Patterns of morbidity and rehospitalisation following spinal cord injury

Predictors of cardiopulmonary hospitalization in chronic spinal cord injury

OBJECTIVE

To investigate longitudinal risk factors of hospitalization for circulatory and pulmonary diseases among veterans with chronic spinal cord injury (SCI). Circulatory and respiratory system illnesses are leading causes of death in patients with chronic SCI, yet risk factors for related hospitalizations have not been characterized.

DESIGN

Prospective cohort study.

SETTING

Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts. PARTICIPANTS/DATA SOURCES: Veterans (N=309) greater than or equal to 1 year post-SCI from the VA Boston Chronic SCI cohort who completed a health questionnaire and underwent spirometry at study entry. Baseline data were linked to 1996 through 2003 hospitalization records from the VA National Patient Care Database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Cardiopulmonary hospital admissions, the predictors of which were assessed by multivariate Cox regression.

RESULTS

Of 1478 admissions observed, 143 were a result of cardiopulmonary (77 circulatory and 66 respiratory) illnesses. Independent predictors were greater age (3% increase/y), hypertension, and the lowest body mass index quintile (<22.4 kg/m2). A greater percentage-predicted forced expiratory volume in 1 second was associated with reduced risk. SCI level and completeness of injury were not statistically significant after adjusting for these risk factors.

CONCLUSIONS

Cardiopulmonary hospitalization risk in persons with chronic SCI is related to greater age and medical factors that, if recognized, may result in strategies for reducing future hospitalizations.

Transcutaneously coupled, high-frequency electrical stimulation of the pudendal nerve blocks external urethral sphincter contractions

BACKGROUND

Detrusor-sphincter dyssynergia is a condition in which reflexive contractions of the external urethral sphincter occur during bladder contractions, preventing the expulsion of urine. High-frequency stimulation (kHz range) has been shown to elicit a fast-acting and reversible block of action potential propagation in peripheral nerves, which may be a useful technique in the management of this condition.

OBJECTIVE

The aim of these experiments was to see if a newly developed stimulus delivery system, capable of transmitting current transcutaneously to remote peripheral nerves using a passive implanted conductor, was an effective way to transmit high-frequency waveforms to the pudendal nerve to block ongoing sphincter contractions.

METHODS

High-frequency waveforms were delivered through the skin to the pudendal nerve using a passive implanted conductor in 6 adult cats anesthetized with isoflurane. Five of the experiments were acute, terminal procedures, and the remaining cat was implanted with a permanent electrode system allowing evaluation for 6 months. Typical stimulation parameters were in the range of 1 to 10 kHz and 1 to 10 mA.

RESULTS

Complete blocking of external urethral sphincter contractions was achieved in 5 of the 6 animals. High-frequency stimulation was also tested in the chronically implanted animal without anesthesia, and the stimulation was tolerated with minimal aversive reactions.

CONCLUSIONS

The transcutaneous passive implanted conductor stimulus delivery system is an effective way to stimulate the pudendal nerve at high frequency, leading to sphincter relaxation. This system may provide a simple means to implement this stimulation paradigm in people with detrusor-sphincter dyssynergia.

Issues and challenges for development of a sustainable service model for people with spinal cord injury living in rural regions

OBJECTIVE

To develop and implement a service model for people with spinal cord injury (SCI) living in rural regions.

DESIGN

Service development, pilot evaluation study.

SETTING

Regional and remote areas of the state of New South Wales, Australia.

PARTICIPANTS

Persons with SCI, caregivers, and health professionals.

INTERVENTION

Phase 1 included initial needs analysis, followed by education and resource development tailored to needs of rural health professionals, caregivers, and persons with SCI. Phase 2 included coordination, professional support, and network development by part-time rural key worker and metropolitan-based project officer, documenting health- and service-related issues.

MAIN OUTCOME MEASURES

Self-perception of confidence as a result of education as well as reported issues, adverse health events, and barriers to service provision.

RESULTS

Clinician confidence in managing people with SCI improved after education. Various health-related, environmental, and psychosocial issues were reported. Limited availability of resources and health infrastructure, particularly in more isolated or smaller towns, challenged service provision. Rural key workers played a central role in supporting local clinicians and service providers, improving communication and service coordination between rural health professionals and metropolitan SCI services.

CONCLUSION

Education and support for rural workforce that may be limited in numbers and capacity, and a model facilitating communication and coordination between services, are essential for improving health outcomes of rural people with SCI.

A select combination of neurotrophins enhances neuroprotection and functional recovery following spinal cord injury

Previously, we have shown that topical application of brain-derived neurotrophic factor (BDNF) or insulin-like growth factor 1 (IGF-1) given within 5 to 30 min after a focal trauma to the rat spinal cord attenuates spinal cord injury (SCI)-induced breakdown of the blood-spinal cord barrier (BSCB), edema formation, motor dysfunction, and cell injury. This investigation was undertaken to find out whether a combination of select neurotrophins (BDNF, glial cell line-derived neurotrophic factor [GDNF], neurotrophin 3 [NT-3], or nerve growth factor [NGF]) will further enhance the neuroprotective efficacy of growth factors in SCI. The neurotrophins (0.1-1 microg/10 microL in phosphate-buffered saline) were applied 30, 60, or 90 min after injury topically over the traumatized spinal cord either alone or in combination. The SCI was performed by making a unilateral incision into the right dorsal horn of the T10-T11 segment under Equithesin anesthesia. The rats were allowed to survive 5 h after trauma. Topical application of BDNF, GDNF, or NGF 30 min after SCI in high concentration (0.5 microg and 1 microg) significantly improved the motor functions and reduced the BSCB breakdown, edema formation, and cell injury seen at 5 h. These beneficial effects of neurotropins were absent when administered separately either 60 or 90 min after SCI. However, a combination of BDNF and GDNF (but not with NT-3 or NGF) given either 60 or 90 min after SCI significantly reduced the motor dysfunction and spinal cord pathology at 5 h. These novel observations suggest that a select group of neurotrophins in combination have potential therapeutic value for the treatment of SCI in clinical situations.

Spinal cord transection modifies ileal fluid and electrolyte transport in rats

Spinal cord injury (SCI) is associated with severe autonomic changes, including inhibition of gastrointestinal (GI) motility. GI motility changes are known to affect electrolytes transport and these changes have not been adequately studied after SCI. We studied the ileal permeability to fluid and electrolytes in rats submitted to experimental spinal cord transection (SCT), between T4 and T5, throughout the first week after SCT. SCT increased ileal secretion of Na+ (P<0.05) and decreased the Cl(-) absorption during the first week post SCI (P<0.05). Water transport was also significantly altered, leading to increased water secretion following the Na+ gradient. Ileal secretion of K+ was significantly increased 1 and 7 days after spinal cord injury. To our knowledge, the present findings are the first direct evidence that SCT alters ileal electrolyte transport in rats. Further studies are necessary to evaluate the mechanisms involved in this phenomenon.

The burden of terrorism: high rate of recurrent hospital referrals

BACKGROUND

Recurrent emergency room referrals and re-hospitalisation of terror victims (external cause of injury E990-E998 and selected cases from E970-E978) [International Classification of Diseases, 9th revision. Clinical modification, 5th ed. (ICD-9-CM). Los Angeles, CA: Practice Management Information Corporation; 1998] have not as yet been examined in the literature. Our objective was to evaluate the extent of hospital services' usage following a terror event and to characterise the casualties who return for hospitalisation and rehabilitation following their discharge.

METHODS

A retrospective longitudinal study including all terror victims who were hospitalised at our level I trauma centre between October 2000 and March 2004. Data on the first hospitalisation of these victims (n=497 cases) were retrieved from the hospital's trauma registry. Data on recurrent emergency room referrals and re-hospitalisation of the 464 cases who survived were taken from the hospital's administrative computerised database.

RESULTS

Four hundred and ninety-seven terror victims were hospitalised, of which 464 survived their first hospitalisation. Two hundred and nineteen (47%) were subsequently re-referred to the hospital. The total number of recurrent hospital referral days amounted to 77% of the total first hospitalisation days for all casualties. A strong association was found with regard to severity of injury, length of stay in the intensive care unit (ICU) and total length of stay. Logistic regression analysis found total length of stay of initial hospitalisation as the only significant variable.

CONCLUSIONS

The recurrent hospitalisation of terror victims places a heavy burden on the health system. Further studies should be conducted to determine the reasons for these recurrent referrals and to explore whether the number of recurrent referrals can be reduced or at least planned for.

Preliminary reliability and validity of a Spinal Cord Injury Secondary Conditions Scale

BACKGROUND/OBJECTIVE

Although the impact of secondary conditions after spinal cord injury (SCI) on health, well being, and financial burden have been studied, there are psychometrically sound scales of secondary conditions in the extant literature. The use of such scales allows for cross-sample comparison of secondary condition prevalence rates and associations with functional, medical, and psychosocial factors. Thus, the purpose of this study was to evaluate the preliminary reliability of a SCI secondary conditions scale.

METHODS

The Spinal Cord Injury Secondary Conditions Scale (SCI-SCS) is a 16-item scale based on the Seekins Secondary Conditions Scale. Sixty-five individuals with SCI completed written surveys at 5 time-points over 2 years.

RESULTS

Internal consistency across each of the time-points exceeded 0.76; test-retest reliability ranged from 0.569 to 0.805. Convergent validity was assessed with 6 physical functioning items from the SF-12. Spearman (coefficients were all statistically significant and ranged from 0.317 (accomplished less because of health problems) to 0.644 (pain). The most prevalent secondary conditions were chronic pain, joint and muscle pain, and sexual dysfunction.

CONCLUSIONS

Preliminary testing of the SCI-SCS suggests that it is a reliable and valid scale, and further development (ie, factor analysis, item revision) and examination of validity are recommended with larger and more diverse SCI samples.

Disease prevalence and use of preventive services: comparison of female veterans in general and those with spinal cord injuries and disorders

BACKGROUND

Disease prevalence and use of preventive services may differ between women veterans in general and those with spinal cord injuries and disorders (SCI&D). Prevention is particularly important in SCI&D, and disparities may exist in receipt of this care, particularly when special equipment and body adjustments are needed, among women with SCI&D.

METHODS

To compare disease prevalence and preventive service use among female veterans in general and those with SCI&D, we conducted a cross-sectional survey among female veterans in general (n = 478) and those with SCI&D (n = 115). Behavioral Risk Factor Surveillance System (BRFSS) survey questions were administered to veterans with SCI&D and compared with 2003 CDC BRFSS data.

RESULTS

Female veterans with SCI&D were similar in age and race but were better educated and less likely to be employed than female veterans in general. Coronary heart disease (CHD) prevalence was higher in those with SCI&D (17% vs. 8%, p < 0.0001). Health status was lower in SCI&D (27%) than in general female veterans (41%), p = 0.002. Fewer women with SCI&D, than female veterans in general reported having received recommended dental care (56% vs. 69%, p = 0.004), colon screening in prior 5 years (59% vs. 72%, p = 0.023) or prior 10 years (67% vs. 92%, p< 0.0001), mammogram (84% vs. 91%, p = 0.019), and Pap smear (88% vs. 98%, p < 0.0001). There were no differences in receipt of respiratory vaccinations or cholesterol screening.

CONCLUSIONS

Receipt of services that require the use of equipment, body adjustments, and potential discomfort due to disability was lower in women with SCI&D. Veterans Affairs (VA) is doing well in most areas, but there are gaps in receipt of some preventive services. Efforts to increase preventive care in women with SCI&D should address equipment and access barriers and patient and provider education.

Reasons for rehospitalization in patients with spinal cord injury: 5 years' experience

The aim of this study was to determine the causes of rehospitalization in patients with spinal cord injury (SCI) treated in Istanbul Physical Medicine and Rehabilitation Centre and to compare the data with previous studies. Patients who were rehospitalized after an initial phase of rehabilitation between 1 January 1996 and 31 December 2001 were enrolled into the study. SCI patients aged 17 years or over at the time of injury were included. This retrospective study was designed using our medical records. In 5 years, 733 SCI patients were treated and 56 of them experienced rehospitalization. We examined the demographic and injury characteristics of rehospitalized patients with SCI. The SPSS computer programme was used for statistical analysis. We found that the rate of rehospitalization was 7.6%, the length of stay (LOS) was 72.21 days and the average age was 34.25 years. The reasons for rehospitalization were, in descending order, spasticity 25%, additional rehabilitation 21.4%, pressure sores 17.9%, urinary infection 16.1%, spinal surgery 8.9%, urinary system surgery 5.4% and pain 5.4%. Statistical significance was found between mean age and causes. The patients who were rehospitalized because of spinal surgery had a lower mean age than those rehospitalized because of pain (P=0.04, F=2.4). The most frequent reasons for rehospitalization of patients over 25 years old were spasticity and pressure sores. In conclusion, SCI patients' LOS was longer than found in previous studies because of a lack of efficient home rehabilitation. The most frequent cause of rehospitalization was spasticity, because of uncontrolled medical therapy. The study demonstrates how education of the patients and their families is important, and that home-based rehabilitation services must be established and supported by government.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Control of urinary bladder function with devices: successes and failures

The management of urinary tract dysfunction is crucial for the health and well-being of people with spinal cord injury. Devices, specifically catheters, play an important role in the daily regime of bladder management for most people with spinal cord injury. However, the high incidence of complications associated with the use of catheters, and the fact that the spinal segments involved in lower urinary tract control remain intact in most cord-injured people, continue to motivate research into devices that could harness the nervous system to provide greater control over lower urinary tract function. Mechanical devices discussed in this review include catheters, artificial urethral sphincters, urethral stents and intraurethral pumps. Additionally, many attempts to restore control of the lower urinary tract with electrical stimulation have been made. Stimulation sites have included: inside the bladder, bladder wall, thigh, pelvic floor, dorsal penile nerve, pelvic nerve, tibial nerve, sacral roots, sacral nerves and spinal cord. Catheters and sacral root stimulators are two techniques whose efficacy is well established. Some approaches have proven less successful and others are still in the development stage. Modifications to sacral root stimulation including posterior root stimulation, anodal blockade and high-frequency blockade as well as new techniques including intraspinal microstimulation, urethral afferent stimulation and injectable microstimulators are also discussed. No single device has yet restored the control and function of the lower urinary tract to the pre-injury state, but new techniques are bringing this possibility closer to reality.

Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury

The impact of spinal cord injury on an individual's gastrointestinal tract function is often poorly understood by the general public and also by those involved with persons with spinal cord injury. This chapter reviews the anatomy, physiology and function of the gastrointestinal tract, with particular emphasis on neurological control mechanisms. In turn, it relates the effect that spinal cord injury has on the neurological control of the gastrointestinal tract. The symptoms that are encountered by patients in the acute phase following injury, and by individuals in the months/years after injury, with particular reference to the effect of altered autonomic nervous system control of the gastrointestinal tract, are discussed. Together with a following summary of current bowel management regimens and techniques, this chapter aims to provide an overall view of the effect that autonomic dysfunction due to spinal cord injury has on gastrointestinal function.

Rehospitalization following compensable work-related tetraplegia

DESIGN

Descriptive study.

OBJECTIVES

To document the characteristics of rehospitalization following work-related tetraplegia, investigate risk factors for rehospitalization and identify opportunities for rehospitalization prevention.

SETTING

Workers' compensation administrative database with national coverage.

METHODS

The administrative database of a large workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In all, 61 cases were identified where detailed rehospitalization information was available. Medical payment data were extracted, rehospitalization reasons were coded, and rates, costs and length of stay were calculated.

RESULTS

In all, 62% of cases were rehospitalized at some time during the period for which data were available. The average number of days the study group spent rehospitalized per year was 9.2 and the average annual cost was 14,197 US dollars. The most common reasons for rehospitalization were dermatological (23%), orthopedic (18%) and urological (14%). It was found that as many as 74% of the total number of days persons spent rehospitalized, 64% of the monies spent on rehospitalization, and 47% of rehospitalizations could have been prevented.

CONCLUSIONS

Consistent with earlier research, the ability to identify risk factors for rehospitalization was limited. However, the current study does highlight the extent to which rehospitalizations disrupt the lives of people with work-related tetraplegia and that a substantial proportion of rehospitalizations can be avoided.

SPONSORSHIP

The research was supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research National Model SCI Systems (Grant no. H133N00024).

Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects

OBJECTIVE

To examine age-period-duration patterns of the prevalence of pressure ulcers in community-residing people with spinal cord injury (SCI).

DESIGN

Multicenter cohort study.

SETTING

Nine Model Spinal Cord Injury Systems throughout the United States.

PARTICIPANTS

People with SCI (N=3361) injured between 1986 and 1995 and followed up thereafter on a yearly basis through 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Physician-confirmed pressure ulcers of stage II or greater at the follow-up visits.

RESULTS

The multivariable generalized estimating equations model showed a significant trend toward increasing pressure ulcer prevalence in the recent years (1994-2002 vs 1984-1993: odds ratio=1.4; 95% confidence interval, 1.2-1.6) not explained by aging, years since injury, or demographic and clinical factors. The risk of pressure ulcers appeared to be steady during the first 10 years and increased 15 years postinjury. Pressure ulcers were more common among the elderly, men, African Americans, singles, subjects with education less than high school, unemployed, subjects with complete injury, and subjects with history of pressure ulcers, rehospitalization, nursing home stay, and other medical conditions. Injury cause and level had no significant effect.

CONCLUSIONS

These results highlight the need for research into factors that contribute to the increasing pressure ulcer prevalence.