Spinal Cord Injury Providers’ Perceptions Of Barriers To Implementing Selected Clinical Practice Guideline Recommendations

Abstract

Background/Objective: Twelve focus groups were conducted at 6 Department of Veterans Affairs (DVA) Spinal Cord Injury (SCI) Centers. The purpose of these focus groups was to identify provider-perceived barriers to implementing selected recommendations of two clinical practice guidelines (CPGs)-Prevention of Thromboembolism in Spinal Cord Injury and Management of Neurogenic Bowel in Adults With Spinal Cord Injury-at their sites.

Methods: A total of 75 SCI direct-care staff (including physicians, nurses, dieticians, rehabilitation therapists, psychologists, and social workers) participated in the focus groups, which were conducted by trained focus group facilitators. Woolfs framework was used to classify perceived barriers into 1 of 4 categories: (a) lack of knowledge, (b) lack of agreement, (c) lack of ability, or (d) lack of systematic reminders for implementation. The "lack of ability" category was further expanded to reflect which specific aspect of the environment was seen as the obstacle: (a) patient, (b) provider, (c) SCI unit, (d) hospital or medical center, or (e) non-Veterans Affairs (VA) hospital setting.

Results: Providers disagreed with the recommendation to reinstitute prophylaxis in patients with nona cute SCI to prevent deep vein thrombosis and identified a number of system-level problems with providing appropriate prophylaxis. Providers identified patient reluctance to changing their bowel programs and difficulties in documenting changes in the patients' bowel program as obstacles to implementing the neurogenic bowel CPG.

Conclusion: Based on this feedback, interventions were developed to address provider-perceived barriers. These interventions were implemented at 6 Veterans Affairs SCI Centers.

J Spinal Cord Med. 2003;26:48-58     

Physiologic Basis Of Digital–Rectal Stimulation For Bowel Evacuation In Patients With Spinal Cord Injury: Identification Of An Anorectal Excitatory Reflex

Abstract

Background and purpose: Although advances in rehabilitation practices, pharmacology, and surgery offer new bowel program alternatives, digital-rectal stimulation is still utilized to facilitate defecation in patients with spinal cord injury (SCI) . We speculated that defecation induced by such a technique is mediated through a reflex mechanism.

Methods: The study comprised 18 healthy volunteers (10 men, 8 women, mean age 36.6 ± 9.7 years) and 9 patients with SCI (6 men, 3 women, mean age 35 .1 ± 11 .2 years). The anal canal was dilated by a balloon inflated in 2-ml increments to 10 ml, and rectal pressure response was then recorded. The test was repeated after separate block of the external and internal anal sphincters and after individual anesthetization of the anal canal and rectum.

Results: In normal subjects, the rectal pressure rose significantly (p<0.01) with 2-ml inflation. Increases in anal dilatation effected further rectal pressure elevations (p < 0.001 ), although there were no significant differences among the 4-, 6-, and 10-ml distensions (p > 0.05). The rectal pressure rise occurred with external, but not with internal, sphincter paralysis. In the subjects with paraplegia, there was no rectal pressure response to the 2- and 4-ml anal dilatations, while the 6-, 8-, and 10-ml distensions effected significant pressure increases (p<0.001, p<0.001, p<0.001, respectively) that did not differ significantly among the 3 distending volumes. Internal sphincter inhibition,in contrast to the external sphincter, produced no rectal pressure response. In both normal subjects and subjects with paraplegia, the rectal pressure response did not occur after individual anesthetization of the rectum and anal canal.

Conclusions: Anal dilatation induces rectal contraction through stimulation of mechanoreceptors, possibly in the internal sphincter.Rectal contraction upon anal dilatation suggests a reflex relationship that was absent onindividual anesthetization of the possible2arms of the reflex arc: anal canal and rectum.This relationship, which we term the "anorectal excitatory reflex ," appears to be evoked on digital anal dilatation. The reflexmight be of diagnostic significance in defecationdisorders and has the potential to be used as an investigative tool.     

Comparison Of Parenting Styles Of Persons With And Without Spinal Cord Injury And Their Children’s Social Competence And Behavior Problems

Abstract

Objective: This study compared the parenting styles of 62 individuals with spinal cord injury (SCI) and 62 individuals without disabilities and the behavior of their children aged 6 through 13 years.

Methods: The relationship between parenting style and children’s behavior was assessed. Pairs were matched by gender of parent and age and gender of child. The Parenting Dimensions Inventory and the Child Behavior Checklist were administered via telephone.

Results: After controlling for income, the 2 groups did not differ in the parenting factors of warmth/structure and strictness. Their children did not differ in social competence or behavior problems.

Conclusion: Regardless of disability status, warmth and structure were found to be the aspects of parenting that were related to children’s outcomes.     

Evaluation Of Cranberry Supplement For Reduction Of Urinary Tract Infections In Individuals With Neurogenic Bladders Secondary To Spinal Cord Injury.A Prospective,Double-Blinded,Placebo–Controlled,Crossover Study

Abstract

Objective: To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTis) in persans with spinal cord injury (SCI).

Design: A prospective, double–blinded, placebo–controlled, crossover study.

Participants: 21 individuals with neuragenie bladders secondary to SCI. Main Outcome Measures: Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts.

Methods: lndividuals with neuragenie bladders due to SCI were recruited and randomly assigned to standardized 400–mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1–week “washout period,” participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count 2: 1 0 perhigh power field) in centrifuged urine. Participa nts with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7–day washaut period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead’s random effect approach.

Results: There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups.

Conclusion: Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTis in individuals with neuragenie bladders. Further Long–term studies evaluating specific types of bladder management and UTis will help to determine whether there is any role for the use of cranberries in individuals with neuragenie bladders.     

Fatal Spinal Cord Injury of the 20th President Of The United States: Day–By-–Day Review Of His Clinical Course,With Comments

Abstract

Background: This article presents the medical history of the 20th president of the United States, James A. Garfield, with an emphasis on hisspinal cord injury (SC I). Numerous references debate the care he received from the medical and surgical perspectives, but little has been written about the essential aspect of his gunshot wound-namely, the darnage to his spinal cord. President Garfield was shot in the lumbar spine and was bedridden until he died 80 days following his injury. This article contrasts state-of-the-art care in 1881 to today’s standards of care for SCI.

Method: Literature review. Arecord of daily reports of the president’s condition was analyzed. Comparisons were made between the president’s care and what is now available.

Findings: Although the president had access tothebest physicians, the chronicle of his course underscores the deficiencies in basic medical care, the controversies concerning surgical intervention, and the problems inherent in the care of a prominent patient. Press releases did not overtly address spinal cord trauma and its complications so as to avoid conveying the president’s degree of incapacity. Garfield ’s SCI was documented on autopsy. The bullet entered the 1Oth intercostal space, 3 112 inches to the right of the spinous processes, fracturing the 11th and 12th vertebrae and nicking the Tl 2-L 1 disc. The bullet then passed through the right side of the body of L 1 and exited the vertebra anteriorly and to the left and lodged behind the pancreas, where it was found encased by a firm cyst.

Conclusion: Deficiencies in general medical care and surgical technique at the time contributed to the president’s demise. This case was marked by controversies that still are debated today-for example, whether the bullet should have been removed surgically. Examination of available evidence suggests that with today’s advances in medical, surgical, and SCI medicine, a person with this type of injury would likely survive and be a candidate for rehabilitation.     

Low Serum 3,3′,5-Triiodothyronin (T3) and Reciprocally High Serum 3,3′,5′-Triiodothyronin (Reverse T3) Concentration in Spinal Cord Injury Patients

ABSTRACT

Thyroid function tests were performed on 115 spinal cord injury patients. Serum thyroxine, thyroid stimulating hormone, and T₃ resin uptake were within normal range in all patients. Serum T₃ levels tended to be low in paraplegic and quadriplegic patients, even though they were clinically euthyroid and other thyroid functions were normal. Serum reverse T₃ levels were reciprocally higher in these patients.     

Platform abstracts: Academy of Spinal Cord Injury ProfessionalsEducational Conference 2013: The Changing Face of Spinal Cord InjuryBally's Hotel,Las Vegas,NevadaSeptember 2–4, 2013Platform Abstracts 1–29Abstracts 1-3 ASCIP are the Award-Winning Student Research Presentations*

Objective

Studies have shown that management with an indwelling catheter for patients with neurogenic bladder dysfunction (NGB) is associated with more complications that are urological but little is known about the effects on quality of life.

Design

A prospective cross-sectional cohort study in a tertiary care neurourology clinic.

Participants/Methods

Patients were defined according to bladder management: group 1 (diaper voiding, indwelling urethral, suprapubic tube, or condom catheter) or group 2 (urinate normally, clean intermittent catheterization (CIC), or stoma).

Results

The 158 patients (67 women and 91 men) with mean age of 42.4 years (range 18.8–75.4 years) had a mean time from neurologic insult of 15.9 years. Sixty five percent of the cohort had a traumatic spinal cord injury and the remainder had other causes for NGB (multiple sclerosis, spina bifida, and non-traumatic SCI). Thirty patients were included in group 1 and 120 in group 2. Health-Related quality of Life (HRQOL) responses were similar for both bladder management groups (SF-12, AUA Symptom Index, Incontinence Symptom Index). However, when patients were explicitly asked “In general how satisfied are you with the way your bladder is managed?” they were more satisfied if they did not have an indwelling catheter or diaper voiding (P value 0.02). A subgroup analysis of patients using CIC (self or caregiver) showed catheterization frequency of 5.5 ± 1.8 times per day and a majority viewed CIC as easy (mean score 2.6 ± 2.1, range: 1 very easy to 10 extremely difficult).

Conclusion

Patients utilizing an indwelling catheter or diaper voiding were no more satisfied with their HRQOL than were those utilizing CIC or stoma to manage their bladders. When asked specifically about their bladder management, patients were significantly less satisfied with their bladder management if they were using an indwelling catheter or diaper voiding. While these results are limited by the small and self-selected cohort, these data illustrates the need for standardized validated questionnaires to assess bladder management satisfaction in the neurogenic bladder patient population.

• J Spinal Cord Med. 2013 Sep; 36(5): 504–523.
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• 2. NEEDS ASSESSMENT FOR SPINAL CORD INJURY MALE FERTILITY PROGRAM AT UNIVERSITY OF UTAH HEALTH CARE*

J Spinal Cord Med. 2013 Sep; 36(5): 504–523. doi: 10.1179/1079026813Z.000000000206

2. NEEDS ASSESSMENT FOR SPINAL CORD INJURY MALE FERTILITY PROGRAM AT UNIVERSITY OF UTAH HEALTH CARE*

Katarina Lesjak Waters, DNP, FNP-C, MSN, APRNAuthor information Copyright and License information DisclaimerPhysical Medicine and Rehabilitation Division, University of Utah Health Care, Salt Lake City, UT, USACopyright notice