Alan Casey

Efficacy and Safety of Tol Terodine in People With Neurogenic Detrusor Overactivity

Abstract Objective: To compare tolterodine with oxybutynin and placebo in people with neuragenie detrusor overactivity. Design: Prospective, randomized, double-blind, crossover trial plus open-label comparative stage. Participants: Ten participants with neuragenie detrusor overactivity due to spinal cord injury or multiple sclerosis who usedintermittent catheterization. Methods: Bladder capacity on cystometrogram, a 10-day record of catheterization volumes, number of incontinent episodes perday, and perceived dry mouth using a visual analog scale (VAS) were measured for the following: (a) a blinded comparison:tolterodine, 2 mg twice daily, vs placebo, twice daily; and (b) an unblinded comparison: oxybutynin vs tolterodine, each atself-selected doses (SSDs). Results: Tolterodine, 2 mg twice daily, was superior to placebo in enhancing catheterization volumes (P<0.0005) and reducingincontinence (P<0.001 ), but was comparable with placebo in cystometric bladder capacity. Efficacy of tolterodine SSD wascomparable with oxybutynin SSD with regard to catheterization volumes, degree of incontinence, and cystometric bladder capacity.The side effect profile (dry mouth) was comparable between tolterodine, 2 mg twice daily, and placebo, but differed significantlywhen comparing tolterodine SSD with oxybutynin SSD (P<0.05). Conclusion: T olterodine, when used at SSDs, is comparable with oxybutynin at SSDs in enhancing bladder volume and improvingcontinence, but with less dry mouth. T olterodine at the recommended dosage of 2 mg twice daily improves incontinence and bladdervolumes compared with placebo, and without significant dry mouth. Larger doses of tolterodine may be needed to achieve best effectin this population, but further studies are required.

A Randomized, Double-Blinded, Crossover Pilot Study Assessing the Effect of Nabilone on Spasticity in Persons With Spinal Cord Injury

OBJECTIVES To determine whether nabilone, a synthetic cannabinoid, alleviates spasticity in people with spinal cord injury (SCI). DESIGN A double-blind, placebo-controlled crossover study. SETTING Outpatient rehabilitation clinics. PARTICIPANTS We recruited volunteers (N=12) with SCI and spasticity. One subject, a paraplegic man, dropped out of the study because of an unrelated cause. Eleven subjects completed the study; all subjects were men with an average age of 42.36 years; 6 of them were persons with tetraplegia, and 5 were persons with paraplegia. INTERVENTIONS The subjects received either nabilone or placebo during the first 4-week period (0.5mg once a day with option to increase to 0.5mg twice a day), and then outcome measures were assessed. After a 2-week washout, subjects were crossed over to the opposite arm. MAIN OUTCOME MEASURES The primary outcome was the Ashworth Scale for spasticity in the most involved muscle group, in either the upper or lower extremities, chosen by the subject and clinician. The secondary outcomes included the sum of the Ashworth Scale in 8 muscle groups of each side of the body measured by the clinician; Spasm Frequency Scale and visual analog scale, reported by the subject; Wartenberg Pendulum Test, in order to quantify severity of spasticity; and the Clinicians and Subjects Global Impression of Change. RESULTS One subject dropped out during the placebo arm because of an unrelated urinary stricture, and 11 subjects completed the study. There was a significant decrease on active treatment for the Ashworth in the most involved muscle (mean difference +/- SD, .909+/-.85; P=.003), as well as the total Ashworth score (P=.001). There was no significant difference in other measures. Side effects were mild and tolerable. CONCLUSIONS Nabilone may be beneficial to reduce spasticity in people with SCI. We recommend a larger trial with a more prolonged treatment period and an option to slowly increase the dosage further.

Evidence-informed recommendations for rehabilitation with older adults living with HIV: a knowledge synthesis

Objective Our aim was to develop evidence-informed recommendations for rehabilitation with older adults living with HIV. Design We conducted a knowledge synthesis, combining research evidence specific to HIV, rehabilitation and ageing, with evidence on rehabilitation interventions for common comorbidities experienced by older adults with HIV. Methods We included highly relevant HIV-specific research addressing rehabilitation and ageing (stream A) and high-quality evidence on the effectiveness of rehabilitation interventions for common comorbidities experienced by older adults ageing with HIV (stream B). We extracted and synthesised relevant data from the evidence to draft evidence-informed recommendations for rehabilitation. Draft recommendations were refined based on people living with HIV (PLHIV) and clinician experience, values and preferences, reviewed by an interprofessional team for Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (quality) rating and revision and then circulated to PLHIV and clinicians for external endorsement and final refinement. We then devised overarching recommendations to broadly guide rehabilitation with older adults living with HIV. Results This synthesis yielded 8 overarching and 52 specific recommendations. Thirty-six specific recommendations were derived from 108 moderate-level or high-level research articles (meta-analyses and systematic reviews) that described the effectiveness of rehabilitation interventions for comorbidities that may be experienced by older adults with HIV. Recommendations addressed rehabilitation interventions across eight health conditions: bone and joint disorders, cancer, stroke, cardiovascular disease, mental health challenges, cognitive impairments, chronic obstructive pulmonary disease and diabetes. Sixteen specific recommendations were derived from 42 research articles specific to rehabilitation with older adults with HIV. The quality of evidence from which these recommendations were derived was either low or very low, consisting primarily of narrative reviews or descriptive studies with small sample sizes. Recommendations addressed approaches to rehabilitation assessment and interventions, and contextual factors to consider for rehabilitation with older adults living with HIV. Conclusions These evidence-informed recommendations provide a guide for rehabilitation with older adults living with HIV.

The effects of sildenafil on the cardiovascular response in men with spinal cord injury at or above the sixth thoracic level.

Abstract Background: Sildenafil is efficacious for erectile dysfunction in men with spinal cord injury (SCI), but can induce hypotension in neurologically intact people. Those with SCI at or above the sixth thoracic level (T6) often have pre-existing hypotension, yet the cardiovascular response to sildenafil has not been studied in this group. Objective: To evaluate the effect of sildenafil on the cardiovascular response in men with complete SCI at or above T6. Methods: This was a randomized, double-blind, placebo-controlled, cross-over study. Twenty-three SCI participants were each randomly given placebo; sildenafil, 50 mg; and sildenafil, 1 00 mg; separated by at least 1 week. The following were measured before administration, and hourly for 4 hours afterward: (a) blood pressure (BP) and heart rate (HR) , both supine and sitting; and (b) perceived dizziness on a visual analog scale upon sitting. Results: Analysis was done using a 4-way repeated-measures analysis of variance. No significant changes occurred with placebo. Sildenafil caused the following changes. Systolic BP changed little in thoracic spinal cord-injured (TSCI) participants, but decreased significantly (P < 0.005) in cervical spinal cord-injured (CSCI) participants. Diastolic BP decreased in all participants (P < 0.005). HR increased in the TSCI participants for 1 hour (P < 0.05), but was not altered in the CSCI participants. Dizziness increased in the TSCI participants after administration of 100 mg (P < 0.05) and in the CSCI participants after administration of 50 mg (P < 0.05). There were no adverse events or outcomes. Conclusion: Sildenafil induces significant hypotension in people with cervical-level injuries-more so than in thoracic-level injuries-and can cause dizziness in both populations. It should be prescribed with caution and informed consent from the patient.

Neurogenic overactive bladder in spinal cord injury and multiple sclerosis: role of onabotulinumtoxinA

Abstract People with neurogenic overactive bladder from either multiple sclerosis or spinal cord injury often suffer significant morbidity and decreased quality of life. Here we review the pathophysiology of neurogenic overactive bladder and the impact it can have on people with multiple sclerosis or spinal cord injury. We also address the various traditional treatment options and focus on the use of botulinum toxin A (specifically onabotulinumtoxinA) for this condition.

Ultrasound Guided Phenol Block of the Obturator Nerve for Severe Adductor Spasticity: A Pilot Study

Objective: To assess the efficacy of phenol block of the obturator nerve in treating severe adductor spasticity. Design: A prospective pilot study. Setting: Outpatient rehabilitation clinics. Participants: We recruited 5 participants with severe adductor spasticity. Four were persons with multiple sclerosis and one was a person with adult cerebral palsy. All participants were women and had an average age of 60.4 years; four participants had bilateral severe adductor spasticity and one had unilateral severe adductor spasticity. Interventions: A total of 9 phenol blocks of the obturator nerve were performed. Five were performed with ultrasound guidance, followed by localization of the obturator nerve by peripheral nerve stimulator. Four were performed using anatomic landmark and peripheral nerve stimulator for localization. Outcome Measures: The primary outcome measure was the Modified Ashworth Scale score of the hip adductor at 1 month after the obturator nerve block. The secondary outcomes measures include Modified Ashworth Scale (MAS) score of the hip adductors at 6 months, distance between the right and left medial femur condyles in supine with hip extended to neutral, Disability Assessment Scale (DAS) score, Goal Attainment Scale (GAS) score, Spasticity Numeric Rating Scale score and Subjects’ and Physician Global Impression of Changes scores. Results: There was statistically significant decrease in the MAS score at 1-month compared to baseline (2.43 vs. 4; P=0.001). There was no statistically significant difference in the secondary outcomes. There were no reported adverse effects of procedure. Conclusion: This study suggests that phenol block of the obturator nerve is effective in treating severe adductor spasticity. We recommend a larger study with more participants and longer follow up period to allow further assessment of the efficacy of the phenol block of the obturator nerve in treating severe adductor spasticity.

MP91-20 A RANDOMIZED DOUBLE-BLIND, PLACEBO-CONTROLLED, CROSS-OVER TRIAL ASSESSING THE EFFECT OF TADALAFIL (CIALIS) ON THE CARDIOVASCULAR RESPONSE IN MEN WITH COMPLETE SPINAL CORD INJURY ABOVE THE SIXTH THORACIC LEVEL

ultrasonography (D-CDDU) was used as the evaluation tools. Assessments were made at 2 time points: 1 month and 7 months after urethroplasty. RESULTS: The mean patient age was 31.4 7.0 years (Group 1) and 33.3 7.2 years (Group 2) repectively (p>0.05). No patients ended the penile rehabilitation program because of treatment-related adverse events in both groups. In Group 1, 57.1% (16/28) patients have erections sufficient to finish the vaginal intercourse compared to 46.9% (14/32) in Group 2 at 7 months after urethroplasty. At 7 months after urethroplasty, the IIEF-5 score is (16.5 4.0) and (13.6 4.3) respectively in Group 1 and Group 2 (p<0.05). According to D-CDDU, the cavernosal artery peak systolic velocity (PSV) is (37.1 7.4) cm/second and (31.6 9.7) cm/second (p<0.05), the cavernosal artery end diastolic velocity(EDV) is (4.1 0.9) cm/second and (4.2 1.2) cm/second (p>0.05), and the penile length change is (3.1 0.9) cm and (2.4 0.9) cm(p<0.05) respectively in Group 1 and Group 2 after drug injection. NPT testing shows that the number of erectile events is (2.4 2.0) and (2.8 1.7) (p>0.05), the duration of erectile events is (12.1 4.1) min and (11.5 4.7)min (p>0.05), and the penile Avg Event Rigidity is (26.9 10.2) cm and (26.4 11.6) cm (p>0.05)respectively in Group 1 and Group 2. CONCLUSIONS: This short term study showed that early use of VED is useful and well-tolerated in the penile rehabilitation for the patients after posterior urethral anastomotic urethroplasty because of PFUDD.