Eldon Loh

Bladder cancer in individuals with spinal cord injuries

Study design:Prospective scoping review.Objectives:To conduct a scoping review of all the literature related to bladder cancer in individuals with spinal cord injuries (SCI).Methods:Literature search of the databases Pubmed, CINAHL, ProQuest, PsychINFO and Scopus up to and including August 2012. Articles related to bladder cancer among SCI patients were identified, and data pertaining to epidemiology, risk factors, screening, prevention and management was reviewed and summarized.Results:An association between bladder cancer and SCI was first reported in the 1960s, with some case reports suggesting an alarmingly high rate among SCI patients. More recent epidemiological studies have reported this risk to be substantially lower. However, bladder cancer in SCI patients tends to present at an earlier age and at a more advanced pathological stage than bladder cancer in the general population. Presenting symptoms may be atypical, and early recognition is important to improve prognosis with surgical resection. Several risk factors have been identified, including indwelling catheters, urinary tract infections and bladder calculi. Screening of SCI patients for bladder cancer is routinely recommended in many SCI management guidelines and by expert consensus; however, evidence for screening tools and protocols is lacking.Conclusion:Bladder cancer is a rare, and potentially lethal occurrence in SCI patients. Physicians need to have a high index of suspicion for bladder cancer, particularly among SCI patients managed with long-term indwelling catheters.

Cadaveric study of sacroiliac joint innervation: implications for diagnostic blocks and radiofrequency ablation.

Background and Objectives Optimization of clinical outcomes of lateral branch radiofrequency ablation or blocks for sacroiliac joint (SIJ) pain requires precise nerve localization; however, there is a lack of comprehensive morphological studies. The objectives of this cadaveric study were to document SIJ innervation relative to bony landmarks in 3 dimensions and to identify reference points visible under ultrasound and fluoroscopy for optimal needle placement. Methods In 25 cadaveric hemipelves, L5-S4 lateral branches were exposed, digitized, and modeled in 3 dimensions. The models were used to compare innervation patterns between specimens and to quantify the distances of the nerves innervating the SIJ relative to the transverse sacral tubercles (TSTs) and posterior sacral foramina. Quadrants of origin of the nerves were recorded. Results The SIJ was innervated by the posterior sacral network: S1-S2 contributed in all specimens, S3 in 88%, L5 in 8%, and S4 in 4%. Most frequently, the lateral branch(es) emerged from the inferolateral S1, superolateral and inferolateral S2, and superolateral S3 quadrants. All TSTs were easily identifiable elevations that were used to landmark the nerves innervating the SIJ. The majority of branches of the posterior sacral network crossed the lateral sacral crest between TST1-3, with the greatest concentration between TST2-3. Only 3 specimens had a branch superior or inferior to these landmarks. Conclusions Based on the innervation pattern and using bony landmarks identifiable under ultrasound and fluoroscopy, 2 radiofrequency ablation techniques were proposed. Further research is required to determine the accuracy and reliability of needle placement and to evaluate clinical outcomes.

Anticonvulsant medication use for the management of pain following spinal cord injury: systematic review and effectiveness analysis

Study design:Systematic review and effectiveness analysis.Objectives:Assess the effectiveness of anticonvulsants for the management of post spinal cord injury (SCI) neuropathic pain.Setting:Studies from multiple countries were included.Methods:CINAHL, Cochrane, EMBASE and MEDLINE were searched up to April 2013. Quality assessment was conducted using the Jadad and the Downs and Black tools. Effect sizes and odds ratios were calculated for primary and secondary outcome in the included studies.Results:Gabapentinoids, valproate, lamotrigine, levetiracetam and carbamazepine were examined in the 13 included studies, ten of which are randomized controlled trials. Large effect size (0.873–3.362) for improvement of pain relief was found in 4 of the 6 studies examining the effectiveness of gabapentin. Pregabalin was shown to have a moderate to large effect (0.695–3.805) on improving neuropathic pain post SCI in 3 studies. Valproate and levetiracetam were not effective in improving neuropathic pain post SCI, while lamotrigine was effective in reducing neuropathic pain amongst persons with incomplete lesions and carbamazepine was found effective for relief of moderate to intense pain.Conclusion:Gabapentin and pregabalin are the two anticonvulsants which have been shown to have some benefit in reducing neuropathic pain.

Meta-Analysis of Botulinum Toxin A Detrusor Injections in the Treatment of Neurogenic Detrusor Overactivity After Spinal Cord Injury

OBJECTIVE To examine the effectiveness of botulinum toxin type A (BTX-A) on neurogenic detrusor overactivity (NDO) in individuals with spinal cord injury (SCI). DATA SOURCES MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to June 2012. STUDY SELECTION Trials examining the use of BTX-A injections into the detrusor wall in the treatment of NDO after SCI were included if (1) ≥ 50% of study sample comprised subjects post-SCI; (2) outcomes of interest were assessed before and after treatment with a single injection of BTX-A; and (3) the sample size was ≥ 3. DATA EXTRACTION A standardized mean difference ± SE (95% confidence interval) was calculated for at least 1 of the following outcomes in every study: postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, catheterization frequency, and maximum flow rate. Results from all studies were then pooled using a random-effects model. Treatment effect sizes were interpreted as small, >0.2; moderate, >0.5; or large, >0.8. DATA SYNTHESIS Fourteen studies representing data from 734 subjects were included. After BTX-A injection, large treatment effects were observed in postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, and catheterization frequency (P<.01). Rate of incontinence episodes was reduced from 23% to 1.31% after BTX-A treatment. No significant decrease in max flow rate was observed (P=.403). CONCLUSIONS Results of the meta-analysis indicate BTX-A is effective in treating NDO after SCI. The use of BTX-A was associated with a decrease in incontinence episodes, catheter use, and bladder pressures.

Gabapentinoids Are Effective in Decreasing Neuropathic Pain and Other Secondary Outcomes After Spinal Cord Injury: A Meta-Analysis

OBJECTIVE To examine the effectiveness of gabapentin and pregabalin in diminishing neuropathic pain and other secondary conditions in individuals with spinal cord injury (SCI). DATA SOURCES A systematic search was conducted using multiple databases for relevant articles published from 1980 to June 2013. STUDY SELECTION Controlled and uncontrolled trials involving gabapentin and pregabalin for treatment of neuropathic pain, with ≥3 subjects and ≥50% of study population with SCI, were included. DATA EXTRACTION Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohens d to calculate standardized mean difference (SMD), SE, and 95% confidence interval (CI) for primary (pain) and secondary outcomes (anxiety, depression, sleep interference) was conducted. DATA SYNTHESIS Eight studies met inclusion criteria. There was a significant reduction in the intensity of neuropathic pain at <3 months (SMD=.96±.11; 95% CI, .74-1.19; P<.001) and between 3 and 6 months (SMD=2.80±.18; 95% CI, 2.44-3.16; P<.001). A subanalysis found a significant decrease in pain with gabapentin (SMD=1.20±.16; 95% CI, .88-1.52; P<.001) and with pregabalin (SMD=1.71±.13; 95% CI, 1.458-1.965; P<.001). A significant reduction in other SCI secondary conditions, including sleep interference (SMD=1.46±.12; 95% CI, 1.22-1.71; P<.001), anxiety (SMD=1.05±.12; 95% CI, .81-1.29; P<.001), and depression (SMD=1.22±.13; 95% CI, .967-1.481; P<.001) symptoms, was shown. A significantly higher risk of dizziness (risk ratio [RR]=2.02, P=.02), edema (RR=6.140, P=.04), and somnolence (RR=1.75, P=.01) was observed. CONCLUSIONS Gabapentin and pregabalin appear useful for treating pain and other secondary conditions after SCI. Effectiveness comparative to other analgesics has not been studied. Patients need to be monitored closely for side effects.

Effectiveness of transcranial direct current stimulation for the management of neuropathic pain after spinal cord injury: a meta-analysis

Objectives:To conduct a systematic review and meta-analysis to examine the effect of transcranial direct current stimulation (tDCS) on reducing neuropathic pain intensity in individuals with spinal cord injury (SCI).Methods:Medline, CINAHL, EMBASE and PsycINFO databases were searched for all relevant articles published from 1980 to November 2014. Trials were included if (i) tDCS intervention group and a placebo control group were present; (ii) at least 50% of participants in the study had an SCI and there were at least three participants; (iii) participants were aged 18 years or older; and (iv) persistent pain for at least 3 months. Studies were excluded if: (i) the tDCS intervention group was compared with an active treatment group; (ii) there was insufficient reporting detail to enable pooling of data; and (iii) it was a nonclinical trial (that is, reviews, epidemiology, basic sciences). A standardized mean difference (SMD)±s.e. and 95% confidence interval (CI) was calculated for each outcome of interest and the results were pooled using a fixed or random effects model, as appropriate. Effect sizes were interpreted as: small >0.2, moderate >0.5, large >0.8.Results:Five studies met inclusion criteria of which four were randomized controlled trials and one was a prospective controlled trial. The pooled analysis found a significant effect of tDCS on reducing neuropathic pain after SCI post treatment (SMD=0.510±0.202; 95% CI, 0.114–0.906; P<0.012); however, this effect was not maintained at follow-up (SMD=0.353±0.272; 95% CI, −0.179 to 0.886; P<0.194). A reduction of 1.33 units on a 10-item scale was observed post treatment. No significant adverse events were reported.Conclusion:Meta-analytic results indicate a moderate effect of tDCS in reducing neuropathic pain among individuals with SCI; however, the effect was not maintained at follow-up. A mean pooled decrease of 1.33 units on a 10-item scale was found post treatment. Several factors were implicated in the effectiveness of tDCS in reducing pain. Due to the limited number of studies and lack of follow-up, more evidence is required before treatment recommendations can be made.

Neuropathic Pain Post Spinal Cord Injury Part 1: Systematic Review of Physical and Behavioral Treatment

BACKGROUND Neuropathic pain has various physiologic and psychosocial aspects. Hence, there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury (SCI). OBJECTIVE The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI. METHODS MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing nonpharmacological treatment of pain post SCI. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a treatment or intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention was being studied. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale. RESULTS The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI: physical and behavioral treatments. The pooled sample size of all studies included 433 participants. Of the 16 studies included, 7 were level 1, 3 were level 2, and 6 were level 4 studies. CONCLUSIONS Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain. Of these interventions, transcranial electrical stimulation had the strongest evidence of reducing pain. Despite a growing body of literature, there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain.

Systematic Review of Pharmacologic Treatments of Pain After Spinal Cord Injury: An Update

OBJECTIVE To update a systematic review of published research on pharmacotherapy for pain post-spinal cord injury (SCI). DATA SOURCES PubMed/MEDLINE, CINAHL, Embase, and PsycINFO databases were searched for articles from 2009 to September 2015 examining treatment of pain post-SCI. STUDY SELECTION Studies were included for analysis if they met the following 4 a priori criteria: (1) written in the English language; (2) ≥50% of subjects had an SCI, unless results were stratified by population type; (3) participants included ≥3 subjects with an SCI; and (4) any intervention involving pharmacologic treatment for the improvement of pain. DATA EXTRACTION Randomized controlled trials were assessed for methodologic quality using the Physiotherapy Evidence Database scoring system. All research designs were given a level of evidence according to a modified Sackett Scale. DATA SYNTHESIS Seven new studies met our inclusion criteria. The new studies fell into the following categories: analgesics (n=1), anticonvulsants (n=2), antidepressants (n=2), antispastics (n=1), and cannabinoids (n=1). There was evidence for 5 new pharmacotherapies among the SCI population; these included the following: oxycodone, duloxetine, venlafaxine, phenol block, and dronabinol. Levels of evidence for all therapy modalities were updated based on the new evidence. CONCLUSIONS Anticonvulsants remain the most studied and supported pharmacotherapy for neuropathic pain post-SCI. Antidepressants showed reduction in pain only among those with comorbid depression. Botulinum toxin and phenol blocks were supported for the reduction of mixed pain post-SCI.

Determination of clinically relevant content for a musculoskeletal anatomy curriculum for physical medicine and rehabilitation residents

To address the need for more clinical anatomy training in residency education, many postgraduate programs have implemented structured anatomy courses into their curriculum. Consensus often does not exist on specific content and level of detail of the content that should be included in such curricula. This article describes the use of the Delphi method to identify clinically relevant content to incorporate in a musculoskeletal anatomy curriculum for Physical Medicine and Rehabilitation (PM&R) residents. A two round modified Delphi involving PM&R experts was used to establish the curricular content. The anatomical structures and clinical conditions presented to the expert group were compiled using multiple sources: clinical musculoskeletal anatomy cases from the PM&R residency program at the University of Toronto; consultation with PM&R experts; and textbooks. In each round, experts rated the importance of each curricular item to PM&R residency education using a five‐point Likert scale. Internal consistency (Cronbachs alpha) was used to determine consensus at the end of each round and agreement scores were used as an outcome measure to determine the content to include in the curriculum. The overall internal consistency in both rounds was 0.99. A total of 37 physiatrists from across Canada participated and the overall response rate over two rounds was 97%. The initial curricular list consisted of 361 items. After the second iteration, the list was reduced by 44%. By using a national consensus method we were able to objectively determine the relevant anatomical structures and clinical musculoskeletal conditions important in daily PM&R practice. Anat Sci Educ 7: 135–143.

Neuropathic pain post spinal cord injury part 2: systematic review of dorsal root entry zone procedure.

BACKGROUND Pharmacotherapy may not sufficiently reduce neuropathic pain in many individuals post spinal cord injury (SCI). The use of alternative therapies such as surgery may be effective in reducing neuropathic pain in these individuals. However, because of the invasive nature of surgery, it is important to examine the evidence for use of this treatment. OBJECTIVE The purpose of this study was to conduct a systematic review of published literature on the surgical treatment of neuropathic pain after SCI. METHODS MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles in which surgical treatment of pain after SCI was examined. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a surgical intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention involving the dorsal root entry zone (DREZ) procedure was used to reduce pain. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale. RESULTS Eleven studies met the inclusion criteria. One study provided level 2 evidence, and the rest provided level 4 evidence. The DREZ procedure was shown to be more effective for segmental pain than for diffuse pain after SCI. Further, individuals with conus medullaris level injury were found to have a higher level of neuropathic pain relief than those with cervical, thoracic, or cauda equina injury. CONCLUSIONS The studies demonstrated that the DREZ procedure may be effective in reducing segmental pain. Hence, DREZ may be important in treatment of neuropathic pain in individuals resistant to less invasive treatments. Because the studies lacked control conditions and examination of long-term effects, there is a need for larger trials with more stringent conditions.