Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis

OBJECTIVES

To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization.

DESIGN

A qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews.

SETTING

Community.

PARTICIPANTS

A sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants' self-report of their medical experiences from the time of injury through the early recovery period.

RESULTS

We identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care).

CONCLUSIONS

In appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.

Understanding the factors that influence social and community participation as perceived by people with non-traumatic spinal cord injury

Introduction

The number of people with non-traumatic spinal cord injury is rising in developed countries such as Australia and Great Britain. People with non-traumatic spinal cord have different gender, injury and age-related profiles compared to those with traumatically acquired spinal cord injury; therefore, their lived experience is likely to be different. However, the specific issues and challenges that this group faces have not been well investigated.

Method

Semi-structured in-depth interviews were conducted with 17 adults with non-traumatic spinal cord injury. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

Findings

The factors that influenced the social and community participation of people with non-traumatic spinal cord injury were grouped into three broad areas: person factors, factors in the physical and institutional environment, and factors in the social or cultural environment.

Conclusion

The findings from this study inform the understanding of occupational therapists regarding the social and community participation of people with non-traumatic spinal cord injury and how this can be facilitated. Assisting people with non-traumatic spinal cord injury to participate in meaningful social and community-based activities is important to maximise their quality of life.

Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia

PURPOSE

Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients.

METHODS

Nineteen patients with C4-8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology.

RESULTS

Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients' ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants.

CONCLUSIONS

We built a conceptual model that outlines how patients' personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills.

CLINICAL RELEVANCE

To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.

Growing Older With a Physical Disability: A Special Application of the Successful Aging Paradigm

Objectives

In the United States, the average age of people living with early-acquired physical disabilities is increasing. This cohort is said to be aging with disability and represents a unique population among older adults. Given recent policy efforts designed to merge aging and disability services, it is critical that models of "successful aging" include and are relevant to this population. However, many current definitions of successful aging emphasize avoidance of disability and high levels of physical function as necessary to well-being.

Method

In 9 focus groups, we examined perspectives of "successful aging" in 49 middle-aged and older individuals living with spinal cord injury, multiple sclerosis, muscular dystrophy, or postpolio syndrome. Transcripts were analyzed using a structured qualitative coding approach and Dedoose indexing software.

Results

Participants ranged in age from 45 to 80 years (M = 62) and had lived with their disability diagnosis for an average of 21 years. Analysis revealed 4 primary themes of successful aging: resilience/adaptation, autonomy, social connectedness, and physical health (including access to general and specialty healthcare).

Discussion

Results highlight the need for a nuanced application of the "successful aging" paradigm in this population.

Leisure time physical activity among older adults with long-term spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To describe participation in leisure time physical activity (LTPA) (amount, intensity and type) among older adults with long-term spinal cord injury (SCI), and to investigate the associations with sociodemographics, injury characteristics and secondary health conditions (SHCs).

SETTING

Home settings in southern Sweden.

METHODS

Data from the Swedish Aging with Spinal Cord Injury Study (SASCIS). The physical activity recall assessment for people with SCI was used to assess LTPA among 84 men and 35 women (mean age 63.5 years, mean time since injury 24 years, injury levels C1-L5, American Spinal Injury Association Impairment Scale A-D). Associations were analyzed statistically using hierarchical multivariable regression.

RESULTS

Twenty-nine percent reported no LTPA, whereas 53% performed moderate-to-heavy intensity LTPA. The mean minutes per day of total LTPA was 34.7 (±41.5, median 15, range 0-171.7) and of moderate-to-heavy LTPA 22.5 (±35.1, median 5.0, range 0-140.0). The most frequently performed activities were walking and wheeling. Sociodemographics, injury characteristics and SHCs (bowel-related and bladder-related problems, spasticity and pain) explained 10.6% and 13.4%, respectively, of the variance in total and moderate-to-heavy LTPA. Age and wheelchair use were significantly, negatively associated with total LTPA. Women, wheelchair users and employed participants performed significantly less moderate-to-heavy LTPA than men, those using walking devices/no mobility device and unemployed participants.

CONCLUSION

Many older adults with long-term SCI do not reach the amount or intensity of LTPA needed to achieve fitness benefits. Research is needed on how to increase LTPA and to identify modifiable factors that could enhance their participation.

Social activity and relationship changes experienced by people with bowel and bladder dysfunction following spinal cord injury

STUDY DESIGN

Exploratory qualitative.

OBJECTIVES

The aim of this study was to describe the experiences of bowel and bladder dysfunction on social activities and relationships in people with spinal cord injury living in the community.

SETTING

People living with spinal cord injury experiencing bowel and bladder dysfunction.

METHODS

Participants were recruited through the Australian Quadriplegic Association Victoria. Semi-structured in-depth interviews were undertaken with purposively selected participants to ensure representation of age, gender, spinal cord injury level and compensation status. A thematic analysis was performed to interpret patient experiences.

RESULTS

Twenty-two participants took part in the study. Bladder and bowel dysfunction altered relationships because of issues with intimacy, strained partner relationships and role changes for family and friends. A lack of understanding from friends about bladder and bowel dysfunction caused frustration, as this impairment was often responsible for variable attendance at social activities. Issues with the number, location, access and cleanliness of bathrooms in public areas and in private residences negatively affected social engagement. Social activities were moderated by illness, such as urinary tract infections, rigid and unreliable bowel routines, stress and anxiety about incontinence and managing the public environment, and due to continuous changes in plans related to bowel and bladder issues. Social support and adaptation fostered participation in social activities.

CONCLUSION

Tension exists between managing bowel and bladder dysfunction and the desire to participate in social activities. Multiple intersecting factors negatively affected the social relationships and activities of people with spinal cord injury and bowel and bladder dysfunction.

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.

Medication-related problems in individuals with spinal cord injury in a primary care-based clinic

OBJECTIVE

To determine the frequency of medical problems, reason for referral/primary complaint, products used, medication-related problems, and polypharmacy in patients with spinal cord injury (SCI) seen at an interprofessional primary care mobility clinic.

DESIGN

Retrospective review of medical records of patients with SCI for patient visits between August 2012 and March 2013.

METHODS

Data were abstracted from medical records of patients with SCI.

RESULTS

Of 74 patients who presented to the clinic, 19 had an SCI. Mean age was 46.7 years and 74% were male. Most frequent medical problems were depression/anxiety (37%), osteoporosis/osteopenia (26%), hypertension (21%), dyslipidemia (21%), and osteoarthritis (21%). Most common presenting complaints were pain (23%) and bowel/bladder issues (13%). Most common medication-related problems were untreated conditions (41%), ineffective medications (21%), adverse drug reactions (18%), and under- and over-dosage (each 9%). Patients with SCI most frequently used products to treat pain (68%), constipation (42%), muscle spasm (42%), hypertension (42%), and depression (37%). When including natural health products, vitamins and minerals, polypharmacy was seen in 74% of patients with SCI (63% when limited to prescription and over-the-counter medications). For patients with SCI in whose care a pharmacist collaborated, a mean of 3.2 medication-related problems per patient were identified compared with 1 per patient when the pharmacist was not involved.

CONCLUSION

This study is the first to describe medication use, polypharmacy and medication-related problems in patients with SCI seen at an interprofessional primary care clinic. Use of high-risk medications, polypharmacy, and medication-related problems in patients with SCI suggest the need for collaborative interprofessional care that includes a pharmacist.

Participation in activities and secondary health complications among persons aging with traumatic spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To describe participation in activities and explore the relationship with secondary complications among persons aging with a traumatic spinal cord injury (SCI).

SETTING

A regional SCI outpatient center in Sweden.

METHODS

Data were collected through a phone survey, which included 10 activities from the instrument PARTS/M-v3 (PARTicipation Survey/Mobility version-3) together with data from the participants' medical records. Cross-tabulation and χ² were used for data analysis.

RESULTS

In this study, 121 persons matched the inclusion criteria and the final study sample comprised 73 participants (60% response rate): 55 men and 18 women. Mean age was 63.7±9.4 years, and mean time since injury was 36.3±9.2 years. Regardless of duration of SCI, all 73 participated in dressing, bathing and leisure activities. Women reported better health than men. Particularly for those who lived 36-55 years after injury; increasing pain, fatigue, spasticity and decreased muscle strength were negatively affecting participation in activities, especially exercise and active recreation. Additionally, a need to save strength/energy was also a reason for not participating in the activities. Perceived future support and concerns in relation to personal assistance, assistive devices and rehabilitation was also reported.

CONCLUSION

Increasing secondary health complications and a need to save strength/energy influenced participation in activities. Laws and/or governmental policies regarding personal assistance and assistive devices did not always support participation in activities. Interventions should aim to create a balance among activities in everyday life.

Prevalence and associated factors of pain in the Swiss spinal cord injury population

STUDY DESIGN

Population-based, cross-sectional.

OBJECTIVES

To determine pain prevalence and identify factors associated with chronic pain in individuals with spinal cord injury (SCI) living in Switzerland.

SETTING

Swiss SCI Cohort Study (SwiSCI).

METHODS

Pain characteristics were assessed using an adapted version of the International SCI Pain Basic Data Set, adding one item of the SCI Secondary Conditions Scale to address chronic pain. Pain prevalence was calculated using stratification over demographic, SCI-related and socioeconomic characteristics; odds ratios (adjusted for non-response) for determinants of severity of chronic pain were calculated using stereotype logistic regressions.

RESULTS

Pain (in the past week) was reported by 68.9% and chronic pain by 73.5% (significant 36.9%) of all participants (N=1549; 28% female). Most frequently reported pain type was musculoskeletal (71.1%). Back/spine was the most frequently reported pain location (54.6%). Contrasting the 'significant' to the 'none/mild' category of chronic pain, adjusted odds ratios were 1.54 (95% CI: 1.18-2.01; P<0.01) for women (vs men); 6.64 (95% CI: 3.37-11.67; P<0.001) for the oldest age group 61+ (vs youngest (16-30)); 3.41 (95% CI: 2.07-5.62; P<0.001) in individuals reporting severe financial hardship (vs no financial hardship). Individuals reporting specific SCI-related health conditions were 1.41-2.92 (P<0.05) times more likely to report chronic pain as 'significant' rather than 'none/mild' compared with those without the respective condition.

CONCLUSIONS

Pain is highly prevalent in individuals with SCI living in Switzerland. Considered at risk for chronic pain are women, older individuals and individuals with financial hardship and specific secondary health conditions. Longitudinal studies are necessary to identify predictors for the development of pain and its chronification.

Health and economic benefits of physical activity for patients with spinal cord injury

Spinal cord injury (SCI) is a traumatic, life-disrupting event with an annual incidence of 17,000 cases in the US. SCI is characterized by progressive physical deconditioning due to limited mobility and lack of modalities to allow safe physical activity that may partially offset these deleterious physical changes. Approximately, 50% of patients with SCI report no leisure-time physical activity and 15% report leisure-time physical activity below the threshold where meaningful health benefits could be realized. Collectively, about 363,000 patients with SCI, or 65% of the entire spinal cord injured population in the US, engages in insufficient physical activity and represents a target population that could derive considerable health benefits from even modest physical activity levels. Currently, the annual direct costs related to SCI exceed US$45 billion in the US. Rehabilitation protocols and technologies aimed to improve functional mobility have potential to significantly reduce the risk of medical complications and cost associated with SCI. Patients who commence routine physical activity in the first post-injury year and experience typical motor function improvements would realize US$290,000 to US$435,000 in lifetime cost savings, primarily due to fewer hospitalizations and less reliance on assistive care. New assistive technologies that allow patients with SCI to safely engage in routine physical activity are desperately needed.

The Impact Of Sports Activities On Quality Of Life Of Persons With A Spinal Cord Injury: VPLIV ŠPORTNIH AKTIVNOSTI NA KAKOVOST ŽIVLJENJA OSEB S POŠKODBO HRBTENJAČE

Objectives

Studying the quality of life of people with a spinal cord injury is of great importance as it allows the monitoring of both functioning and adaptation to disability. The aim of this study was to determine the difference between persons with a spinal cord injury involved in sports activities and those not involved in sports activities in relation to their quality of life and the presence of secondary health conditions (pressure ulcers, urinary infections, muscle spasms, osteoporosis, pain, kidney problems-infections, calculosis and poor circulation).

Methods

The study included a total of 44 participants with spinal cord injury-paraplegia of both genders; 26 of them were athletes and 18 were not athletes. The athletes were training actively for the last two years, minimally 2-3 times per week. A specially designed questionnaire, medical documentation and the Spinal Cord Injury Quality of Life Questionnaire (SCI QL-23) were used for research purposes. Chi-square test was used to analyze the differences between the groups, while multiple analysis of variance (MANOVA) was used to determine the differences between the sets of variables.

Results

Among the participants, the athletes perceived higher quality of life than the non-athletes (male gender p<0.001 and female gender p<0.05). Regarding secondary health conditions, the athletes reported the presence of less pain (p=0.034) and a subjective feeling of better circulation (p=0.023).

Conclusion

The implementation of sports activities significantly improves quality of life in the population of people with spinal cord injury-paraplegia. However, sports activities only partially affect secondary health conditions.

Secondary health conditions experienced by people with spinal cord injury within community living: implications for a National Disability Insurance Scheme

BACKGROUND

Australia's National Disability Insurance Scheme (NDIS) provides supports for individuals, delivered through a personalised participant planning process, to influence choice and goal attainment.

AIM

This study aimed to use both quantitative and qualitative methods to examine the impact of secondary health conditions on the experiences of people with spinal cord injury (SCI) who have returned to community living, in the context of Australia's National Disability Strategy and recently launched NDIS. Exploration of lived experience of health conditions following SCI utilising this mixed methods approach may offer important insights for effective planning within an NDIS.

METHODS

A cross-sectional survey using the Spinal Cord Injury Secondary Conditions Scale (SCISCS), demographic questionnaire and in-depth interview was undertaken with 33 people with SCI living in the community. Demographic and SCISCS data were reported using descriptive statistics. Interviews were audio-taped, transcribed and analysed thematically.

RESULTS

Participants were on average 58.5 years of age and 20 years post-injury. Five key themes emerged relating to (i) spasm and pain; (ii) sexual dysfunction; (iii) pressure areas; (iv) fatigue; and (v) the impact of secondary health conditions on life role participation and choice of supports and equipment.

CONCLUSION

Secondary health conditions can significantly impact occupational participation following SCI. Appropriate intervention, including customised equipment and direct support, if delivered as part of an effective NDIS, may prevent or reduce the severity of these conditions and offer the potential to influence health and participation outcomes of people who have returned to community living.

Clinical effectiveness and safety of powered exoskeleton-assisted walking in patients with spinal cord injury: systematic review with meta-analysis

Background

Powered exoskeletons are designed to safely facilitate ambulation in patients with spinal cord injury (SCI). We conducted the first meta-analysis of the available published research on the clinical effectiveness and safety of powered exoskeletons in SCI patients.

Methods

MEDLINE and EMBASE databases were searched for studies of powered exoskeleton-assisted walking in patients with SCI. Main outcomes were analyzed using fixed and random effects meta-analysis models.

Results

A total of 14 studies (eight ReWalk™, three Ekso™, two Indego^®, and one unspecified exoskeleton) representing 111 patients were included in the analysis. Training programs were typically conducted three times per week, 60–120 minutes per session, for 1–24 weeks. Ten studies utilized flat indoor surfaces for training and four studies incorporated complex training, including walking outdoors, navigating obstacles, climbing and descending stairs, and performing activities of daily living. Following the exoskeleton training program, 76% of patients were able to ambulate with no physical assistance. The weighted mean distance for the 6-minute walk test was 98 m. The physiologic demand of powered exoskeleton-assisted walking was 3.3 metabolic equivalents and rating of perceived exertion was 10 on the Borg 6–20 scale, comparable to self-reported exertion of an able-bodied person walking at 3 miles per hour. Improvements in spasticity and bowel movement regularity were reported in 38% and 61% of patients, respectively. No serious adverse events occurred. The incidence of fall at any time during training was 4.4%, all occurring while tethered using a first-generation exoskeleton and none resulting in injury. The incidence of bone fracture during training was 3.4%. These risks have since been mitigated with newer generation exoskeletons and refinements to patient eligibility criteria.

Conclusion

Powered exoskeletons allow patients with SCI to safely ambulate in real-world settings at a physical activity intensity conducive to prolonged use and known to yield health benefits.

Medical complications during pregnancy and childbirth in women with SCI in Switzerland

STUDY DESIGN

A retrospective interview study of mothers with spinal cord injuries (SCIs) who gave birth over the last 15 years.

OBJECTIVES

To identify the medical complications of women with SCIs during pregnancy and childbirth in Switzerland and to describe how they dealt with these complications.

SETTINGS

Swiss Paraplegic Research in Nottwil, the University of Lausanne and participants' homes.

METHODS

Data were collected by self-reported questionnaires and descriptive analysis was conducted.

RESULTS

Seventeen women with SCIs who gave birth to 23 children were included. Thirteen of the women were paraplegics and four were tetraplegics. All of them practiced an independent bladder management. Three women changed their bladder management techniques during pregnancy. Five women reported an increased bladder evacuation frequency during pregnancy, and six women reported a new onset or increase in incontinence. We observed no significant increase in bowel dysfunction or skin breakdown due to their pregnancies. Ten women were hospitalised during the course of their pregnancies. Aside from urinary tract infections/pyelonephritis, women were hospitalised for falls, hypertension, pneumonia, preeclampsia, pre-term labour or tachycardia.

CONCLUSION

The results of our study clearly demonstrated that, although medical complications are not infrequent during pregnancy in women with SCIs, pregnancy and delivery in this group of women are possible without posing intolerable risks to the mothers or the children. Urological problems seemed to be the most frequent complication during pregnancy.

SCI Longitudinal Aging Study: 40 Years of Research

BACKGROUND

The Spinal Cord Injury (SCI) Longitudinal Aging Study was initiated in 1973 and has conducted 8 assessments over the past 40 years. It was designed to help rehabilitation professionals understand the life situation of people with SCI, but it has developed into the most long-standing study of aging and SCI and has resulted in over 50 publications.

OBJECTIVE

Our purpose was to provide a detailed history of the study, response patterns, utilization of measures, and a summary of key findings reported in the literature.

METHODS

Five participant samples have been incorporated over the 40 years, with enrollment in 1973, 1984, 1993 (2 samples), and 2003. A total of 2,208 participants have completed 6,001 assessments, with a particularly large number of assessments among those who are more than 40 years post injury (n = 349).

RESULTS

The overall results have indicated changing patterns of outcomes over time as persons with SCI age, with some notable declines in participation and health. There has been a survivor effect whereby persons who are more active, well-adjusted, and healthier live longer.

CONCLUSIONS

This study has several important features that are required for longitudinal research including (a) consistency of follow-up, (b) consistency of measures over time, (c) addition of new participant samples to counteract attrition, and (d) inclusion of a large number of individuals who have reached aging milestones unparalleled in the literature. Data from this study can inform the literature on the natural course of aging with SCI.

Review of secondary health conditions in postpolio syndrome: prevalence and effects of aging

OBJECTIVE

This study sought to better understand the prevalence and the severity of secondary health conditions in individuals with postpolio syndrome (PPS) as well as the association between these conditions and aging.

DESIGN

A scoping literature review was conducted searching electronic databases for studies published from 1986 to 2011. The scoping review provided information regarding the prevalence and associations of secondary health conditions in PPS with age or other duration-related variables.

RESULTS

The findings indicate that (1) individuals with PPS experience a number of serious secondary health conditions; (2) the most common conditions or symptoms are fatigue, pain, respiratory and sleep complaints, and increased risk for falls; (3) reports of the associations between the frequency or the severity of conditions and age-related factors are variable, perhaps because of methodological inconsistencies between studies; and (4) there is a marked lack of longitudinal research examining the natural course of health conditions in people aging with PPS.

CONCLUSIONS

Longitudinal research is needed to understand the course of health conditions and the impact of multiple secondary conditions in people aging with PPS. Efforts are also needed to develop and test the efficacy of interventions to prevent these secondary health conditions or reduce their negative impact.

Lifetime prevalence of chronic health conditions among persons with spinal cord injury

OBJECTIVE

To assess lifetime prevalence of 7 chronic health conditions (CHCs) among a cohort of adults with chronic traumatic spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Adults with SCI who were ≥18 years of age, were ≥1 year postinjury, and had residual neurologic effects impeding full recovery (n=1678).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

CHCs were measured using questions from the Behavioral Risk Factor Surveillance System for diabetes (not including gestational), heart attack (also called a myocardial infarction), angina or coronary artery disease, stroke, hypertension (not including during pregnancy), high blood cholesterol, or cancer.

RESULTS

Of participants, 49.5% reported having at least 1 CHC, with 23.2% reporting ≥2 CHCs. The most frequently reported CHC was high cholesterol (29.3%) followed by hypertension (28.7%) and diabetes (11.8%). Although the prevalence of CHCs significantly increased with increasing age, only hypertension and cancer were significantly associated with years postinjury. Four CHCs (diabetes, coronary artery disease, hypertension, high cholesterol) were significantly related to mobility status as measured by injury level and ambulatory status. However, after controlling for age, years postinjury, sex, and race, mobility status became nonsignificant in relation to coronary artery disease, but it remained significantly associated with diabetes, hypertension, and high cholesterol.

CONCLUSIONS

Clinicians should be aware of the risk of CHCs in persons with SCI and should screen for these conditions and regular maintenance activities related to SCI.

Definitions of quality of life: what has happened and how to move on

BACKGROUND

Quality of life (QOL) is an important outcome in spinal cord injury (SCI) rehabilitation, but it is unclear how to define and measure it.

OBJECTIVE

The aims of this article are to (a) show how the concepts of QOL and health-related quality of life (HRQOL) have evolved over time, (b) describe the various ways QOL has been defined and measured, and (c) provide recommendations on how to be as clear and consistent as possible in QOL research.

METHOD

A narrative review of the QOL literature was performed.

RESULTS

Roots of the term "quality of life" in health care can be traced back to the definition of health by the World Health Organization in 1948. The use of the word "well-being" in this definition is probably a main factor in the continuing confusion about the conceptualization of QOL. Within the field of SCI rehabilitation, the Dijkers's QOL model, distinguishing between utilities, achievements, and subjective evaluations and reactions, has been very influential and the basis for several reviews and databases. Nevertheless, literature shows that it is still difficult to consistently use the term "quality of life" and categorize QOL measures. Several aspects of QOL that are specific for individuals with SCI have been identified.

CONCLUSIONS

Researchers should be as specific and clear as possible about the concept and operationalization of QOL in their studies. Readers should not take the term "quality of life" for granted, but should inspect the topic of the study from the actual measures used.

Health care utilization and expenditures among Medicaid beneficiaries with neuropathic pain following spinal cord injury

Background

The study aimed to evaluate health care resource utilization (HRU) and costs for neuropathic pain (NeP) secondary to spinal cord injury (SCI) among Medicaid beneficiaries.

Methods

The retrospective longitudinal cohort study used Medicaid beneficiary claims with SCI and evidence of NeP (SCI-NeP cohort) matched with a cohort without NeP (SCI-only cohort). Patients had continuous Medicaid eligibility 6 months pre- and 12 months postindex, defined by either a diagnosis of central NeP (ICD-9-CM code 338.0x) or a pharmacy claim for an NeP-related antiepileptic or antidepressant drug within 12 months following first SCI diagnosis. Demographics, clinical characteristics, HRU, and expenditures were compared between cohorts.

Results

Propensity score-matched cohorts each consisted of 546 patients. Postindex percentages of patients with physician office visits, emergency department visits, SCI- and pain-related procedures, and outpatient prescription utilization were all significantly higher for SCI-NeP (P<0.001). Using regression models to account for covariates, adjusted mean expenditures were US$47,518 for SCI-NeP and US$30,150 for SCI only, yielding incremental costs of US$17,369 (95% confidence interval US$9,753 to US$26,555) for SCI-NeP. Factors significantly associated with increased cost included SCI type, trauma-related SCI, and comorbidity burden.

Conclusion

Significantly higher HRU and total costs were incurred by Medicaid patients with NeP secondary to SCI compared with matched SCI-only patients.