Economics of managed care in spinal cord injury

OBJECTIVE: To determine and describe trends in economic variables related to the care of individuals with spinal cord injury (SCI) and significant changes in these trends coincident with major developments in medical care cost control. DATA SOURCES: Data from the National Spinal Cord Injury Statistical Center (NSCISC) database were used to review the economic trends in SCI management from 1973 to 1998 and their relation to managed care and other health care cost-containment measures. A panel of SCI health care specialists was interviewed to determine the appropriate data variables to be reviewed. The Shepherd Center Care Health Management Program, Atlanta, GA, is presented as an example of a fiscally successful managed care program for patients with SCI. DATA EXTRACTION: Data from the NSCISC database for the years studied were extracted and converted to a form suitable for analysis by means of the statistical software SAS. DATA SYNTHESIS: Statistical techniques included multiple regression analysis, logistic regression analysis, and model selection methods. CONCLUSIONS: Trends in economic variables, in the care of individuals with SCI show changes coincident with the introduction of Diagnostic Related Groups (DRGs) and managed care as models for provider reimbursement. Significant changes occurred in acute care charges, rehabilitation charges, length of stay, rehospitalization 1 year postinjury, time from injury to admission to a Model System, and discharges to a nursing home.     

Nursing models and self-concept in patients with spinal cord injury--a comparison between UK and Taiwan

The purpose of this study is to investigate rehabilitation nurses' care for patients with spinal cord injury (SCI). It also examines how rehabilitation nurses perceive their role in assessing the alteration of self-concept and the interventions they use in helping patients to develop a more positive perception of themselves. A critical review of common models in use was undertaken including Roper, Logan and Tierney's Activities of Living Model, Roy's Adaptation Model and Orem's Self-care Deficit Nursing Theory. A nursing framework has been developed for rehabilitation nursing. Data were collected by questionnaire. The findings indicate that rehabilitation nurses are aware of the alteration in self-concept for patients with SCI. Although nursing interventions include physiological, psychological and social aspects of care, nurses do not feel that current nursing models are useful in SCI nursing and tend to support the specially designed model.     

The perceived benefits and barriers of sport in spinal cord injured individuals: a qualitative study

Purpose: This study explores what individuals with spinal cord injury (SCI) perceive to be the benefits of becoming involved in organized sport and identifies the barriers to participation. Method: Seven SCI athletes from a variety of sports were interviewed in a semi-structured format. Results: 20 benefits and 18 individual barriers were identified and categorized into sub-themes: benefits were categorized into sub-themes of "socialization," "self-worth," "physical challenge" and "emotional." Barriers were grouped into "organization," "medical," "emotional," "a lack of available information" and "views held by others." Conclusion: A variety of benefits from participating in sport were identified, including socialization, the acquisition of knowledge from others, the development of greater awareness of health and well-being issues, weight maintenance, functional development and independence. Barriers identified included financial constraints, the lack of information regarding medical complications and sporting opportunities, and the need for able-bodied support. The findings have implications for the rehabilitation of individuals with SCI. [Box: see text].     

Functional improvement after pediatric spinal cord injury

OBJECTIVE: To describe the functional gain (FGain) with pediatric spinal cord injury inpatient rehabilitation and to identify the relationship of various factors to FGain in pediatric spinal cord injury inpatient rehabilitation. DESIGN: Retrospective chart review of a series of 91 children with spinal cord injury admitted from 1993 to 1998 in a freestanding rehabilitation hospital. Admission and discharge functional status were assessed with the Pediatric Functional Independence Measure (WeeFIM) instrument for children 7 yr. The outcome measure is the FGain (difference between the discharge and admission functional status). RESULTS: Significant gains in functional status were observed in all patients. FGain was not significantly related to age, sex, length of inpatient rehabilitation, pathogenesis, or completeness or neurologic level of injury. However, there was a trend for higher FGain for patients with incomplete spinal cord injury and traumatic spinal cord injury. CONCLUSIONS: Functional improvement occurs with pediatric spinal cord injury inpatient rehabilitation. There is a trend for higher FGain in patients with less severe injury and traumatic injury. The lack of relationship between FGain and length of inpatient rehabilitation suggests that a variety of other factors influence the relationship between FGain and length of inpatient rehabilitation.     

Traumatic spinal cord injury: an acute care rehabilitation perspective

Traumatic spinal cord injury (SCI) can have a devastating effect on the patient, family members, and acute care staff. A multidisciplinary team effort is essential for the psychosocial support of the patient and family through the injury process. SCI rehabilitation management in the acute care setting will be reviewed along with the process for selecting an appropriate rehabilitation facility.     

Bridging the gap: transitional rehabilitation services for people with spinal cord injury

Purpose : To review the current international rehabilitation and healthcare climate and describe a new model of service delivery aimed at enhancing the continuity of care for people with spinal cord injury (SCI).

Method : An extensive literature review was undertaken and a new model of service delivery conceptualized and implemented in the Australian context of SCI rehabilitation.

Results : This new model of service delivery aims to improve the rehabilitation continuum for people with SCI by reducing the time spent in hospital, increasing consumer control over the rehabilitation environment and enhancing community re-integration. The new model recognizes the changing nature of the healthcare system, the legislative frameworks within which rehabilitation services are provided and the increasing role of the consumer.

Conclusions : Models of rehabilitation that address the need for shorter periods of hospitalization and attempt to improve client outcomes are integral to ensure sustainable rehabilitation services in the future.     

Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation

Harkema SJ, Hillyer J, Schmidt-Read M, Ardolino E, Sisto SA, Behrman AL. Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation. Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a "paradigm shift." Not only do we recognize the potential of the damaged nervous system, but we also see that "recovery" can and should be valued and defined broadly. Quality-of-life measures and the individual's sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation's NeuroRecovery Network.     

Spinal cord injury and outdoor experiences

Anecdotal evidence from spinal cord injury (SCI) rehabilitation clients suggests that nature experiences and outdoor pursuits are valued ingredients in a SCI rehabilitation program, in particular for those individuals who were outdoor enthusiasts pre-injury and/or who sustained their injury during outdoor pursuits. Model SCI centres in North America offer outdoor activities as components of SCI rehabilitation. A literature review on the effects and dynamics of nature experiences and outdoor pursuits in SCI rehabilitation and adjustment reveals a lacuna of empirical research in this area. Studies on leisure and recreation following SCI offer insights into how non-vocational rehabilitation activities assist functional independence, quality of life, and community re-integration. Systematic research is needed to ascertain the value and contribution of outdoor experiences in SCI rehabilitation; further, research is needed to document how contact with 'blue-green nature' may assist in the identity reconstruction process and in adjustment to life with a physical disability.     

Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan

Rathore FA, Farooq F, Muzammil S, New PW, Ahmad N, Haig AJ. Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan.Recent natural disasters have highlighted the lack of planning for rehabilitation and disability management in emergencies. A review of our experience with spinal cord injury (SCI) after the Pakistan earthquake of 2005, plus a review of other literature about SCI after natural disasters, shows that large numbers of people will incur SCIs in such disasters. The epidemiology of SCI after earthquakes has not been well studied and may vary with location, severity of the disaster, available resources, the expertise of the health care providers, and cultural issues. A lack of preparedness means that evacuation protocols, clinician training, dedicated acute management and rehabilitation facilities, specialist equipment, and supplies are not in place. The dearth of rehabilitation medicine specialists in developing regions further complicates the issue, as does the lack of national spinal cord registries. In our 3 makeshift SCI units, however, which are staffed by specialists and residents in rehabilitation medicine, there were no deaths, few complications, and a successful discharge for most patients. Technical concerns include air evacuation, early spinal fixation, aggressive management to optimize bowel and bladder care, and provision of appropriate skin care. Discharge planning requires substantial external support because SCI victims must often return to devastated communities and face changed vocational and social possibilities. Successful rehabilitation of victims of the Pakistan earthquake has important implications. The experience suggests that dedicated SCI centers are essential after a natural disaster. Furthermore, government and aid agency disaster planners are advised to consult with rehabilitation specialists experienced in SCI medicine in planning for the inevitable large number of people who will have disabilities after a natural disaster.     

Effectiveness of a head injury program for children: a preliminary investigation

OBJECTIVE: The purpose of this study was to investigate whether a more coordinated, comprehensive head injury rehabilitation program provided at a children's trauma center yielded better outcomes than a less coordinated, less comprehensive program. DESIGN: Using a quasi-experimental design, 64 children with head injury admitted to the center and who received rehabilitation services in either 1995 or 1993 were evaluated by using the Functional Independence Measure for children (WeeFIM)/The Functional Independence Measure (FIM) (e.g., primary outcome measure). Secondary outcomes included "psychosocial adjustment," "return to regular school," and "current problems related to the head injury." RESULTS: No statistically significant differences were found between the groups with respect to mean WeeFIM/FIM scores after controlling for age and injury severity. The 1993 group had poorer scores on the withdrawal subscale of the psychosocial measure (P = 0.02), yet a smaller proportion of these children were enrolled in a special education class (P = 0.02). CONCLUSIONS: This study serves as a model for a larger, definitive study of the effectiveness of rehabilitation for children with head injury. The trends suggest that more comprehensive care may lead to better outcomes.     

Augmentative and alternative communication intervention in children with traumatic brain injury and spinal cord injury

Children and youth who sustain a traumatic brain injury (TBI) and/or spinal cord injury (SCI) may have temporary or permanent disabilities that affect their speech, language and communication abilities. Having a way to communicate can help reduce children's confusion and anxiety, as well as enable them to participate more actively in the rehabilitation process and thus, recover from their injuries. In addition, effective communication with family, care staff, peers, teachers and friends is essential to long-term recovery and positive outcomes for children with TBI and SCI as they are integrated back into their communities. This article describes how rehabilitation teams can use augmentative and alternative communication (AAC) and assistive technologies (AT) to support the communication of children recovering from TBI and SCI over time.     

Aging, gender, and spinal cord injury

OBJECTIVE: To identify differences in the aging experiences of men and women with spinal cord injury (SCI). DESIGN: This study is part of a longitudinal international study of aging and SCI. SETTING: Five centers in England, Canada, and the United States. Three were spinal cord rehabilitation facilities (Stoke-Mandeville Hospital, Southport Hospital, Craig Hospital) and 2 were community agencies (Ontario and Manitoba divisions of the Canadian Paraplegic Association). PARTICIPANTS: A matched sample of 67 men and 67 women with SCI for at least 20 years. The 2 groups were matched on age, country of origin, and duration of disability. Participants had an average age of 57 years and an average disability duration of almost 33 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two measures were taken by interview: demographic form and current status interview. Five others were self-administered and returned by mail: the Perceived Stress Scale, Craig Handicap Assessment and Reporting Technique, Index of Psychological Well-Being, Current Problem Questionnaire, and Life Satisfaction Index. RESULTS: Although both sexes rated their quality of life about equally, women characterized their aging experience as "accelerated," while men characterized it as "complicated." Women reported more effects of pain, fatigue, and skin problems and more transportation problems. Men experienced more health problems, more diabetes, and more adaptive equipment changes. Older men and women with SCI spent their time differently, consistent with traditional gender roles. CONCLUSIONS: These results underline the need for gender-specific consideration of aging experiences associated with SCI and further emphasize the need for primary and preventive care to promote health and well-being as people with SCI survive into old age.     

Does spirituality facilitate adjustment and resilience among individuals and families after SCI?

Purpose: The purpose of this scoping review was to investigate the role of spirituality in facilitating adjustment and resilience after spinal cord injury (SCI) for the individual with SCI and their family members. Method – data sources: Peer reviewed journals were identified using PsychInfo, MEDLINE, CINAHL, Embase and Sociological Abstracts search engines. Study selection: After duplicates were removed, 434 abstracts were screened applying inclusion and exclusion criteria. Data extraction: The selected 28 studies were reviewed in detail and grouped according to methodological approach. Results: Of the 28 studies relating to spirituality and related meaning-making constructs, 26 addressed the adjustment of the individual with SCI alone. Only two included family members as participants. Quantitative studies demonstrated that spirituality was positively associated with life satisfaction, quality of life, mental health and resilience. The utilisation of meaning-making and hope as coping strategies in the process of adjustment were highlighted within the qualitative studies. Clinical implications included recommendations that spirituality and meaning-making be incorporated in assessment and interventions during rehabilitation. The use of narratives and peer support was also suggested. Conclusions: Spirituality is an important factor in adjustment after SCI. Further research into the relationship between spirituality, family adjustment and resilience is needed.

• Implications for Rehabilitation

• Higher levels of spirituality were associated with improved quality of life, life satisfaction, mental health, and resilience for individuals affected by spinal cord injury.

• Health professionals can enhance the role that spirituality plays in spinal rehabilitation by incorporating the spiritual beliefs of individuals and their family members into assessment and intervention.

• By drawing upon meaning-making tools, such as narrative therapy, incorporating peer support, and assisting clients who report a decline in spirituality, health professionals can provide additional support to individuals and their family members as they adjust to changes after spinal cord injury.

     

脊髓损伤后的体位性低血压

体位性低血压是指在直立体位下的血压的下降。体位性低血压常发生在高位脊髓损伤的患者中,影响患者的训练和康复。但到目前为止,其发生原因尚未完全明确。本文主要就脊髓损伤后体位性低血压的可能原因;典型症状、诊断和测量;治疗和预防进行综述。     

Overview of Cochrane Systematic Reviews for Rehabilitation Interventions in Persons With Spinal Cord Injury: A Mapping Synthesis

ObjectiveThis article aims to describe the evidence on rehabilitation interventions for persons with spinal cord injury (SCI) identified in Cochrane Systematic Reviews (CSRs) selected for inclusion in the World Health Organization Rehabilitation Programme–Package of Interventions for Rehabilitation.Data SourcesThe CSRs search was led by the Cochrane Rehabilitation team, using the tagging process, using the terms “spinal cord injury” and “rehabilitation” in the Cochrane Library.Study SelectionWe performed an overview of all the CSRs according to the inclusion criteria defined with the World Health Organization: rehabilitation interventions in persons with SCI.Data ExtractionThe CSRs identified after the screening process were summarized using an evidence map, grouping outcomes, and comparisons of included CSRs indicating the effect and the quality of evidence to provide a comprehensive view of what is known.Data SynthesisOut of 248 CSRs from the past 10 years tagged in the Cochrane Rehabilitation database, 3 were related to SCI. They provide data on 13 outcomes analyzed within 11 comparisons for a total of 64 primary studies, including 2024 participants with SCI. Of these, 7 outcomes and 1 comparison focused on people with cervical SCI. Rehabilitation interventions might improve respiratory outcomes and pain relief in people with SCI. There is uncertainty whether bodyweight-supported treadmill training, robotic-assisted training, and functional electrostimulation affect walking speed and capacity.ConclusionsThe current evidence needs to be confirmed by better quality research. Therefore, future priorities are the improvement of methodological quality of the studies in people with SCI, particularly considering the complexity of this health condition. Further, there is a need for more CSRs in the field.     

Long-term outcomes and life satisfaction of adults who had pediatric spinal cord injuries

Objective: To determine long-term outcomes and life satisfaction of adults who sustained pediatric spinal cord injury (SCI).Design: Structured interview of adults who were 25 years or older who had pediatric SCI.Setting: Community.Participants: A convenience sample of 46 patients from a total of 81 patients who received care in an SCI program: 1 refused participation, 4 died, and 30 were lost to follow-up.Main Outcome Measures: A structured questionnaire including physical, psychosocial, and medical information. The Craig Handicap Assessment and Reporting Technique and two measures of life satisfaction were also administered.Results: Participants were 25 to 34 years old, mean 27 years. Thirty-two had tetraplegia and 14 had paraplegia. Thirty-one were men. Mean years of education was 14. Fifty-four percent were employed, 48% lived independently, and 15% were married. Life satisfaction was associated with education, income, satisfaction with employment, and social/recreation opportunities, and was inversely associated with some medical complications. Life satisfaction was not significantly associated with level of injury, age at injury, or duration of injury.Conclusions: Individuals who had pediatric SCI, much like adult-onset SCI, have the greatest opportunity for a satisfying adult life if rehabilitation emphasizes psychosocial factors such as education, employment, and long-term health management.     

Duplex ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission.

OBJECTIVE: To determine the rate of deep vein thrombosis (DVT) newly diagnosed by duplex ultrasound in patients with acute spinal cord injury (SCI) at admission for rehabilitation. DESIGN: Retrospective case-control study. SETTING: Independent specialized spinal cord rehabilitation hospital. PATIENTS: Data were collected from records of 189 SCI patients admitted for rehabilitation over a 1-year period who underwent a duplex scan and were not admitted with a known diagnosis of DVT. MAIN OUTCOME MEASURES: A DVT newly diagnosed by duplex ultrasound at rehabilitation admission. RESULTS: Twenty-two patients (11.6%) had a newly diagnosed DVT at time of admission. Chi-square analysis found no statistically significant relationship between level of injury (tetraplegia vs paraplegia), motor complete (ASIA A and B) versus incomplete status (ASIA C and D), or cause of SCI (traumatic vs nontraumatic injury) in determining a positive or negative duplex result (chi2 = 1.709, p = .191; chi2 = 1.314, p = .252; chi2 = 3.155, p = .076; respectively). Prophylaxis for DVT decreased the risk of developing a DVT: 4.1% of patients administered prophylaxis as compared to 16.4% of patients not given prophylaxis (chi2 = 6.558, p = .01). Only 38.6% of patients transferred to rehabilitation were undergoing DVT prophylaxis. CONCLUSIONS: The prevalence of DVT in acute SCI patients at admission to rehabilitation is significant. A duplex ultrasound is an important noninvasive technique to screen patients with acute and subacute SCI for DVT on admission to the rehabilitation setting regardless of the completeness, level, or cause of the patients' injury.     

Secondary health conditions in persons with a spinal cord injury for at least 10 years: design of a comprehensive long-term cross-sectional study

Purpose: To describe the prevalence of secondary health conditions (SHCs) (urinary tract and bowel problems, pressure ulcers, spasticity, musculoskeletal and neuropathic pain, sexual dysfunction, respiratory and cardiovascular disorders) in persons with long-term spinal cord injury (SCI), and to explore the impact of SHCs on fitness, active lifestyle, participation and well-being. Methods: A time since injury (TSI)-stratified cross-sectional study among 300 persons between 28- and 65-year-old with a SCI for at least 10 years. Strata of TSI are 10–19, 20–29, and 30 or more years. All eight Dutch rehabilitation centres with a SCI unit will participate. Participants will be invited for a 1-day visit to the rehabilitation centre for an aftercare check-up by the local SCI rehabilitation physician (neurological impairment, SHCs and management), physical tests by a trained research assistant (lung function, wheelchair skills, physical capacity), and they will be asked to complete a self-report questionnaire in advance. Results: Not applicable. Conclusion: This study will provide knowledge on the health status and functioning of persons aging with SCI living in the Netherlands. This knowledge will help us to develop predictive models for the occurrence of SHCs and to formulate guidelines to improve health care for persons with long-term SCI.

Implications for Rehabilitation

• Persons with long-term spinal cord injury may be susceptible to many types of secondary health conditions (i.e. pressure ulcers, urinary tract infections, pain and spasticity).

• Coordinated long-term health care is required for this population but this is currently not operational in all specialized rehabilitation centres in the Netherlands.

• This study aims to develop predictive models for the occurrence of secondary health conditions and to develop guidelines to improve long-term health care for persons living with a spinal cord injury in the Netherlands.

     

Robot-assisted upper extremity rehabilitation for cervical spinal cord injuries: a systematic scoping review

Purpose: To provide an overview of the feasibility and outcomes of robotic-assisted upper extremity training for individuals with cervical spinal cord injury (SCI), and to identify gaps in current research and articulate future research directions.

Materials and methods: A systematic search was conducted using Medline, Embase, PsycINFO, CCTR, CDSR, CINAHL and PubMed on June 7, 2017. Search terms included 3 themes: (1) robotics; (2) SCI; (3) upper extremity. Studies using robots for upper extremity rehabilitation among individuals with cervical SCI were included. Identified articles were independently reviewed by two researchers and compared to pre-specified criteria. Disagreements regarding article inclusion were resolved through discussion. The modified Downs and Black checklist was used to assess article quality. Participant characteristics, study and intervention details, training outcomes, robot features, study limitations and recommendations for future studies were abstracted from included articles.

Results: Twelve articles (one randomized clinical trial, six case series, five case studies) met the inclusion criteria. Five robots were exoskeletons and three were end-effectors. Sample sizes ranged from 1 to 17 subjects. Articles had variable quality, with quality scores ranging from 8 to 20. Studies had a low internal validity primarily from lack of blinding or a control group. Individuals with mild-moderate impairments showed the greatest improvements on body structure/function and performance-level measures. This review is limited by the small number of articles, low-sample sizes and the diversity of devices and their associated training protocols, and outcome measures.

Conclusions: Preliminary evidence suggests robot-assisted interventions are safe, feasible and can reduce active assistance provided by therapists.

• Implications for rehabilitation

• Robot-assisted upper extremity training for individuals with cervical spinal cord injury is safe, feasible and can reduce hands-on assistance provided by therapists.

• Future research in robotics rehabilitation with individuals with spinal cord injury is needed to determine the optimal device and training protocol as well as effectiveness.

     

Walking after spinal cord injury: evaluation, treatment, and functional recovery

OBJECTIVE: To present some recent developments and concepts emerging from both animal and human studies aimed at enhancing recovery of walking after spinal cord injury (SCI). DATA SOURCES: Researchers in the field of restoration of walking after SCI, as well as references extracted from searches in the Medline computerized database. STUDY SELECTION: Studies that reported outcome measures of walking for spinal cord injured persons with an incomplete motor function loss or cats with either a complete or incomplete spinal section. DATA EXTRACTION: Data were extracted and validity was assessed by the authors. DATA SYNTHESIS: This review shows that a multitude of interventions--mechanical, electrical, or pharmacologic--can increase the walking abilities of persons with SCI who have incomplete motor function loss. CONCLUSIONS: A comprehensive evaluation of walking behavior requires tasks involving the different control variables. This comprehensive evaluation can be used to characterize the process of recovery of walking as well as the effectiveness of various treatments.