Michael Acuff

Testosterone levels among men with spinal cord injury: relationship between time since injury and laboratory values.

Clark MJ, Schopp LH, Mazurek MO, Zaniletti I, Lammy AB, Martin TA, Thomas FP, Acuff ME: Testosterone levels among men with spinal cord injury: relationship between time since injury and laboratory values. Am J Phys Med Rehabil 2008;87:758–767 Objectives:The objectives of the present study were to determine the prevalence of low testosterone among a sample of men with spinal cord injury and to examine the relationship among testosterone, time since injury, and select laboratory values. Design:Participants were 102 men with spinal cord injury participating in inpatient or outpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, and laboratory values. Results:Sixty percent of men with spinal cord injury had low testosterone levels. The median testosterone level for the entire sample was 220 ng/dl (normal reference range = 241–827 ng/dl). Low testosterone was significantly associated with less time since injury, lower hemoglobin, and higher prolactin in the univariate analyses at P < 0.05. Conclusions:The results indicate that men with spinal cord injury are at risk for low serum testosterone. Testosterone levels were also related to time since injury and hemoglobin and prolactin levels. These findings suggest the need for changes to occur in clinical practice. Guidelines are needed for when and how often testosterone monitoring should be conducted. Future research should address the pathophysiology of low testosterone and the outcomes of testosterone treatment.

Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation.

Schopp LH, Clark M, Mazurek MO, Hagglund KJ, Acuff ME, Sherman AK, Childers MK: Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:678–684. Objective:Although previous research has shown an association between spinal cord injury (SCI) and testosterone production, these studies have yielded inconsistent results. The present study documented the prevalence of low testosterone among men with SCI. Design:Participants were 92 men with SCI participating in inpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, neurologic level and degree of incomplete function, American Spinal Injury Association Impairment Scale grade, and additional laboratory values, including prealbumin, albumin, hematocrit, and aspartate aminotransferase. Results:The median testosterone level for men who sustained injuries <4 mos earlier was 160 ng/dl. Testosterone categories were significantly associated with age, time since injury, hematocrit, albumin level, and aspartate aminotransferase in the univariate analyses. Age, time since injury, and hematocrit levels were significant predictors of low testosterone in the multivariate analysis. Conclusion:The prevalence of low testosterone among men with acute SCI seems to be high. The results suggest the need for routine screening for low testosterone among men with SCI and consideration given to testosterone replacement therapy. Future research is needed to investigate the etiology, pathogenesis, and potential avenues for treatment of low testosterone among men with SCI.

Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis.

Clark MJ, Petroski GF, Mazurek MO, Hagglund KJ, Sherman AK, Lammy AB, Childers MK, Acuff ME: Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis. Am J Phys Med Rehabil 2008;87:281–284. Objective:To evaluate motor function in men with spinal cord injury (SCI) given testosterone replacement therapy (TRT). Design:American Spinal Injury Association (ASIA) rehabilitation discharge motor index scores were compared between men with SCI given TRT (testosterone cypionate, 200 mg, monthly; n = 50) and a comparison group (n = 480) in a retrospective study. Covariates included admission motor and FIM scores, level of injury (paraplegia/tetraplegia), days since injury, and age. Results:ASIA discharge motor scores for ASIA impairment scale grades C and D were significantly different (P < 0.05) in men with incomplete SCI given TRT, relative to the comparison group. The covariate-adjusted mean discharge score for the TRT group was higher than for the comparison group. There were no significant differences in discharge FIM scores (P = 0.34) for men with incomplete injuries and no differences in the adjusted discharge ASIA motor scores (P = 0.92) or adjusted discharge FIM scores (P = 0.16) for men with complete injuries. Conclusion:The data support a relationship between TRT and strength gains in men with residual motor function after SCI. Prospective studies are necessary to validate these findings.

Consumer-Assistant Education to Reduce the Occurrence of Urinary Tract Infections Among Persons with Spinal Cord Injury

Urinary tract infections (UTIs) have been identified as one of the most common secondary conditions among individuals with spinal cord injury (SCI). This article describes the outcomes of an educational intervention to reduce UTI incidence. Persons with SCI who attended an in-person educational workshop reported a decrease in the occurrence of UTIs over a 6-month period, compared to persons not attending the workshop (p .02). Future studies should include oversampling for those persons at greatest risk, including minorities and those with poor health status, with few social supports, and with high cervical level injuries who rely more extensively on personal assistant services.

Community Reintegration for Persons with Spinal Cord Injury Living in Rural America

Despite the Americans with Disabilities Act (ADA), physical, transportation, information, and health care barriers continue to impede full community reintegration for rural-living persons with spinal cord injury (SCI). Lack of a health care policy that recognizes the unique needs of rural populations is particularly problematic. Innovative enterprises, such as AgrAbility, telehealth, and collaborative programs with independent living centers are few but show promise for overcoming obstacles to community reintegration and full participation among people with SCI in rural areas. Rehabilitation professionals can facilitate this process by participating in advocacy efforts, collaborating with state surveillance systems, developing innovative outreach models, and participating in research to identify and remove barriers to community reintegration.

Tolerability of Opioid Analgesia for Chronic Pain: A Network Meta-Analysis

Aim of this study was to study the tolerability of opioid analgesia by performing a network meta-analysis (NMA) of randomized-controlled trials (RCTs) which investigated effectiveness of opioids for the management of chronic pain. Research articles reporting outcomes of RCT/s comparing 2 or more opioid analgesics for the management of chronic pain were obtained by database search. Bayesian NMAs were performed to combine direct comparisons between treatments with that of indirect simulated evidence. Study endpoints were: incidence of adverse events, incidence of constipation, trial withdrawal rate, and patient satisfaction with treatment. Outcomes were also compared with conventional meta-analyses. Thirty-two studies investigating 10 opioid drugs fulfilled the eligibility criteria. Tapentadol treatment was top-ranking owing to lower incidence of overall adverse events, constipation, and least trial withdrawal rate. Tapentadol was followed by oxycodone-naloxone combination in providing better tolerability and less trial withdrawal rate. Patient satisfaction was found to be higher with oxycodone-naloxone followed by fentanyl and tapentadol. These results were in agreement with those achieved with conventional meta-analyses. Tapentadol and oxycodone-naloxone are found to exhibit better tolerability characteristics in comparison with other opioid drugs for the management of chronic pain and are associated with low trial withdrawal rate and better patient satisfaction.

Poster 409: Incomplete Paraplegia Caused by a T7/T8 Subdural Hematoma in a Middle-Aged Man Started on Warfarin for New Onset Atrial Fibrillation: A Case Report

post herpetic pain syndrome. This virus is morphologically and antigenically identical to the virus that causes chickenpox. It is believed that zoster outbreaks are probably the result of a weakened immune system that fails to halt latent varicella-zoster virus replication. This theory does not always prove true because many patients are found to have healthy intact immune systems. It is uncertain whether factors such as radiation, physical trauma, certain medications, other infections, or stress can also trigger zoster. Conclusions: Herpes zoster expression has not been shown to be associated with physical trauma to the nerve in which the virus resides. This case reveals a loose association between physical trauma to the right C7 foramina and herpatic radiculitis of the exiting nerve. Although it is true, there could be many reasons for the expression of zoster in this case, the expression of zoster along the exact dermatome of the nerve exiting the involved foramina compels us to take a closer look at the diseases association with trauma.

Poster 363: Stanozolol in Osteoporosis Management After Spinal Cord Injury: A Case Report

Disclosures: R. Pfeifer, None. Patients or Programs: A 25-year-old man. Program Description: Patient sustained a work-related injury when he slipped and fell into a split leg position. Immediately, he felt left groin pain radiating into the medial thigh without sensory loss or weakness. The next morning, he noted decreased sensation and weakness in the left leg, progressing to right lower limb weakness and sensory loss, as well as urinary retention and involuntary flatus. On consultation, we noted grade 4/5 strength in the right lower limb, 1-2/5 in the left hip flexors/knee extensors, 3/5 in remaining left leg muscles. Sensory examination revealed decreased sensation to light touch and pinprick below T12 bilaterally with intact vibration and proprioception. Rectal examination showed intact sensation with good tone and volitional contraction. Neurologic work-up was negative except MRI of the thoracolumbar spine, revealing Schmorl’s nodes at T10-T12 and hyperintensity within the spinal cord from T9-T11 centered within left dorsal aspect. Diffusion MRI revealed restricted diffusion corresponding to signal abnormality at T9-T11 consistent with acute spinal cord infarct. Setting: University-based acute care hospital. Results: During the 1-week of acute care, he received physical and occupational therapy with significant lower limb strength recovery to 5/5 on the right, 4/5 in left hip flexors/ knee extensors, 5/5 in remaining left leg muscles. Neurogenic bowel and bladder resolved. On discharge to acute rehabilitation, he ambulated at a supervision level with rolling walker. Two months after injury, he returned to light duty work with mild weakness and paresthesias, ambulating independently. Discussion: In reported cases, fibrocartilaginous embolic spinal cord infarct is typically diagnosed post-mortem. His clinical presentation of trauma with leg splitting, examination and neuroimaging are consistent with spinal cord infarct. In the setting of increased axial load, concomitant Schmorl’s nodes may embolize to the vascular supply of the spinal cord causing infarction. Conclusions: This case represents a clinical diagnosis of fibrocartilaginous spinal cord infarct causing paraplegia. Clinicians should be suspicious of this pathology in cases of trauma without other clear etiology.