Technology. Possibilities and pitfalls

An amazing growing area in healthcare is the increase in the development of technology that is designed to augment human functioning and decrease an individual's dependence on others to provide personal care. Yet, what does it mean to extend a person's life through technology? Within the context of a hypothetical case, this article considers ethical questions raised by new and futuristic technologies designed to augment human functioning. These ethical issues are grounded within the context of the possibilities and the pitfalls of technology. When providing care to patients and families, nurses must recognize and understand the significant ways in which quality of life, personhood, accessibility, and cost may be challenged by the promises of new technologies.

Proximal femoral resection for subluxation or dislocation of the hip in spastic quadriplegia

Management of a painful or contracted hip dislocation in individuals with severe spastic quadriplegia is difficult. Clinical and radiographic results of 12 proximal femoral resection-interposition operations performed in seven non-ambulatory persons (five males, two females; mean age 14 years, 8 months; age range 6 years 11 months to 19 years 8 months) with severe spasticity were reviewed to determine if pain relief and restoration of motion were maintained. At a mean follow-up of 7 years 7 months (median 9 years 6 months) all participants maintained a good sitting position and a functional range of motion with improved hygiene. Hip pain was improved in all participants compared with their preoperative status. Proximal femur migration occurred causing slight pain in one person. Heterotopic ossification was observed but was not clinically significant. Complications included traction pin loosening and infection and a late supracondylar femur fracture 3 months after the operation. Proximal femoral resection effectively decreased pain and restored hip motion in those with severe spastic quadriplegia leading to improved sitting and perineal care.

Appropriateness of the Ilfeld Psychiatric Symptom Index as a screening tool for depressive symptomatology in persons with spinal cord injury

BACKGROUND

Depressive symptomatology is seen in some persons with spinal cord injury (SCI). Identification of a depressed mood can assist clinicians in early treatment. The Ilfeld Psychiatric Symptom Index (Ilfeld PSI) is a screening tool that assesses a range of symptoms: depression, cognitive disturbance, anxiety, and anger. The purpose of this study was to compare the efficacy of the Ilfeld PSI to the Zung Self-Rating Depression Scale (Zung SRS) in persons with chronic SCI.

DESIGN

This was a case-control study.

METHODS

A total of 59 subjects completed the study: 20 persons with tetraplegia, 19 with paraplegia, and 20 age-matched able-bodied controls. The total scores for both measures were analyzed using Pearson correlation, analysis of variance, and chi-square tests.

RESULTS

The Zung SRS total scores correlated with the Ilfeld PSI subscales and index scores. When using the traditional cutoff scores, there was a low level of agreement between scales. The Ilfeld PSI classified 79% of the SCI group and 75% of controls as depressed. In contrast, 8% of the SCI group and none of the controls met criteria for depression using the Zung SRS.

CONCLUSIONS

The Ilfeld PSI screens for a broad range of symptoms; however, it poorly discriminates somatic symptoms unrelated to depression. Therefore, the Ilfeld PSI may not be a useful instrument for persons with SCI.

Disability and a sense of community belonging. A study among tetraplegic spinal-cord-injured persons in France

This article presents a study of the identity of persons with motor impairments with regard to the community of disabled persons. The authors used the Tetrafigap survey on the long-term outcome of Tetraplegic Spinal-cord-injured (TSCI) persons, in France, to study the sense of belonging to the community of disabled persons among 1356 TSCI persons in relation to factors of social participation (both sociological and disability-related) and subjective factors (subjective well-being, social perception of disability, perceived disability). The results show that 44% of TSCI persons felt that disabled persons do not constitute a community (the "no-community" group). Of those who recognised the existence of such a community, 34% said they belonged to it (the "in-community" group) and 22% declared they did not (the "out-community" group). People in the "no-community" group tended to be more socially integrated, whilst those in the "in-community" group tended to have greater social and clinical difficulties. The "out-community" group was more diverse, being made up of both autonomous persons and dependent persons suffering from complications. Factors related to the sense of community belonging were identified using bivariate analysis and multiple logistic regression. Subjective well-being appeared to be independent of any sense of community belonging. However, the authors found a gender difference: women in the "in-community" group described themselves as having a poorer level of well-being than women in the other two groups. The results are discussed in terms of two views on the social treatment of disabilities: universalism and assimilation vs. particularism and positive identity and the growth of the disability movement.

[Psychological implications of medical information for patients - considerations in rehabilitees with spinal cord injuries]

The article describes the necessity of medical information also in patients with severe injury, as a conclusion of subjective illness theory ("lay theory") and other theoretical considerations. Analysing the data of a retrospective questionnaire investigation, 71 persons with spinal cord injuries were explored concerning psychological issues of rehabilitation. The results show empirical evidence of expected positive psychological correlations if patients are satisfied with their medical information. There is a low rate of well-informed patients as well as a high need for this particular information about diagnosis and prognosis; possible reasons are discussed and the lack of information is argued.

Patient requested removal of ventilatory support in high-level tetraplegia: guidelines for the health care provider

Determining treatment and extent of care has been returned to the patient with the advent of the durable power of attorney and reinforcement of patients' rights. To a great extent, patient autonomy replaced the medical team's role of beneficence in the decision-making process. Professionals acknowledge the patient's right in the decisional process of his/her care, though there is skepticism of such decisions being made by the patient who has suffered high-level tetraplegia within the acute care arena. This article explores (a) basing decisions upon life experiences and knowledge, (b) differentiating between informed consent for withdrawing care and consent resulting from stress or depression, (c) assessing the patient's psychological balance, and (d) advocating for the patient when he/she chooses to end all treatment options. Guidelines provide assistance to the health professional and the patient through a potentially volatile ethical dilemma. These provide insight into potential problems for all involved and clearly define steps that individuals should take to assure that the decision is made with informed consent rather than emotions.

Self-care independence after spinal cord injury: patient and therapist expectations and real life performance

PURPOSE

To evaluate changes in self-care performance between rehabilitation discharge and 1 year follow-up and to compare patients' and therapists' expectations of self-care independence with actual self-care performance after discharge.

METHODS

Prospective study of 55 patients with tetraplegia (21 complete and 34 incomplete) after spinal cord injury (SCI) consecutively admitted to a large urban rehabilitation hospital [injury levels: C4 (5), C5 (33), C6 (9), C7 (4), and C8 (4)]. Data were collected using structured patient interviews, occupational therapists' predictions of patients' self care, and Functional Independence Measure ratings by rehabilitation staff.

RESULTS

Analysis showed that for all skills, expectations of patients (mainly African American men) were higher than therapists' predictions, and for 3 of these skills, the differences were statistically significant: eating (Z = -4.47, P < .001 ); bathing (Z = -3.67, P < .001 ); and dressing (Z = -3.16, P = .002). Occupational therapists were better predictors of patients' actual self-care performance at discharge than were patients, although both tended to overestimate patients' performance. There was no evidence that self-care capability declined between discharge and 12 months follow-up, but routine self-care performance varied widely across patient and personal circumstances.

CONCLUSIONS

Differential attrition reduced the study sample to 25 SCI patients who were primarily more severely injured African American men. Results showed that these patients maintained their self-care performance 1 year after discharge, but more innovative strategies must be developed to customize self-care retraining to address the unique needs of this patient population.

Assessment of the impact of pain and impairments associated with spinal cord injuries

OBJECTIVES

To determine the adequacy of the Multidimensional Pain Inventory (MPI) for assessing pain impact after spinal cord injury (SCI) and to determine whether the impact of pain can be separated from other consequences of SCI.

DESIGN

Postal survey.

SETTING

General community.

PARTICIPANTS

Of the 159 subjects contacted who experienced chronic pain, 120 (75.5%) participated.

INTERVENTIONS

Subjects were mailed the original MPI and a set of additional items specific to SCI.

MAIN OUTCOME MEASURE

The MPI.

RESULTS

Confirmatory (CFA) and exploratory factor analyses were performed for each section of the MPI. Elimination of several items, including those related to work in section 1 (pain impact), improved the goodness-of-fit index (GFI). A CFA for section 2 (response of significant other) resulted in acceptable GFI after 2 items were deleted. Decrease in activity levels (section 3) because of other consequences of injury was significantly greater after tetraplegia than after paraplegia. In contrast, pain-related reduction in activities was not associated with injury level. Although other consequences of SCI may have greater impact on activities than pain, severe pain is likely to affect activity levels significantly.

CONCLUSION

The MPI appears to be appropriate for use in a SCI population when modified to eliminate questions related to work and to supplement the activity scale with items addressing decreased activity levels due to pain.

Impact of demographic and medical factors on satisfaction with life after spinal cord injury: a normative study

OBJECTIVE

The aim of this study was (1) to examine demographic and medical predictors of the Satisfaction With Life Scale (SWLS) among individuals with spinal cord injury (SCI) and (2) to provide a normative table for the SWLS that includes appropriate adjustments for the most important predictors of life satisfaction.

STUDY DESIGN

We examined predictors of the SWLS including age, education, sex, race, injury duration, number of rehospitalizations, marital status, employment status, SCI etiology, and level of neurological impairment.

PARTICIPANTS

Individuals in the National Spinal Cord Injury Statistical Center database [from 18 SCI model systems (1995-1999)] undergoing follow-up assessment were included for study.

OUTCOME MEASURE

Satisfaction With Life Scale.

RESULTS

Univariate analyses indicated that marital and employment status, race, sex, education, and injury duration were significant factors associated with scores on the SWLS. In general, individuals who were female, white, married, and currently employed and had a higher education and longer injury duration reported significantly higher scores on the SWLS (P < .01). Effect-size estimates for these factors ranged from 0.16 to 0.41. Regression analyses showed that education, employment status, and injury duration were the strongest unique predictors of satisfaction with life but accounted for only 10% of the variance.

CONCLUSION

The SWLS is a global measure of life satisfaction and is relatively unrelated to demographic and medical characteristics. Normative tables are provided for epidemiologic comparison.

Powered mobility and preschoolers with complex developmental delays

OBJECTIVE

The purpose of this study was to explore the effects of a powered mobility riding toy on the participation behaviors of young children with complex developmental delays.

METHOD

A single-subject withdrawal design was used to study the effects of powered mobility on child-initiated movement occurrences, initiation of contact with others, and affect. The participants were two young children with complex developmental delays, including spastic quadriplegia. The intervention consisted of having the children use a powered mobility riding toy in their school settings during gym class and outdoor recess.

RESULTS

Primary findings were that use of the powered mobility riding toy (a) increased the number of self-initiated movement occurrences; (b) appeared to have some effect on initiation of contacts with adults and, for one child, negative adult initiations and positive peer initiations; and (c) did not have a clear impact on the amount of positive affect.

CONCLUSION

For some young children with severe motor impairments and developmental delay, use of a powered mobility device may increase self-initiated movement occurrences during free play.

Health related functional status in men with spinal cord injury: relationship with lesion level and endurance capacity

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To determine the relationship of health related functional status with lesion level and endurance capacity in persons with spinal cord injury (SCI).

METHODS

Thirty-seven men with SCI were divided in four lesion groups: high tetraplegia (motor complete; C5-C6, n=10), low tetraplegia (motor complete, C6/7-C8, n=9), motor incomplete tetraplegia (n=7), and paraplegia (n=11). Health related functional status was measured with the short version of the Sickness Impact Profile (SIP68), including a physical (SOM), psychological (PSY) and social subscore (SOC). Endurance capacity, defined as maximal power output (PO(max)) and peak oxygen uptake (VO(2peak)), was measured in a maximal exercise test on a wheelchair ergometer.

RESULTS

Total SIP68-score and SOM were significantly different between lesion groups, showing higher values in the high- and low-tetraplegia group. There were no differences between lesion groups for PSY and SOC subscores. VO(2peak) and PO(max) were significantly higher in the paraplegia group, compared to the high and low tetraplegia groups. VO(2peak) was also higher in the motor incomplete versus other tetraplegia groups. Significant Spearman correlation coefficients were found for VO(2peak) and PO(max) with SIP68 and SOM (ranging from -0.68 to -0.79) and SOC (ranging from -0.39 to -0.51). No significant relationship was found with PSY. Hierarchical regression analysis showed that after correction for lesion level, 22% of the variance of SIP68, 8% of the variance of SOM, and 30% of the variance of SOC was explained by PO(max) or VO(2peak).

CONCLUSIONS

Results indicate that there is an evident relationship between the physical dimensions of health related functional status and lesion level, but not for the psychological and social dimensions. After controlling for lesion level a significant amount of the variance of health related functional status can be explained by endurance capacity parameters. Although no causal relationships can be established in this cross-sectional study, these results suggest that functional status may be improved by increasing the endurance capacity.

Components of quality of life for persons with a quadriplegic and paraplegic spinal cord injury

This investigation determined the themes that represented quality of life for persons with a spinal cord injury. Fifteen people (6 females, 9 males; 7 persons with quadriplegia, 8 with paraplegia) participated in this study, which used naturalistic inquiry methodologies. Results showed that quality of life for this population, regardless of severity of impairment, consisted of nine themes: (a) physical function and independence, (b) accessibility, (c) emotional well-being, (d) stigma, (e) spontaneity, (f) relationships and social function, (g) occupation, (h) finances, and (i) physical well-being. The themes of life quality were similar for quadriplegics and paraplegics; however, physical function and independence and physical well-being affected the quality of life of persons with a quadriplegic injury to a greater extent. These findings may provide health professionals with information necessary to assist in the development of programs to enhance quality of life.

Ageing with spinal cord injury: cross-sectional and longitudinal effects

STUDY DESIGN

Longitudinal and cross-sectional.

OBJECTIVE

To determine whether, for studies of ageing with a spinal cord injury, the cross-sectional differences in outcomes across both age and years post injury (YPI) differ from the longitudinal change.

SETTING

Two SCI centres in England: the National Spinal Injuries Centre in Aylesbury, and the Regional Spinal Injuries Centre in Southport.

METHODS

A total of 315 people who sustained spinal cord injuries prior to 1971 underwent comprehensive health and psychosocial status interviews at one or more of the study assessments (1990, 1993, 1996, and 1999). A range of continuous and dichotomous outcomes was analyzed to detect both cross-sectional differences by age and average individual changes over multiple measurements.

RESULTS

Frequently, outcomes changed longitudinally without showing any cross-sectional differences. Cross-sectional age was more commonly associated with the worsening of a condition while cross-sectional YPI was commonly associated with improvement. After controlling for cross-sectional effects, psychological measures generally showed minor deterioration, measures of community integration both improved and deteriorated, upper extremity pain increased, lower enxtremity pain decreased, and participants tended to quit smoking.

CONCLUSION

Using longitudinal findings that control for cross-sectional differences produces a more complete description of ageing with a spinal cord injury.

Self-initiation of EEG-based communication in paralyzed patients

OBJECTIVES

Severely paralyzed patients could learn to voluntarily generate slow cortical potential (SCP) shifts in their electroencephalogram and to use these signals to operate a communication device. To enhance the patients' autonomy, the present study describes the development of a permanently available communication system that can be turned on and off by locked-in patients without external assistance. A skill necessary for turning the system on is the ability to regulate one's slow potentials in the absence of continuous feedback.

METHODS

A stepwise learning approach was employed to train two paralyzed patients to regulate their SCPs without continuous feedback. Elements of the original communication system were gradually removed and elements of the new stand-by mode were introduced.

RESULTS

At the end of the learning procedure, both patients achieved correct response rates of above 84% in training sessions without continuous feedback. This skill enabled them to turn the communication device on and off without assistance from others.

CONCLUSIONS

These findings suggest that severely paralyzed individuals can learn to operate an EEG-based communication device autonomously.

Subjective well-being and severe motor impairments: the Tetrafigap survey on the long-term outcome of tetraplegic spinal cord injured persons

The purpose of the research described in this article is to study the effects of severe motor impairments on a person's well-being, by attempting to throw light upon the inconsistencies found in the previous literature, which are due to problems of a conceptual and methodological nature. The data were gathered during the Tetrafigap survey on the long-term outcome of tetraplegic persons in France. This survey involved 1668 tetraplegic spinal cord injured people. We examine the relationships between the overall assessment of well-being as expressed by the people interviewed, and a range of clinical, social and psycho-social factors. A progressive approach, along with the use of adjustments via linear regressions, has allowed us to identify certain confounding factors, and to analyse the respective effects of the different types of variables studied. Thus current age, the age at which the impairment occurred and having or not having a professional activity do not have any direct links with the assessment of well-being, whereas the existence of pain and the subjective assessment of one's own independence and of the severity of one's disability are predictive factors. The functional independence indicators are only linked to well-being when they relate to situations in which the dependence creates embarrassment due to socio-cultural taboos. The loss of autonomy only affects well-being in as much as it imposes limits to social activity, whether they be relational or occupational. Living as a couple is a negative predictive factor if the couple were together prior to the impairment occurring. The overall results demonstrate the importance of moving beyond any conception of the impact of the impairments on well-being that is too exclusively focused on the individual, and of integrating the socio-cultural meanings of handicap situations and the dynamics of the interactions which take place therein.