Health problems of persons with spinal cord injury living in the Netherlands

Purpose.?To investigate the prevalence of health problems among persons with spinal cord injury (SCI) living in the Netherlands, to identify the problems experienced as most important, and to analyse the experienced impact of these most important problems on daily activities and social life.

Method.?Postal survey among all members of the Dutch Association of Patients with SCI. The questionnaire focused on 26 health problems: 13 secondary impairments, 8 problems of daily living and 5 psychosocial problems.

Results.?The respondents (response rate 45.5%, 454 persons) experienced an average of 8 health problems. The most frequently occurring problems regarded bladder and bowel regulation, spasms, pain, oedema and sexuality. Except for oedema, these problems were also most often cited as the most important. The most disabling condition for both daily and social activities was pain. Few significant relationships were found between the prevalence of health problems and the level, completeness and duration of the injury or gender.

Conclusion.?Persons with SCI living in the community experience many health problems and limitations in daily activities and social life due to these problems. The occurrence of these problems does not diminish with increasing time after injury. This strongly emphasises the need for follow-up care.     

Spinal cord injury rehabilitation research: patient priorities,current deficiencies and potential directions

Purpose.?To highlight research priorities of people with spinal cord injury (SCI), outline the current state of rehabilitation research and suggest potentially fruitful avenues for future inquiry.

Method.?Commentary.

Results.?People with SCI identify pain, depression, fatigue, pressure sores, spasticity and the management of bladder and bowel as research priorities. Research reveals multiple interconnections between these secondary problems, all of which negatively impact quality of life (QOL). However, despite a substantial volume of existing research, significant gaps in knowledge remain, duplications of research effort are apparent and few interventions have an adequate evidence base. Issues concerning community participation – another research priority – have only recently attracted researchers' attention.

Conclusions.?This commentary contends that research should: focus on issues and outcomes of relevance and importance to people living with SCI; address the complexities of secondary conditions and their inter-relationships; appraise environmental barriers to participation in meaningful living; be designed to identify and inform effective and relevant interventions. Innovative approaches to research partnerships, mixed methods and exploring variables usually omitted from quantitative studies might enhance the likelihood that the complexity of issues facing people living with SCI will be identified and addressed. Moreover, a governing focus on achieving lives experienced as hopeful, purposeful, satisfying and meaningful could contribute to enhancing QOL outcomes following SCI.     

Multidisciplinary cognitive behavioural pain management programmes for people with a spinal cord injury: design and implementation

Purpose.?This article seeks to outline the design and implementation of cognitive behavioural pain management programmes (PMPs) for people with spinal cord injury (SCI), illustrated by the experiences in a recently evaluated programme (SpinalADAPT). It is hoped that this will provide an easily accessible account of the relevant design and implementation issues for those who seek to deliver such programmes to persons with a SCI.

Methods.?A collaborative team of pain and SCI professionals developed a modified version of a standard cognitive behavioural pain management programme (ADAPT) based upon experiences of those with SCI who had previously attempted ADAPT. A number of structural and content elements of the programme were identified that required modification in order to accommodate the particular needs of those with SCI.

Results.?The modified programme was subsequently successfully delivered by a combination of SCI and pain health professionals. Three groups of individuals completed the SpinalADAPT, and an evaluation of outcomes compared to standard care are reported elsewhere (Nicholson Perry et al., Clin J Pain 2010;26:206–216).

Conclusions.?It appears feasible to appropriately modify standard PMPs for participants with SCI, and that such programmes may offer benefits in terms of improved quality of life. Further revision and evaluation of such programmes is required.     

Health of people with spinal cord injury in Singapore: implications for rehabilitation planning and implementation

Purpose.?This study aimed to provide a broad overview of the health of people with spinal cord injury (SCI) in Singapore, so as to highlight areas of potential need. These areas could then guide future research and rehabilitation programme development.

Methods.?Demographic data, injury information and information about SCI-related secondary impairments, chronic conditions and their associated risk factors, medical and hospital utilisation, participation (Craig Handicap Assessment and Reporting Technique) and life satisfaction (Satisfaction with Life Scale) were collected via interviews from people living with traumatic SCI.

Results.?On average, participants (50 men and 5 women) were aged 48.3 ± 16.54 years and had had their SCIs for 5 years. ?75%% with tetraplegia. The most prevalent SCI-related secondary impairments were pain, spasms, bladder problems, bowel problems and oedema. Chronic conditions and their associated risk factors were prevalent. Participation and life satisfaction scores were lower than those reported for similar populations cross-culturally.

Conclusion.?The study revealed several health areas that may be affecting the overall health of people with SCI in Singapore. By focusing on community reintegration and health promotion, physiotherapists and other rehabilitation professionals may augment health outcomes and improve the quality of life of this population in Singapore.     

Falls among stroke survivors: an online survey on perceptions and approaches among physiotherapists in Flanders

Objective.?To describe physiotherapists' perceptions of fall risk and appropriate fall prevention interventions in rehabilitating stroke patients.

Method.?A web-based survey addressed to physiotherapy units on a stroke unit, general neurology department or rehabilitation ward/centre in Flanders.

Results.?Hospital response rate was 66.3%. Sixty-five physiotherapy units were taken into account. About 84.6% recognised falls among stroke patients as an essential problem and 73.8% thought falls interfered with the outcome. About 56.9% agreed with the need of a standardised fall assessment at the beginning of the treatment and only 36.9% reported that on their department stroke patients are screened on risk of falling. The most used fall risk assessments are: Berg Balance scale and Tinetti-test. The most popular fall prevention measures are: specific exercises for balance, gait and functional abilities (100%), informative education (92.3%) and adapting or intensifying the treatment after a fall (81.5%).

Conclusions.?Physiotherapy units acknowledge falls as an essential threat, implying a need for risk screening and prevention. However, results reveal that perception of the necessity of such screening is lower and that the performance is even less. This discrepancy underlines the necessity of guidelines and education of therapists working with stroke patients.     

Evaluation of patient education in spinal cord injury rehabilitation: Knowledge,problem-solving and perceived importance

Purpose.?Through inpatient education programmes the person with spinal cord injury (SCI) learns to understand and monitor his or her own physical, emotional and social well-being. The purpose of this study was to determine the patients' knowledge and problem-solving skills regarding SCI at admission, discharge and follow-up at 6 months after discharge; and to determine the perceived importance of each content topic included in the education programme.

Methods.?A one-group repeated measures design was used to evaluate the outcomes. Knowledge was evaluated with a Multiple Choice Questionnaire (MCQ). Problem-solving ability based on participants' responses to Life Situation Scenarios relevant to each topic area was rated on a standardized four-point criterion reference scale. Perceived importance for each topic area was rated on a five-point Likert scale.

Results.?Twenty-three participants completed all assessments. There was significant improvement in MCQ scores from admission to discharge (P = 0.04) and admission to follow-up (P = 0.02). For problem-solving ability, there was a trend toward improvement in all content topics with significant improvement from admission to follow-up for the topic of bowel care (P = 0.004). However, many participants continued to demonstrate poor problem-solving ability. Bowel, Bladder and Skin Care were consistently perceived as the most important education topics.

Conclusions.?Improvements in knowledge do not necessarily translate to improvements in problem-solving ability even for the topics perceived as important. This may indicate the need to incorporate more active learning strategies or contextually based strategies within patient education programmes to facilitate the transfer of knowledge within life situations.     

A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area

Purpose.?To compare a group exercise programme known as the Back to Fitness programme with individual physiotherapy for patients with non-specific low back pain from a materially deprived area.

Method.?This was a randomized controlled trial including 237 physiotherapy patients with back pain lasting more than six weeks. Participants were allocated to either the Back to Fitness programme or to individual physiotherapy, and followed up at three months and 12 months after randomization. The main outcome measure was the Roland Disability Questionnaire. Secondary measures were: SF12, EQ5D, Pain Self-Efficacy Scale. Health care diaries recording patients' use of health care resources were also collected over a 12-month period.

Results.?There were no statistically significant differences in change scores between groups on the primary outcome measure at three months (CI ??2.24 to 0.49) and at 12 months (CI ??1.68 to 1.39). Only minor improvements in disability scores were observed in the Back to Fitness group at three months and 12 months respectively (mean change scores; ??0.89, ??0.77) and in the individual physiotherapy arm (mean change scores; ??0.02, ??0.63). Further analysis showed that patients from the most severely deprived areas were marginally worse at three month follow-up whereas those from more affluent areas tended to improve (CI 0.43 to 3.15).     

The ‘risk inventory for persons with spinal cord injury’: Development and preliminary validation of a risk assessment tool for spinal cord injury

Purpose.?To present a new short instrument to measure perceived risks of common everyday activities engaged in by persons with spinal cord injury (SCI), and to provide preliminary data on its psychometric properties.

Method.?Community-dwelling men and women with SCI (N?=?139) in metropolitan Detroit completed the risk inventory for persons with spinal cord injury (RISCI). They also answered a risk-taking identity question (‘Are you a risk-taker’?) and completed the risk orientation questionnaire (ROQ) (Rohrmann, http://www.rohrmannresearch.net/, 2008), a risk propensity measure.

Results.?All items of the RISCI correlated positively with each other and the total score; internal reliability as measured by Cronbach's α was 0.86. Principal components factor analysis confirmed a one-factor structure which explained 41% of the variance. A three-factor solution with readily interpretable factors explained 64% of the variance. Content validity was established through extensive consultations with persons with SCI in the development of the measure. Discriminant validity was supported by the ability of the RISCI to distinguish between subsamples (for example, between men and women, those with paraplegia and tetraplegia) for whom differences in risk assessment might be expected. Criterion validity was supported by significant relationships in the expected directions between the RISCI and risk-taking identity and between the RISCI and the ROQ.

Conclusions.?Findings suggest that the RISCI is a brief, easy to administer and psychometrically sound measure of perceived risk of activities common in daily life for use with persons with SCI.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction.?Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims:?To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods.?20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results.?Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion.?Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions.?Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up

Purpose.?There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.

Method.?The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.

Results.?Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.

Conclusions.?These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.     

Self-reported activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga – a cross-sectional study

Purpose.?To describe activity limitations in tortured refugees referred for rehabilitation, particularly the impact of neuropathic pain resulting from falanga (beatings under the feet).

Methods.?Physiotherapists assessed 103 consecutively referred torture victims with a long history of sequelae, among them pain and mobility problems. All had been subjected to various forms of physical and psychological torture and 71 victims had also suffered falanga. Main outcome measures used were: the Disability Rating Index (DRI; 12 items) to assess self-reported capacity to carry out daily activities; for falanga victims, a specific foot assessment of sensory function in the feet.

Results.?All patients perceived clear activity limitations according to the DRI. The falanga victims' feet were categorised according to the type of foot pain: stimulus-independent pain; stimulus-evoked pain; no pain. The two groups with foot pain displayed sensory dysfunction and suffered more extensive activity limitations. After correction for confounding factors, these two groups reported significantly more activity limitations in 7 out of 12 DRI items than those who were not exposed to falanga.

Conclusion.?In this group of victims who had chronic pain for at least 5 years after torture, all perceived activity limitations, but pain from falanga had a greater overall impact on disability assessed in terms of daily activities.     

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence

Purpose.?To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction.?Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method.?A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results.?Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions.?The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

Efficacy of an assistive intervention for abdominal surgery patients in postoperative care

Purpose.?The objective of this study was to assess efficacy of a bed-assistive device during at-home recovery through self-reports of self-perceived recovery status and oral pain medication usage.

Methods.?A case-control design was used to determine differences in self-perceived recovery measures and pain medication according to surgical procedure, device/no device, and age strata. Fifteen female patients undergoing abdominal hysterectomy (n = 6) or Cesarean-section (n = 9) procedures were recruited. Stratified sampling techniques were used to assign patients to the control (n = 8; age, 34.0 [6.3] years) and devices groups (n = 7; 40.7 [12.4] years). Both groups completed 12 questionnaires on perceived recovery status, activities of daily living, and pain medication usage over a five-week recovery period. Device group patients received training on device usage prior to surgery. Repeated measures ANOVA were used to analyse data and compare data across experimental groups.

Results.?In general, device users reported higher levels of energy, less pain interference, lower perceived pain, less reliance on pain medication and returned to activities of daily living faster than the control group.

Conclusion.?Self-assistive device usage provides significant subjective and objective improvements during at-home recovery and promotes patient independence.     

Do people with an ileostomy have a different back pain experience to those with a colostomy? A postal survey in Northern Ireland

Background.?The abdominal muscles play a vital role in lumbar stability. The stoma surgery creates a permanent flaw in the abdominal wall and this may increase the risk of low back pain for people with a stoma.

Purpose.?To determine whether there was a difference in back pain experience between the two stoma groups: ileostomy and colostomy.

Method.?A postal questionnaire sent to people in Northern Ireland with an ileostomy or colostomy.

Results.?Over half (56.7%, n?=?417) had back pain in the last 6 months and the primary perceived cause was the stoma surgery. There was a statistically significant deterioration in functional activities in those with back pain when ‘today’ was compared with ‘before surgery’. Those with a colostomy had generally poorer outcomes in respect of pain and disability, than those with an ileostomy.

Conclusion.?Low back pain in people with a stoma is a real and complex issue, especially as there are significant differences between those with an ileostomy when compared with people with a colostomy. Many factors are likely to contribute to a person developing low back pain, not least, the underlying reason for the surgery and the surgical procedure itself.     

The association between cognitive factors,pain and disability in patients with idiopathic chronic neck pain

Purpose.?The aim of this study was to establish the relationship between known cognitive factors and levels of pain and disability in patients with idiopathic chronic neck pain.

Method.?Ninety-four patients referred for physiotherapy because of chronic neck pain completed measures of pain, disability, catastrophising, pain-related fear, pain vigilance and awareness and self-efficacy beliefs. Hierarchical multiple regression analyses were then performed to establish whether the cognitive factors were significant determinants of levels of pain and disability.

Results.?The cognitive measures were significantly related to levels of pain and disability, explaining 23% of the variance in pain intensity and 30% of the variance in disability. Specifically, greater catastrophising (β?=?0.37, p?<?0.05) and lower pain vigilance and awareness (β?=???0.32, p?<?0.05) were associated with greater pain intensity. Moreover, greater catastrophising (β?=?0.26, p?<?0.05) and lower functional self-efficacy beliefs (β?=???0.34, p?<?0.001) were significantly associated with greater levels of disability.

Conclusions.?Cognitive factors were strongly related to levels of pain and disability in patients with chronic neck pain. In view of this, targeting the modification of these cognitive factors should be an integral part of therapy when treating patients with idiopathic chronic neck pain.     

Long duration spinal cord injury: Perceptions of functional change over time

Purpose.?To investigate perceptions of functional change over time held by individuals with long duration spinal cord injury (SCI) living in Queensland, Australia.

Method.?A retrospective telephone questionnaire was administered to 84 individuals who had sustained a SCI more than 20 years previously and were older than 15 at the time of injury. Motor subset scores of the Functional Independence Measure (FIM) and a single scale measuring mobility aids status (MAIDS), were collected for three points in time – post discharge from initial rehabilitation (D/C point); approximately 10 years post injury (Mid point) and currently (Current point).

Results.?A significant number of participants perceived that their function had increased between the D/C and Mid points and had subsequently decreased between the Mid and Current points. Participants also reported an increasing dependence on mobility aids between the Mid point and the Current point. Those who reported functional decline between the Mid and Current points were significantly older than those who did not report functional decline but did not differ in duration of injury or age at onset.

Conclusions.?The results support the need for services that provide assessment and intervention for functional changes throughout the life span of people with SCI.     

Haemodynamic effects of physiotherapy programme in intensive care unit after liver transplantation

Objective.?To determine the haemodynamic effects of intensive care physiotherapy after liver transplantation.

Patients and methods.?Thirteen patients were included in the study after liver transplantation. The following physiotherapy programme were applied to the patients in intensive care unit: Respiratory physiotherapy, active joint movements, sitting in bed (first task), sitting at the edge of bed (second task), standing (third task), sitting out of bed (fourth task) and walking (fifth task). Heart rate (HR), mean, systolic and diastolic blood pressures (MBP, SBP, DBP), peripheral oxygen saturation (SpO₂), respiration rate (RR) were recorded before treatment, after each task, after treatment and at the fifth minute of recovery. Pain level was assessed with Visual Analogue Scale (0–10).

Results.?When compared with supine position before treatment, all of the parameters except RR increased after the first task whereas HR, SBP, MBP and pain increased after the second task. After the third task only HR and pain increased. There was no significant difference between the fourth task and pre-treatment values while HR, DBP and pain increased after the fifth task. When measurements of pre-treatment, immediately after treatment and the fifth minute of recovery were compared HR, MBP and pain increased after treatment whereas HR, RR and pain decreased after recovery. There was no significant difference between pre-treatment values and fifth minute of recovery measurements.

Conclusion.?Returning to initial values after a 5-min period shows that cardiopulmonary changes caused by intensive care physiotherapy after liver transplantation are responded at physiological limits.     

Forgiveness and health-related outcomes among people with spinal cord injury

Purpose.?As motor vehicle accidents and violence cause the majority of spinal cord injuries (SCI) sustained in the USA and people with SCI will likely struggle with emotional issues related to the offender, the purpose of this exploratory study was to examine potential salutary effects of forgiveness among people with SCI incurred traumatically. Specifically, we hypothesized that forgiveness would have positive associations with health-related outcomes.

Method.?A community-based sample of 140 adults (19–82 years of age) with SCI completed a self-report survey regarding dispositional forgiveness of self and others, health behavior, health status, and life satisfaction. Hierarchical multiple regression analyses were employed to examine the relationships in question.

Results.?After controlling for demographic variables, forgiveness of self was significantly associated with health behavior and life satisfaction (uniquely accounting for 7% and 13% of the variance, respectively) and forgiveness of others was significantly associated with health status (uniquely accounting for 9% of the variance).

Conclusion.?Results suggest that forgiveness may play a role in the health and life satisfaction of people with traumatic SCI, with the benefit depending on the type of forgiveness offered.     

Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery – a randomised controlled trial

Objective.?Coronary artery bypass grafting (CABG) is accompanied by severe impairment of cardiac autonomous regulation (CAR). This study aimed to determine whether a short-term physiotherapy exercise protocol post-CABG, during inpatient cardiac rehabilitation (CR), might improve CAR.

Design.?Seventy-four patients eligible for CABG were recruited and randomised into physiotherapy exercise group (EG) or physiotherapy usual care group (UCG). EG patients underwent a short-term supervised inpatient physiotherapy exercise protocol consisting of an early mobilisation with progressive exercises plus usual care (respiratory exercises). UCG only received respiratory exercises. Forty-seven patients (24 EG and 23 UGC) completed the study. Outcome measures of CAR included linear and non-linear measures of heart rate variability (HRV) assessed before discharge.

Results.?By hospital discharge, EG presented significantly higher parasympathetic HRV values [rMSSD, high frequency (HF), SD1)], global power (STD RR, SD2), non-linear HRV indexes [detrended fluctuation analysis (DFA)α1, DFAα2, approximate entropy (ApEn)] and mean RR compared to UCG (p?<?0.05). Conversely, higher values of mean HR, low frequency (LF) (sympathetic activity) and the LF/HF (global sympatho-vagal balance) were found in the UCG.

Conclusions.?A short-term supervised physiotherapy exercise protocol during inpatient CR improves CAR at the time of discharge. Thus, exercise-based inpatient CR might be an effective non-pharmacological tool to improve autonomic cardiac tone in patient's post-CABG.