Liu-Ing Bih

The Relationship Between Sitting Stability and Functional Performance in Patients With Paraplegia

OBJECTIVES To compare sitting stability between patients with high and low thoracic spinal cord injury (SCI), to determine the factors that can predict sitting stability, and to examine the relationship between sitting stability and functional performance. DESIGN Cross-sectional assessment was performed on subjects with paraplegia. SETTING Rehabilitation hospital affiliated with a medical university. PARTICIPANTS Convenience sample of 30 adults with complete chronic thoracic SCI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES (1) Postural sway during quiet sitting over 30 seconds was recorded as static sitting stability, and composite maximal weight-shift during leaning tasks over 30 seconds was measured as dynamic sitting stability; (2) age, body weight, trunk length, trunk strength, postonset duration, injury level, and presence of spasticity were examined as predictive variables for sitting stability; and (3) the time for completion of upper- and lower-body dressing and undressing and transfer was measured as functional performance. RESULTS A significant difference in composite maximal weight-shift was found between high and low thoracic SCI subjects (t=2.90, P<.01). Injury level and trunk length were 2 important predictive factors for dynamic sitting stability, and they explained 43.5% of the variance. Only the completion time of upper-body dressing and undressing correlated significantly with static (r=.465, P=.01) and dynamic (r=-.377, P<.05) sitting stability. CONCLUSIONS The subjects with low thoracic SCI showed better dynamic sitting stability than those with high thoracic SCI. Injury level and trunk length, not trunk flexion or extension strength, predicted the outcome of dynamic sitting stability. Measures were not precise enough to predict functional performance from the viewpoint of injury level and sitting stability. The underlying premise that a reduction or increase in trunk strength is indicative of poorer or better sitting stability in SCI individuals is questioned, and implications for problem identification and treatment planning are discussed.

Bladder shape impact on the accuracy of ultrasonic estimation of bladder volume

OBJECTIVE Variations in bladder shape can lead to errors in ultrasonic estimation of the bladder volume. The purposes of this study were to compare the accuracies of various formulas to estimate bladder volume from sonographic measurements and to assess the impact of bladder shape on the accuracy of bladder volume estimation. STUDY DESIGN Twenty-four healthy volunteers (13 men, 11 women) and 55 spinal cord injury patients (48 men, 7 women) underwent ultrasonographic measurements of dimensions before and after voiding. Bladder shape was classified as cuboid, ellipsoid, or triangular prism. Ten formulas from the literature were applied to estimate bladder volume, using the volume voided or catheterized as the standard, and then linear regression was used to obtain optimal correction coefficients for the whole data set as well as each of the three bladder shapes. SETTING Rehabilitation hospital affiliated with a medical college. RESULTS The most accurate of the 10 formulas tested was height (H) X transverse depth (Dt) x weight (W) x 0.7 (mean error 17.4%+/-11.6%). Linear regression analysis yield optimal correction coefficients of .72 for the whole data set and .89, .81, and .66 for cuboidal, ellipsoid, and triangular prism-shaped bladders, respectively. The mean error for the estimation of bladder volume using .72 as the correction coefficient was 16.9%+/-11.9% and decreased to 12.7%+/-10.1% (p < .0001, paired t test) when the bladder shape was taken into account. CONCLUSION Using bladder shape for reference and applying the corresponding correction coefficient to volume calculations will improve the accuracy of the estimation.

Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury.

OBJECTIVE To evaluate the effect of a single cystoscopic injection of botulinum toxin to the external urethral sphincter in treating detrusor external sphincter dyssynergia. DESIGN An open treatment trial with pre- and post-treatment evaluations. SUBJECTS A total of 20 suprasacral spinal cord injured patients with pure detrusor external sphincter dyssynergia. METHODS A single dose of 100 IU botulinum toxin A was applied into the external urethral sphincter via cystoscopy. Outcome measurements included maximal detrusor pressure, maximal urethral pressure, detrusor leak point pressure, integrated electromyography, and maximal pressure on static urethral pressure profilometry obtained 4 weeks post-treatment. Post-voiding residuals were checked pre- and post-injection. RESULTS There were significant reductions in integrated electro notmyography and static and maximal urethral pressure, but not in maximal detrusor pressure and detrusor leak point pressure after treatment. Post-voiding residuals were significantly decreased at all evaluation periods. In the sub-group analysis, patients who showed good effects of treatment had significantly lower baseline integrated electro-myography (p<0.05). CONCLUSION This study demonstrates the effect of a single cystoscopic injection of botulinum toxin in detrusor external sphincter dyssynergia. Integrated electromyography is a good evaluation tool for the net effect and dosage of botulinum toxin. Patients with severe spasticity over the external urethral sphincter may require repeated injections or higher doses.

Autonomic Dysreflexia During Urodynamic Examinations in Patients With Suprasacral Spinal Cord Injury

OBJECTIVE To investigate blood pressure (BP) and pulse rate (PR) changes during urodynamic (UD) examinations in patients with suprasacral spinal cord injury (SCI). DESIGN A case control study. SETTING Tertiary hospital affiliated with a medical university. PATIENTS Control subjects (n=22) and patients with suprasacral SCI (n=120). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Systolic (SBP) and diastolic BP (DBP) and PR before and during UD studies. RESULT Healthy subjects had an average SBP change of 9.7 ± 10.6 mm Hg and a maximal SBP increase of 21 mm Hg. Autonomic dysreflexia (AD) was defined as an SBP increase of 20mm Hg or more, and incidence rates were 36.7% overall, 42.6% in patients with injury level at or above T6, and 15.4% in patients with lesions below T6. Both SBP and DBP changes in patients with SCI showed significant negative correlations with injury levels (r=-.383 and -.315; P<.05). The BP increase was more significant in patients with SCI who had detrusor sphincter dyssynergia (DSD), especially the continuous type, or severely impaired bladder compliance than in those who did not. Most patients (75%) had no significant PR changes (within 10 beats/min) during AD responses and only 22.7% had a decrease of 10 beats/min or more. Patients younger than 50 years had a greater PR decrease than those 50 years or older (-7.1 ± 9.0 vs 0.7 ± 11.4 beats/min; P<.05). CONCLUSIONS AD occurred not only in patients with lesions above T6, but also in those with lower lesion levels. Patients with higher injury level, continuous DSD, or a poorly compliant bladder had greater SBP changes during UD studies. During AD reactions, younger patients tended to have a greater PR decrease than older patients.

Transperineal Injection of Botulinum Toxin A for Treatment of Detrusor Sphincter Dyssynergia: Localization With Combined Fluoroscopic and Electromyographic Guidance

OBJECTIVE To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI). DESIGN A prospective, open-label trial. SETTING A rehabilitation hospital affiliated with a medical university. PARTICIPANTS Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD. INTERVENTIONS 100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy. MAIN OUTCOME MEASURES (1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI). RESULTS Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H2O, 45cm H2O, and 92cm H2O, respectively (all P values <.05). The mean QLI significantly improved from -0.68+/-0.27 to 0.66+/-0.19 (P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters. CONCLUSION With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.

The accuracy of ultrasonic estimation of bladder volume: A comparison of portable and Stationary equipment

OBJECTIVE To compare the accuracy of portable and stationary ultrasonography equipment in estimating residual bladder volume. DESIGN A prospective study. SETTING A rehabilitation hospital affiliated with a medical university in Taiwan. PARTICIPANTS Sixty-four patients with voiding dysfunction. INTERVENTIONS Each patient received both types of ultrasonography, plus catheterization (as the criterion standard for measuring bladder volume). MAIN OUTCOME MEASURES The mean errors and mean percentage error resulting from use of the 2 types of equipment were recorded. RESULTS Stationary real-time ultrasonography had a lower absolute error (21.9+/-25.0 mL vs 34.4+/-38.2 mL) and percentage error (13.1%+/-10.5% vs 36%+/-52.4%) than the portable ultrasonography (P<.05). CONCLUSION Stationary ultrasonography provided a more accurate estimate of residual bladder volumes than did the portable device. However, portable ultrasonography is more convenient to use and has an acceptable accuracy for clinical use.

Comparison of ultrasonographic renal excursion to fluoroscopic diaphragmatic excursion for the assessment of diaphragmatic function in patients with high cervical cord injury.

OBJECTIVE To compare the renal excursion detected by ultrasonography with the diaphragmatic excursion recorded by fluoroscopy in estimating the diaphragmatic function in patients with high cervical cord injury. DESIGN Prospective, blinded comparative study. SETTING A rehabilitation hospital affiliated with a medical university. PARTICIPANTS Fifteen consecutively admitted patients with high cervical cord injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Chest radiographs, fluoroscopy of diaphragmatic motion, and ultrasonography of renal motion. RESULT Of the 15 patients, 2 were diagnosed with hemidiaphragm paralysis using fluoroscopy and renal ultrasonography. The average diaphragmatic excursion was 59 mm (range, 30-83 mm) in 28 nonparalyzed hemidiaphragms. The average renal excursion was 49 mm (range, 28-61 mm). The correlation coefficient for fluoroscopic hemidiaphragm excursion and ultrasonographic renal excursion was .853. CONCLUSION Ultrasonographic renal excursion and fluoroscopic diaphragmatic excursion correlated highly. With the fluoroscopy results as the criterion standard, the diagnostic sensitivity and specificity were both 100% for renal sonography. With the advantages of convenience of use, no radiation exposure, and high reproducibility, renal ultrasonography is recommended as a first-line screening and long-term follow-up tool for assessment of diaphragmatic function.

Transrectal Ultrasound–Guided Transperineal Botulinum Toxin A Injection to the External Urethral Sphincter for Treatment of Detrusor External Sphincter Dyssynergia in Patients With Spinal Cord Injury

OBJECTIVE To evaluate the effects of a single transrectal ultrasound (TRUS)-guided transperineal injection of botulinum toxin A (BTX-A) to the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD). DESIGN Descriptive study. SETTING Rehabilitation hospital affiliated with a medical university. PARTICIPANTS Patients (N=18) with suprasacral spinal cord injury who had DESD confirmed on video-urodynamic study. INTERVENTIONS A single dose of 100U BTX-A was applied into the EUS via TRUS-guided transperineal route injection. MAIN OUTCOME MEASURES Maximal detrusor pressure, detrusor leak-point pressure, integrated electromyography (iEMG), maximal pressure on static urethral pressure profilometry, and postvoiding residuals. RESULTS There were significant reductions in iEMG (P=.008) and static (P=.012) and dynamic urethral pressure (P=.023), but not in detrusor pressure and detrusor leak-point pressure after treatment. Postvoiding residuals also significantly decreased in the first and second month after treatment (P<.012). CONCLUSIONS TRUS-guided transperineal injection of BTX-A has beneficial effects in treating DESD.

Comparing a transrectal ultrasound-guided with a cystoscopy-guided botulinum toxin a injection in treating detrusor external sphincter dyssynergia in spinal cord injury.

Objective:The aim of this study was to compare the results of a transrectal ultrasound-guided botulinum toxin injection with those of a cystoscopy-guided method to the external urethral sphincter in treating detrusor external sphincter dyssynergia. Design:A total of 18 suprasacral spinal cord-injured patients with detrusor external sphincter dyssynergia were included in the present study. A single dose of 100 IU botulinum toxin A was applied into the external urethral sphincter via a transrectal ultrasound-guided transperineal route. We retrospectively compared the outcome measurements with 20 suprasacral spinal cord-injured patients previously treated with the same dose of botulinum toxin through a cystoscopy-guided procedure. Results:There were significant reductions in integrated electromyography and urethral pressure but not in detrusor pressure and leak point pressure after treatment. Postvoiding residuals were significantly decreased in the first, second, and third months in the cystoscopy group and in the first and second months in the transrectal ultrasound group. There were no significant differences between the groups in all of the outcome measures. Conclusions:This study demonstrates that transrectal ultrasound-guided transperineal botulinum toxin injection may be an alternative for a cystoscopy-guided injection. This alternative procedure provides clinicians with an innovative and less invasive method that is performed without requiring anesthesia or cystoscopy.

Sonographic diagnosis of hydronephrosis in patients with spinal cord injury: influence of bladder fullness

OBJECTIVE To investigate and compare the diagnostic accuracy of prevoid and postvoid renal sonography in detecting hydronephrosis in patients with spinal cord injury. STUDY DESIGN A prospective, blind comparison of renal sonography and excretory urography in 67 spinal cord injury patients who underwent periodic urologic examinations. Renal sonography was performed twice, once when the patients bladder was physiologically full (prevoid) and again when it was just emptied (postvoid). RESULTS Of 140 kidneys, 24 from 16 patients were found to have hydronephrosis by excretory urography; 116 kidneys had normal urogram findings. Prevoid sonography missed the diagnosis of hydronephrosis in one kidney and showed hydronephrosis in 18 kidneys that had normal results on excretory urography (sensitivity, 95.8%; specificity, 84.5%; negative predictive value, 99.0%). The postvoid sonograms did not detect hydronephrosis in four kidneys and showed hydronephrosis in six kidneys that had normal results on excretory urography (sensitivity, 83.3%; specificity, 94.8%; negative predictive value, 96.5%). Compared to excretory urography, renal sonography detected eight more upper urinary tract abnormalities, which were confirmed by cystograms or radioisotopic renograms. CONCLUSION Performing renal sonography while the bladder is full can increase the sensitivity in detecting hydronephrosis in asymptomatic spinal cord injured patients.