Gianna M. Rodriguez

Bladder Management After Spinal Cord Injury in the United States 1972 to 2005

PURPOSE Studies have shown that bladder management with an indwelling catheter for patients with spinal cord injury is associated with more urological complications such as stones, urinary infection, urethral strictures and bladder cancer. However, little is known about actual bladder management for these patients in clinical practice. MATERIALS AND METHODS Using the National Spinal Cord Injury Database the bladder management method was determined at discharge from rehabilitation and at each 5-year followup period for 30 years. RESULTS At discharge from rehabilitation (24,762 patients) the selection of bladder management with a condom catheter decreased steadily from a peak of 34.6% in 1972 to a low of 1.50% in 2001. The use of clean intermittent catheterization increased from 12.6% in 1972 to a peak of 56.2% in 1991. Indwelling catheter use initially decreased from 33.1% in 1972 to 16.5% in 1991 but increased to 23.1% in 2001. Of 12,984 individuals with followup data those originally using an indwelling catheter for bladder management were unlikely to switch to another method, with 71.1% continuing to use an indwelling catheter at 30 years. Individuals using clean intermittent catheterization and condom catheterization at discharge home did not continue to use these methods with only 20% and 34.6% remaining on the same management, respectively. CONCLUSIONS With time bladder management with clean intermittent catheterization has increased in popularity. However, only 20% of patients initially on clean intermittent catheterization remained on this form of bladder management. More research on the safety of each of these methods needs to be performed to provide better guidance to aid with this decision.

Systematic Review of Urological Followup After Spinal Cord Injury

PURPOSE There is no consensus on the appropriate urological followup of individuals after spinal cord injury but it is well known that they are at risk for renal deterioration, bladder cancer and stones. We systematically reviewed the literature to evaluate evidence of urological screening in this population. MATERIALS AND METHODS We reviewed 385 abstracts, of which 50 met study inclusion criteria. We rated evidence using American Academy of Neurology 2004 guidelines. RESULTS A total of 12 articles evaluated urinary tract infection screening. Patient reported symptoms used to predict urinary tract infection yielded mixed results and urine dipstick testing had the same accuracy as microscopy. Routine urine culture was unnecessary in healthy, asymptomatic individuals with normal urinalysis. Urodynamics probably must be done periodically (6 articles) but there was no information on frequency. In 11 articles ultrasound was recommended as a useful, noninvasive and possibly cost-effective screening method. Renal scan was a good method for further testing, especially if ultrasound was positive (11 articles). Evidence was sufficient (11 articles) to recommend ultrasound of the urinary tract to detect urinary tract stones with good sensitivity but not plain x-ray of the kidneys, ureters and bladder (2 articles). There was insufficient evidence to recommend urine markers or cytology for bladder cancer screening (9 articles). CONCLUSIONS Based on this review no definitive recommendations for screening can be made except routine renal ultrasound. Urodynamics are an important part of screening but the frequency is unclear. The optimum bladder cancer screening method has not been defined.

Relationship of spasticity to soft tissue body composition and the metabolic profile in persons with chronic motor complete spinal cord injury.

Abstract Background/Objective: To determine the effects of spasticity on anthropometrics, body composition (fat mass [FM] and fat-free mass [FFM]), and metabolic profile (energy expenditure, plasma glucose, insulin concentration, and lipid panel) in individuals with motor complete spinal cord injury (SCI). Methods: Ten individuals with chronic motor complete SCI (age, 33 ± 7 years; BMI, 24 ± 4 kg/m2; level of injury, C6—T11; American Spinal Injury Association A and B) underwent waist and abdominal circumferences to measure trunk adiposity. After the first visit, the participants were admitted to the general clinical research center for body composition (FFM and FM) assessment using dual energy x-ray absorptiometry. After overnight fasting, resting metabolic rate (RMR) and metabolic profile (plasma glucose, insulin, and lipid profile) were measured. Spasticity of the hip, knee, and ankle flexors and extensors was measured at 6 time points over 24 hours using the Modified Ashworth Scale. Results: Knee extensor spasticity was negatively correlated to abdominal circumferences (r = -0.66, P = 0.038). After accounting for leg or total FFM, spasticity was negatively related to abdominal circumference (r = -0.67, P = 0.03). Knee extensor spasticity was associated with greater total %FFM (r = 0.64; P = 0.048), lower %FM (r = -0.66; P = 0.03), and lower FM to FFM ratio. Increased FFM (kg) was associated with higher RMR (r = 0.89; P = 0.0001). Finally, spasticity may indirectly influence glucose homeostasis and lipid profile by maintaining FFM (r = -0.5 to -0.8, P < 0.001). Conclusion: Significant relationships were noted between spasticity and variables of body composition and metabolic profile in persons with chronic motor complete SCI, suggesting that spasticity may play a role in the defense against deterioration in these variables years after injury. The exact mechanism is yet to be determined.

Medical and Psychosocial Complications Associated With Method of Bladder Management After Traumatic Spinal Cord Injury

OBJECTIVES To determine the relationships between bladder management method and medical complications (renal calculi or decubitus ulcers), number of hospital days, and psychosocial factors. We hypothesized that indwelling catheterization would be associated with more complications, more hospitalizations, and worse psychosocial outcomes compared with other bladder management methods. DESIGN Inception cohort study. SETTING Model spinal cord injury (SCI) centers funded by the National Institute on Disability and Rehabilitation Research from 1973 to 2005. PARTICIPANTS Persons with new traumatic SCI (N=24,762) enrolled in the National SCI Database entire data set forms I and II. Patients were stratified according to the bladder management method recorded at each time of data collection into 1 of 4 groups as follows: indwelling catheterization, spontaneous voiding, condom catheterization, and intermittent catheterization. Those who reported no management method or errors in reporting were excluded (n=1564). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Medical complications, including pressure ulcer number and grade of worst ulcer, kidney stones, and hospitalizations, as well as psychosocial factors (satisfaction with life, perceived health status, societal participation), were stratified by bladder management method. Results were adjusted for level and completeness of neurologic injury and other confounding and modifying factors. RESULTS Compared with other forms of bladder management, use of an indwelling catheter was associated with more pressure ulcers and longer and more hospitalizations for all causes and urology-specific causes. Indwelling catheter use was associated with the lowest levels of participation, but similar satisfaction with life and perceived health status. CONCLUSIONS Indwelling catheterization was associated with more medical complications and lower levels of participation than other bladder management methods, but more research is required to ascertain the causality of these complications.

International Standards for Neurological Classification of Spinal Cord Injury: Cases With Classification Challenges

Abstract The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is routinely used to determine the levels of injury and to classify the severity of the injury. Questions are often posed to the International Standards Committee of the American Spinal Injury Association regarding the classification. The committee felt that disseminating some of the challenging questions posed, as well as the responses, would be of benefit for professionals utilizing the ISNCSCI. Case scenarios that were submitted to the committee are presented with the responses as well as the thought processes considered by the committee members. The importance of this documentation is to clarify some points as well as update the SCI community regarding possible revisions that will be needed in the future based upon some rules that require clarification.

Home-Based Overnight Transcutaneous Capnography/Pulse Oximetry for Diagnosing Nocturnal Hypoventilation Associated With Neuromuscular Disorders

OBJECTIVE To determine the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco(2)) monitoring/oxygen saturation by pulse oximetry (Spo(2)) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders. DESIGN Retrospective case series analyzed consecutively. SETTING Multidisciplinary neuromuscular respiratory failure (NMRF) clinic at an academic institution. PARTICIPANTS Subjects (N=35, 68.6% men; mean age, 46.9y) with spinal cord injury (45.7%) or other neuromuscular disorders underwent overnight tests with tc-Pco(2)/Spo(2) monitoring. Fifteen (42.9%) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV). INTERVENTIONS A respiratory therapist brought a calibrated tc-Pco(2)/Spo(2) monitor to the patients home and provided instructions for data collection during the subjects normal sleep period. Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco(2) (ET-Pco(2)) were recorded at a clinic visit before monitoring. MAIN OUTCOME MEASURES Detection of NH (tc-Pco(2) ≥50mmHg for ≥5% of monitoring time). Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo(2) ≤88% for ≥5% of monitoring time), FVC, BMI, or daytime ET-Pco(2) could predict the presence of NH. RESULTS NH was detected in 18 subjects (51.4%), including 53.3% of those using BiPAP or TV. NH was detected in 43.8% of ventilator-independent subjects with normal daytime ET-Pco(2) (present for 49.4%±31.5% [mean ± SD] of the study period), and in 75% of subjects with an elevated daytime ET-Pco(2) (present for 92.3%±8.7% of the study period). Oxygen desaturation, BMI, and FVC were poor predictors of NH. Only 3 attempted monitoring studies failed to produce acceptable results. CONCLUSIONS Home-based, unsupervised monitoring with tc-Pco(2)/Spo(2) is a useful method for diagnosing NH in NMRF.

Risk Factors Associated With Neurogenic Bowel Complications and Dysfunction in Spinal Cord Injury.

OBJECTIVES To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling. DESIGN Cross-sectional observational study. SETTING A Spinal Cord Injury Model System, with additional participants recruited from other sites. PARTICIPANTS Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling. RESULTS Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake. CONCLUSIONS These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Menopause Characteristics and Subjective Symptoms in Women With and Without Spinal Cord Injury

OBJECTIVE To examine menopause transition characteristics and symptom bother in women with spinal cord injury (SCI). DESIGN Prospective cohort (4 data collection periods across 4 years). SETTING Community. PARTICIPANTS Women (n=62) with SCI (injury levels C6-T12, nonambulatory, >36mo postinjury; 86.1% retention) and women without SCI (n=66; 92.9% retention) with intact ovaries, not using hormone therapy, and between the ages of 45 and 60 years volunteered. A total of 505 observations were collected and analyzed. INTERVENTIONS None. MAIN OUTCOME MEASURES Age at final menstrual period (FMP), transitions through menopause status classifications, and menopause symptom bother (vasomotor, somatic, psychologic symptoms). RESULTS The number of women transitioning through a menopause status classification over the course of the study did not significantly vary by group (P=.263), nor did age at FMP (P=.643). Women with SCI experienced greater bother of somatic symptoms (a subscale, P<.001), bladder infections (P<.001), and diminished sexual arousal (P=.012). Women without SCI had significantly greater bother of vasomotor symptoms (P=.020). There were no significant group by menopause status interactions; main effects for menopause status were significant only for vasomotor symptoms and vaginal dryness. CONCLUSIONS Results suggested that women with SCI experience greater symptom bother in certain areas, but that patterns of symptom bother across menopause, transition through menopause, and age at FMP are similar to those of their peers. Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury. These findings provide a framework that women with SCI and their health care providers can use to address the menopause transition and highlight the importance of multidisciplinary involvement to maximize health and well being during this transition.

Positive airway pressure therapy for sleep-disordered breathing confers short-term benefits to patients with spinal cord injury despite widely ranging patterns of use

Study designProspective, cohort study.ObjectivesTo evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI).SettingAcademic tertiary care center, USA.MethodsOverall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months.ResultsOverall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL.ConclusionsDespite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Self-Report of Behaviors to Manage Neurogenic Bowel and Bladder by Individuals with Chronic Spinal Cord Injury: Frequency and Associated Outcomes

Background: The management of neurogenic bowel and bladder by individuals with spinal cord injury (SCI) often requires a complicated set of behaviors to optimize functioning and reduce complications. However, limited research is available to support the many recommendations that are made. Objective: To describe the occurrence of behaviors associated with the management of neurogenic bowel and bladder among individuals with chronic SCI and to explore whether relationships exist between the performance of those behaviors and outcomes related to health and quality of life. Methods: A survey was developed based on clinical guidelines to collect self-report information about the performance of specific behaviors associated with the management of neurogenic bowel and bladder by individuals with SCI. It was administered to 246 individuals with chronic SCI living in the community as part of a larger ongoing study. Results: Results suggest that the methods that those with SCI use to manage neurogenic bowel and bladder are multifaceted. Many methods are performed with significant consistency, but significant variations exist for some and are often associated with neurological status, methods of evacuation, and quality of life. Conclusion: Many people with SCI of long duration are not sure of the sources of recommendations for some of the management activities that they or their personal care assistants conduct. It is prudent for clinicians working with these people to review their recommendations periodically to ensure that they are current and understood.