academic hospital in Quebec, Canada.

PARTICIPANTS

Thirty-six subjects with a calcifying tendinitis of the shoulder.

INTERVENTIONS

Subjects were randomized into 1 of 2 groups: physiotherapy during 6 weeks (10 sessions) plus acetic acid iontophoresis for the treatment group (n=18) and sham acetic acid iontophoresis for the control group (n=18).

MAIN OUTCOME MEASURES

The Shoulder Pain and Disability Index (SPADI), shoulder range of motion (ROM); and radiologic evaluation of shoulder calcifications.

RESULTS

Nine patients dropped out, leaving 27 assessable subjects for analysis. Interim analysis showed that, in both groups, treatment led to improvement, as measured by the SPADI score (P=.004), ROM of the shoulder for abduction (P<.001), internal rotation (P=.001), external rotation (P<.001), and the mean number of calcifications per subject (P=.010). Although no formal significant intervention effects (P=.13) were found for the primary endpoint (SPADI), exploratory analyses suggest a greater improvement in the treatment group (P=.001) than in the control group (P=.33).

CONCLUSIONS

Despite a trend toward greater improvement in the SPADI score in the treatment group, the use of acetic acid iontophoresis and physiotherapy for the treatment of calcifying tendinitis of the shoulder did not result in better clinical and radiologic effects than those observed in subjects treated by physiotherapyalone.

Colonic transit time after spinal cord injury: any clinical significance?

BACKGROUND

Both bowel dysfunction and increases in colonic transit time (CTT) are frequently observed in individuals with spinal cord injury; however, it is unknown whether there is an association between chronic intestinal problems and changes in CTTs. The current study investigates a possible relationship between the main intestinal symptoms of SCI patients and CTT values.

METHODS

The following clinical variables and symptoms were investigated and collected in 30 individuals with SCI: total time for bowel care, abdominal pain, abdominal gas, success of rectal emptying, fecal incontinence, and decrease in quality of life. Total and segmental CTTs (right colon, left colon, and rectosigmoid colon) were assessed using radiopaque markers. The effects of the sociodemographic variables and the clinical symptoms on the different CTTs (total and segmental) were analyzed.

RESULTS

The assessed clinical conditions were observed in the following percentages of subjects: abdominal gas symptoms (70%), fecal incontinence (56%), abdominal pain (63%), total time for bowel care > 1 hour (11%), difficult rectal emptying (66%), and decrease in quality of life (36%). We also observed an increase in total CTT in 47% of subjects; increases in segmental CTT were found in the right colon in 23%, in the left colon (60%), and in the rectosigmoid segment (23%). Statistical analyses failed to show a significant difference in mean CTT values between the group of symptomatic patients (1 or more symptoms) and the group of asymptomatic patients. No significant difference could be detected in the incidence of each intestinal symptom between the group of participants with normal CTT values and those with abnormal CTT values. For each of the clinical data assessed separately, a significantly longer CTT (left colon) was associated with the lack of abdominal pain (P < .03) and the presence of fecal incontinence (P < .01); successful rectal emptying was associated with significantly shorter total (P < .02) and segmental CTTs for the left colon (P < .01) and rectosigmoid colon (P < .05).

CONCLUSIONS

Besides an association between shorter CTT and successful rectal emptying, there was little relationship between CTTs and intestinal symptoms in this study of patients with SCI.

Health-related quality of life after spinal cord injury

PURPOSE

The purpose of this study was to assess health-related quality of life (HRQOL) in spinal-cord-injured adults living in Quebec (Canada).

METHOD

Subjects with spinal cord injury (SCI) all of whom were members of the Quebec Paraplegic Association who gave their consent to participate completed the 36-item Short Form Health Survey (SF-36); sociodemographic and medical data were also solicited.

RESULTS

Five hundred and eighty-seven participants were studied. The findings show a significant decrease in the score of the eight health concepts as measured by the SF-36 as well as that of the physical component summary measure (p<0.05). Analysing the various medical and sociodemographic variables with the eight scales of the SF-36 indicate that younger age, employment and the lack of hospitalization in the previous year were associated with a better quality of life. Mid- and long-term medical complications related to a spinal cord lesion and the impact of ageing are discussed briefly.

CONCLUSION

HRQOL is decreased in the studied population with an SCI.

Colonic transit time after spinal cord injury

Colonic transit time (CTT) was measured with abdominal radiographs using Chaussade's technique in 30 spinal cord injured patients (ASIA A and B) following ingestion of 20 radiomarkers per day for three days. A significant increase in total CTT (p = 0.0001) and segmental CTT of the right colon (p = 0.0004) and of the left colon (p = 0.0001) was shown. While using on the average only 2.3 films of the abdomen per patient, we obtained results comparable with other radiologic techniques which use radiomarkers to measure CTT. The clinical relevance of these results is not clear and their correlation with intestinal symptoms remains to be investigated.

Increased reactive oxygen species formation in semen of patients with spinal cord injury

OBJECTIVES

To evaluate reactive oxygen species production of semen samples and Percoll-washed spermatozoa from men with spinal cord injuries and to determine if there is a relationship between this reactive oxygen species production and sperm motility.

PARTICIPANTS

Semen samples from healthy volunteers and infertile patients were collected by masturbation.

INTERVENTIONS

Semen samples from men with a spinal cord injury were obtained by electroejaculation or by masturbation after treatment with physostigmine.

MAIN OUTCOME MEASUREMENTS

Motility was measured using the CellSoft computer-assisted analysis system (Cryo Resources Ltd., Montgomery, NY). Luminol-amplified chemiluminescence was used to measure reactive oxygen species production.

RESULTS

Semen samples and Percoll-washed spermatozoa from men with a spinal cord injury produced reactive oxygen species at much higher frequency and levels than equivalent preparations from infertile men or healthy volunteers. There was an inverse relationship between the percentage of motility and reactive oxygen species production in Percoll-washed spermatozoa from men with a spinal cord injury.

CONCLUSION

Semen samples and Percoll-washed spermatozoa from men with spinal cord injury produce high levels of reactive oxygen species that may be related to the low sperm motility and infertility observed in these men.

The effect of therapeutic massage on H-reflex amplitude in persons with a spinal cord injury

BACKGROUND AND PURPOSE

The effect of therapeutic massage on the H-reflex amplitude in persons without neurological impairment has been established. To investigate its effects in a sample of persons with a spinal cord injury (SCI), two independent but interrelated studies were undertaken. Study 1 investigated whether the recorded response (H-reflex amplitude) to massage with the subjects in the supine testing position was similar to that recorded in previous studies in which the subjects were tested in the prone position. This study was undertaken because the prone testing position was considered inappropriate for persons with SCI. In study 2, the therapeutic effect of massage (petrissage) on H-reflex amplitude in persons with SCI was examined.

SUBJECTS

Seven persons without neurological impairment volunteered to participate in study 1, and 10 individuals with a traumatic SCI volunteered to participate in study 2.

METHODS

The two studies shared many methodological features and involved the recording of 10 H-reflex and M-response peak-to-peak amplitudes from the triceps surae muscle during each of five sequential, 3-minute time periods. Massage treatment (MASS) was given during the third time period, and the premassage time periods (C1, C2) and postmassage time periods (C3, C4) served as control conditions. Study 2, in addition to recording the peak-to-peak amplitudes of the recorded responses, also included the recording of the H-reflex latencies.

RESULTS

The results of study 1 showed that massage applied with the subjects in the supine position decreased the H-reflex amplitude during the massage. A 56% decrease in the H-reflex amplitude was recorded. Study 2 demonstrated a 27% mean group decrease in the H-reflex peak-to-peak amplitude during the massage for all subjects, with variations in individual responses ranging from an increase in the H-reflex amplitude of 20% to a decrease of 84%. An analysis of variance revealed that the H-reflex means of the five conditions were significantly different. Newman-Keuls post hoc analyses revealed that the mean of the MASS condition (2.01 mV) was significantly different from the means of C1, C2, and C4 (2.79, 2.81, 2.58 mV). The mean of C3 (2.42 mV) was not found to be statistically different from the means of the other conditions. These changes were noted against a stable M-response.

CONCLUSION AND DISCUSSION

The results recorded in study 1 are comparable to those obtained with the subjects in the prone position. Based on these results, the supine position was adopted as the testing position for study 2. Study 2 further showed a decrease in H-reflex amplitude concomitant with massage in persons with SCI, but no long-term effects were noted.

[Adhesive capsulitis of the shoulder: a comparative study of arthrography with intra-articular corticotherapy and with or without capsular distension]

A double-blind, prospective study of 45 patients with adhesive capsulitis of the shoulder compared the therapeutic efficacy of distensive and nondistensive arthrography in combination with the intra-articular injection of corticosteroids. After 1 and 3 months there was no significant difference between the two treatments in the degree of pain or of limitation of movement experienced by the patients. More than 80% of the patients who experienced pain at rest and nocturnal pain improved under both treatment regimens. Scapulohumeral mobility increased significantly but only partially within the first month of treatment. Articular capacity and the duration of symptoms before treatment were of no prognostic value.