Health-related quality of life in persons with long-standing spinal cord injury

A Systematic Review of the Impact of Spinal Cord Injury on Costs and Health-Related Quality of Life

OBJECTIVE

To systematically review the health-related quality of life (HRQoL) burden and costs of spinal cord injury (SCI) on health services, patients and wider society.

METHODS

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted in March 2021 through Scopus, PubMed and Embase databases. Inclusion criteria were quantitative studies on SCI reporting healthcare costs, social costs and/or HRQoL measured with the Euroqol EQ-5D or Short-Form 36. Risk of bias was assessed using the QualSyst tool. Descriptive analyses, random-effects direct meta-analysis and random-effects meta-regression were conducted.

RESULTS

A total of 67 studies were eligible for inclusion. SCI individuals tend to report higher HRQoL in mental than physical dimensions of the Short-Form 36. Neurological level of SCI negatively affects HRQoL. Cross-sectional studies find employment is associated with better HRQoL, but the effect is not observed in longitudinal studies. The estimated lifetime expenditure per individual with SCI ranged from US$0.7 million to US$2.5 million, with greater costs associated with earlier age at injury, neurological level, United States of America healthcare setting and the inclusion of non-healthcare items in the study.

CONCLUSIONS

SCI is associated with low HRQoL on mobility and physical dimensions. Mental health scores tend to be greater than physical scores, and most dimensions of HRQoL appear to improve over time, at least over the first year. SCI is associated with high costs which vary by country.

CLINICAL TRIALS REGISTRATION

This review was registered in PROSPERO (registration number: CRD42021235801).

Predictive factors and quality of life assessment among patients with spinal cord injury in the Middle East: a systematic review

PURPOSE

Spinal cord injury (SCI) is impairment of the spinal cord that adversely affects patients' health and quality of life (QoL). The aim of the study was to assess the quality of life (QoL) and related factors in patients with traumatic spinal cord injury in Middle Eastern countries.

METHODS

PubMed, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCOhost, psycINFO, and Google Scholar were systematically searched for eligible studies published in peer-reviewed journals up till October 2023.

RESULTS

Out of 1060 papers found in the literature, only 18 studies from Iran, Lebanon, and Turkey met the inclusion criteria. The majority of the studies employed the SF-36 scale to assess for QoL. In general, all SCI patients had reduced QoL scores when compared to the healthy population. Some of the factors such as age, education level, the level of injury, time since injury onset, marriage, and job opportunities were correlated with SCI subjects QoL. Our papers were assessed and found to be of both good and high quality.

CONCLUSION

This review emphasizes the significant shortage of QoL studies among SCI patients in the Middle East countries and highlights the importance of improving the QoL of this marginalized population. This work should enhance the governments to establish rehabilitation centers, social and economic support systems, and mental health services to diminish complications arising from SCI.

The Effect of Concomitant Spinal Cord Injury on Postoperative Health-related Quality of Life After Traumatic Subaxial Cervical Spine Injuries: A Nationwide Registry Study

OBJECTIVE

To evaluate the effect of spinal cord injury (SCI) on the health-related quality of life (HRQoL) in patients surgically treated for traumatic subaxial cervical spine injuries and investigate the agreement between objective neurologic outcomes and patient reported outcome measures (PROMs) in that context.

STUDY DESIGN

Observational study on prospectively collected multi-institutional registry data.

SETTING

Sweden.

PARTICIPANTS

Patients with traumatic subaxial spine injuries identified in the Swedish Spine Registry (Swespine) between 2006 and 2016.

INTERVENTIONS

Anterior, posterior, or anteroposterior cervical fixation surgery.

MAIN OUTCOMES

Patient-reported outcome measures (PROMs) consisting of EQ-5D-3Lindex and Neck Disability Index (NDI).

RESULTS

Among the 418 identified patients, 93 (22%) had a concomitant SCI. In this group, 30 (32%) had a complete SCI (Frankel A), and the remainder had incomplete SCIs (17%) Frankel B; 25 (27%) Frankel C; 22 (24%) Frankel D. PROMs significantly correlated with the Frankel grade (P<.001). However, post hoc analysis revealed that the differences between adjacent Frankel grades failed to reach both statistical and clinical significance. On univariable linear regression, the Frankel grade was a significant predictor of a specific index derived from the EQ-5D-3L questionnaire (EQ-5D-3Lindex) at 1, 2, and 5 years postoperatively as well as the NDI at 1 and 2 years postoperatively (P<.001). Changes of PROMs over time from 1, to 2, and 5 years postoperatively did not reach statistical significance, regardless of the presence and degree of SCI (P>.05).

CONCLUSION

Overall, the Frankel grade significantly correlated with the EQ-5D-3Lindex and NDI and was a significant predictor of PROMs at 1, 2, and 5 years. PROMs were stable beyond 1 year postoperatively regardless of the severity of the SCI.

Factors affecting sexual health in individuals with spinal cord injury: A systematic scoping review

PURPOSE

This study aims to review the literature to explore some factors affecting sexual and partnership adjustment in individuals with spinal cord injury (SCI).

METHODS

This study was based on the methodological framework of scoping reviews, including 3 methodological steps: (1) identifying relevant studies (searching for related studies); (2) selecting related studies; (3) collecting key findings, summarizing, and reporting the results. The electronic databases were searched including Medline (PubMed), Scopus, Web of Science, Embase, and Cochrane Library. Studies were included if they reported data about the related factors of sexual and partnership adjustment in individuals with SCI. No limitations were considered in terms of time or methodology of the search.

RESULTS

After the full-text screening, 52 studies were included from the year of 1978 - 2019 with various methodologies. The present review demonstrated that proper sexual health among individuals with SCI is related to several factors including the anatomical factor, level of the injury, completeness of the injury, psycho-social factor, socio-economic status, and type of relationship.

CONCLUSION

With consideration of factors affecting sexual and partnership adjustment in individuals with SCI, a better estimation of sexual health can be achieved in clinical to improve the relationship and quality of life.

An assessment of disability and quality of life in people with spinal cord injury upon discharge from a Bangladesh rehabilitation unit

DESIGN

Cross-sectional.

OBJECTIVES

The purpose of the study was to determine the level of disability and quality of life of people with spinal cord injury at the end of their inpatient rehabilitation at a rehabilitation center in Bangladesh. These outcomes were considered indicators of successful rehabilitation and a basis for comparing the success of reintegration into community.

SETTING

Center for the Rehabilitation of the Paralyzed, Bangladesh.

METHODS

Two standard structured questionnaires, the WHODAS 2.0 and WHOQOL-BREF, was used to collect data to assess level of disability and quality of life (QOL). Data were analyzed using Mann-Whitney-U test and Kruskal-Wallis test.

RESULTS

One hundred participants (91 men and 9 women) with SCI were recruited. Just prior to discharge from in-patient rehabilitation at CRP people with SCI perceived themselves overall as having on average a mild level of disability, and good QOL in physical, psychological, and environmental health domains. They indicated poor QOL in the social health domain. There were some specific differences in various WHODAS 2.0 Domains and overall scores when comparing age, gender, type and level of injury, occupation, and income. Between-group comparisons indicated that male participants had a significantly higher quality of life in the Environmental Health Domain and those with a paraplegic injury had a significantly higher quality of life in the Physical Health Domain.

CONCLUSION

By the end of their rehabilitation people with SCI had a relatively positive perception of level of disability and QOL. However, the results of other research has found that post-discharge their disability level increase and QOL decrease across all domains. Hence, it is recommended that more monitoring of level of disability and QOL is conducted post-discharge, along with a greater focus on community-based rehabilitation strategies and procedures to contribute to long-term reduction in level of disability and improved QOL.

Cognitive function, quality of life, and aging: relationships in individuals with and without spinal cord injury

Background: Correlations between aging, cognitive impairment and poor quality of life (QOL) have been observed for many patient populations.Objective: The purpose of this study was to examine these correlations in individuals with and without spinal cord injury (SCI).Methods: 23 individuals with complete SCI and 20 individuals without SCI ("NON") underwent assessment of cognitive function via the NIH Toolbox for Neurological and Behavioral Function. Participants self-rated QOL via global and symptom/domain-specific measures.Results: SCI rated global QOL to be lower than NON for the EQ-5D QALY (p < .001), but not the EQ-5D VAS, which imposes no penalty for wheeled mobility. Low QOL clustered mainly in domains pertaining to physical function/symptoms. Participants with SCI reported high QOL for positive affect/well-being and resilience. Cognitive function in SCI did not differ from NON. However, strong correlations between age and cognition observed in NON (all R² > 0.532) were absent in SCI. Significant correlations between cognition and QOL were prevalent for NON but not for SCI.Conclusions: Dissociation of age, cognition and QOL occurred with SCI. Divergence between EQ-5D QALY and VAS suggests that individuals with SCI may recalibrate personal assessments of QOL in ways that minimize the importance of mobility impairment.

Indicators of Quality of Care in Individuals With Traumatic Spinal Cord Injury: A Scoping Review

STUDY DESIGN

Scoping review.

OBJECTIVES

To identify a practical and reproducible approach to organize Quality of Care Indicators (QoCI) in individuals with traumatic spinal cord injury (TSCI).

METHODS

A comprehensive literature review was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL) (Date: May 2018), MEDLINE (1946 to May 2018), and EMBASE (1974 to May 2018). Two independent reviewers screened 6092 records and included 262 full texts, among which 60 studies were included for qualitative analysis. We included studies, with no language restriction, containing at least 1 quality of care indicator for individuals with traumatic spinal cord injury. Each potential indicator was evaluated in an online, focused group discussion to define its categorization (healthcare system structure, medical process, and individuals with Traumatic Spinal Cord Injury related outcomes), definition, survey options, and scale.

RESULTS

A total of 87 indicators were identified from 60 studies screened using our eligibility criteria. We defined each indicator. Out of 87 indicators, 37 appraised the healthcare system structure, 30 evaluated medical processes, and 20 included individuals with TSCI related outcomes. The healthcare system structure included the impact of the cost of hospitalization and rehabilitation, as well as staff and patient perception of treatment. The medical processes included targeting physical activities for improvement of health-related outcomes and complications. Changes in motor score, functional independence, and readmission rates were reported as individuals with TSCI-related outcomes indicators.

CONCLUSION

Indicators of quality of care in the management of individuals with TSCI are important for health policy strategists to standardize healthcare assessment, for clinicians to improve care, and for data collection efforts including registries.

Quality of Life after Surviving a Spinal Cord Injury: An Observational Study in South India

Background

Spinal cord injury (SCI) and its negative impact on the quality of life (QOL) is a significant public health concern in India. People with SCI suffer from serious health, economic, and social consequences in their lives. Often, care for SCI survivors is left to their immediate family members in India. Appropriate planning is needed for prevention, rehabilitation, health, and psychological care for SCI in the country.

Purpose

This study assessed the overall QOL of SCI survivors and their satisfaction levels with specific domains and their importance of QOL.

Materials and Methods

In this observational study, two instruments, Farrens and Power for QOL and Barthel Index for functional abilities, were administered to a convenience sample of participants drawn from Narayana Medical College, Nellore, in South India.

Results

Statistically, SCI survivors were found moderately and very satisfied with their QOL. Their perception about importance of health, functioning, social, and economic subscale also did not differ statistically.

Relationships Between Functionality, Depression, and Anxiety With Community Integration and Quality of Life in Chronic Traumatic Spinal Cord Injury

OBJECTIVES

The aims of the study were (1) to identify relationships between functional and psychological aspects with community integration and quality of life assessments in people with chronic traumatic spinal cord injury and (2) to analyze clinical and demographic predictors of quality of life dimensions.

DESIGN

This is an observational cohort study, and correlation coefficients were calculated between the Functional Independence Measure, the Hospital Anxiety and Depression Scale, the Community Integration Questionnaire, and the World Health Organization Quality of Life-BREF dimensions (physical [D1], psychological [D2], social [D3], and environmental [D4]). Quality of life predictors were identified using multiple linear regression analyses.

RESULTS

Nine hundred seventy-five people with traumatic spinal cord injury assessed since 2007-2020 were included. The Community Integration Questionnaire home integration correlated strongly with the Functional Independence Measure self-care (r = 0.74) and transfers (r = 0.62) for participants with tetraplegia. The specific Hospital Anxiety and Depression Scale items (known as the anhedonia subscale) correlated strongly with D1 (r = -0.65), D2 (r = -0.69), D3 (r = -0.53), and D4 (r = -0.51) for participants with paraplegia and D1 (r = -0.53), D2 (r = -0.61), D3 (r = -0.47), and D4 (r = -0.53) for participants with tetraplegia. The Hospital Anxiety and Depression Scale-depression was the most relevant predictor of D1 (β = -0.61) and D2 (β = -0.76).

CONCLUSIONS

The Functional Independence Measure transfers and self-care were strongly associated with the Community Integration Questionnaire home integration (in participants with tetraplegia). Anhedonia was strongly related to all four World Health Organization Quality of Life-BREF Scale dimensions, being the Hospital Anxiety and Depression Scale-depression the most relevant predictor of D1 and D2.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to (1) Determine the associations between functional and psychological measures with community integration domains and quality of life from a multidimensional perspective (physical, psychological, social, and environmental) in persons with chronic traumatic paraplegia or tetraplegia living in the community; (2) Identify long-term clinical and demographic predictors of specific quality of life dimensions (e.g., physical and psychological) in persons with paraplegia or tetraplegia living in the community; and (3) Illustrate the strength of the identified associations and the impact of the quality of life predictors to suggest possible specific aspects to be addressed by professionals in clinical practice.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Which factors have an association to the Quality of Life (QoL) of people with acquired Spinal Cord Injury (SCI)? A cross-sectional explorative observational study

STUDY DESIGN

Cross-sectional explorative observational study.

OBJECTIVES

To identify factors which have an association to the self-perceived Quality of Life (QoL) for persons with acquired spinal cord injury (SCI).

SETTING

Eight specialized SCI-centers in Germany. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI).

METHODS

Self-disclosure questionnaire, created from the InSCI group, translated and adapted for Germany. The questionnaire collects a very broad range of data and, and due to its design as a self-report, is particularly suitable for the analysis on QoL. Because of the content, which is binding for all participating states, it allows a direct comparability of the results. Included in Germany were 1479 persons with acquired SCI aged 18 years and older.

RESULTS

Various factors were identified with high associations to QoL, including changeable and unchangeable ones, such as those of particular importance: pain, sleep problems, sexual dysfunction, age, and time since onset of SCI. Some results confirmed reports of previous studies, others were surprising.

CONCLUSION

this study provides an important basis for the planned analysis of the InSCI participating countries in the 6 WHO regions. Germany was able to contribute the largest study population. The concrete study design of InSCI allows us to directly compare data and helps us to improve ourselves within the framework of a "learning health system". Medical measures can be orientated towards the found results, in order to ensure the best possible care and support by the therapeutic team, individually adapted to the person, place of residence and impairment.

Quality of Life in Patients with Spinal Cord Injury: A Prospective Longitudinal Study

Introduction Spinal cord injury (SCI) is one field of neurotrauma where fierce research has been going on to achieve a cure for the dreaded disease. Complete cure of this condition still remains elusive. Although focus is mainly on reversing the physical disability, not much importance is given to other factors which have an immense bearing on quality of life (QOL) of the victim. These factors include social health, psychological health, and environmental factors. The Indian Armed Forces offers the unique advantage of following up a patient from the time of injury till rehabilitation. This prospective longitudinal study is the first of its kind in India, undertaken to assess the QOL of the SCI patient from the time of trauma till end of 1 year. We have attempted to measure QOL of the SCI patients in four main domains (physical health, psychological health, social health, and environmental factors) and further tried to highlight the predictors which play a major role in improving QOL. It is proposed that identifying these important predictors and correcting them with appropriate targeted interventions can play a major role in improving the QOL in SCI patients.

Materials and Methods This prospective longitudinal study was carried out in a single tertiary care hospital from May 2017 to October 2019. All patients with SCI were treated and followed up for at least 1 year posttrauma using the World Health Organization Quality of Life-BREF questionnaire. A total of 68 patients were treated and studied. Results were analyzed and conclusions drawn.

Observations and Results Physical health was the most important domain to have an impact on QOL while environmental health had the least. Maximum improvement occurred in all domains during the first 6 months after which the improvement in scores was unimpressive. The degree of improvement correlated directly to the severity of initial motor deficits. Strong caregivers’ support and structured care in a rehabilitation center played important role in improving the QOL of SCI patients.

Conclusion Our study goes on to prove that in order to improve QOL of SCI patients an assessment needs to be undertaken going beyond physical domain. Factors playing a major role in deciding QOL should be identified and then subsequently be corrected with targeted interventions.

Effect of wheelchair-modified rowing exercise on cardiometabolic risk factors in spinal cord injured wheelchair users: protocol for a randomised controlled trial

INTRODUCTION

Cardiovascular and metabolic diseases are a growing concern for individuals with spinal cord injury (SCI). Physical inactivity contributes to cardiometabolic morbidity and mortality in the SCI population. However, previous studies have shown mixed results regarding the effects of exercise on cardiometabolic risk factors in individuals with SCI. This discrepancy could be influenced by insufficient exercise stimuli. Recent guidelines recommend 30 min of moderate-to-vigorous intensity aerobic exercise, three times per week, for improvement in cardiometabolic health in individuals with SCI. However, to date, no studies have implemented an exercise intervention matching the new recommendations to examine the effects on cardiometabolic risk factors. Therefore, the primary objective of this study is to determine the effects of 12 weeks of wheelchair user-modified upper-body rowing exercise on both traditional (constituents of the metabolic syndrome) and novel (eg, vascular structure and function) cardiometabolic risk factors in manual wheelchair users with SCI.

METHODS AND ANALYSIS

A randomised controlled trial will compare 12 weeks of upper-body rowing exercise, 30 min three times per week, with a control group continuing their normal lifestyle. Outcome measurements will be performed immediately before (baseline), after 6 weeks (halfway), 12 weeks of training (post) and 6 months after the termination of the intervention period (follow-up). Outcomes will include inflammatory (eg, C reactive protein) and metabolic biomarkers determined from venous blood (with serum fasting insulin as primary outcome), body composition, arterial blood pressure, cardiorespiratory fitness level, brachial artery vascular structure and function and autonomic nervous system function.

ETHICS AND DISSEMINATION

This trial is reported to the Danish Data Protection Agency (J.nr. 2019-899/10-0406) and approved by the Committees on Health Research Ethics in The North Denmark Region on 12 December 2019 (J.nr. N-20190053). The principal investigator will collect written informed consent from all participants prior to inclusion. Irrespective of study outcomes, the results will be submitted to peer-reviewed scientific journals for publication.

TRIAL REGISTRATION NUMBER

NCT04390087.

The association between secondary health conditions and indirect costs after spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVE

Identify the association between secondary health conditions (SHC) and the indirect costs of traumatic spinal cord injury (SCI) based on the pre-injury and post-injury changes in employment and earnings.

SETTING

Medical university in the southeastern United States (US).

METHODS

A population-based cohort of 304 participants met the following eligibility criteria: received treatment for acute SCI within the state, residual effects resulting from traumatic SCI, at least 1-year post injury, age between 23 and 64 years at the time of injury onset, and younger than 65 years at the time of study measurement. The indirect costs estimate was measured by the annual forgone earnings and fringe benefits calculated as the difference in the sum of earnings and benefits between before injury and after injury adjusting for inflation in 2019 US dollars. We considered seven SHC in this study: bowel accidents, urine accidents, urinary tract infections, pressure sores, unintentional injury, severe pain, and depressive disorder. We used multivariate ordinary least squares regression models to examine their relationship controlling for age, sex, race/ethnicity, marital status, years of education, injury level, and ambulatory status.

RESULTS

The indirect costs were significantly associated with the total number of SHC and with the individual conditions of bowel accidents, urine accidents, pressure sores, and depressive disorder after controlling for age, sex, race/ethnicity, marital status, years of education, injury level, and ambulatory status.

CONCLUSIONS

Preventing SHC relates to better economic consequences for individuals, their families, and society, even after accounting for differences in severity of SCI.

Quality of life among men with spinal cord injury in Lebanon: A case control study

BACKGROUND

Spinal cord injury (SCI) is a permanent disability which negatively affects individuals' health and particularly their quality of life.

OBJECTIVE

To assess the quality of life (QoL) among Lebanese men with spinal cord injury and to compare it to a healthy control group.

METHODS

A case control study was conducted. Fifty-one Lebanese patients with spinal cord injury and 51 age- sex-matched healthy persons were included in the study.

RESULTS

Compared to healthy controls, the mean scores of eight domains of SF-36 were significantly lower in SCI group: physical functioning (PF) (26.5 vs 87; p value <0.0001), role limitations due to physical (RP) (57.8 vs 93.6; p value <0.0001), bodily pain (BP) (60.5 vs 90.7; p value, 0.0001), general health (GH) (49.5 vs 76.6; p value <0.0001), vitality (VT) (51.2 vs 71.3; p value <0.0001), social functioning (SF) (68.9 vs 91.2; p value <0.0001), role limitations due to emotional problems (RE) (71.2 vs 91.5; p value 0.003) and mental health (MH) (62.9 vs 79; p value <0.0001). Concerning PCS and MCS scores, SCI patients reported significantly lower scores than control group (p value <0.0001).

CONCLUSION

Participants with SCI reported reduced QoL in comparison with normal individuals.

Employment status, hours working, and gainful earnings after spinal cord injury: relationship with pain, prescription medications for pain, and nonprescription opioid use

STUDY DESIGN

Cross-sectional self-report assessment. Econometric modeling.

OBJECTIVES

Identify the relationship of multiple pain indicators, prescription pain medication, nonprescription opioid use, and multiple indicators of quality employment among those with spinal cord injury (SCI).

SETTING

Data were collected at a medical university in the Southeastern United States (US).

METHODS

Participants included 4670 adults with traumatic SCI of at least one-year duration who were enrolled in a study of health and longevity. They were identified from three sources including a specialty hospital and two population-based state SCI surveillance systems. Econometric modeling was used for three outcome variables: employment status, hours per week spent working, and earnings.

RESULTS

Several pain parameters were significantly related to multiple employment outcomes. Prescription medication to treat pain was associated with lower odds of employment, fewer hours working, and lower conditional earnings. Nonprescription opioid use was only related to fewer hours working. Painful days, number of painful conditions, and pain intensity were all related to employment outcomes, but the pattern varied by outcome. The number of painful conditions was most consistently related to employment. Multiple demographic, injury, and educational factors were related to employment, with better outcomes among those with less severe SCI and greater educational achievements.

CONCLUSIONS

The presence of significant pain and use of either prescription pain medications or the use of nonprescription opioids may have a significant adverse effect on both the probability of employment and quality of employment. Rehabilitation and vocational professionals should routinely assess pain and associated medications in vocational and career planning.

Contextualizing the lived experience of quality of life for persons with spinal cord injury: A mixed-methods application of the response shift model

Objective: The objective of this study was to gain greater insight into individuals' quality of life (QOL) definitions, appraisals, and adaptations following spinal cord injury (SCI). Design: A mixed-methods design, applying the Schwartz and Sprangers response shift (RS) model. RS is a cognitive process wherein, in response to a change in health status, individuals change internal standards, values, or conceptualization of QOL Setting: Community-dwelling participants who receive medical treatment at a major Midwestern medical system and nearby Veterans' Affairs hospital. Participants: A purposive sample of participants with SCI (N = 40) completed semi-structured interviews and accompanying quantitative measures. Interventions: Not applicable. Outcome Measures: Qualitative data were analyzed using content analysis to identify themes. Analysis of variance were performed to detect differences based on themes and QOL, well-being, and demographic and injury characteristics. Results: Four RS themes were identified, capturing the range of participant perceptions of QOL. The themes ranged from complete RS, indicating active engagement in maintaining QOL, to awareness and comparisons redefining QOL, to a relative lack of RS. Average QOL ratings differed as a function of response shift themes. PROMIS Global Health, Anxiety, and Depression also differed as a function of RS themes. Conclusion: The RS model contextualizes differences in QOL definitions, appraisals, and adaptations in a way standardized QOL measures alone do not.

Implementing volunteer peer mentoring as a supplement to professional efforts in primary rehabilitation of persons with spinal cord injury

Study design

A feasibility study, supplemented by a noncontrolled pretest/posttest.

Objectives

To examine if a nationwide volunteer peer-mentoring program for in-patients with acute/subacute spinal cord injury is feasible and achievable.

Setting

The Spinal Cord Injury Center of Western Denmark and Clinic for Spinal Cord Injuries, Rigshospitalet, Denmark.

Methods

Volunteer mentor groups were formed similarly in two highly specialized SCI centers covering Denmark. Hospital staff was responsible for referral to the mentoring project and for the interdisciplinary evaluation of patient eligibility. At each of the two centers, a person living with the consequences of SCI coordinated the intervention in collaboration with healthcare personnel. Designated project personnel introduced eligible participants to the project. Staff at the SCI centers arranged to fit in the supplementary mentoring with ongoing treatment. A self-report questionnaire was completed prior to and after peer intervention. Outcome: patient reports regarding mentoring sessions, change in quality of life (QoL), depression items from the Short Form Health Survey (SF-36), pain frequency and intensity (11-point Numerical Rating Scale).

Results

A nationwide mentor corps was established. Fifty-two eligible in-patients completed the study. Significant improvement in QoL was found after mentoring. Frequency and intensity of pain did not change, although five out of nine depression items improved significantly. A majority (94%) of the participants recommended others to meet with a peer mentor.

Conclusions

Establishing a nationwide volunteer mentor system at a highly specialized neuro-rehabilitation units for SCI in-patients is both feasible and acceptable.

Hospital based care at home; study protocol for a mixed epidemiological and randomized controlled trial

Background

Individuals with spinal cord injuries (SCI) are prone to pressure ulcers (PUs) because of the loss of sensorimotor function involved as well as increased skin moisture. Treatment of PU after SCI is complicated, involving different specialties and with need for long-lasting follow-up. This study should identify risk factors for PU after SCI, and find an effective and less time-consuming treatment for the condition among different available methods for follow-up.

Method/design

The first part of this research project aims to investigate the prevalence of PU among persons with SCI based on an epidemiological design. The study will identify possible risk factors for acquiring PU. A questionnaire focusing on previous and present PUs will be sent to persons who suffered SCIs between January 2004 and January 2014. In the second part we will compare two different treatment regimens of PU through a randomized controlled pilot trial (RCT) where we will compare outpatient SCI follow-up in a hospital versus outpatient follow-up from the patient’s home, using telemedicine (teleSCI) interventions. We will compare the healing of the PU in the two groups (usual care versus teleSCI). The Tissue, Infection, Moisture Edge (TIME) registration form, the Photographic Wound Assessment Tool (PWAT) and the change in the ulcer size will be used to monitor the healing. Changes in health-related quality of life (HRQoL) and the need for assistance will be assessed using the Five Dimensions European Quality of Life scale (EQ-5D), the generic Medical Outcomes Study 12-item Short Form Health Survey (SF-12) modified version, the International Spinal Cord Injury Quality of Life Data set (ISCI-QoL Data set), and the Spinal Cord Independence Measure scale, version III (SCIM III). In addition to primary outcome measures, a cost-benefit evaluation and an assessment of patient satisfaction and participation will be performed, using customized questionnaires.

Discussion

The first part of the research project will reveal the epidemiology of PU after SCI, and explore the risk factors. This part enables further prevention of PU after SCI and this information will be used in the follow-up RCT. Videoconferencing in the outpatient follow-up of persons with SCI and PU will change clinical routines and facilitate interdisciplinary collaboration, communication and competence exchange among participants of the health care services. Our research protocol allows comparing methods for interaction between medical specialists at hospitals, local caregivers in the community, next of kin, and persons with SCI and PU. The RCT should identify advantages as well as challenges in the management of PU in different follow-up settings. This study aims to identify risk factors for PU after SCI, and find an effective and less time consuming treatment for the condition among different available methods for follow- up.

Trial registration

www.ClinicalTrials.gov, ID: NCT02800915, last update 9 October 2017.

The National Regional Ethical Committee (REC) 2014/ 684/ REK-Nord. https://helseforskning.etikkom.no/prosjekterirek/prosjektregister/prosjekt?p_document_id=469163&p_parent_id=473640&_ikbLanguageCode=n

https://app.cristin.no/projects/show.jsf?id=545284

https://www.sunnaas.no/kliniske-studier/bruk-av-telemedisin-som-virkemiddel-til-samhandling-i-poliklinisk-oppfolging-av-pasienter-med-ryggmargsskade-og-trykksar

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3185-y) contains supplementary material, which is available to authorized users.

Quality of life after spinal cord injury in Thai individuals: A mixed-methods study

Background:

Patients with spinal cord injury (SCI) face various health-related difficulties. Physical limitations and health-related complications in individuals with SCI can lead to activity restrictions and lowering their quality of life (QoL). It is important to assess the QoL in population with SCI to gain more valuable insights into aspects of health-related QoL (HRQoL) that could play a key role in improving care for persons with SCI.

Objective:

To quantitatively measure the QoL in persons with SCI in Thailand and expand the results through qualitative investigation to provide meaning, context and depth of “how” and “why” they rated, defined and addressed their QoL in that way.

Methods:

The philosophical assumption of this study was set based on the post-positivist views using mixed-methods sequential explanatory design. The quantitative data were collected and analyzed in 101 Thai individuals with SCI using standardized Thai version of the Short Form Health Survey version 2 (SF-36v2), followed by the qualitative investigation of semi-structured interviews in 11 volunteers who participated in the SF-36v2 phase. Priority is given to quantitative data. The data integration occurred at the qualitative data collection through the data interpretation and discussion stage.

Results:

With regard to quantitative data, a recent study found a statistically significant difference (p<0.05) in four domains for male and three domains for the female when comparing the SF-36 Thai normative data with SF-36v2 SCI data. Qualitative data revealed that the most salient themes of HRQoL in individuals with SCI were “supporting factors toward QoL” and “driving force post injury”. The integration of the findings revealed that the qualitative data could individually explain and define QoL as well as support quantitative results. The connection of both findings indicated that the higher scores in psycho-social variables and lower scores in physical domains of SF-36v2 in Thai persons with SCI may be due to unique Thai family traditions and community values.

Conclusion:

The scores on SF-36v2 and the replies in the qualitative investigation of QoL themes of Thai individuals with SCI were similar to those of other research, but this study is unique in that it specifically represents the Thai socio-environmental-cultural aspects.

Fractures and musculoskeletal ailments in persons 20+ years after a traumatic spinal cord injury in Norway

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To gain insights into fracture rate and musculoskeletal ailments among Norwegians with a spinal cord injury (SCI) acquired more than 20 years ago.

SETTINGS

Sunnaas Hospital, Nesoddtangen, Norway.

METHODS

165 persons with SCI were interviewed in 2004-2005 by questionnaires and clinical examination. Descriptive statistics and a logistic regression analysis were performed to identify variables associated with bone fractures and musculoskeletal ailments.

RESULTS

Around half of the participants experienced a fracture after injury and excessive use of alcohol increased the odds (OR 0.09; CI 0.01-0.74) of suffering a post-injury fracture (p = 0.03). Sixty percent experienced shoulder ailments after the SCI and the use of orthosis to the knee and hip increased the odds (OR 4.4; CI 1.4-13) of experiencing shoulder ailment (p = 0.01).

CONCLUSION

Around half of the 165 participants reported to have suffered a fracture and over 100 to experience musculoskeletal ailment 20 years after injury. We suggest that prevention strategies and symptom management must be embedded in follow-up visits after SCI.

Quality of life after spinal cord injury: The impact of pain

BACKGROUND

Pain is a common complication after spinal cord injury (SCI). A mixture of nociceptive and neuropathic pain (NP) can present. Limited studies have investigated the impact of different pain phenotypes on quality of life (QoL) post-SCI.

METHODS

Members registered to a national support group for those with SCIs were surveyed (n = 1574). The survey comprised questions relating to demographics and SCI characteristics, The Douleur Neuropathique 4 (DN4) (interview), the International SCI Pain Basic Data Set recording the worst pain and the World Health Organisation Quality of Life BREF (WHOQOL-BREF). An ANCOVA model with post hoc analysis explored between group factors of pain type and intensity of pain categories on QoL, controlling for additional confounding variables. Significance was set p < 0.05. A linear regression explored whether pain intensity, type or interference best predicted QoL.

RESULTS

The response rate was 41% (n = 643), 70% (n = 447) were male. The mean age of respondents was 52 years (SD 14.2) and mean time from SCI was 17 years (SD 12.4). In the previous week, 71% (n = 458) experienced pain, 37% (n = 236) of which had NP as defined in the study. Respondents experiencing NP demonstrated significantly poorer QoL than those without pain (p < 0.001) or nociceptive pain (p < 0.05). Those reporting high pain intensity had significantly lower QoL than those with moderate or no pain (p < 0.001). Pain interference consistently and best-predicted domains of QoL (p < 0.001).

CONCLUSION

High-intensity pain and NP negatively impacts QoL post-SCI. However pain interference more than intensity or type best explains the variance in QoL reported.

SIGNIFICANCE

Neuropathic pain type and severe pain intensities negatively impact QoL after SCI. Pain interference items better predict reported QoL than either pain type or intensity, suggesting better pain management strategies are warranted.

Exploring narratives of resilience among seven males living with spinal cord injury: a qualitative study

Background

It is a challenge for both individuals and families when an illness or traumatic injury results in a severe spinal cord injury. The on-going physical impairments experienced by persons with spinal cord injury play themselves out over time. Few qualitative studies have explored how health, resilience and wellbeing interplay across time among persons living with the consequences of severe physical injuries. Thus, the aim of this study was to obtain a deeper understanding of how individuals with spinal cord injury reflect upon the efforts, strategies and agency they perform to sustain long term resilience and wellbeing.

Methods

In this exploratory qualitative study, we conducted a thematic analysis of in-depth interviews with seven men who had lived with spinal cord injury for 2–32 years and who previously had undergone medical rehabilitation.

Results

The efforts revealed by the participants in normalising life with a spinal cord injury required continued flexibility, persistency and solution-focused adjustment, interpreted as processes documenting resilience. The participants were marshalling personal resources to handle challenges over time. They explained that they succeeded in maintaining health and wellbeing by manoeuvring between different strategies such as being self-protective and flexible as well as staying active and maintaining a positive attitude. Further, support from relational resources were of utmost importance emotionally, socially and when in need of practical assistance. When harnessing relational resources when needed, the participants underlined that balancing dependence and autonomy to remain a part of ordinary life was essential in staying emotionally stable.

Conclusions

The findings of the present study show similarities to those of previous studies with regard to the participants’ attribution of their resilience and wellbeing to their innate personal abilities and strong connection to their family and friends. In addition, the current participants provide enlightening nuances and depth that expand our understanding of the construct of resilience by highlighting the importance of continuously exerting agency, willpower and strength through rational cognitive strategies to adjust and adapt to chronic and new challenges.

Electronic supplementary material

The online version of this article (10.1186/s40359-017-0211-2) contains supplementary material, which is available to authorized users.

Health status of regularly physically active persons with spinal cord injury

Study design

A non-controlled cross-sectional study.

Objectives

To make a descriptive examination of health status in persons with paraplegia and tetraplegia who exercise regularly according to Canadian guidelines.

Settings

Sunnaas Rehabilitation Hospital and the Norwegian School of Sport Sciences.

Methods

Eighteen persons (men/women = 9/9), aged 41‒72 years with spinal cord injury (SCI), who exercise regularly were included. Post-injury years ranged from 4 to 48 years. Clinical examination of body composition, bone mineral density (BMD), forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), diffusion capacity (DL_CO), cardiorespiratory fitness (VO_2max), and self-reported quality of life (QOL) obtained by questionnaire was performed. Lung function results are presented as % predicted and VO_2max as absolute values relative to body weight. All results are given as median and range.

Results

Persons with paraplegia (n = 13) were defined as overweight with fat mass 42% (25‒51). BMD 1.047 g cm⁻² (0.885‒1.312) was within normal range. FVC 95% predicted (60‒131), FEV₁ 90% predicted (61‒119), DL_CO 77% predicted (56‒103), and VO_2max 16.66 ml kg⁻¹ min⁻¹ (12.15‒25.28) defined good aerobic capacity according to age controlled reference values (18). Persons with tetraplegia (n = 5) were slightly overweight with fat mass 35% (26‒47). BMD 1.122 g cm⁻² (1.095‒1.299) was within normal range. FVC 72% predicted (46‒91), FEV₁ 75% predicted (43‒83), DL_CO 67% predicted (56‒84), and VO_2max 16.70 ml kg⁻¹ min⁻¹ (9.91‒21.01) defined excellent aerobic capacity according to reference values (18). QOL was ranked as median 7.5 (0‒10 scale).

Conclusions

Persons with SCI who exercise regularly following the Canadian guidelines responded with rather positive associations for health outcomes. Additional research is needed to strengthen our findings.

Computer-Assessed Preference-Based Quality of Life in Patients with Spinal Cord Injury

Objectives

Our aims were to (1) measure quality of life (QoL) in spinal cord injury (SCI) patients using different methods and analyze differences; (2) enable targeted treatments by identifying variables that affect QoL; and (3) provide decision-makers with useful data for cost-utility analyses in SCI population.

Methods

Seventy-one participants were enrolled. The computer-based tool UceWeb was used to elicit QoL in terms of utility coefficients, through the standard gamble, time trade-off, and rating scale methods. The SF36 questionnaire was also administered. Statistical analyses were performed to find predictors of QoL among collected variables.

Results

Median values for rating scale, time trade-off, and standard gamble were 0.60, 0.82, and 0.85, respectively. All scales were significantly correlated. Rating scale and SF36 provided similar values, significantly lower than the other methods. Impairment level, male gender, older age, living alone, and higher education were correlated with lower QoL but accounted for only 20% of the variation in utility coefficients.

Conclusions

Demographic and clinical variables are useful to predict QoL but do not completely capture utility coefficients variability. Therefore, direct preference-based utility elicitation should be strengthened. Finally, this is the first study providing data that can be used as a reference for cost-utility analyses in the Italian SCI population.

Impact of bladder, bowel and sexual dysfunction on health status of people with thoracolumbar spinal cord injuries living in the community

OBJECTIVE

The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.

METHODS

Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.

RESULTS

Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.

CONCLUSION

Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.

C-reactive protein as an available biomarker determining mental component of health-related quality of life among individuals with spinal cord injury

OBJECTIVES

C-reactive protein (CRP) has been shown to correlate with health-related quality of life (HRQL) in some chronic medical conditions. However, these associations have not yet described in spinal cord injury (SCI). In this study, we tried to identify biomarkers associated with HRQL in SCI.

DESIGN

Cross-sectional.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Referred patients to Brain and Spinal Cord Injury Research Center between November 2010 and April 2013.

OUTCOME MEASURE

Blood samples were taken to measure circulatory CRP, leptin, adiponectin, ferritin, parathyroid hormone, calcitonin, thyroid hormones, fasting plasma glucose and lipid profile. All the analyses were performed with adjustment for injury-related confounders (level of injury, injury completeness and time since injury) and demographic characteristics. HRQL was measured with Short Form health survey (SF-36).

RESULTS

The initial inverse association between CRP and total score of SF-36 (P: 0.006, r = -0.28) was lost after adjustment for confounders. However, the negative correlation between CRP and Mental Component Summary (MCS) remained significant (P: 0.0005, r = -0.38). Leptin level was inversely correlated with Physical Component Summary (PCS) (P: 0.02, r = -0.30).

CONCLUSION

Although CRP and leptin levels were not related with total scores of SF-36 questionnaire, CRP can be more useful in determining mental component of HRQL whereas leptin can be a determinant of physical component. The combined consideration of these two biomarkers may help to predict HRQL in individuals with SCI.

Health Related Quality of Life in a Dutch Rehabilitation Population: Reference Values and the Effect of Physical Activity

PURPOSE

To establish reference values for Health Related Quality of Life (HRQoL) in a Dutch rehabilitation population, and to study effects of patient characteristics, diagnosis and physical activity on HRQoL in this population.

METHOD

Former rehabilitation patients (3169) were asked to fill in a questionnaire including the Dutch version of the RAND-36. Differences between our rehabilitation patients and Dutch reference values were analyzed (t-tests). Effects of patient characteristics, diagnosis and movement intensity on scores on the subscales of the RAND-36 were analyzed using block wise multiple regression analyses.

RESULTS

In total 1223 patients (39%) returned the questionnaire. HRQoL was significantly poorer in the rehabilitation patients compared to Dutch reference values on all subscales (p<0.001) except for health change (p = 0.197). Longer time between questionnaire and last treatment was associated with a smaller health change (p = 0.035). Higher age negatively affected physical functioning (p<0.001), social functioning (p = 0.004) and health change (p = 0.001). Diagnosis affected outcomes on all subscales except role limitations physical, and mental health (p ranged <0.001 to 0.643). Higher movement intensity was associated with better outcomes on all subscales except for mental health (p ranged <0.001 to 0.190).

CONCLUSIONS

HRQoL is poorer in rehabilitation patients compared to Dutch reference values. Physical components of HRQoL are affected by diagnosis. In rehabilitation patients an association between movement intensity and HRQoL was found. For clinical purposes, results of this study can be used as reference values for HRQoL in a rehabilitation setting.

Upregulation of PTP1B After Rat Spinal Cord Injury

Protein tyrosine phosphatase 1B (PTP1B), a member of the protein tyrosine phosphatase family, attaches to the endoplasmic reticulum (ER) via its C-terminal tail. Previous studies have reported that PTP1B participates in various signal transduction pathways in many human diseases, including diabetes, cancers, osteoporosis, and obesity. It also plays an important role in the ER stress. ER stress induced by spinal cord injury (SCI) was reported to result in cell apoptosis. Till now, the role of PTP1B in the injury of the central nervous system remains unknown. In the present study, we built an adult rat SCI model to investigate the potential role of PTP1B in SCI. Western blot analysis detected a notable alteration of PTP1B expression after SCI. Immunohistochemistry indicated that PTP1B expressed at a low level in the normal spinal cord and greatly increased after SCI. Double immunofluorescence staining revealed that PTP1B immunoreactivity was predominantly increased in neurons following SCI. In addition, SCI resulted in a significant alteration in the level of active caspase-3, caspase-12, and 153/C/EBP homologous transcription factor protein, which were correlated with the upregulation of PTP1B. Co-localization of PTP1B/active caspase-3 was also detected in neurons. Taken together, our findings elucidated the PTP1B expression in the SCI for the first time. These results suggested that PTP1B might be deeply involved in the injury response and probably played an important role in the neuro-pathological process of SCI.

Is Level of Injury a Determinant of Quality of Life Among Individuals with Spinal Cord Injury? A Tertiary Rehabilitation Center Report

OBJECTIVES

The role of injury-related variables in determining health-related quality of life (HRQOL) among Iranian persons with spinal cord injury (SCI) has not yet been fully described. In this study, we compared HRQOL between individuals with injury at cervical level and those with injury at thoracolumbar sections and evaluated the discriminating value of injury level as a determinant of HRQOL among Iranian people with SCI.

METHODS

Individuals with SCI, who were referred to Brain and Spinal Cord Injury Research Center, were invited to participate in this investigation. HRQOL was assessed using the Short Form (SF-36) questionnaire to determine the quality of life (QOL) in eight domains: physical functioning (PF), role limitation due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitation due to emotional problems (RE), and mental health (MH).

RESULTS

Ninety patients with paraplegia and 94 quadriplegic patients participated in this investigation. The mean score of PF domain was significantly lower in patients with injury at cervical level (p < 0.0001). There was no significant difference in other domains of SF-36 between subjects with paraplegia and quadriplegia (p = 0.670, 0.700, 0.910, 0.710, 0.730, 0.290 and 0.850 for RP, RE, VT, MH, SF, BP and GH, respectively). Similarly, the mean physical component summary (PCS) score was significantly higher among individuals with injury at thoracolumbar sections (p < 0.0001). The mean mental component summary (MCS) score did not differ between the two groups (p = 0.720).

CONCLUSIONS

Patients with SCI at the cervical level have similar mental health compared to those with injury at thoracolumbar sections, which shows proper mental adaptability in quadriplegic individuals. Injury level can be used as a major determinant of the physical component of QOL among people with SCI.

Psychosocial aspects of spinal cord injury pain: a meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVES

Although the association between modifiable psychosocial factors and spinal cord injury (SCI) pain has been identified, the full range of psychological and social difficulties for those who experience acute and/or persistent pain remains unclear. This meta-analysis consolidates the available evidence, using the International Classification of Functioning, Disability and Health (ICF) as a reference framework.

METHODS

Nineteen studies that examined persistent neuropathic, nociceptive or mixed pain subtypes in adults with a SCI (newly acquired and chronic; Nparticipants=2934) were identified from electronic database searches. Standardised mean differences between SCI pain and no-pain groups on self-reported psychosocial outcomes were calculated, along with 95% confidence intervals, fail-safe Ns and heterogeneity statistics.

RESULTS

Twenty individual outcomes were grouped into nine ICF-related categories. Emotional functions were the most frequent (100%) psychosocial outcomes assessed, with pain contributing to heightened stress (d=-0.85), depression (d=-2.49) anxiety (d range=-0.85 to -1.45), poor self-efficacy (d=-0.77), lowered wellbeing (d range=-0.67 to -1.02) and decreased use of adaptive coping, such as illness acceptance (d=-0.85). Activity limitations and participation restriction were examined by seven studies (43%), although these findings were largely characterised by single studies.

CONCLUSIONS

Multicomponent treatments that target mood disturbance and foster community connections are important in SCI pain management. However, to improve the comparability of future studies, SCI pain research must adopt definitions of pain consistent with the International Spinal Cord Injury Pain Classification along with validated outcomes that map onto the ICF framework.

Muscle activity and mood state during simulated plant factory work in individuals with cervical spinal cord injury

[Purpose] The present study investigated the physical and mental effects of plant factory work in individuals with cervical spinal cord injury and the use of a newly developed agricultural working environment. [Subjects] Six males with C5–C8 spinal cord injuries and 10 healthy volunteers participated. [Methods] Plant factory work involved three simulated repetitive tasks: sowing, transplantation, and harvesting. Surface electromyography was performed in the dominant upper arm, upper trapezius, anterior deltoid, and biceps brachii muscles. Subjects’ moods were monitored using the Profile of Mood States. [Results] Five males with C6–C8 injuries performed the same tasks as healthy persons; a male with a C5 injury performed fewer repetitions of tasks because it took longer. Regarding muscle activity during transplantation and harvesting, subjects with spinal cord injury had higher values for the upper trapezius and anterior deltoid muscles compared with healthy persons. The Profile of Mood States vigor scores were significantly higher after tasks in subjects with spinal cord injury. [Conclusion] Individuals with cervical spinal cord injury completed the plant factory work, though it required increased time and muscle activity. For individuals with C5–C8 injuries, it is necessary to develop an appropriate environment and assistive devices to facilitate their work.

Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury

Traumatic spinal cord injury (SCI) may result in tetraplegia (motor and/or sensory nervous system impairment of the arms, trunk and legs) or paraplegia (motor and/or sensory impairment of the trunk and/or legs only). The adverse effects of SCI on health, fitness and functioning are frequently compounded by profoundly sedentary behaviour. People with paraplegia (PP) and tetraplegia (TP) have reduced exercise capacity due to paralysis/paresis and reduced exercising stroke volume. TP often further reduces exercise capacity due to lower maximum heart-rate and respiratory function. There is strong, consistent evidence that exercise can improve cardiorespiratory fitness and muscular strength in people with SCI. There is emerging evidence for a range of other exercise benefits, including reduced risk of cardio-metabolic disease, depression and shoulder pain, as well as improved respiratory function, quality-of-life and functional independence. Exercise recommendations for people with SCI are: ≥30min of moderate aerobic exercise on ≥5d/week or ≥20min of vigorous aerobic ≥3d/week; strength training on ≥2d/week, including scapula stabilisers and posterior shoulder girdle; and ≥2d/week flexibility training, including shoulder internal and external rotators. These recommendations may be aspirational for profoundly inactive clients and stratification into "beginning", "intermediate" and "advanced" will assist application of the recommendations in clinical practice. Flexibility exercise is recommended to preserve upper limb function but may not prevent contracture. For people with TP, Rating of Perceived Exertion may provide a more valid indication of exercise intensity than heart rate. The safety and effectiveness of exercise interventions can be enhanced by initial screening for autonomic dysreflexia, orthostatic hypotension, exercise-induced hypotension, thermoregulatory dysfunction, pressure sores, spasticity and pain.

Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury

RATIONALE

Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting.

OBJECTIVES

To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients.

METHODS

The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application.

RESULTS

Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures.

CONCLUSIONS

This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients.

Views and attitudes towards sexual functioning in men living with spinal cord injury in kerala, South India

Context:

Sexual dysfunction is a major concern for Indian men living with a spinal cord injury. Few first-hand reports exist about the experience of living with an altered sense of sexual identity and the inability to express sexual concerns.

Aims:

In this qualitative study, the authors explore views and attitudes towards sexual functioning in men living with a spinal cord injury in Kerala, India.

Materials and Methods:

Semi-structured and open-ended interviews were conducted with seven participants according to IE Seidman's phenomenological approach. Thematic analysis followed the analytic process outlined by Moustakas (1990).

Results:

Identification of seven interconnected themes included: Recalling an active sexual life, disconnection with sexual identity, incongruence between emotional and physical capability, spousal isolation, social readjustment of spouse, physical barriers to sexual functioning, coping, and reintegration.

Conclusions:

Patient's descriptions of suffering demonstrate complexities of experience in sexual functioning. All patients were sexually active prior to the injury. This was now lost causing anxiety, distress, and sadness. A huge gap existed between sexual desire and physical capability. The patient and spouse were now isolated emotionally, socially, and physically. Physical barriers included urinary incontinence and indwelling catheters. While several self-evolved coping strategies were identified, support from palliative care services was not evident. Two important gaps exist in research and practice: (1) Attention to sexual issues and whole-person care. (2) Attention to quality of sexual life. Future qualitative studies on sexual dysfunction could provide a useful adjunct to current literature which is predominantly biomedical in its approach.

Adding insult to injury: discontinuous insurance following spine trauma

BACKGROUND

Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.

METHODS

We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.

RESULTS

The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.

CONCLUSIONS

Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

Analysis of selected determinants of health-related quality of life in persons with spinal cord injury

The aim of the study was the analysis of factors determining health-related quality of life (HRQoL) in persons with spinal cord injury (SCI).

The study involved 100 persons with SCI dependent on using a wheelchair in everyday life, including 22 females and 78 males. Study conducted using the SF-36 questionnaire used to assess HRQoL.

Based on the statistical analysis of the collected research material it has been shown highly significant correlations between the physical and mental dimensions of HRQoL and age at the day of injury and age at the day of the survey. There were also highly significant differences in the physical dimension of HRQoL due to the following variables: clinical pattern of injury, marital status, level of education and participation/non-participation in the active rehabilitation camp. In the case of the mental dimension of the HRQoL there was a significant variation due to the same variables with the exception of clinical pattern of SCI.

Based on the undertaken research it was shown that people with higher levels of HRQoL are characterized by: lower age at the time of the study, lower age at the time of injury, long time since injury, paraplegia, marital status – single, secondary/higher level of education and participation in the active rehabilitation camps in the past.

Evaluation of a community reintegration outpatient program service for community-dwelling persons with spinal cord injury

Objective. To evaluate the effectiveness of a community reintegration outpatient (CROP) service for promoting well-being and community participation following spinal cord injury (SCI). Participants. Community-dwelling adults (N = 14) with traumatic and nontraumatic SCI. Interventions. The CROP service is a 12-week (1 × week; 120 minutes) interprofessional closed therapeutic education service. Main Outcome Measure(s). Moorong Self-Efficacy Scale (MSES); Impact on Participation and Autonomy (IPA); Positive Affect and Negative Affect Scale (PANAS); Coping Inventory of Stressful Situations (CISS); World Health Organization Quality of Life (WHOQOL-BREF); semistructured qualitative interviews. Methods. Twenty-one participants were recruited from two subsequent CROP services, with only 14 persons completing all data assessments. Data were collected at baseline (week 0), at exit (week 12), and at a three-month follow-up. Semistructured interviews were conducted at exit. Results. Self-efficacy (MSES) and positive affect (PANAS) improved from baseline to exit (P < .05), but the changes were not maintained at follow-up. Qualitative analysis identified four major themes related to therapeutic benefits: (1) role of self; (2) knowledge acquisition; (3) skill application; and (4) group processes. Conclusions. Participation in a therapeutic education service has the potential to improve well-being in persons with SCI, but there is a need to identify strategies to maintain long-term gains.

Quality of life in and after spinal cord injury rehabilitation: a longitudinal multicenter study

PURPOSE

To investigate the changes in quality of life (QOL) in persons with spinal cord injury (SCI) and their close persons during the first 2 years post injury.

METHOD

Longitudinal multiple sample multiple wave panel design. Data included 292 patients recruited from Austrian British German Irish and Swiss specialist SCI rehabilitation centers and 55 of their close persons. Questionnaire booklets were administered at 6 weeks 12 weeks 1 year and 2 years after injury to both samples.

RESULTS

Study 1 investigated the WHOQOL-BREF domains in individuals with SCI and found differences mostly in the physical domain indicating that QOL increases for persons with SCI from onset. An effect of the culture was observed in the psychological and environmental domains with higher QOL scores in the German-speaking sample. Study 2 compared individuals with SCI to their close persons and found differences in the physical environmental and social domains over time. The scores on the psychological dimension did not significantly differ between the persons with SCI and their close persons over time.

CONCLUSION

QOL measured by the WHOQOL-BREF shows that QOL changes during rehabilitation and after discharge. Apart from the physical dimension the persons with SCI and their close persons seem to experience a similar change in QOL. Further longitudinal research is suggested to clarify the mutual adjustment process of people with SCI and their close persons and to explore cultural differences in QOL between English-and German-speaking countries.

Health-related quality of life in patients with traumatic spinal cord injury in Estonia

OBJECTIVES

To describe health-related quality of life (HRQoL) in persons with traumatic spinal cord injury (TSCI) and to assess factors that affect HRQoL.

STUDY DESIGN

Cross-sectional.

METHODS

Eighty Estonian-speaking TSCI patients from the Estonian TSCI database were included in the study. The RAND-36 questionnaire, the Life Orientation Test, the Emotional State Questionnaire and the Brief Social Support Questionnaire were used.

RESULTS

There were 66 men and 14 women; the mean age was 38.9±14.8 years. The mean time that had elapsed since injury was 4.2 years. According to the RAND-36 scales, the lowest scores were given for physical health-related domains, followed by the energy/fatigue and the general health domains. The regression analysis adjusted to age and gender revealed that age, employment and category of the American Spinal Injury Association (ASIA) Impairment Scale during the acute phase of injury were significant factors in predicting physical functioning (P<0.001). Age, depression and general anxiety were significant predictors of emotional well-being (P<0.001). Age and depression were independently associated with general health (P<0.001).

CONCLUSION

As expected, physical functioning and physical role limitation were the most pronounced deficits in HRQoL. Compared with data from other countries, all scores for the RAND-36 scales are lower in Estonian TSCI patients. The HRQoL following TSCI is affected by severity of injury, depression, age and employment status.