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D - Bladder Continence

Figure 6.0 Volume at Maximum Detrusor Presure During Filing (ml). Canadian trial results of use of bot ulinum toxin , onto the detrusor in neurogenic blader. Reproduced Figure 5.0 from Herschorn et al.2 © 2011 American Urological Association Education and Research, Inc. Reprinted with permision. 600 500 400 300 200 100 0 Baseline Week 6 Week 24 Week 36 Volume cc Weeks a��er injec��on Where We Need to Go and Where We are Headed BoNT-A Placebo p< .05 p< .01 Currently, there are four published clinical practice guidelines, and at least nine key references to provide evidence-based recommendations; as well as a variety of validated assessment tools, used in the management of neurogenic bladder. Despite the availability of these resources, there are many key clinical issues that relate to the need for rehabilitation leadership, in best practice implementation (BPI). The top two priority areas needed to optimize clinical care are: 1. Use of botulinum toxin therapy for the detrusor muscle Due to recent publication of Level 1 evidence demonstrating the efficacy of intravesicular botulinum toxin studies (see Figure 6.0),2,3 Health Canada approval for intravesicular botulinum toxin was obtained, in December 2011. However, the processes and timelines for adoption of this therapy, in provincial formularies, are unclear (estimated timeline is 2017). There is a need to advocate for access to intravesicular botulinum toxin for those who have failed intermittent catheterization, and conventional anticholinergic medications. Further definition of an adequate trial of conventional treatment is needed. 2. Long-term self-management is key to life-long bladder health To achieve this, there needs to be coordinated, interdisciplinary follow up and management of individuals with neurogenic overactive bladder. Follow up and management include ongoing patient education on the effects of neurogenic bladder, and the need for appropriate management; management of secondary complications of neurogenic overactive bladder, and assessment of the need for surgical referral, for issues such as continent catheterizable stomas - with or without bladder augmentation. In addition to working towards resolution of these clinical issues, knowledge innovation is required for bladder continence, post-SCI, as follows: 1. Newer-generation anticholinergics need to be further addressed in the SCI population Those available require better funding (e.g., M3 receptor antagonists) uniformly, across Canada. Presently unfunded are sustained-action anticholinergics, with more acceptable side effects (e.g., less dry mouth). 2. The use of botulinum toxin needs further evaluation, especially in the area of sphincter management There is a lack of quality studies to date.4 Although the effectiveness of detrusor injections for incontinence management is well investigated, long-term use of botulinum toxin for detrusor muscle injections needs further evaluation, including effects on issues other than incontinence (e.g., frequency of catherizations, medication use, intervals of treatment, dosage). Funding issues also need to be resolved, as this is largely unfunded, in Canada, at present. 3. Education is a key component to life-long bladder continence The question of what information should be delivered, in what format, by whom and when, can only be answered by designing studies to systematically evaluate interdisciplinary education programs, for bladder continence. The implementation of best practices, in a structured and measureable framework (once evidence is available), is key to resolving these top clinical issues. A common barrier to best practice implementation is the lack of funding to allow for interventions requiring external resources, such as pharmaceuticals on the formulary for SCI, and appropriate health professionals to provide the evidence-based best practice interventions. In order to ensure that any practice is effective, an agreement on measures of performance is needed. In an evolving healthcare environment that promotes continuous quality improvement (CQI), accreditation at the level of Distinction for SCI through Accreditation Canada might be achievable with the quality indicators shown in the following table. 58 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


D - Bladder Continence
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