Validation of the Spinal Cord Injury–Functional Index for Use in Community-Dwelling Individuals With SCI

ObjectiveTo evaluate the psychometric properties of the Spinal Cord Injury–Functional Index (SCI-FI) instruments in a community-dwelling sample.DesignCross-sectional study.SettingCommunity setting.ParticipantsIndividuals (N=269) recruited from 6 SCI Model Systems sites.InterventionsNot applicable.Main Outcome MeasuresParticipants completed computer adaptive test and short form versions of 4 SCI-FI/Capacity (C) banks (ie, Ambulation, Basic Mobility, Fine Motor, Self-Care) and 1 SCI-FI/Assistive Technology (AT) bank (Wheelchair Mobility) at baseline and after 2 weeks. The Self-Report Functional Measure (SRFM) and the clinician-rated motor FIM were used to evaluate evidence of convergent validity.ResultsPearson correlations, intraclass correlation coefficients, minimal detectable change, and Bland-Altman plots supported the test-retest reliability of the SCI-FI instruments. Correlations were large with the SRFM (.69-.89) and moderate-to-large for the FIM instrument (.44-.64), supporting convergent validity. Known-groups validity was demonstrated by a significant main effect of injury level on all instruments and a main effect of injury completeness on the SCI-FI/C instruments. A ceiling effect was detected for individuals with incomplete paraplegia on the Fine Motor/C and Self-Care/C Short Forms.ConclusionFindings support the test-retest reliability, convergent validity, and known-groups validity of the SCI-FI/C instruments and the SCI-FI/AT Wheelchair Mobility instruments for use by community-dwelling individuals.     

Employment and Job Benefits Among Those With Spinal Cord Dysfunction: A Comparison of People With Spinal Cord Injury and Multiple Sclerosis

Objective(1) Identify the proportion of participants with spinal cord dysfunction (SCD) reporting each of 10 job benefits and compare the proportions between participants with spinal cord injury (SCI) and multiple sclerosis (MS); and (2) examine if diagnostic criteria, demographics, education level, and functional limitations are associated with the number of job benefits received.DesignEconometric modeling of cross-sectional data using a 2-step data analytic model of employment and job benefits.SettingMedical university in the southeastern United States.ParticipantsParticipants (N=2624) were identified from the southeastern United States. After eliminating those age 65 and older, there were 2624 adult participants with SCD; 1234 had MS and 1390 had SCI.InterventionsNot applicable.Main Outcome MeasuresCurrent employment status; number of benefits received and specific benefits received.ResultsA greater proportion of participants with MS received benefits, with significant differences observed on all but 1 type of benefit. Among those who were employed, a greater number of benefits was associated with having MS, greater education, younger age, married or in an unmarried couple, and not having functional restrictions with cognition, doing errands, or shopping alone in the community, and walking.ConclusionsEmployed participants with MS were more likely to receive job benefits, indicative of a higher quality of employment, compared to participants with SCI. Employment without benefits is a form of underemployment that disproportionately affects individuals with many of the same characteristics that initially lead to disparities in probability of gainful employment.     

Validation of Upper Extremity Motor Function as a Key Predictor of Bladder Management After Spinal Cord Injury

ObjectiveTo validate if better upper extremity (UE) motor function predicts clean intermittent catheterization (CIC) adoption and adherence after spinal cord injury (SCI) using a validated instrument (as opposed to prior research using scales based on expert opinion).DesignWe examined data from the Neurogenic Bladder Research Group SCI registry, a multicenter, prospective, observational study assessing persons with neurogenic bladder following SCI. All participants who were unable to volitionally void and were >1 year post injury were included. Participants were dichotomized into those performing CIC vs those using other bladder management methods. In addition to demographic and clinical characteristics, UE motor function was examined using the SCI-Fine Motor Function Index using validated categorization levels: (1) no activities requiring hand function, (2) some activities involving gross hand movement, (3) some activities requiring dexterity or coordinated UE movement, or (4) most activities requiring dexterity and coordinated UE movement. Associations were examined using logistic regression.SettingMulticenter study.ParticipantsRegistry participants unable to volitionally void after SCI (N=1236).InterventionNot applicable.Main Outcome MeasureUpper extremity motor function association with CIC.ResultsA total of 1326 individuals met inclusion criteria (66% performing CIC, 60% male, and 82% white). On multivariate analysis, better UE motor function was associated with a statistically increased odds of performing CIC (odds ratio, 3.10 [Level 3] and odds ratio, 8.12 [Level 4] vs Levels 1 and 2 [P<.001]).ConclusionIn persons with SCI who are unable to volitionally void, UE motor function is highly associated with CIC. These results validate prior findings and continue to suggest that following SCI, the degree of preserved UE motor function is associated with CIC more than any other factor.     

Exoskeletons for Personal Use After Spinal Cord Injury

Before the development of robotic exoskeletons, mobility options beyond a wheelchair were very limited for most people lacking leg movement due to spinal cord injury (SCI). Over the years, robotic exoskeletons have become more widely available and now have the potential to be successfully used for personal use at home and in the community. However, it is important that users set realistic expectations. The features and capabilities of each robotic exoskeleton differ, and how exoskeletons are used may vary greatly between individuals. Robotic exoskeletons can allow individuals with SCI with varying levels of injury to safely and functionally walk for personal mobility or exercise. The following special communication will discuss important considerations surrounding exoskeleton use including feasibility, safety, cost, speed, and potential health benefits of using an exoskeleton for everyday life for people with SCI.     

Various Surfaces Benefited Functional Outcomes and Fall Incidence in Individuals With Spinal Cord Injury: A Randomized Controlled Trial With Prospective Data Follow-up

ObjectivesTo compare effects of walking training on a walking track with different surfaces (WTDS), including artificial grass, soft, and pebbles, as compared to overground walking training on the functional ability necessary for independence and incidence of falls of ambulatory individuals with spinal cord injury (SCI).DesignA randomized controlled trial (single-blinded design) with 6-month prospective fall data follow-up.SettingTertiary rehabilitation centers and several communities.ParticipantsIndependent ambulatory individuals (N=54) with SCI who walked with or without a walking device.InterventionParticipants were randomly arranged into a control group (overground walking training, n=26) or experimental group (walking training over a WTDS, n=28) for 30 min/d, 5 d/wk over 4 weeks.Main Outcome MeasuresThe 10-m walk test, timed Up and Go test, five times sit-to-stand test, and 6-minute walk test were repeatedly measured 4 times, including before training, and after 2 and 4 weeks, and 6 months. In addition, participants were prospectively monitored for the fall data over 6 months.ResultsParticipants who walked with an average speed of 0.52 m/s and postinjury time >7 years could safely walk over a WTDS. They demonstrated significant improvement at 2 and 4 weeks after experimental training (P<.001), but not after control training. During the 6-month follow-up, participants in the experimental group also had the number of those who fell (n=5, 18%) fewer than those in the control group (n=12, 46%).ConclusionsBeing at a chronic SCI with ability of independent walking, participants needed a challenging task to promote their functional outcomes and minimize fall risk. The findings suggest the use of various surfaces as an alternative rehabilitation strategy for these individuals.     

Investigating Characteristics of Quality Peer Mentors With Spinal Cord Injury

ObjectiveTo identify characteristics (1) of high- and low-quality spinal cord injury (SCI) peer mentors; (2) that should be used to match SCI peer mentors and mentees.DesignThe study was conducted in partnership with three Canadian provincial SCI organizations using an integrated knowledge translation approach. The Delphi exercise was completed in three rounds. In Round 1, people with SCI completed a thought-listing exercise to identify characteristics of high- and low-quality peer mentors and for matching. In Rounds 2 and 3, people with SCI and community organization staff rated characteristics from the previous round on an 11-point scale. After the final round, the remaining characteristics were thematically analyzed.SettingCommunity-based peer mentorship programs in three Canadian provinces.ParticipantsPeople with SCI and SCI community organization staff (Round 1, n=45; Round 2, n=27; Round 3, n=25).InterventionsNot applicable.Main Outcome MeasuresConsensus-based list of characteristics.ResultsParticipants reached consensus on 215 characteristics of quality peer mentors and 11 characteristics for peer mentor-mentee matching (ICC=0.96). A consensus-based characterization of high- and low-quality peer mentorship was created and included six overarching themes: competencies, personality characteristics, emotional state, mentor outlook, reason for mentoring, and role model.ConclusionA consensus-based characterization of quality peer mentorship was co-developed with input from over 50 members of the SCI community. Findings highlight that peers have both interpersonal and intrapersonal characteristics that contribute to quality mentorship. The findings highlighted the importance of matching mentors on lived experience and shared interests. Findings will inform future research and SCI peer mentorship programs.     

Racial and Ethnic Differences in Obesity in People With Spinal Cord Injury: The Effects of Disadvantaged Neighborhood

ObjectiveTo examine the role of neighborhood in the relation between race and obesity in people with spinal cord injury (SCI).DesignA cross-sectional analysis of survey data from National SCI Database linked with neighborhood data from American Community Survey by census tract.SettingA total of 17 SCI Model Systems centers.ParticipantsIndividuals (N=3385; 2251 non-Hispanic whites, 760 non-Hispanic blacks, 374 Hispanics) who completed a follow-up assessment during 2006-2017 (mean duration of injury, 8.3±9.9y) and resided in 2934 census tracts.InterventionNot applicable.Main Outcome MeasuresBody mass index (BMI) (kg/m²).ResultsThe overall prevalence of obesity was 52.9% (BMI≥25.0) and 23.3% (BMI≥30.0). Hispanics were 67.0% more likely to be obese (BMI≥30.0 kg/m²) relative to non-Hispanic whites (odds ratio, 1.67; 95% confidence interval, 1.27-2.18), after controlling for demographic and injury-related characteristics. Most of the non-Hispanic blacks (66.8%) were living in neighborhoods with high concentrated disadvantaged index (CDI), compared to 35.0% of Hispanics and 9.2% of non-Hispanic whites living in this similar neighborhood status (P<.0001). After accounting for CDI, the odds of being obese in Hispanics decreased (odds ratio, 1.51; 95% confidence interval, 1.15-1.99). Regardless of race and ethnicity, people with SCI from disadvantaged neighborhoods were 42.0%-70.0% more likely to be obese than those from minimal CDI neighborhoods.ConclusionsNeighborhood characteristics partially diminish racial differences in obesity. Weight management for the SCI population should target those who are Hispanic and living in the disadvantaged neighborhoods.     

Reductions in Cardiac Structure and Function 24 Months After Spinal Cord Injury: A Cross-Sectional Study

ObjectiveTo determine the alterations in cardiac structure and function that occur in the months after spinal cord injury (SCI).Study DesignCross-sectionalSettingRehabilitation HospitalParticipantsVolunteers (N=29; 4 women, 25 men) between 3 and 24 months after SCI.Main Outcome MeasuresTransthoracic echocardiography was performed on each volunteer. The relationships between time since injury and neurologic and sensory levels of injury to cardiac structure and function were assessed via multiple linear regression.ResultsTime since injury was most strongly associated with reductions in left ventricular end diastolic volume (r²=0.156; P=.034), end systolic volume (r²=0.141; P=.045), and mass (r²=0.138; P=.047). These structural changes were paralleled by reduced stroke volume (r²=0.143; P=.043) and cardiac output (r²=0.317; P=<.001). The reductions in left ventricular structure and systolic function were not differentially affected by neurologic or sensory levels of injury (P=.084-.921).ConclusionsThese results suggest progressive reductions in left ventricular structure and systolic function between 3 and 24 months after SCI that occur independent of neurologic and sensory levels of injury.     

Applying a Bookmarking Approach to Setting Clinically Relevant Interpretive Standards for the Spinal Cord Injury–Functional Index/Capacity Basic Mobility and Self-Care Item Bank Scores

ObjectivesTo develop clinically relevant interpretive standards for the Spinal Cord Injury–Functional Index/Capacity (SCI-FI/C) Basic Mobility and Self-Care item bank scores.DesignModified “bookmarking” standard-setting methodology, including 2 stakeholder consensus meetings with individuals with spinal cord injury (SCI) and SCI clinicians, respectively, and a final, combined (consumers and clinicians) “convergence” meeting.SettingTwo SCI Model System centers in the United States.ParticipantsFourteen adults who work with individuals with traumatic SCI and 14 clinicians who work with individuals with SCI.Main Outcome MeasuresPlacement of bookmarks between vignettes based on SCI-FI Basic Mobility and Self-Care T scores. Bookmarks were placed between vignettes representing “No Problems,” “Mild Problems,” “Moderate Problems,” and “Severe Problems” for each item bank.ResultsEach consensus group resulted in a single set of scoring cut points for the SCI-FI/C Basic Mobility and Self-Care item banks. The cut points were similar but not identical between the consumer and clinician groups, necessitating a final convergence meeting. For SCI-FI/C Basic Mobility, the convergence group agreed on cut scores of 61.25 (no problems/mild problems), 51.25 (mild problems/moderate problems), and 41.25 (moderate problems/severe problems). For SCI-FI/C Self-Care, the convergence group agreed on cut scores of 56.25 (no/mild), 51.25 (mild/moderate), and 38.75 (moderate/severe).ConclusionsThe results of this study provide straightforward interpretive guidelines for SCI researchers and clinicians using the SCI-FI/C Basic Mobility and Self-Care instruments. These results are appropriate for the full bank, computer adaptive test, and short-form versions of the SCI-FI/C Basic Mobility and Self-Care item banks.     

Effects of Performance-Based Training on Gait and Balance in Individuals With Incomplete Spinal Cord Injury

ObjectiveTo determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI).DesignConvenience sample, prepilot and postpilot study.SettingHuman performance research laboratory.ParticipantsAdults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury.InterventionsTwo 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary.Main Outcome MeasuresBerg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway.ResultsFourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P<.001). SCI-FAI scores showed a mean increase of 2.47±3.44 (P=.01). Spatiotemporal measures of gait showed no significant changes.ConclusionThis pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.     

Participation in People Living With Spinal Cord Injury in Switzerland: Degree and Associated Factors

ObjectiveTo describe different domains of participation such as productive, leisure and social activities and describe sociodemographic and spinal cord injury (SCI)-related characteristics that are associated with participation in these domains in a large sample of community-dwelling individuals with SCI in Switzerland.DesignCross-sectional population-based survey within the Swiss Spinal Cord Injury Cohort Study. Participation in major life domains was measured by the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation). Univariable unconditional analysis and unbiased recursive partitioning were used to identify the predominant associations of sociodemographic and SCI-related characteristics with multiple dimensions of participation.SettingCommunity.ParticipantsSwiss residents aged 16 years or older and living with traumatic or nontraumatic SCI (N=1549).InterventionsNot applicable.Main Outcome MeasureThe USER-Participation, a 32-item self-report questionnaire with 3 scales (Frequency, Restrictions, and Satisfaction) to assess key domains of participation (productive, leisure, social).ResultsFrequency (median 34.5 out of 100) in productive, outdoor leisure, and social activities was reduced with distinctive perceived restrictions in work and education, sports, and partner relationships. Domestic leisure activities (65.4%) and maintaining social relationships (76.1%) were those activities most often performed and with least perceived restrictions. Participants were generally satisfied with their current daily life activities. Lower scores across all participation scales were associated with more severe SCI, higher age, being female, not having a partner, and lower level of education.ConclusionsThis study provides a thorough analysis of participation in major life domains of individuals with SCI in Switzerland. Different risk groups for reduced levels in participation in productive, leisure, and social activities were identified. This population-based evidence is instrumental to the better targeting of rehabilitation and policy interventions that aim to improve community participation.     

What Lies Beneath: Why Some Pressure Injuries May Be Unpreventable for Individuals With Spinal Cord Injury

ObjectiveTo investigate intersections between pressure injury (PrI) history, muscle composition, and tissue health responses under physiologically relevant loading conditions for individuals with spinal cord injury (SCI).DesignRepeated measures study design with annual follow-up for up to 3 years.SettingTertiary care center.ParticipantsPersons with SCI (N=38). Exclusion criteria included having an open pelvic region PrI at the time of recruitment, presence of systemic disease, and/or known sensitivity to contrast.InterventionsNot applicable.Main Outcome MeasuresGluteal muscle composition, ischial interface pressures, tissue oxygenation.ResultsIschial region mean interface pressures are the same for individuals with or without a PrI history. Tissue oxygenation is lower during sitting for persons with a PrI history. Individuals with >15% gluteal intramuscular fat were statistically highly significantly (P<.001) more likely to have a history of severe or recurrent PrI. Intramuscular adipose tissue (IMAT) levels within the gluteal muscle may remain low over time or muscle tissue in the gluteal muscle region may be almost entirely replaced by IMAT. In the current study cohort, it was found that muscle composition also continues to change over time even for individuals with long-standing SCI.ConclusionsSoft-tissue compositional changes, specifically IMAT, provides a reliable indicator of PrI history and may provide a key to personalized PrI risk status for persons with SCI. The current findings confirm that interface pressure mapping alone is a limited indicator for PrI development.     

Integrated Knowledge Translation Guiding Principles for Conducting and Disseminating Spinal Cord Injury Research in Partnership

ObjectiveTo address a gap between spinal cord injury (SCI) research and practice by rigorously and systematically co-developing integrated knowledge translation (IKT) guiding principles for conducting and disseminating SCI research in partnership with research users.DesignThe process was guided by the internationally accepted The Appraisal of Guidelines for REsearch & Evaluation (AGREE) II Instrument for evaluating the development of clinical practice guidelines.SettingNorth American SCI research system (ie, SCI researchers, research users, funders).ParticipantsThe multidisciplinary expert panel (n=17) and end users (n=35) included individuals from a North American partnership of SCI researchers, research users, and funders who have expertise in research partnerships.InterventionsNot applicable.Main Outcome MeasuresClarity, usefulness, and appropriateness of the principles.ResultsData regarding 125 principles of partnered research were systematically collected from 4 sources (review of reviews, scoping review, interviews, Delphi consensus exercise). A multidisciplinary expert panel held a 2-day meeting to establish consensus, select guiding principles, and draft the guidance. The panel reached 100% consensus on the principles and guidance document. The final document includes a preamble, 8 guiding principles, and a glossary. Survey data showed that the principles and guidance document were perceived by potential end users as clear, useful, and appropriate.ConclusionsThe IKT Guiding Principles represent the first rigorously co-developed, consensus-based guidance to support meaningful SCI research partnerships. The principles are a foundational tool with the potential to improve the relevance and impact of SCI research, mitigate tokenism, and advance the science of IKT.     

Effect of Exoskeletal-Assisted Walking on Soft Tissue Body Composition in Persons With Spinal Cord Injury

ObjectiveTo determine the effect of overground walking using a powered exoskeleton on soft tissue body composition in persons with spinal cord injury (SCI).DesignA prospective, single group observational pilot study.SettingMedical center.ParticipantsPersons (N=8) with chronic (>6mo) SCI between 18 and 65 years old who weighed less than 100 kg.InterventionsOverground ambulation training using a powered exoskeleton (ReWalk) for 40 sessions, with each session lasting up to 2 hours, with participants training 3 times per week.Main Outcome Measure(s)Dual-energy x-ray absorptiometry (DXA) was used to measure lean mass (LM) and fat mass (FM) from the whole body, arms, legs and trunk. DXA was also used to assess visceral adipose tissue (VAT). Walking performance was measured by 6-minute walk test.ResultsParticipants significantly lost total body FM (?1.8±1.2kg, P=.004) with the loss of adiposity distributed over several regional sites. Six of the 8 participants lost VAT, with the average loss in VAT trending toward significance (?0.141kg, P=.06). LM for the group was not significantly changed.ConclusionsSustained and weekly use of powered exoskeletons in persons with SCI has the potential to reduce FM with inferred improvements in health.     

Transforming a Traumatic Brain Injury Measure of Participation Into a Psychometrically Sound Spinal Cord Injury Participation Measure

ObjectiveTo evaluate the use of Participation Assessment with Recombined Tools–Objective (PART-O) in spinal cord injury (SCI) and compare it with the Craig Handicap Assessment and Reporting Technique–Short Form (CHART-SF).DesignFollow-up survey of inception cohort.SettingCommunity.ParticipantsIndividuals with SCI, rehabilitated at 2 large SCI Model Systems and enrolled in the SCI Model Systems National Database, who were due for routine follow-up (N=468; median age at injury, 29; median time post injury, 5 years).InterventionsNot applicable.Main Outcome MeasuresPART-O and CHART-SF.ResultsUse of Rasch analysis identified an SCI-specific scoring of PART-O that demonstrated unidimensionality (first contrast eigenvalue of 1.76) with no misfitting items or disordered steps in any response categories. Person separation and reliability were 2.00 and .80, respectively. Unlike CHART-SF, PART-O had a relatively normal distribution with no floor or ceiling effects. Test-retest reliability PART-O administered 2-4 weeks apart was 0.97, with a reliable change index of 3.1 points on a 100-point scale. PART-O correlated 0.79 with the sum of 3 CHART-SF domains with similar content. The PART-O scoring was initially validated on a second data set.ConclusionsPART-O can be used successfully to measure participation in a population of people with SCI. A new method of scoring PART-O in SCI provides an initially validated, univariate interval measure of participation with good psychometric properties that has advantages over the CHART-SF legacy measure of participation.     

Effects of Bilateral Transcutaneous Tibial Nerve Stimulation on Neurogenic Detrusor Overactivity in Spinal Cord Injury: A Urodynamic Study

ObjectiveTo study the short-term effect of bilateral transcutaneous tibial nerve stimulation (TTNS) on urodynamic study (UDM) parameters in spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO).DesignSingle-blinded sham-controlled study.SettingRehabilitation center.ParticipantsSCI patients with NDO (N=17) were recruited. Fifteen patients (mean age, 40±18y) completed the study. Most of the patients had chronic incomplete SCI.InterventionsUDM was performed 3 times. The first UDM was performed after taking anticholinergics for 1 hour to assess the effects of medication. After stopping anticholinergics for a 5 half-lives, the second UDM was performed immediately after a 20-minute sham TTNS (switch on for 30s at the beginning, switch off for 20min, and switch on for 30s before stopping). The third UDM was performed immediately after a 20-minute bilateral TTNS.Main Outcome MeasuresReflex volume (mL), cystometric capacity (mL), maximum pressure detrusor (mmH₂O), and bladder compliance (mL/mmH₂O).ResultsUDM tracings were interpreted by 2 blinded assessors. This study used per-protocol analysis and repeated measures Analysis of variance with Bonferroni post hoc analysis. When compared with sham stimulation, bilateral TTNS and anticholinergics produced greater increases in reflex volume (136.1±99.88, 212.2±112.82, and 226.3±111.52 mL; P<.001), cystometric capacity (218.3±137.66, 319.1±143.74, and 350.7±163.43 mL; P<.001), and compliance (5.8±6.81, 7.9±6.74, 9.7±8.12 mL/cmH₂O; P=.02). No significant differences were found in reflex volume, cystometric capacity, or compliance between bilateral TTNS and anticholinergics (P>.05). The maximum pressure detrusor was not significantly different between groups (P>.05).ConclusionBilateral TTNS may be an effective short-term intervention to improve UDM parameters in SCI with NDO. Further study is necessary to determine the long-term effects and benefits of combined bilateral TTNS with anticholinergics.     

Genitourinary Complications Are a Leading and Expensive Cause of Emergency Department and Inpatient Encounters for Persons With Spinal Cord Injury

ObjectivesTo determine the rates of emergency department (ED) visits and inpatient hospitalizations for genitourinary (GU) complications after spinal cord injury (SCI) using a national sample; to examine which patient and facility factors are associated with inhospital mortality; and to estimate direct medical costs of GU complications after SCI.DesignRetrospective cross-sectional and cost analysis of the 2006 to 2015 National Inpatient Sample and National Emergency Department Sample from the Healthcare Cost and Utilization Project.ParticipantsSCI-related encounters using various International Classification of Disease, Ninth Edition, Clinical Modification diagnosis codes. The inpatient sample included 1,796,624 hospitalizations, and the ED sample included 618,118 treat-and-release visits.Main Outcome MeasuresThe exposure included a GU complication, identified by International Classification of Disease, Ninth Edition, Clinical Modification codes 590-599. The outcomes then included an ED visit or hospitalization, death prior to discharge, and direct medical costs estimated from reported hospital charges.ResultsFor the inpatient sample, we observed a 2.5% annual increase (95% confidence interval [CI], 1.8-3.2) in the proportion of SCI-related hospitalizations with any GU complication from 2006 to 2011, and a lesser rate of increase of 0.9% (95% CI, 0.4-1.4) each year from 2011 to 2015. Age, level of injury, and payer source were correlated to inhospital mortality. The costs of GU-related health care use exceeded $4 billion over the study period.ConclusionsThis study shows the rates and economic burden of health care use associated with GU complications in persons with SCI in the United States. The need to develop strategies to effectively deliver health care to the SCI population for these conditions remains great.     

A Cross-Sectional Study to Investigate the Effects of Perceived Discrimination in the Health Care Setting on Pain and Depressive Symptoms in Wheelchair Users With Spinal Cord Injury

ObjectivesIn a sample of wheelchair users with spinal cord injury (SCI), the objectives were to investigate which participant characteristics are associated with greater perceived discrimination in the health care setting, and how such discrimination relates to health outcomes of pain and depressive symptoms.DesignSurvey, cross-sectional.SettingSpinal Cord Injury Model Systems (SCIMS) Center.ParticipantsFull-time wheelchair users with SCI from 9 SCIMS centers (N=410), with data collected between 2011 and 2016.InterventionsN/A.Main OutcomesA 7-item questionnaire inquiring about perceived discrimination by hospital staff, self-reported pain severity over the past month using a 0-10 Numeric Rating Scale, and depressive symptoms using the 2-question Patient Health Questionnaire screener.ResultsParticipants who were black or from the lowest income group were more likely to report experiencing more discrimination than those who were white or from the highest income group, respectively (incidence rate ratio=2.2-2.6, P<.01). Those who reported more perceived discrimination had greater risk of severe pain compared to no pain (relative risk [RR]=1.11; 95% confidence interval [95% CI], 1.01-1.23; P<.05), mild depressive symptoms (RR=1.09; 95% CI, 1.02-1.17; P<.05), and severe depressive symptoms (RR=1.12; 95% CI, 1.04-1.21; P<.05) compared to no symptoms.ConclusionsWheelchair users with SCI who were from more disadvantaged groups (black, lower income levels) reported experiencing more discrimination in their health care setting. Furthermore, those who reported more discrimination were more likely to report worse mental and physical health outcomes. Attempts to reduce discrimination in health care settings may lead to better outcomes for people with SCI. These observations were correlational and not causal; a prospective analysis is necessary to prove causation. Future investigations should further explore the effect of discrimination on the many facets of living with an SCI.