Lower extremity fracture prevention and management in persons with spinal cord injuries and disorders: The patient perspective

Context/ObjectiveTo describe patient experiences with fracture prevention and management among persons with spinal cord injuries/disorders (SCI/D).DesignQualitative data collected via semi-structured telephone interviews.SettingVeterans Health Administration (VA) SCI/D System of Care.ParticipantsVeterans with SCI/D (n = 32) who had experienced at least one lower-extremity fracture in the prior 18 months.InterventionsN/A.Outcome MeasuresInterview questions addressed patients’: pre-fracture knowledge of osteoporosis and bone health, diagnosis and management of osteoporosis, history and experiences with fracture treatment, and post-fracture care and experiences.ResultsParticipants expressed concerns about bone health and fractures in particular, which for some, limited activities and participation. Participants recalled receiving little information from providers about bone health or osteoporosis and described little knowledge about osteoporosis prevention prior to their fracture. Few participants reported medication management for osteoporosis, however many reported receiving radiographs/scans to confirm a fracture and most reported being managed non-operatively. Some reported preference for surgical treatment and believed their outcomes would have been better had their fracture been managed differently. Many reported not feeling fully included in treatment decision-making. Some described decreased function, independence and/or participation post-fracture.Conclusion(s)Our results indicate that persons with SCI/D report lacking substantive knowledge about bone health and/or fracture prevention, and following fracture, feel unable and/or hesitant to resume pre-fracture participation. In addition, our findings indicate that individuals with SCI/D may not feel as engaged as they would like to be in establishing fracture treatment plans. As such, persons with SCI/D may benefit from ongoing discussions with providers about risks and benefits of fracture treatment options and consideration of subsequent function and participation, to ensure patients preferences are considered.     

Sexual health counselling in patients with spinal cord injury: Health care professionals’ perspectives

Objectives: We aimed to explore barriers to discussing sexual health with spinal cord injured (SCI) patients as perceived by health care professionals, to determine interest and preferences regarding further education in sexual health, and to assess the perceived need for an inpatient Sexual Health Team.Design: Pre and post surveys were completed by attendees following a 1–2 hour educational session on sexual health and SCI, assessing core elements including participant characteristics, confidence levels, and perceptions towards sexual health counselling and education.Setting: Wascana Rehabilitation Centre, a facility in Regina, SK offering inpatient and outpatient rehabilitation services in Saskatchewan.Participants: Eighty-six participants with a mean age of 39 years took part in this study. Among them, nearly half were nurses.Interventions: Educational sessions on SCI patients’ sexual health.Outcome Measures: Self-administered surveys.Results: Significant differences were observed between pre- and post-session participant responses regarding their confidence levels (P < 0.001). Most participants (82.1%) had never provided sexual health counselling to SCI patients. The main perceived barrier to lack of sexual health counselling was insufficient training; the preferred learning method was via in-person workshops. The majority (80%) of participants indicated a Sexual Health Team should be created and 39.4% of participants expressed interest in becoming a member of this team.Conclusion: These results support that an educational session may help improve the confidence, knowledge, and perceptions around delivery of sexual health education of SCI patients. Study results suggest a perceived need for a Sexual Health Team and interest from health care professionals to become more involved in sexual health counselling.     

Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: A pilot randomized controlled trial

Abstract

Objectives

To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D).

Design

Blinded, block-randomized controlled pilot trial.

Setting

Two Department of Veterans Affairs (VA) SCI Centers.

Participants

Veterans were recruited March–September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings.

Intervention

Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education.

Outcome measures

Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation.

Results

Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25–3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI ?0.08–2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care.

Conclusions

A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants’ knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.     

Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: A pilot randomized controlled trial

Objectives

To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D).

Design

Blinded, block-randomized controlled pilot trial.

Setting

Two Department of Veterans Affairs (VA) SCI Centers.

Participants

Veterans were recruited March–September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings.

Intervention

Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education.

Outcome measures

Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation.

Results

Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25–3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI −0.08–2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care.

Conclusions

A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants’ knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.     

脊柱脊髓损伤合并重型颅脑损伤的早期诊治体会

目的：探讨早期诊治脊柱、脊髓损伤合并重型颅脑损伤病例，降低伤残率、死亡率的有效措施。方法：回顾性分析本院45例患者，及采取的相应诊断治疗措施。结果：临床治愈26例，好转14例，死亡5例。结论：骨科、神经外科和急诊科医生必须给予足够的重视，早期正确检查、及早诊断和有效治疗至关重要，常规行头部和脊柱脊髓影像学检查十分必要，进一步可采取CT三维重建、MRI等检查，提高早期诊断率，对降低伤残与死亡率有着十分重要的临床意义。     

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.     

Secondary health conditions and disability among people with spinal cord injury: A prospective cohort study

Objective: To examine how secondary health conditions (SHCs) that develop early after a spinal cord injury (SCI) are related to disability over time.Design: Prospective cohort study.Setting: Two spinal units in New Zealand (Burwood Spinal Unit and Auckland Spinal Rehabilitation Unit).Participants: Between 2007 and 2009, 91 people participated in three telephone interviews approximately 6, 18, and 30 months after the occurrence of a SCI.Outcome measures: SHCs were measured using 14 items derived from the Secondary Complications Survey. Disability was measured using the 12-item World Health Organization Disability Assessment Schedule 2.0. Linear regression analyses were performed to investigate associations between SHCs at 6 months and disability at each assessment point.Results: The most prevalent SHCs were leg spasms, constipation, back pain, pain below the level of SCI, and shoulder pain. Constipation, urinary tract infection, and headaches at 6 months post-SCI were associated with significantly higher levels of disability at each subsequent follow-up, independent of age, sex and SCI impairment. Back pain, and pain below the SCI, at 6 months were associated with significantly greater disability at 18 months, and difficulty coughing at 6 months was associated with significantly greater disability at 30 months.Conclusion: The experience of specific SHCs in the first 6 months after an SCI is related to greater long-term disability. In order to reduce the disability burden of people with SCI, efforts should be directed toward early prevention of these SHCs.     

中性粒细胞在急性脊髓损伤中作用的实验研究

目的：观察中性粒细胞在脊髓压迫伤中的局部聚集情况及其可能的作用。方法：采用压迫法致大鼠脊髓中度损伤，实验动物分正常大鼠损伤组、低白细胞血症大鼠损伤组和假手术组。观察伤后1、3、6、12、24h伤段脊髓髓过氧化物酶(MPO)活性，记录双下肢运动诱发电位(MEP)，应用斜板试验评价大鼠的运动功能。结果：脊髓压迫伤后1h MPO活性开始升高，3h达到高峰。低白细胞血症组伤后3hMPO活性较对照组明显降低，脊髓运动功能的改善较对照组明显。结论：脊髓损伤后局部中性粒细胞聚集增加，可能参与脊髓继发性损伤。     

Association between seeking oral health information online and knowledge in adults with spinal cord injury: A pilot study

Abstract

Objective

To characterize adults with spinal cord injury (SCI) who seek oral health information online, and investigate whether seeking oral health information online is associated with oral health knowledge and behaviors.

Methods

An online oral health survey was posted on the South Carolina Spinal Cord Injury Association website. Respondents were 192 adult residents of the US ages 19–83 years who identified themselves as having SCI occurring at least 1 year before the survey date.

Results

About 12% (n = 23) of the respondents searched oral health information online in the past 12 months. Significant associations between the proportion of respondents who searched for oral health information online and socio-demographic and the proportion of respondents who engaged in various oral health behaviors were not detected. However, multivariable logistic regression indicated that respondents who searched oral health information online in the past 12 months have 3.4 times the odds of possessing adequate oral health knowledge compared to respondents who did not search oral health information online (adjusted odds ratio = 3.41, 95% confidence interval = 1.35, 8.62, P = 0.01).

Conclusions

Given the significant association between seeking oral health information online and adequate oral health knowledge, this study suggests that online oral health information may be a potential avenue for dental health professionals to supplement oral health education in adults with SCI.     

Association between seeking oral health information online and knowledge in adults with spinal cord injury: a pilot study

Objective

To characterize adults with spinal cord injury (SCI) who seek oral health information online, and investigate whether seeking oral health information online is associated with oral health knowledge and behaviors.

Methods

An online oral health survey was posted on the South Carolina Spinal Cord Injury Association website. Respondents were 192 adult residents of the US ages 19–83 years who identified themselves as having SCI occurring at least 1 year before the survey date.

Results

About 12% (n = 23) of the respondents searched oral health information online in the past 12 months. Significant associations between the proportion of respondents who searched for oral health information online and socio-demographic and the proportion of respondents who engaged in various oral health behaviors were not detected. However, multivariable logistic regression indicated that respondents who searched oral health information online in the past 12 months have 3.4 times the odds of possessing adequate oral health knowledge compared to respondents who did not search oral health information online (adjusted odds ratio = 3.41, 95% confidence interval = 1.35, 8.62, P = 0.01).

Conclusions

Given the significant association between seeking oral health information online and adequate oral health knowledge, this study suggests that online oral health information may be a potential avenue for dental health professionals to supplement oral health education in adults with SCI.     

Physical and occupational therapist rehabilitation of lower extremity fractures in veterans with spinal cord injuries and disorders

Context/ObjectiveThe risk of lower extremity (LE) fractures in persons with spinal cord injury or disorders (SCI/D) is double that of the able-bodied population. LE fractures are the most common fracture location in SCI/D. Physical therapists (PTs) and occupational therapists (OTs) play an important role in rehabilitating LE fractures in Veterans with SCI/D. This paper describes their role in assisting persons with SCI/D and LE fractures to return to previous function and levels of participation.DesignCross-sectional semi-structured interviews were conducted by telephone. Setting: VA SCI centersParticipantsPurposive sample of therapists (PTs and OTs) experienced in LE fracture rehabilitation in SCI/D Interventions: NA.Outcome MeasuresCoding of responses used a data-driven thematic and deductive approach, dictated by a semi-structured interview guide addressing the entire treatment process.ResultsParticipants strongly advocated for early PT/OT involvement in post-fracture rehabilitation in order to recommend braces and devices to minimize skin breakdown, and needs for patient equipment, skills training and/or caregiver assistance resulting from post-fracture mobility changes. Seating specialists should be involved in post-fracture seating assessments in wheelchair users to address changes in alignment, deformities, limb length discrepancies and/or seating posture during and following fracture management.ConclusionPTs and OTs are critical in rehabilitating LE fractures in persons with SCI/D and LE fractures, bringing expertise in patient function, ambulatory status, transfer strategies, mobility equipment, spasticity, lifestyle, and home and caregiver support. Involving them early in the rehabilitation process, along with orthopedic surgeons, physiatrists and other SCI clinicians can address the multiple and often unique issues that occur in managing fractures in this population.     

Spinal injuries in the pediatric age group: a review of 82 cases of spinal cord and vertebral column injuries

A review of 82 children with spinal cord and/or vertebral column injury treated in our department between 1968 and 1993 showed that 67% of the patients were boys and the average age was 11.4 years. The cause, vertebral level, and type of injury, and the severity of neurological injury varied with the age of the patient. The cause of pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (56%) followed by vehicular accidents (23%). The most frequent level of spinal injury was in the cervical region (57%, 47 patients) followed by the lumbar region (16.5%, 13 patients). In our series, 18% of the patients had complete injury and the overall mortality rate was 3.6%. Eleven children (13%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 39 (47%) had evidence of neurological injury. Although the spinal injury patterns differed between children and adolescents, the outcome was found to be predominantly affected by the type of neurological injury (P<0.05). Children with complete myelopathy uniformly remained with severe neurological dysfunction; children with incomplete myelopathy recovered nearly normal neurological function. Finally, the authors conclude that most spinal injuries can be successfuly managed with nonoperative therapy. The literature is reviewed as to the treatment and outcome of pediatric spinal injuries.     

Continuous intrathecal infusion of baclofen in patients with spasticity caused by spinal cord injuries

The aim of this study was to determine the efficacy and safety of intrathecal baclofen therapy delivered by a programmable pump for the chronic treatment of spinal spasticity. Twelve patients with intractable spasticity caused by spinal cord injuries underwent implantation of a programmable continuous infusion pump after significant reduction in spasticity following an intrathecal test bolus of baclofen. No deaths or new permanent neurological deficits occurred following surgery or chronic intrathecal baclofen therapy. The follow-up (12 months) shows a reduction in rigidity in the lower limb of 2.0 points on the Ashworth scale and in the upper limb of 1.2 points. Muscle spasms were reduced from a mean preoperative score of 2.8 to a mean postoperative score of 1.0. In two cases, we observed postoperative catheter dislocation, a complication which could be corrected surgically. This study demonstrates that chronic intrathecal baclofen infusion is a safe and effective form of treatment of intractable spasticity in patients with spinal cord injury. There is considerable reduction in the risk of infection in view of the fact that interrogation and programming of the implanted programmed pumps is noninvasive. Electronic Publication     

TRH对大鼠脊髓损伤后SCBF和SEP的影响

脊髓损伤（ＳＣＩ）后内源性阿片肽释放，并参与脊髓的继发损伤机制。ＴＲＨ可阻断阿片肽的自主神经效应，而不影响痛觉。本实验探讨大剂量ＴＲＨ（２ｍｇ／ｋｇ／ｈ）治疗对大鼠脊髓打击伤（Ａｌｌｅｎｓ法１０ｇｘ５ｃｍ）后脊髓血流量（ＳＣＢＦ）和脊髓诱发电位（ＳＥＰ）的影响。脊髓损伤后１ｈ，ＳＣＢＦ开始显著下降，持续至伤后２４ｈ，ＳＥＰ峰潜时呈进行性延长趋势；伤后即刻静脉注射ＴＲＨ（２ｍｇ／ｋｇ／ｈ，共５次），可使伤后即刻和２４ｈ的ＳＣＢＦ显著升高，并使伤后ＳＣＢＦ下降时间延迟３ｈ，同时ＳＥＰ峰潜时有不同程度改善。结果表明，ＴＲＨ对受伤脊髓早期有一定的防治作用，并具有一定的后发效应；同时也可促进脊髓的神经传导功能。本文亦对ＴＲＨ治疗ＳＣＩ的病理生物学机制进行了讨论。     

应用改进封闭脊髓窗技术活体观察脊髓损伤后脊髓微循环变化

目的:探讨应用改进的封闭脊髓窗技术活体观察大鼠脊髓损伤后脊髓微循环变化的可行性及效果.方法:改进传统的脊髓窗,设计带有打击探头的脊髓窗.45只SD大鼠随机分为对照组(n=20)和实验组(n=25).实验组大鼠脊髓窗安装完成后进行窗内打击脊髓,然后即时观察并记录打击后2h内打击点周围微动脉直径的变化.对照组大鼠在脊髓窗安装完成后不进行打击,只对脊髓微动脉直径进行连续2h观察并记录.术后两组大鼠进行BBB运动功能评分,处死动物取脊髓标本切片,HE染色,观察脊髓组织改变情况.结果:实验组大鼠打击点周围2～6mm的微动脉直径在打击后10min、30min、1h、2h各时间点均较打击前明显减小,术后2d及7d时BBB功能评分明显低于术前,病理切片可见脊髓打击区神经组织变性液化.对照组大鼠在观测开始及结束时脊髓微动脉直径无明显变化,术后BBB评分与术前BBB评分均为21分,病理切片未见脊髓损伤表现.结论:改进的封闭脊髓窗技术可以有效地实现窗内打击脊髓,并可以安全地对脊髓表面微血管进行活体观测.脊髓表面打击点周围2～6mm的微动脉在脊髓损伤后10min即发生痉挛.     

Reliability and validity of the function in sitting test among non-ambulatory individuals with spinal cord injury

Context: Trunk impairment among non-ambulatory individuals with spinal cord injury (SCI) reduces the ability to maintain a functional sitting position and perform activities of daily living. Measuring functional sitting balance is complex and difficult in a clinical setting. The function in sitting test (FIST) is a clinical measure that includes the assessment of all the components of sitting balance. The purpose of this study is to assess the reliability and validity of the 14-item FIST among non-ambulatory individuals with SCI.Participants: Twenty-six individuals with chronic SCI.Outcome measures: Participants were evaluated with the FIST, the modified Functional Reach Test (lateral and forward mFRT) and a posturography assessment (virtual time to contact – VTC). The FIST was re-assessed during a second study visit 12 weeks later. Test-retest reliability was evaluated using intraclass coefficient correlation (ICC), the minimal detectable change (MDC) was calculated and the internal consistency reliability was assessed using Cronbach''s coefficient-α. Concurrent validity of the FIST was also tested with the mFRT and the VTC.Results: Test-retest reliability was found to be excellent (ICC = 0.95) with a MDC of 4. The internal consistency was satisfactory (0.81). Moreover, the FIST correlates with the lateral mFRT (r = 0.64, P = 0.001) but not with the forward mFRT and the VTC.Conclusion: These observations provide evidence that the FIST is a reliable clinical measure with partially established validity for non-ambulatory individuals with SCI. Further studies are needed to strengthen the validity of the FIST and explore this measure in a larger sample.     

Availability and need of home adaptations for personal mobility among individuals with spinal cord injury

Objective: To identify the availability and unmet need of home adaptations (HAs) among the Swiss population with spinal cord injury (SCI).

Design: Cross-sectional study.

Setting: Swiss Spinal Cord Injury Community Survey 2012.

Participants: Individuals aged 16 or older with chronic SCI living in Switzerland.

Interventions: Not applicable.

Outcome measures: The availability of ten HAs (self-report) was analyzed by sex, age, living situation, indoor mobility, SCI severity, SCI etiology and time since SCI. The unmet need (self-report of not having a HA but needing it) of HAs was analyzed by financial hardship.

Results: Among the 482 study participants (mean age 55.2 years, standard deviation 15.0 years, 71.6% males), 85.1% had at least one HA. The most frequent HA was a wheelchair accessible shower (62.7%). Availability of HAs markedly varied with indoor mobility (e.g. 38.4% of participants using a wheelchair had a stair lift compared to 17.4% of those walking) and with SCI severity (e.g. 54.8% of those with complete paraplegia had a wheelchair accessible kitchen worktop compared to 26.0% of those with incomplete paraplegia). Unmet need was highest for adjustable kitchen worktops (78.7% of those with a need) and adjustable kitchen cabinets (75.7%) and lowest for wheelchair accessible showers (9.4%) and grab bars next to the toilet (8.5%). No significant differences in unmet need were found when stratifying for financial hardship.

Conclusion: Availability of HAs is dependent on indoor mobility and SCI severity. There is a considerable degree of unmet need for selected HAs, which couldn't be explained by financial hardship.     

Cervical stenosis in spinal cord injury and disorders

Context/Objective: The purpose of this study was to characterize etiologies of spinal cord injury and disorders (SCI/D) in persons with and without cervical stenosis/spondylosis (CSS) and to describe clinical characteristics and underlying comorbidities in these populations.

Design and Setting: We reviewed administrative data for 1954 Veterans who had onset of traumatic or non-traumatic tetraplegia during FY 1999–2007. This included 1037 with a diagnosis of CSS at or in the two years prior to SCI onset of SCI/D and 917 without a diagnosis of CSS.

Outcome Measures: Demographics, etiologies of SCI/D and comorbidities by CSS status.

Results: Veterans with SCI/D and CSS were older, more likely to have incomplete injuries and more likely to be Black than those with SCI/D and no CSS. Of patients with traumatic etiologies for SCI, 35.1% had a diagnosis of CSS at the time of or in the 2 years prior to SCI onset. Of those with tetraplegia due to falls, 40.0% had CSS, whereas for other known traumatic etiologies the percentages with CSS were lower: vehicular (25.0%); sports (16.1%); and acts of violence (10.2%). Total comorbidity scores measured by the Charlson co morbidity index and CMS Hierarchical Condition Category (CMS-HCC) were higher in those with CSS and SCI/D compared to those with SCI/D without CSS (P?<?0.0001 respectively).

Conclusions: CSS is commonly present in patients with new traumatic tetraplegia. Falls are a particularly important potentially modifiable risk for SCI in patients with CSS.