Masculine role variables and outcomes among men with spinal cord injury

Purpose.?Few studies have considered the impact of masculine role variables on outcome and adjustment to SCI among men. The present study examined the relations among SCI, views of masculinity, psychological adjustment, and rehabilitation outcomes among men with SCI.

Method.?The sample included 20 men with SCI receiving inpatient rehabilitation, with a mean age of 45 years. Data included demographic variables as well as Conformity to Masculine Norms Inventory (CMNI), Gender Role Conflict Scale (GRCS), Functional Independence Measure (FIM), and Satisfaction with Life Scale ratings, and change in marital status.

Results.?The findings revealed that satisfaction with life was positively related to scores on the CMNI Violence scale, FIM change from admission to discharge was positively related to the CMNI Emotional Control scale and negatively related to the CMNI Dominance scale. Change in marital status was inversely related to the CMNI Emotional Control and Primacy of Work scales and the GRCS Restricted Emotionality and Power, Success, and Competition scales.

Conclusions.?The findings show that certain aspects of the traditional masculine role (i.e., ability to modulate strong emotions) may be adaptive in the rehabilitation process, whereas other aspects (i.e., a dominant interpersonal style) may present a barrier to effective rehabilitation.     

Masculine role variables and outcomes among men with spinal cord injury

Purpose. Few studies have considered the impact of masculine role variables on outcome and adjustment to SCI among men. The present study examined the relations among SCI, views of masculinity, psychological adjustment, and rehabilitation outcomes among men with SCI.

Method. The sample included 20 men with SCI receiving inpatient rehabilitation, with a mean age of 45 years. Data included demographic variables as well as Conformity to Masculine Norms Inventory (CMNI), Gender Role Conflict Scale (GRCS), Functional Independence Measure (FIM), and Satisfaction with Life Scale ratings, and change in marital status.

Results. The findings revealed that satisfaction with life was positively related to scores on the CMNI Violence scale, FIM change from admission to discharge was positively related to the CMNI Emotional Control scale and negatively related to the CMNI Dominance scale. Change in marital status was inversely related to the CMNI Emotional Control and Primacy of Work scales and the GRCS Restricted Emotionality and Power, Success, and Competition scales.

Conclusions. The findings show that certain aspects of the traditional masculine role (i.e., ability to modulate strong emotions) may be adaptive in the rehabilitation process, whereas other aspects (i.e., a dominant interpersonal style) may present a barrier to effective rehabilitation.     

护理干预对脊髓损伤患者压疮的影响

目的 探讨预防脊髓损伤患者压疮发生的干预方法。方法 将84例经压疮危险因素评估评分≤14分的患者随机分为观察组与对照组各42例。观察组进行护理干预,对照组给予常规护理。观察两组患者实施各护理方案后1周内压疮发生率、发生时间、发生程度等指标。结果 观察组患者压疮发生率、压疮程度均显著低于对照组(P＜0.05),压疮发生时间明显延迟(P＜0.05)。结论 护理干预可有效降低脊髓损伤患者的压疮发生率,延迟难免性压疮的首次发生时间,减轻压疮发生程度,减少患者痛苦,提升基础护理质量。     

Risk factors for early occurring pressure ulcers following spinal cord injury

We carried out a prospective study to determine the association between immobilization in the immediate postinjury period and the development of pressure ulcers in spinal cord-injured patients following their admission to Charity Hospital, New Orleans. Of 39 patients consecutively admitted to the hospital, 23 (59%) developed a grade one ulcer within 30 days, mostly in the sacral region (57%), the peak time of onset being day 4 postinjury (6/23 cases). In partial support of an earlier retrospective study (Linares HA, Mawson AR, Suarez E, Biundo JJ Jr: Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987;10:571-573), duration of unrelieved pressure prior to ward admission was significantly associated with ulcers developing within the first eight days of injury (P = 0.04), but not with ulcers developing during the entire 30-day observation period (P = 0.09). Time on the spinal board was also significantly associated with ulcers developing within 8 days (P = 0.01), but not with ulcers developing within 30 days (P = 0.09). An unexpected finding was the significant inverse association between systolic blood pressure and the development of ulcers both within 8 days (P = 0.03) and within 30 days (P = 0.02), suggesting that reduced tissue perfusion increases the spinal cord-injured patient's susceptibility to pressure ulcers.     

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

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.     

Evaluation of a self‐efficacy enhancement program to prevent pressure ulcers in patients with a spinal cord injury

Aim

This study developed a self‐efficacy enhancement program and evaluated its effects on the self‐care behaviors, self‐care knowledge, and self‐efficacy regarding pressure ulcer prevention in patients with a spinal cord injury.

Methods

This was a multicenter randomized controlled trial. Six hospitals were invited to recruit patients with a spinal cord injury who were undergoing rehabilitation after receiving acute treatment. These hospitals were randomly allocated into experimental (three hospitals) or control (three hospitals) groups and 47 patients participated (24 in the experimental group and 23 in the control group). The experimental group was given an 8 week self‐efficacy enhancement program for pressure ulcer prevention. The self‐efficacy enhancement program consisted of small‐group face‐to‐face intervention (education and skills training), education with computer animation, phone counseling, face‐to‐face counseling, and self‐management records. The control group only received a pressure ulcer prevention information booklet. Self‐care knowledge, self‐efficacy, self‐care behaviors, and pressure ulcer incidence were measured at baseline and after the 8 week self‐efficacy enhancement program.

Results

The experimental group showed a significantly greater improvement in self‐care knowledge, self‐efficacy, and self‐care behaviors for pressure ulcer prevention than did the control group. One participant in the control group developed a pressure ulcer, while none of the participants in the experimental group developed a pressure ulcer; this difference was not statistically significant.

Conclusions

The self‐efficacy enhancement program enabled patients with a spinal cord injury to engage in continued self‐care behaviors and helped them to improve their knowledge and self‐efficacy concerning pressure ulcer prevention.

     

Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury

OBJECTIVE: To describe the challenges of conducting a large randomized controlled trial (RCT) to assess the effectiveness of an intervention to prevent recurrent pressure ulcers among a high-risk population of subjects with spinal cord injury (SCI). DESIGN: Prospective multisite, randomized design comparing outcomes of patients who received individualized education and structured telephone counseling follow-up with those of patients receiving customary care. This study was stopped early because of unanticipated recruitment problems. SETTING: Six Veterans Affairs SCI specialty centers. PARTICIPANTS: Veterans (N=150) treated for stage III or IV pelvic pressure ulcers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Recurrence (defined as new skin breakdown in the pelvic area) and time to recurrence. The study was stopped early because of slow recruitment, so the focus of this study is lessons learned, not the main planned outcome measures. RESULTS: Subject recruitment did not meet original expectations because almost 50% of those enrolled left the hospital with the study ulcer unhealed (having a healed ulcer was a requirement for participation). No significant differences were observed between groups on rate of or time to recurrence at the time the study was stopped. Among the 6 sites, variability in ulcer management (eg, length of stay, receipt of medical vs surgical treatment, sitting tolerance before discharge) and time to recurrence (median, 4mo) were observed. CONCLUSIONS: RCTs in real-world settings are the most robust method of assessing the effectiveness of prevention strategies. However, in complex, rapidly changing health care organizations, blinding is infeasible, it may be impractical to control for every variable that influences a study's outcome, and any assumptions that usual care is static are probably mistaken. Investigators must be prepared to use innovative approaches to maintain the integrity of the study design, including flexibility in inclusion and exclusion criteria to support accrual, obtaining a better understanding of the important aspects of usual care that may need to be standardized, continuous improvement within the intervention arm, and anticipation and minimization of risks from organizational changes. With attention to these delivery system issues and the usual design features of randomized trials, we believe real-world care settings can serve as important laboratories to test pressure ulcer prevention strategies in this population.     

Infertility in men with spinal cord injury

Infertility is a significant and frustrating problem for many men after spinal cord injury. The two major causes are poor semen quality and ejaculatory dysfunction. Factors attributed to poor semen quality include stasis of prostatic fluid, testicular hyperthermia, recurrent urinary tract infections, abnormal testicular histology, possible changes in the hypothalamic-pituitary-testicular axis, possible sperm antibodies, chronic long-term use of various medications, and type of bladder management. Further work is needed to define the impact and importance of each of these factors. Ejaculations are reported to occur in only 5% of men with spinal cord injury (SCI) who have complete upper motor lesions and 18% of those who have complete lower motor lesions. Ejaculations occur in up to 70% of men with incomplete lesions. Methods that have been used to induce an ejaculate include intrathecal neostigmine, subcutaneous physostigmine, direct aspiration of sperm from the vas deferens, vibratory stimulation, electroejaculation, and direct stimulation of the hypogastric nerve. The most commonly used methods in the United States are electroejaculation and vibratory stimulation; using these two methods, ejaculates can be obtained up to 85% and 59% of the time, respectively. Each of these methods has advantages and disadvantages. Particular care needs to be given to monitoring men undergoing these procedures who are prone to autonomic dysreflexia. The future outlook is encouraging once improved technology for obtaining semen and various methods to assist reproduction, such as in vitro fertilization, are available.     

Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention

Rintala DH, Garber SL, Friedman JD, Holmes SA. Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention.

Objective

To test the hypothesis that enhanced education and structured follow-up after pressure ulcer surgery will result in fewer recurrences.

Design

Randomized controlled trial.

Setting

Veterans Affairs medical center.

Participants

Forty-nine veteran men with spinal cord injury or dysfunction were approached on admission for pressure ulcer surgery. Five never had surgery, 2 refused to participate, and one withdrew. Forty-one were randomized into 3 groups. Three participants' ulcers did not heal, so follow-up could not begin.

Interventions

Group 1 received individualized pressure ulcer education and monthly structured telephone follow-up (n=20); group 2 received monthly mail or telephone follow-up without educational content (n=11); and group 3 received quarterly mail or telephone follow-up without educational content (n=10). Follow-up continued until recurrence, death, or 24 months.

Main Outcome Measure

Time to pressure ulcer recurrence.

Results

Group 1 had a longer average time to ulcer recurrence or end of study than groups 2 and 3 (19.6mo, 10.1mo, 10.3mo; P=.002) and had a smaller rate of recurrence (33%, 60%, 90%; P=.007). Survival analysis confirmed these findings (P=.009).

Conclusions

Individualized education and structured monthly contacts may be effective in reducing the frequency of or delaying pressure ulcer recurrence after surgical repair of an ulcer.     

Pressure ulcers in veterans with spinal cord injury: a retrospective study

Pressure ulcers are a major complication of spinal cord injury (SCI) and have a significant effect on general health and quality of life. The objectives of this retrospective chart review were to determine prevalence, duration, and severity of pressure ulcers in veterans with SCI and to identify predictors of (1) outcome in terms of healing without surgery, not healing, or referral for surgery; (2) number of visits veterans made to the SCI outpatient clinic or received from home care services for pressure ulcer treatment; and (3) number of hospital admissions and days hospitalized for pressure ulcer treatment. From a sampling frame of 553 veterans on the Houston Veterans Affairs Medical Center SCI roster, 215 (39%) were reported to have visited the clinic or received home care for pressure ulcers (ICD-9 code 707.0 = decubitus, any site) during the 3 years studied (1997, 1998, and 1999). From this sample, 102 veterans met the inclusion criteria for further analyses, 56% of whom had paraplegia. The duration of ulcers varied greatly from 1 week to the entire 3-year time-frame. Overall, Stage IV pressure ulcers were the most prevalent as the worst ulcer documented. Number and severity of ulcers predicted outcome and healthcare utilization. This study illustrates the magnitude of the pressure ulcer problem among veterans with SCI living in the community. Reducing the prevalence of pressure ulcers among veterans with SCI will have a significant impact on the Department of Veterans Affairs' financial and social resources. Innovative approaches are needed to reduce pressure ulcer risk in veterans with SCI.     

Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury

The purpose of this study was to assess the efficacy of high voltage pulsed direct current (HVPC) for healing of pressure ulcers in patients with spinal cord injury. Seventeen patients having pressure ulcers in the pelvic region were randomly assigned to either an HVPC group or a placebo HVPC group. Treatments were given for 1 hour a day for 20 consecutive days. The HVPC protocol consisted of an aluminum-foil electrode placed over the ulcer and set at negative polarity in reference to the dispersive electrode placed on the thigh. Stimulator frequency was set at 100 pps, and an intensity of 200 V was used. Measurements of ulcer surface area were conducted before treatment and after treatment days 5, 10, 15, and 20. To measure ulcer area (in square millimeters), slides taken at each measurement time were projected at actual size, traced, and digitized. Percentage of change compared with pretreatment ulcer size was calculated for each measurement time. Ulcers in the HVPC group demonstrated significantly greater percentage-of-change decreases from their pretreatment size than did ulcers in the placebo group at days 5, 15, and 20. The results suggest that HVPC, in conjunction with good nursing care, can significantly increase the healing rate of pelvic ulcers in patients with spinal cord injury.     

Spinal cord injury and pressure ulcers

The SCI person is at high risk for pressure ulcers; thus, pressure ulcer prevention is a critical component of care. Guidelines exist to promote evidenced-based practice for the prevention and treatment of pressure ulcers in the SCI. There is a discrepancy between what persons with SCI know about pressure ulcer prevention and what they are doing to reduce their risk of developing this serious complication. Objective data demonstrate that adherence to a skin care regimen contributes to the prevention of pressure ulcers. Knowledge about pressure ulcer prevention and treatment must be appropriately focused for the patient, family, and the health care team and must be reinforced over time.     

Evaluation of the cost-effectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury

Mittmann N, Chan BC, Craven BC, Isogai PK, Houghton P. Evaluation of the cost-effectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury.

Objective

To evaluate the incremental cost-effectiveness of electrical stimulation (ES) plus standard wound care (SWC) as compared with SWC only in a spinal cord injury (SCI) population with grade III/IV pressure ulcers (PUs) from the public payer perspective.

Design

A decision analytic model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness of ES plus SWC to SWC in a cohort of participants with SCI and grade III/IV PUs. Model inputs for clinical probabilities were based on published literature. Model inputs, namely clinical probabilities and direct health system and medical resources were based on a randomized controlled trial of ES plus SWC versus SWC. Costs (Can $) included outpatient (clinic, home care, health professional) and inpatient management (surgery, complications). One way and probabilistic sensitivity (1000 Monte Carlo iterations) analyses were conducted.

Setting

The perspective of this analysis is from a Canadian public health system payer.

Participants

Model target population was an SCI cohort with grade III/IV PUs.

Interventions

Not applicable.

Main Outcome Measure

Incremental cost per PU healed.

Results

ES plus SWC were associated with better outcomes and lower costs. There was a 16.4% increase in the PUs healed and a cost savings of $224 at 1 year. ES plus SWC were thus considered a dominant economic comparator. Probabilistic sensitivity analysis resulted in economic dominance for ES plus SWC in 62%, with another 35% having incremental cost-effectiveness ratios of $50,000 or less per PU healed. The largest driver of the economic model was the percentage of PU healed with ES plus SWC.

Conclusions

The addition of ES to SWC improved healing in grade III/IV PU and reduced costs in an SCI population.     

Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury

Saunders LL, Krause JS, Acuna J. Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury.ObjectiveTo assess the associations of race and socioeconomic status (SES) with pressure ulcers (PUs) after accounting for health care access among persons with spinal cord injury (SCI).DesignCross-sectional.SettingLarge specialty hospital in the southeastern United States.ParticipantsPersons with traumatic SCI who (1) had residual effects from their injury, (2) were 18 years or older at the time of the survey, and (3) were a year or more postinjury at the time of survey (N=2549).InterventionsNone.Main Outcome MeasuresOutcomes were measured by a mail-in survey: having a current PU (yes vs no), having a PU in the past year with or without reduced sitting time (no PU, no reduced sitting time, month or less, ≥5wk), and having at least 1 PU surgery since SCI onset (yes vs no).ResultsOf participants, 39.3% reported a PU in the past year, 19.9% had a current PU, and 21.9% reported having had surgery for a PU since their SCI onset. While race was preliminarily associated with each PU outcome, it became nonsignificant after controlling for SES and health care access. In each analysis, household income was significantly associated with PU outcomes after controlling for demographic and injury factors and remained significant after accounting for the health care access factors. Persons with lower income had higher odds of each PU outcome. Health care access was not consistently related to PU outcomes.ConclusionsEven after accounting for health care access, household income, a measure of SES, remained significantly associated with PU outcomes after SCI; however, race became nonsignificant.     

Earnings among people with spinal cord injury

Krause JS, Terza JV, Dismuke C. Earnings among people with spinal cord injury.

Objective

To identify differences in conditional and unconditional earnings among participants with spinal cord injury (SCI) attributable to biographic, injury, educational, and employment factors by using a 2-part model (employment, earnings).

Design

A secondary analysis of cross-sectional survey data.

Setting

A Midwestern university hospital and a private hospital in the Southeastern United States.

Participants

All participants (N=1296) were adults between the ages of 18 and 64 who had a traumatic SCI at least 1 year before study initiation.

Interventions

Not applicable.

Main Outcome Measures

Earnings were defined by earnings within the previous 12 months and were measured by a single categoric item. Conditional earnings reflect the earnings of employed participants, whereas unconditional earnings reflect all participants with $0 in earnings recorded for those unemployed.

Results

Sex and race were significantly related to conditional earnings, even after controlling for educational and vocational variables. Additionally, conditional earnings (employed participants only) were related to 16 or more years of education, number of years employed, the percentage of time after SCI spent employed, and working in either government or private industry (not self-employed or family business). There was a greater number of significant variables for unconditional earnings, largely reflective of the influence of the portion employed (those not working having $0 in earnings).

Conclusions

Efforts to improve employment outcomes should focus on facilitating return to work immediately after injury, returning to preinjury job, maintaining regular employment, and working for placement in government or private industry. Special efforts may be needed to promote vocational outcomes among women and nonwhites.