Preventive care among primary care patients living with spinal cord injury

Objective: Context/Objective: Family physicians may lack the knowledge or resources to adequately support patients with spinal cord injury (SCI). Our objectives were to determine patterns of preventive care for patients with SCI in a primary care setting (i.e. cancer screening, influenza vaccinations, general physicals, bone mineral density tests), and determine physicians’ level of comfort with providing primary care to patients with SCI.

Design: i) Retrospective chart review, ii) Survey of physicians in the family practice.

Setting: Six primary care practice sites in Ontario, Canada.

Participants: All adult rostered patients of the family practice with SCI; All family physicians in the six sites.

Outcome Measures: Proportion of patients up-to-date on cancer screening, proportion of patients with influenza vaccinations, general physicals, bone mineral density tests; physicians’ level of comfort with providing care to patients with SCI.

Results: Sixty patients were included in analyses. Rates of cancer screening were generally poor. The highest uptake was seen for cervical cancer screening, where 50% of eligible women were up-to-date on Pap tests. Only 36.7% of patients were up-to-date on colorectal cancer screening. Only 14 (23.3%) patients had a documented general physical exam in their electronic record. There was a recorded flu vaccination for 55% of patients, and of those, there was a median of 19 months since last vaccination. Fifteen physicians (21.4%) responded to the survey. Ten physicians reported at least one patient with SCI, with the maximum being 20 patients. Comfort level in managing SCI-relevant conditions varied and was lowest for spasticity, respiratory issues and autonomic dysreflexia, where only 27.3% of respondents had some level of comfort.

Conclusion There are many opportunities to improve the preventive care of patients living with SCI.     

The impact of early spasticity on the intensive functional rehabilitation phase and community reintegration following traumatic spinal cord injury

Context/Objectives: To determine the impact of spasticity presenting during the acute care hospitalization on the rehabilitation outcomes following a traumatic spinal cord injury (TSCI).

Design: Retrospective cohort study.

Setting: A single Level 1 trauma center specialized in SCI care.

Participants: 150 individuals sustaining an acute TSCI.

Interventions: Not applicable.

Outcome Measures: The total inpatient functional rehabilitation length of stay. The occurrence of medical complications and the discharge destination from the inpatient functional rehabilitation facility were also considered.

Results: 63.3% of the cohort presented signs and/or symptoms of spasticity during acute care. Individuals with early spasticity developed medical complications during acute care and during intensive functional rehabilitation in a higher proportion. They were also hospitalized significantly longer and were less likely to return home after rehabilitation than individuals without early spasticity. Early spasticity was an independent factor associated with increased total inpatient rehabilitation length of stay.

Conclusion: The development of signs and symptoms of spasticity during acute care following a TSCI may impede functional rehabilitation outcomes. In view of its association with the occurrence of early spasticity, higher vigilance towards the prevention of medical complications is recommended. Early assessment of spasticity during acute care is recommended following TSCI.     

Perceived Quality of Care and Outcomes Following Spinal Cord Injury: Minority Status In The Context Of Multiple Predictors

Abstract

Objective: T o determine whether patients with spinal cord injury (SCI) who are members of minority groups experience a disadvantage with regard to quality of care, and investigate predictors of perceived quality of care and indicators of outcome.

Design: Correlational analysis of longitudinal data.

Sample: One hundred and forty-three individuals with SCI in the first year following injury (43.3 % tetraplegia, 56.7% paraplegia; 53.6% of total had complete injuries).

Setting: Hospital and post discharge (usually outpatient) care at 3 SCI model systems.

Main Outcome Measures: Perceived quality of acute, rehabilitative, and continuing care rated by patients according to standardformat. Objective indicators of amount of care (eg, length of stay [LOS], charges) and outcomes (eg, medical complications,Functional lndependence Measure [FIM] scores, a life satisfaction measure [the Diener Scale], and the Craig Handicap and Reporting Technique [CHART; a community participation scale]).

Results: Minorities did not report statistically significant differences in perceived quality of care or other indicators (eg, amount ofcare, medical complications, FIM gain, life satisfaction, and CHART scores) compared with other groups. Severity ofinjury affected LOS and activity outcomes. Satisfaction with medical care before the injury significantly predicted perceived quality of acute hospital care, inpatient rehabilitation, and continuing ca re (P < 0.03, 0.02, and 0.02, respectively) .

Conclusion: A number of factors may affect variations in perceived quality of care and outcomes, but ethnicity is not always the most important predictor. Asking patients about their satisfaction with previous care can assist in distinguishing satisfaction with currentcare from pre-existing biases.     

Implementing a self-management mobile app for spinal cord injury during inpatient rehabilitation and following community discharge: A feasibility study

Objective: To determine the feasibility of implementing and evaluating a self-management mobile app for spinal cord injury (SCI) during inpatient rehabilitation and following community discharge.

Design: Pilot feasibility study.

Setting: Rehabilitation hospital and community.

Participants: Inpatients from rehabilitation hospital following admission for their first SCI.

Intervention: A mobile app was developed to facilitate self-management following SCI. The app consisted of 18 tools focusing on goal setting, tracking various health aspects, and identifying confidence regarding components of self-management. In-person training and follow-up sessions were conducted during inpatient rehabilitation and follow-up calls were provided after participants were discharged into the community.

Main outcome measures: Participants completed outcome measures at baseline, community discharge, and 3-months post discharge. This study focused on feasibility indicators including recruitment, retention, respondent characteristics, adherence, and app usage. Additionally, participants’ self-management confidence relating to SCI (e.g. medication, skin, bladder, pain) was evaluated over time.

Results: Twenty participants (median age 39, IQR: 31 years, 85% male) enrolled in the study. Participants’ Spinal Cord Injury Independence Measure (SCIM-III) median score was 23 and IQR was 33 (range: 7–84), which did not correlate with app usage. Retention from admission to discharge was 85% and 70% from discharge to 3-months post discharge. Individuals in the study who used the app entered data an average of 1.7x/day in rehabilitation (n?=?17), and 0.5x/day in the community (n?=?7). Participants’ bowel self-management confidence improved between admission and discharge (P?<?0.01).

Conclusions: Feasibility indicators support a larger clinical trial during inpatient rehabilitation; however, there were challenges with retention and adherence following community discharge.     

SCIitelsafe Prefect Series: The Supplemental Cursing Taxonomy

Context: Spinal cord injury (SCI) rehabilitation nurses document the occurrence of educational and care management efforts in traditional nursing documentation methods but not the intensity (or dose) of such interactions. This article describes a process to capture these nursing interventions.

Methods: Nurses at 6 US inpatient SCI centers used 2 in-person meetings and weekly telephone calls over 9 months to develop a taxonomy of nursing patient education efforts and care management.

Results: This was subsequently incorporated into a point-of-care documentation system and used to capture details of nursing care for 1,500 SCI rehabilitation patients enrolled in the SCIRehab study. The taxonomy consists of 10 education and 3 care management categories. The point-of-care system includes time spent on each category along with an indication of whether the patient and/or family received the education/care management. In addition, a subjective measure of patient participation in nursing activities is included.

Conclusions: Creation of a SCI rehabilitation nursing taxonomy is feasible, and its use has had an impact on nursing practice. It also has implications for future clinical documentation, because greater accuracy and details of patient education and care management will be a permanent practice in the participating systems at the conclusion of the study.     

Incidence,Etiology, and Risk Factors for Fever Following Acute Spinal Cord Injury

Abstract

Objective: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI).

Design: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2- year period was performed.

Setting: The study was performed at a tertiary care, Level I trauma center.

Participants: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study.

Main Outcome Measures: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured.

Results: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5°F vs 101.1°F on acute and 101.5°F vs 100.7°F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4°F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation).

Conclusions: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost- efficient fever workup in individuals with SCI.     

Clinical Activities Of The Model Spinal Cord Injury System

Abstract

Objective: To review clinical activities that have resulted from funding of the Model Spinal Cord Injury System (MSCIS).

Methods: Review of the literature and responses from Model Systems Centers.

Results: Clinical benefits derived from MSCIS funding have been classified into 5 different areas: shift of spinal cord care from individual centers to care from a “Systems approach”; data collection as a stimulus for improved clinical care; service comprehensiveness to improve clinical care; research as a stimulus for improved clinical care; and dissemination of MSCIS research findings for educational purposes and to improve care provided by all SCI centers, including those not funded by the MSCIS.

Conclusion: Many clinical benefits have been derived from the MSCIS program. Current research and developments being studied at model systems across the nation should continue to lead to new standards of care for persons with SCI.     

Long-term compliance with bladder management in patients with spinal cord injury: A Saudi-Arabian perspective

Objective: To examine long-term compliance with bladder management in patients with spinal cord injury (SCI) at a tertiary care rehabilitation facility in Saudi Arabia.

Design: Cross-sectional survey.

Setting: Tertiary care rehabilitation facility in Saudi Arabia.

Participants: A self-administered questionnaire was distributed to patients with SCI during their clinic visits. 50 patients (41 males and nine females) participated in the survey. Data documentation included demographic characteristics, type and level of injury, compliance with bladder management and barriers in compliance.

Main outcome measures: The type of bladder management employed at first follow-up visit was compared with that employed at discharge.

Results: Eleven out of 41 patients who were discharged on clean intermittent catheterization (CIC) stopped it within 3 months of discharge, mainly due to lack of accessibility and financial support to buy catheters. Of the total sample, 23% reported that they did not know the difference between catheter types and their advantages, and 49% stated that they did not receive proper health education regarding bladder management.

Conclusion: CIC was the most commonly used bladder management technique in patients with SCI following up at a tertiary care rehabilitation facility in Saudi Arabia. Compliance with CIC may be improved by ensuring access to catheters post-discharge and by providing appropriate education about bladder management during inpatient rehabilitation.     

The Influence of Age and Gender on Rehabilitation Outcomes in Nontraumatic Spinal Cord Injury

Abstract

Study Design: Retrospective, 3-year case series.

Objective: To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI).

Setting: Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI.

Method: Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores.

Results: Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P - 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P=0.04) subscores. There were no significant relationships between gender and FIM subscale scores.

Conclusions: Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.     

Utilization and access to healthcare services among community-dwelling people living with spinal cord injury

Objective: Describe the utilization, accessibility, and satisfaction of primary and preventative health-care services of community-dwelling individuals with spinal cord injury (SCI).

Design: Cross sectional, in-person or telephonic survey, utilizing a convenience sample.

Setting: Community.

Participants: Individuals with SCI greater than 12-months post injury.

Interventions: N/A.

Outcome measures: Demographic, injury related, and 34-item questionnaire of healthcare utilization, accessibility, and satisfaction with services.

Results: The final sample consisted of 142 participants (50 female, 92 male). Ninety-nine percent of respondents had a healthcare visit in the past 12-months with primary care physicians (79%), with SCI physiatrists (77%) and urologists (50%) being the most utilized. 43% of the sample reported an ER visit within the past 12-months, with 21% reporting multiple visits. People who visited the ER had completed significantly less secondary education (P?=?0.0386) and had a lower estimate of socioeconomic status (P?=?0.017). The majority of individuals (66%) were satisfied with their primary care physician and 100% were satisfied with their SCI physiatrist. Individuals who did not visit an SCI physiatrist were significantly more likely to live in a rural area (P?=?0.0075), not have private insurance (P?=?0.0001), and experience a greater decrease in income post injury (P?=?0.010).

Conclusion: The delivery of care for people with SCI with low socioeconomic status may be remodeled to include patient-centered medical homes where care is directed by an SCI physiatrist. Further increased telehealth efforts would allow for SCI physiatrists to monitor health conditions remotely and focus on preventative treatment.     

The effects of robot assisted gait training on temporal-spatial characteristics of people with spinal cord injuries: A systematic review

Context: Robotic assisted gait training (RAGT) technology can be used as a rehabilitation tool or as an assistive device for spinal cord injured (SCI) individuals. Its impact on upright stepping characteristics of SCI individuals using treadmill or overground robotic exoskeleton systems has yet to be established.

Objective: To systematically review the literature and identify if overground or treadmill based RAGT use in SCI individuals elicited differences in temporal-spatial characteristics and functional outcome measures.

Methods: A systematic search of the literature investigating overground and treadmill RAGT in SCIs was undertaken excluding case-studies and case-series. Studies were included if the primary outcomes were temporal-spatial gait parameters. Study inclusion and methodological quality were assessed and determined independently by two reviewers. Methodological quality was assessed using a validated scoring system for randomized and non-randomized trials.

Results: Twelve studies met all inclusion criteria. Participant numbers ranged from 5-130 with injury levels from C2 to T12, American Spinal Injuries Association A-D. Three studies used overground RAGT systems and the remaining nine focused on treadmill based RAGT systems. Primary outcome measures were walking speed and walking distance. The use of treadmill or overground based RAGT did not result in an increase in walking speed beyond that of conventional gait training and no studies reviewed enabled a large enough improvement to facilitate community ambulation.

Conclusion: The use of RAGT in SCI individuals has the potential to benefit upright locomotion of SCI individuals. Its use should not replace other therapies but be incorporated into a multi-modality rehabilitation approach.     

Relational empathy and holistic care in persons with spinal cord injuries

Objective: Describe perceptions of persons with SCI on their receipt of holistic care and relational empathy during health care encounters.

Design: Mailed survey.

Participants/Setting: Individuals with SCI who received care from the largest suppliers of SCI care and rehabilitation (Veterans Health Administration and SCI Model Systems).

Outcome Measures: Using a survey and administrative databases, we collected demographic and injury characteristics, health status, health conditions, and the main outcome: Consultation and Relational Empathy (CARE) measure.

Results: The sample included 450 individuals with SCI (124 Veterans and 326 civilians). Response rate was 39% (450/1160). Analyses were conducted on patients with complete data (n?=?389). Veterans and civilians with SCI differed across many demographic characteristics, age at injury, and etiology, but mean CARE scores were equivalent. Fewer than half of the full SCI cohort had CARE scores above the normative value of 43. Having a recent pressure ulcer showed a trend for lower odds of having a normative or higher CARE score. Odds of having an above-normative CARE score were nearly 2 times greater for individuals with tetraplegia, and odds were higher for those with higher physical and mental health status.

Conclusions: Higher physical and mental health status and tetraplegia were each independently associated with greater perceptions of holistic care and empathy in the therapeutic patient-provider relationship. Limited empathy, communication, and holistic care may arise when providers focus on disease/disease management, rather than on patients as individuals. Frequent health care use and secondary conditions may affect empathy and holistic care in encounters, making it essential to understand and employ efforts to improve the therapeutic relationship between patients with SCI and their providers.     

SCIRehab Project Series: The Psychology Taxonomy

Context: The integration of psychologists as members of the rehabilitation team has occurred in conjunction with the evolution and adoption of interdisciplinary teams as the standard of care in spinal cord injury (SCI) rehabilitation. Although the value of psychological services during rehabilitation is endorsed widely, specific interventions and their association with patient outcomes have not been examined adequately.

Objective: To address this shortcoming, psychologists from 6 SCI centers collaborated to develop a psychology intervention taxonomy and documentation framework.

Methods: Utilizing an interactive process, the lead psychologists from 6 centers compiled an inclusive list of patient characteristics assessed and interventions delivered in routine psychological practice at the participating rehabilitation facilities. These were systematically grouped, defined, and compared.

Results: The resulting taxonomy became the basis of a documentation framework utilized by psychologists for the study. The psychology taxonomy includes 4 major clinical categories (assessment, psychotherapeutic interventions, psychoeducational interventions, and consultation) with 5 to 10 specific activities in each category.

Conclusions: Examination of psychological interventions and their potential association with positive outcomes for persons who sustain SCI requires the development of a taxonomy. Results of these efforts illustrate similarities and differences in psychological practice among SCI centers and offer the opportunity to blend research and clinical practice in an innovative approach to evidence-based practice improvement. The established taxonomy provides a basic framework for future studies on the effect of psychological interventions.     

Clinical Taxonomy Development and Application in Spinal Cord Injury Research: The SCIRehab Project

Background/Objective: Applying practice-based evidence research methodology to spinal cord injury (SCI) rehabilitation requires taxonomy (typology or classification) of rehabilitation interventions provided by every discipline contributing to SCI rehabilitation. The rehabilitation field currently lacks such taxonomy. Methods: SCIRehab project researchers and clinicians representing 7 rehabilitation disciplines from 6 US inpatient SCI rehabilitation facilities worked in discipline groups during 2 face-to-face meetings and weekly discipline-specific teleconferences for 9 months to identify key contributions of each discipline to SCI rehabilitation and to develop a classification of treatment interventions used by each discipline. These clinician groups were charged with designing documentation systems that collected enough details to describe treatment adequately while not imposing an unrealistic data collection burden on clinicians. Completed documentation systems were programmed onto handheld personal digital assistants (PDAs) to facilitate data entry by clinicians at the point of care.

Results: Seven discipline-specific SCI rehabilitation taxonomies were developed that describe and quantify intervention activities (major categories of treatment offered by the discipline) and the activity-specific details (variables deemed important to fully describe the interventional process). Much treatment information is unique to each discipline; some is common across disciplines.

Conclusions: The taxonomies provide a format with which clinicians document actual interventions performed with or for patients. The SCIRehab project has developed the first comprehensive multidisci-plinary taxonomy for describing the details of the SCI rehabilitation process and designed a PDA-based documentation system based on that taxonomy that allows clinicians to describe the specifics of their interactions with their patients.     

Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers

Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia.

Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health.

Setting: Urban and rural areas of Mongolia.

Participants: A purposive sample of 16 persons with traumatic SCI.

Interventions: Not applicable.

Outcome Measures: Not applicable.

Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life.

Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia.