Community Reintegration in Rehabilitated South Indian Persons With Spinal Cord Injury

Samuelkamaleshkumar S, Radhika S, Cherian B, Elango A, Winrose W, Suhany BT, Prakash MH. Community reintegration in rehabilitated South Indian persons with spinal cord injury.

Objectives

To explore community reintegration in rehabilitated South Indian persons with spinal cord injury (SCI) and to compare the level of community reintegration based on demographic variables.

Design

Survey.

Setting

Rehabilitation center of a tertiary care university teaching hospital.

Participants

Community-dwelling persons with SCI (N=104).

Interventions

Not applicable.

Main Outcome Measures

Craig Handicap Assessment and Reporting Technique (CHART).

Results

The mean scores for each CHART domain were physical independence 98±5, social Integration 96±11, cognitive independence 92±17, occupation 70±34, mobility 65±18, and economic self sufficiency 53±40. Demographic variables showed no statistically significant difference with any of the CHART domains except for age and mobility, level of education, and social integration.

Conclusions

Persons with SCI in rural South India who have completed comprehensive, mostly self-financed, rehabilitation with an emphasis on achieving functional ambulation, family support, and self-employment and who attend a regular annual follow-up show a high level of community reintegration in physical independence, social integration, and cognitive independence. CHART scores in the domains of occupation, mobility, and economic self-sufficiency showed lower levels of community reintegration.     

Employment Trajectories After Spinal Cord Injury: Results From a 5-Year Prospective Cohort Study

Objectives

To identify different employment trajectories in individuals with spinal cord injury (SCI) after discharge from initial rehabilitation and to determine predictors of different trajectories from demographic, injury, functional, and psychological characteristics.

Design

Prospective cohort study with baseline measurement at the start of active rehabilitation, a measurement at discharge, and follow-up measurements at 1, 2, and 5 years after discharge.

Setting

Eight rehabilitation centers with SCI units in The Netherlands.

Participants

People with acute SCI (N=176), aged between 18 and 60 years at baseline, who completed at least 2 follow-up measurements.

Interventions

Not applicable.

Main Outcome Measure

Employment was defined as having paid work for ≥12h/wk.

Results

Using latent class growth mixture modeling, 3 distinct employment trajectories were identified: (1) no employment group (22.2%), that is, participants without employment pre-SCI and during 5-year follow-up; (2) low employment group (56.3%), that is, participants with pre-SCI employment and a low, slightly increasing probability of employment during 5-year follow-up; and (3) steady employment group (21.6%), that is, participants with continuous employment pre-SCI and within 5-year follow-up. Predictors of steady employment versus low employment were having secondary education (odds ratio, 4.32; 95% confidence interval, 1.69–11.02) and a higher FIM motor score (odds ratio, 1.04; 95% confidence interval, 1.01–1.06) at discharge.

Conclusions

Distinct employment trajectories after SCI were identified. More than half of the individuals with SCI had a low employment trajectory, and only one-fifth of the individuals with SCI had a steady employment trajectory. Secondary education and higher functional independence level predicted steady employment.     

Effectiveness of Supported Employment for Veterans With Spinal Cord Injury: 2-Year Results

Objective

To examine if supported employment (SE) remains more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI) at 2-year follow-up.

Design

Prospective, randomized, controlled, multisite trial of SE versus TAU with 24 months of follow-up.

Setting

SCI centers.

Participants

Subjects (N=201) were enrolled and completed baseline interviews. At interventional sites, subjects were randomized to SE (n=81) or TAU (n=76). At observational sites, 44 subjects were enrolled in a nonrandomized TAU condition.

Intervention

The intervention was a SE program called the SCI Vocational Integration Program, which followed the principles of the individual placement and support model of SE for persons with mental illness.

Main Outcome Measures

Competitive employment in the community within 2 years.

Results

For the entire 2-year follow-up period, SE subjects were significantly more likely to achieve employment (30.8%; 95% confidence interval [CI], 21.8–41.6) than either the TAU subjects at the intervention sites (10.5%; 95% CI, 5.2–19.7; P<.001) or the TAU subjects at the observational sites (2.3%; 95% CI, 0.0–12.9; P<.002). Most subjects who obtained competitive employment did so in year 1, and the average time to first employment was about 17 weeks.

Conclusions

SE was better than usual practices in improving employment outcomes for veterans with SCI across a 2-year follow-up period. Although SE continued to be superior to traditional practices over the entire study, the first year of participation in SE may represent a critical window for achieving employment after SCI.     

Health Care Utilization and Barriers Experienced by Individuals With Spinal Cord Injury

Objectives

To identify from whom individuals with spinal cord injury (SCI) seek health care, the percentage who receive preventative care screenings, and the frequency and types of barriers they encounter when accessing primary and specialty care services; and to examine how sociodemographic factors affect access to care and receipt of preventative screenings.

Design

Cross-sectional, observational study using an Internet-based survey.

Setting

Internet based.

Participants

Adults (N=108) with SCI who use a wheelchair as their primary means of mobility in the community.

Interventions

Not applicable.

Main Outcome Measures

Health care utilization during the past year, barriers encountered when accessing health care facilities, and receipt of routine care and preventative screenings.

Results

All but 1 participant had visited a primary care provider within the past 12 months, and 85% had had ≥1 visit to specialty care providers. Accessibility barriers were encountered during both primary care (91.1%) and specialty care (80.2%) visits; most barriers were clustered in the examination room. The most prevalent barriers were inaccessible examination tables (primary care=76.9%; specialty care=51.4%) and lack of transfer aids (primary care=69.4%; specialty care=60.8%). Most participants had not been weighed during their visit (89%) and had remained seated in their wheelchair during their examinations (85.2%). Over one third of individuals aged ≥50 years had not received a screening colonoscopy, 60% of women aged ≥50 years had not had a mammogram within the past year, 39.58% of women had not received a Papanicolaou smear within the previous 3 years, and only 45.37% of respondents had ever received bone density testing.

Conclusions

Individuals with SCI face remediable obstacles to care and receive fewer preventative care screenings than their nondisabled counterparts. We recommend that clinics conduct Americans with Disabilities Act self-assessments, ensure that their clinical staff are properly trained in assisting individuals with mobility disabilities, and take a proactive approach in discussing preventative care screenings with their patients who have SCI.     

Wheelchair Repairs, Breakdown, and Adverse Consequences for People With Traumatic Spinal Cord Injury

McClure LA, Boninger ML, Oyster ML, Williams S, Houlihan B, Lieberman JA, Cooper RA. Wheelchair repairs, breakdown, and adverse consequences for people with traumatic spinal cord injury.

Objectives

To investigate the frequency of repairs that occurred in a 6-month period and the consequences of breakdowns on wheelchair users living with spinal cord injuries (SCIs), and to determine whether certain wheelchair and subject characteristics are associated with an increased number of repairs and adverse consequences.

Design

Convenience sample survey.

Setting

Sixteen Model Spinal Cord Injury Systems Centers that are part of the national database funded through the Department of Education, National Institute on Disability and Rehabilitation Research.

Participants

People with SCI who use a wheelchair for more than 40h/wk (N=2213).

Intervention

Not applicable.

Main Outcome Measures

The frequency of wheelchair repairs and occurrence of adverse consequences caused by a wheelchair breakdown in a 6-month period.

Results

Within a 6-month period, 44.8% of full-time wheelchair users completed a repair, and 8.7% had an adverse consequence occur. People who use power wheelchairs required significantly more repairs (P<.001), and adverse consequences occurred more frequently (P<.001) compared with manual wheelchair users. The presence of power seat functions, and a person's occupational status or sex did not influence the number of repairs or adverse consequences.

Conclusions

Frequent repairs and breakdown can negatively impact a person's life by decreasing community participation and threatening health and safety. Mandatory compliance with the American National Standards Institute and the Rehabilitation Engineering and Assistive Technology Society of North America standards, changes in insurance reimbursement policy, and patient and clinician education are necessary to reduce the number of repairs and adverse consequences that occur.     

Changes in Pulmonary Function During the Early Years After Inpatient Rehabilitation in Persons With Spinal Cord Injury: A Prospective Cohort Study

Objective

To describe changes in pulmonary function (PF) during the 5 years after inpatient rehabilitation in persons with spinal cord injury (SCI) and to study potential determinants of change.

Design

Prospective cohort study.

Setting

Eight rehabilitation centers with specialized SCI units.

Participants

Persons with SCI (N=180).

Interventions

Not applicable.

Main Outcome Measures

PF was determined by forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) as a percentage of the predicted value, at the start of rehabilitation, at discharge, and 1 and 5 years after discharge from inpatient rehabilitation. The population was divided into 3 subgroups on the basis of whether their PF declined, stabilized, or improved.

Results

FVC improved on average 5.1% over the whole period between discharge of inpatient rehabilitation and 5 years thereafter, but changes differed largely between persons. FVC declined in 14.9% of the population during the first year after discharge. During this year, body mass index, inspiratory muscle strength, change in peak power output, and change in peak oxygen uptake differed significantly between subgroups. FVC declined in 28.3% of the population during the following 4 years, but no differences were found between the subgroups for this period. Subgroups based on changes in FEV₁ differed only with respect to change in peak oxygen uptake the first year after discharge.

Conclusions

In our study, many persons with SCI showed a decline in PF, larger than the normal age-related decline, during the 5 years after inpatient rehabilitation. Results suggest that a decline in PF during the first year after inpatient rehabilitation is associated with higher body mass index, lower inspiratory muscle strength, and declined physical fitness.     

Predictors and Outcomes of Antibiotic Adequacy for Bloodstream Infections in Veterans With Spinal Cord Injury

Evans CT, Burns SP, Chin A, Weaver FM, Hershow RC. Predictors and outcomes of antibiotic adequacy for bloodstream infections in veterans with spinal cord injury.

Objective

To identify predictors and outcomes associated with receiving inadequate empirical antimicrobial treatment for bloodstream infections (BSIs) in persons with spinal cord injury (SCI).

Design

Retrospective cohort study from October 1, 1997, through September 30, 2004.

Setting

A Department of Veterans Affairs SCI center that serves approximately 700 patients a year.

Participants

Hospitalized patients with SCI (N=123) who had 1 or more BSIs during the study period.

Interventions

Not applicable.

Main Outcome Measures

Adequacy of antimicrobial treatment (inadequate treatment was defined as the absence of antimicrobial agents for a particular organism within 2 days after the collection of blood cultures and/or the microorganism's resistance to the antimicrobial administered), hospital length of stay (LOS) post-BSI infection, and in-hospital and 30-day mortality. Cluster-adjusted multivariable models were assessed.

Results

Over one third (88; 37.4%) of the 235 episodes of BSI identified received inadequate empirical antibiotic treatment. Having a polymicrobial BSI was associated with inadequate treatment (odds ratio [OR]=3.28; 95% confidence interval [CI]=1.62–6.65; P=.001). Factors protective against inadequate therapy included having a comorbid pressure ulcer (OR=0.37; 95% CI=0.21–0.68; P=.001) or a BSI that was not primary (OR=0.30; 95% CI=0.15–0.58; P<.0001). Mortality did not differ between the inadequate and adequate treatment groups (11.4% vs 10.9%; P=.92). Similarly LOS postinfection was not affected by treatment status (inadequate treatment median=22d vs adequate treatment median=27d; P=.98).

Conclusions

Over one third of patients received inadequate empirical treatment, which was associated with having a polymicrobial BSI. However, inadequate treatment was not associated with increased mortality or LOS postinfection.     

Cost-Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries

Objective

To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs).

Design

Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI.

Setting

SCI centers in the Veterans Health Administration.

Participants

Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76).

Intervention

A vocational rehabilitation program of SE for veterans with SCI.

Main Outcome Measures

Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities.

Results

Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care.

Conclusions

An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.     

Effects of Wheelchair Cushions and Pressure Relief Maneuvers on Ischial Interface Pressure and Blood Flow in People With Spinal Cord Injury

Objective

To investigate the effectiveness and interactions of 2 methods of pressure ulcer prevention, wheelchair cushions and pressure relief maneuvers, on interface pressure (IP) and blood flow of the buttocks.

Design

Within-subject repeated measures.

Setting

Rehabilitation center.

Participants

Wheelchair users with a spinal cord injury or disorder (N=17).

Interventions

Participants performed 3 forward leans and 2 sideward leans with different degrees of lean while seated on each of 3 different wheelchair cushions.

Main Outcome Measures

IP measured with a custom sensor and blood flow measured with laser Doppler flowmetry were collected at the ischial tuberosity.

Results

Pressure relief maneuvers had a significant main effect on the ischial IP (P<.001); all maneuvers except for the small frontward lean resulted in a significant reduction in IP compared with upright sitting. Blood flow significantly varied across postures (P<.001) with flow during upright sitting and small forward leans being significantly lower than during the full and intermediate leans in both the forward and sideward directions.

Conclusions

The results of the study highlight the importance of positioning wheelchair users in a manner that facilitates in-seat movement. Regardless of the cushion being used, the pressure relief maneuvers resulted in very large reductions in IPs and significant increases in buttock blood flow. Only the small frontward lean was shown to be ineffective in reducing pressure or increasing blood flow. Because these pressure relief maneuvers involved postural changes that can occur during functional activities, these pressure relief maneuvers can become a part of volitional pressure relief and functional weight shifts. Therefore, clinical instruction should cover both as a means to impart sitting behaviors that may lead to better tissue health.     

Survival in Persons With Traumatic Spinal Cord Injury Receiving Structured Follow-Up in South India

Objective

To assess the survival in persons with traumatic spinal cord injury (SCI) receiving structured follow-up in South India.

Design

Retrospective study.

Setting

Rehabilitation center.

Participants

Persons with traumatic SCI (N=490) residing within a 100-km radius of the institute who were managed and regularly followed up by the rehabilitation center between the years 1981 and 2011.

Interventions

Not applicable.

Main Outcome Measures

Survival rates and mortality risk factors. Measures were estimated using the product limit (Kaplan-Meier) method and the Cox model.

Results

The survival rate after SCI was 86% after 5 years, 71% after 15 years, and 58% after 25 years. Survival of persons with complete high cervical injury is substantially low compared with other levels of SCI. Level of injury and extent of lesion (Frankel classification and/or American Spinal Injury Association Impairment Scale) play a significant role in predicting survival of this population.

Conclusions

Survival rates of regularly followed-up persons with SCI from this study show promising results, though survival rates are lesser when compared with studies from developed countries. Better understanding of the predictors, causes of deaths, comprehensive rehabilitation, community integration, and regular follow-up could possibly assist in improving survival rates.