Natural course of life changes after spinal cord injury: a 35-year longitudinal study

Evidence-based recommendations for the rehabilitation and management of the ageing population with spinal cord injury: a systematic review of clinical practice guidelines

INTRODUCTION

The intersection of ageing and spinal cord injury (SCI) is of global concern. Two scenarios have been described: 1) "SCI with ageing," an increase in the average age of SCI onset, and 2) "ageing with SCI," an increase in post-injury life expectancy. These scenarios entail complex health care and rehabilitation needs due to the accumulation of comorbidities, ageing-related and SCI-induced physiological changes, and post-SCI secondary health conditions. We systematically reviewed Clinical Practice Guidelines (CPGs) with the objective of identifying the extent to which SCI CPGs include recommendations for the rehabilitation and management of people who are "ageing with SCI" or who have acquired an "SCI with ageing". We termed these as "ageing-related recommendations". We also aimed to describe them and identify gaps.

EVIDENCE ACQUISITION

We searched PubMed (NCBI), CINAHL Complete (EBSCOhost) and Embase (Elsevier) for relevant CPGs between 28 December 2022 and 5 January 2023. Included CPGs were evidence-based and had at least one ageing-related recommendation for SCI rehabilitation and management. We used the two core sets of the International Classification of Functioning, Disability and Health (ICF) to identify gaps.

EVIDENCE SYNTHESIS

Only 16 (30%) of the 52 identified CPGs included ageing-related recommendations. Most were recent US or European publications and lacked specific chapters on ageing. These CPGs included 40 ageing-related recommendations, mostly "strong" but based on "low" to "very low" quality of evidence. The overall quality of the development process was low and did not consider the values and preferences of stakeholders and patients. Common topics included cardiovascular, bone, metabolic, bowel, bladder, and skin health. The recommendations could be linked to 30 ICF categories which represented only 18% of the ICF categories included in the comprehensive versions of two ICF Core Sets. Key gaps were found in mobility, interpersonal interactions, and relationships, neuromusculoskeletal and movement-related, mental, sensory and pain functions.

CONCLUSIONS

There is a notable lack of high-quality ageing-related recommendations for SCI management and rehabilitation. Future research should prioritize the generation of high-quality evidence to develop age-sensitive CPGs. Future SCI CPGs need to address the complex challenges at the interface of ageing and SCI, considering patient and stakeholder preferences.

Quality of life from the patient perspective at the end of the first rehabilitation after the onset of spinal cord injury/disorder - A qualitative interview-based study

CONTEXT

At present, there is a lack of information concerning patients' perspectives on their quality of life (QoL) after a recently acquired spinal cord injury/disorder (SCI/D).

OBJECTIVE

To explore patients' perspectives on their QoL during their first inpatient rehabilitation after the onset of SCI/D.

METHODS

Qualitative study. Semi-structured face-to-face interviews were conducted with 20 participants aged 18 years or older at least three months after the onset of SCI/D and two weeks before they were discharged from their first rehabilitation. Audio-recorded interviews were transcribed and analyzed according to the thematic content analysis. Interviewees rated their QoL with the SCI QoL data set.

RESULTS

The interviewees judged their satisfaction with life as a whole, their physical and mental health, as relatively high with values between six and eight (with 10 meaning complete satisfaction). They highlighted social aspects, health topics, and the experience of autonomy as relevant to their concept of QoL. The aspects that positively influenced QoL included the level of well-being in the current social and institutional environment, the increased level of energy, strength, and autonomy in daily life, and an improved mental state derived from general positive personal attitudes. In contrast, the social restrictions during the COVID-19 pandemic, physical issues including pain, a lack of progress associated with psychological dissatisfaction, and limitations in personal independence decreased patients' QoL.

CONCLUSION

Since the interviewees described different aspects from the areas of social, health and autonomy as important for their QoL, exploring and addressing these areas should be used to achieve an individualized first rehabilitation.

Social Integration among Adults Aging with Spinal Cord Injury: The Role of Features in the Built and Natural Environment

A growing number of adults are aging with spinal cord injury (SCI) acquired earlier in life. Social integration is important for health and participation after SCI. However, little is known about the role of the community built environment for supporting social integration among adults aging with SCI. Using a structured telephone survey with 182 adults aging with SCI in the Midwestern United States, we found that more community built environment facilitators (e.g., curb cuts, automatic doors, paved surfaces) and fewer barriers (e.g., gravel surfaces, crowds) significantly increased the odds of regularly engaging in both formal and informal social activities.

Strategies employed in coping with physical disabilities acquired during adulthood in rural South Africa

Background

Society places people with physical disabilities acquired during adulthood in disadvantaged positions, especially when they cannot participate in activities like their non-disabled counterparts. The situation can be worse for individuals who acquire disabilities during adulthood, where they have to learn to cope with the adulthood-acquired physical disabilities.

Objectives

This study aimed to identify the types of physical disabilities acquired during adulthood and their causes and explore how participants defined their disabilities and the coping strategies they used.

Methods

The study used a phenomenological research design. Five adults (three women, two men) with adulthood-acquired disabilities were purposefully selected from a rural area in Limpopo, South Africa. Data were collected using semi-structured interviews. Thematic analysis was used to generate themes about coping strategies study participants used.

Results

The results show four types of adulthood-acquired disabilities amongst the participants: visual impairment, paraplegia, weakened muscles which led to bilateral amputation, loss of function on both hands and legs. Participants' meanings of their physical adulthood-acquired disabilities ranged from a punishment, pain, not a bother, black magic, to results of doing wrong things to someone. In coming to terms with their adulthood-acquired disabilities, participants used problem- and emotion-focused strategies. Four themes from the participants' responses were spiritual support, social support, substance dependency, access to health and rehabilitation services.

Conclusion

The study contributes to understanding the experiences of individuals who acquired disabilities in adulthood, how they define their disabilities and the divergent coping strategies they use. This study established that participants used problem-focused, positive emotion-focused and negative emotion-focused coping strategies.

Health-related factors for work participation of persons with Spinal Cord Injury in Finland

OBJECTIVE

To explore work participation and the health-related factors affecting work participation among the Finnish Spinal Cord injury (FinSCI) study population (n = 884).

METHODS

A cross-sectional explorative observational study in the FinSCI community survey applying Patient-Reported Outcomes Measurement Information System (PROMIS®) forms on Social Health and Global Health. Analyses of socio-demographic and injury-related data were performed.

RESULTS

Employment among the study population (n = 452) was 26.5%. Physical, Mental, Social and General Health were better in the employed group compared with work-age persons not working. Logistic regression showed that work participation was related to all health domains, but Physical Health and Ability to Participate in Social Roles and Activities in Social Health were the strongest indicators of likelihood of being at work. Paraplegia and young age were associated with increased likelihood of work participation.  Conclusion: The first national survey among people with spinal cord injury in Finland shows low level of employment. The results suggest that pain, physical function, and ability to participate in social roles should be monitored by health and vocational professionals when assessing a person's likelihood of being in work.

Life Satisfaction in Individuals With Long-Term Traumatic Spinal Cord Injury: An Investigation of Associated Biopsychosocial Factors

OBJECTIVE

To investigate relationships between self-reported biological, psychological, and social factors and global, vocational, and home life satisfaction in individuals with traumatic spinal cord injury (SCI) an average of more than 30 years postinjury.

DESIGN

Cross-sectional analyses of self-report assessment data.

SETTING

Specialty and university hospitals in the southeastern and midwestern United States.

PARTICIPANTS

Individuals with a history of traumatic SCI (n=546) who responded to the most recent data collection period of the SCI Longitudinal Aging Study (2018-2019) and who were at least 2 years postinjury and at least 18 years or older at initial study enrollment.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Global life satisfaction, home life satisfaction, and vocational life satisfaction as measured by the Life Situation Questionnaire-Revised.

RESULTS

Taken together, the biopsychosocial variables explained 55.1% of the variance in global life satisfaction. Less severe depressive symptoms, greater emotional social support, and greater instrumental social support were significantly associated with greater global life satisfaction. Together, the independent variables explained 50.7% of the variance in home life satisfaction. Being in a relationship, having less severe depressive symptoms, having greater emotional social support, and having greater instrumental social support were significantly associated with home life satisfaction. Together, the independent variables explained 44.8% of the variance in vocational satisfaction. Being White, non-Hispanic, having more years of education, being in a relationship, having less severe depressive symptoms, and having greater emotional social support were significantly associated with greater vocational satisfaction.

CONCLUSION

These results support the need to assess psychological symptoms and available social support as potential modifiable factors related to several domains of life satisfaction in this aging population. Improving psychological symptoms and strengthening available social support may relate to improved life satisfaction.

[Quality of life in patients with spinal cord injury for at least 10years: Importance of secondary health complications]

OBJECTIVE

To determine the quality of life of spinal cord injuries with more than 10 years of evolution. Assess the prevalence of secondary complications, and their relationship with quality of life and time since the injury.

PATIENTS AND METHOD DESIGN

Cross-sectional epidemiological study.

STUDY SUBJECTS

Patients with traumatic spinal cord injury, more than 10 years after the injury, and who met the inclusion criteria.

METHOD

Quality of life was assessed using the International spinal cord injury quality of life basic data set. Variables included: individual factors, neurological deficit, level of injury and secondary complications.

RESULTS

131 subjects were included in the study with a mean age of 49 years, and a time since the injury of 21 years (11-53 years). The mean number of secondary complications was 2, the most frequent being urological, in 76 subjects (58%). There were no significant differences between the number of complications and the time elapsed since the spinal cord injury. The quality of life was significantly lower in those with a higher number of complications (P=.003). Urological complications (P=.04, 95% CI: -1.02 to 2), musculoskeletal pain (P=.01, 95% CI: 1-6), respiratory complications (P=.05, 95% CI: -3 to 0.1) and neuropathic pain that interfered with basic life activities (P=.01, 95% CI: 1-5) were significantly related to a lower quality of life.

CONCLUSIONS

Secondary complications are common after spinal cord injury, although their number does not increase over time after injury. Quality of life is conditioned by the existence of different complications such as the existence of musculoskeletal pain.

Detecting subgroups in social participation among individuals living with spinal cord injury: a longitudinal analysis of community survey data

STUDY DESIGN

Longitudinal community survey.

OBJECTIVES

To determine subgroups in social participation of individuals living with spinal cord injury (SCI).

SETTING

Community.

METHODS

Data were collected in 2012 and 2017 as part of the community survey of the Swiss Spinal Cord Injury cohort. Participation was assessed using the 33-item Utrecht Scale of Evaluation of Rehabilitation-Participation evaluating frequency of, restrictions in and satisfaction with productive, leisure, and social activities. Linear mixed-effects model trees were used to distinguish subgroups in participation associated with sociodemographic and lesion characteristics.

RESULTS

In all, 3079 observations were used for the analysis, of which 1549 originated from Survey 2012, 1530 from Survey 2017, and 761 from both surveys. Participants were mostly male (2012: 71.5%; 2017: 71.2%), aged on average 50 years (2012: 52.3; 2017: 56.5), with an incomplete paraplegia (2012: 37.5%; 2017: 41.8%) of traumatic origin (2012: 84.7%; 2017: 79.3%). There was limited within-person variation in participation over the 5-year period. Participation varied with age, SCI severity, education, financial strain, number of self-reported health conditions (SHCs), and disability pension level. Among modifiable parameters, the number of SHCs and disability pension level emerged as the most frequent partitioning variables, while education was most informative for participation in productive, leisure, and social activities.

CONCLUSIONS

Long-term rehabilitation management and clinical practice should target people most prone to decreased participation in major life domains. Our study indicates that the alleviation of SHCs, engagement in further education, or adjusting disability pension level are promising areas to improve participation of persons living with SCI.

Differential Odds of Employment and Estimation of Earnings Among Those With Spinal Cord Injury

Our purpose was to identify demographic, educational, and injury-related characteristics associated with odds of employment and estimates of differential earnings among participants with spinal cord injury (SCI). Self-report assessments were obtained from 1,983 participants who had traumatic SCI, were 18+ years old, and less than 65 years of age. All were recruited into the current cross-sectional study from previous studies of health and aging from the Midwestern and Southeastern United States. Midwestern participants had 2.41 higher odds of employment. Older age at injury was associated with lower odds of employment. There were no sex differences in the odds of employment, but women had an estimated US$19,431 lower conditional earnings. Non-Hispanic Blacks had 69% lower odds of employment, and those working had an estimated US$12,058 lower earnings. Ambulatory participants had higher odds of employment (odds ratio [OR] = 4.66) and higher conditional earnings (US$17,277) than those with the most severe SCI. Those with 4-year or postgraduate degrees had substantially higher odds of employment (OR = 4.15, OR = 5.72, respectively) and higher conditional earnings (US$29,990, US$44,580, respectively) compared with those with a high school certificate or less. These findings underscore the importance of policies to promote the optimal quality employment outcomes for people with SCI.

Participation in People Living With Spinal Cord Injury in Switzerland: Degree and Associated Factors

OBJECTIVE

To describe different domains of participation such as productive, leisure and social activities and describe sociodemographic and spinal cord injury (SCI)-related characteristics that are associated with participation in these domains in a large sample of community-dwelling individuals with SCI in Switzerland.

DESIGN

Cross-sectional population-based survey within the Swiss Spinal Cord Injury Cohort Study. Participation in major life domains was measured by the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation). Univariable unconditional analysis and unbiased recursive partitioning were used to identify the predominant associations of sociodemographic and SCI-related characteristics with multiple dimensions of participation.

SETTING

Community.

PARTICIPANTS

Swiss residents aged 16 years or older and living with traumatic or nontraumatic SCI (N=1549).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The USER-Participation, a 32-item self-report questionnaire with 3 scales (Frequency, Restrictions, and Satisfaction) to assess key domains of participation (productive, leisure, social).

RESULTS

Frequency (median 34.5 out of 100) in productive, outdoor leisure, and social activities was reduced with distinctive perceived restrictions in work and education, sports, and partner relationships. Domestic leisure activities (65.4%) and maintaining social relationships (76.1%) were those activities most often performed and with least perceived restrictions. Participants were generally satisfied with their current daily life activities. Lower scores across all participation scales were associated with more severe SCI, higher age, being female, not having a partner, and lower level of education.

CONCLUSIONS

This study provides a thorough analysis of participation in major life domains of individuals with SCI in Switzerland. Different risk groups for reduced levels in participation in productive, leisure, and social activities were identified. This population-based evidence is instrumental to the better targeting of rehabilitation and policy interventions that aim to improve community participation.

Understanding the Changing Health Care Needs of Individuals Aging With Spinal Cord Injury

Background: Individuals over age 65 are projected to account for over 20% of the general population by 2030. This trend is reflected in an increase in the age of individuals sustaining traumatic spinal cord injury (SCI). Based on current evidence, there is concern regarding the needs of older individuals aging with SCI and current health care services. Research is limited regarding factors that contribute to health status and treatment outcomes associated with aging 5 or more years post SCI. Objective: The purpose of this qualitative study was to explore changing health care needs of individuals aging with SCI and their caregivers and to identify the environmental supports and barriers to achieving long-term health and treatment outcomes. Methods: This was a phenomenological study utilizing semi-structured interviews. Inclusion criteria were age greater than 60 years old and 5 years post SCI. Between October 2014 and January 2016, 41 individuals with SCI and eight caregivers participated in the semi-structured interviews. Emergent themes and quotations were noted and analyzed using established methods. Triangulation was used to establish rigor and trustworthiness. Results: Data analysis of the interviews revealed four themes (health literacy, health services, changes with age, and environment) and 10 subthemes. Conclusion: Rehabilitation programs should consider the health literacy of older individuals with SCI and their caregivers. Similarly, these programs should be designed to allow them to identify and utilize resources in solving barriers to everyday participation. Further investigation is required to examine the macro-environmental influences (systems and policies) on the changing health care needs of individuals aging with SCI.

Functional independence of persons with long-standing motor complete spinal cord injury in the Netherlands

Context/Objective: Since life expectancy of persons with spinal cord injury (SCI) has improved, it is relevant to know whether this group is able to maintain functional abilities many years after onset of SCI. Objectives of this study were (1) to examine associations between time since injury (TSI) and functional independence in persons with long-standing SCI and (2) to explore associations between functional independence and level of injury, comorbidities, mental health, waist circumference and secondary health conditions (SHCs).Design: TSI-stratified cross-sectional study. Strata were 10-19, 20-29 and 30+ years.Setting: Community.Participants: 226 persons with long-standing SCI. Inclusion criteria: motor complete SCI; age at injury 18-35 years; TSI ≥ 10 years; current age 28-65 years; wheelchair dependency.Interventions: Not applicable.Outcome measures: The Spinal Cord Independence Measure III (SCIM) was administered by a trained research assistant. Level of injury, comorbidities, mental health, waist circumference and SHCs were assessed by a rehabilitation physician.Results: Mean TSI was 23.6 (SD 9.1) years. No significant differences in SCIM scores were found between TSI strata. SCIM scores were lower for persons with tetraplegia, autonomic dysreflexia, hypotension, more than four SHCs and a high waist circumference. In linear regression analyses, TSI nor age was associated with the SCIM total score. Only level of injury (β = -0.7; P < .001) and waist circumference (β = -0.1; P = .042) were independent determinants (explained variance 55%).Conclusion: We found no association between TSI and functional independence in persons with long-standing motor complete SCI. This study confirms the possible effect of overweight on functional independence.

Examining the relationship between post-traumatic stress disorder and social participation among Veterans with spinal cord injuries and disorders

PURPOSE

The objectives of this study were to examine differences in social participation among Veterans with spinal cord injuries/disorders with and without post-traumatic stress disorder, and determine if lower social participation was independently associated with having post-traumatic stress disorder.

METHODS

A cross-sectional mailed national survey was sent to a national sample of Veterans with spinal cord injuries/disorders who received prior-year Veterans Affairs healthcare. Surveys provided data on: demographics, health conditions, injury characteristics, and social participation. Analyses included bivariate comparisons, and multivariate logistic regression to determine if lower social participation was independently associated with post-traumatic stress disorder.

RESULTS

Veterans with (vs. without) post-traumatic stress disorder (n = 896) reported lower social participation (40.2 vs. 43.9, p < 0.0001). Multivariate analyses showed that longer duration of injury (OR = 0.98, 95% CI: 0.97-1.00, p = 0.04) and white race (OR = 0.62, 95% CI: 0.38-1.01, p = 0.05) were associated with lower odds of post-traumatic stress disorder, while a greater number of health conditions (OR = 1.43, 95% CI: 1.25-1.64, p < 0.0001) was associated with greater odds. When controlling for covariates, lower social participation was independently associated with post-traumatic stress disorder (OR = 0.94, 95% CI: 0.90-0.98, p = 0.003).

CONCLUSIONS

Results indicate post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. Efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation. Implications for Rehabilitation Individuals with spinal cord injuries/disorders often have post-traumatic stress disorder; in Veterans with spinal cord injuries/disorders this may be compounded by trauma incurred through military experiences. Social participation, an important aspect of rehabilitation and community integration following spinal cord injury or disorder, may be hindered by symptoms of post-traumatic stress disorder. Our data show that post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. These results indicate that efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation in this patient population.

Meaning and components of quality of life among individuals with spinal cord injury in Yogyakarta Province, Indonesia

PURPOSE

Knowledge on the meaning of quality of life in individuals with spinal cord injury in developing countries is limited. This study aims to explore the meaning and components of quality of life for individuals with spinal cord injury in a rural area in Indonesia.

METHOD

Data were obtained through semi-structured interviews with 12 individuals with paraplegia (8 males, 4 females) aged 24-67 years. Thematic analysis was used to identify themes that constitute meaning and components of quality of life.

RESULTS

Quality of life was not an easily understood concept, while "life satisfaction" and "happiness" were. Life satisfaction was associated with a person's feeling when achieving goals or dreams and related to fulfillment of needs. Thirteen components of life satisfaction were identified and categorized into five domains as follows: (1) participation: earning income and work, being useful to others, community participation, and having skills and knowledge, (2) social support: social support, social relationship, (3) relationship with God: injury is God's will, praying, (4) independence: being independent, mobility and accessibility, and health, and (5) psychological resources: accepting the condition, maintaining goals and motivation.

CONCLUSIONS

Social, cultural and religious influences were prominent in the perception of life satisfaction. The measurement of quality of life for individuals with spinal cord injury in Indonesia needs to consider locally perceived meaning and components of quality of life. Implications for Rehabilitation Financial, social and health needs of individuals with spinal cord injury in Indonesia must be immediately addressed. To increase financial independence, rehabilitation professionals should equip individuals with spinal cord injury with adequate self-employment skills. Sociocultural and religious aspects should be considered in the measurement of quality of life.

The natural course of spinal cord injury: changes over 40 years among those with exceptional survival

OBJECTIVES

To identify 40-year longitudinal changes in health, activity, employment, life satisfaction and self-rated adjustment after spinal cord injury.

STUDY DESIGN

Longitudinal, mailed self-report.

METHODS

Participants were identified from outpatient records of a Midwestern USA university hospital in 1973. Follow-ups were conducted in 1984 and approximate 10-year intervals thereafter. A total of 49 participants completed each of the five assessments. Data were reviewed and analyzed by research team members and a research associate with experience in biostatistics at a medical university in Southeastern USA. Life Situation Questionnaire included the following: (1) demographic and injury characteristics, (2) educational status and employment, (3) community participation, (4) life satisfaction, (5) adjustment, and (6) recent medical history.

RESULTS

Proportion of individuals with 10+ non-routine physician visits increased from consistently <10% to >40% during the 40 years. Proportion who spent a week or more in hospital increased from a low of 10% at 20-year follow-up to 43% at 40-year follow-up. Percentage employed and average hours employed initially improved over time but decreased substantially during the last two times of measurement. Satisfaction with health, sex life and social life declined over time, whereas satisfaction with employment improved initially and was maintained over time. Self-rated current adjustment remained stable, whereas predicted future adjustment declined steadily over 40 years.

CONCLUSIONS

Age-related declines were apparent for need of physician visits and hospitalizations, with notable declines in satisfaction with sex life, social life and health. However, not all indices declined over time. Participants appeared to maintain stability when rating their own adjustment.

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

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

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

SETTING

A regional SCI outpatient center in Sweden.

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence of hypertension and associated risk factors in people with long-term spinal cord injury living in the Netherlands

PURPOSE

To describe the prevalence of hypertension and associated risk factors in people with long-term spinal cord injury (SCI) and to compare the prevalence of high blood pressure and/or the use of antihypertensive drugs with the prevalence in the Dutch general population.

METHOD

Multicentre cross-sectional study (N = 282). Hypertension was defined as a systolic blood pressure (SBP) of ≥140 mmHg and/or a diastolic blood pressure (DBP) of ≥90 mmHg after ≥2 blood pressure measurements during ≥2 doctor visits. High blood pressure was defined as a single measurement of a SBP of ≥140 mmHg and/or a DBP of ≥90 mmHg.

RESULTS

The prevalence of hypertension was 21.5%. Significant predictors were: lesion level below C8 (T1-T6: OR =6.4, T7-L5: OR =10.1), history of hypercholesterolemia (OR =4.8), longer time since injury (OR =1.1), higher age (OR =1.1). The prevalence of high blood pressure and/or the use of antihypertensive drugs was higher in men (T1-T6 lesion: 48%; T7-L5 lesion: 57%) and women (T1-T6 lesion: 48%; T7-L5 lesion: 25%) with a SCI below C8 compared to Dutch able-bodied men (31%) and women (18%).

CONCLUSION

High blood pressure is common in people with SCI. Screening for hypertension during annual checkups is recommended, especially in those with a SCI below C8. Implications for Rehabilitation High blood pressure is common in people with long-term SCI living in the Netherlands and its prevalence is higher in both men and women with a spinal cord lesion level below C8 compared with the age-matched Dutch general population. It is recommended to screen for hypertension during annual checkups in people with SCI, especially in those with a higher risk of developing hypertension, e.g. those with a spinal cord lesion level below C8 and an age of ≥45 years or a time since injury of ≥20 years. When a high blood pressure is measured in people with SCI, they should receive a further assessment of the blood pressure according to the available guidelines for the general population, including ambulatory 24 h-blood pressure monitoring.

Demographic and clinical characteristics of patients with spinal cord injury: a single hospital-based study

STUDY DESIGN

Retrospective study.

OBJECTIVES

To evaluate the demographic and clinical characteristics of patients diagnosed with spinal cord injury (SCI) admitted to a single center.

SETTING

Single center study, México.

METHODS

This study reviewed 433 patients with SCI. Data were extracted from medical records and retrospectively reviewed.

RESULTS

A total of 433 patients with a diagnosis of SCI were included in the analysis. Of these, 346 (79.9%) had traumatic SCI (TSCI) and 87 (20.1%) had non-traumatic SCI (NTSCI). The principal causes of traumatic TSCI were motor vehicle accidents in 150 patients (43.4%), falls in 107 patients (30.9%) and a result of firearms in 58 patients (16.8%). Tumoral cord compression was the main cause of NTSCI in 50 patients (57.4%), followed by degenerative disease-causing myelopathy in 17 patients (19.5%). The proportion of patients affected with NTSCI was significantly lower, 29.9 vs 79.1% (P=0.0001), the age of patients was higher 53.9 vs 37.8 (P<0.002) and SCI was less severe, AIS D 41.33 vs 9.5% (P=0.0001) compared with the TSCI group.

CONCLUSIONS

The demographic profiles of patients with TSCI and NTSCI differ in terms of proportion of total SCIs, patient age, male:female ratio and incomplete vs complete injury. The most common etiology of TSCI was motor vehicle accidents (43.4%), and neurological lesions were complete in 62.7% of patients. The most common etiology of NTSCI was tumoral spinal lesions (57.4%), and lesions were incomplete in 75.8% of patients.

The Impact of Health Behaviors and Health Management on Employment After SCI: Physical Health and Functioning

Background: Research has shown that employment following spinal cord injury (SCI) is related to health and functioning, with physical health and functioning after SCI frequently identified as a primary barrier to employment. Objective: To examine the relationship between employment and behaviors associated with the management of physical health and functioning as described by individuals with SCI who have been employed post injury. Methods: A qualitative approach using 6 focus groups at 2 sites included 44 participants with SCI who had worked at some time post injury. Heterogeneous and homogeneous groups were created based on specific characteristics, such as education, gender, or race. A semi-structured interview format asked questions about personal, environmental, and policy-related factors influencing employment after SCI. Groups were recorded, transcribed, and entered into NVivo before coding by 2 reviewers. Results: Within the area of behaviors and management of physical health and functioning, 4 overlapping themes were identified: (1) relearning your own body and what it can do; (2) general health and wellness behaviors; (3) communication, education, and advocacy; and (4) secondary conditions and aging. Specific themes articulate the many types of behaviors individuals must master and their impact on return to work as well as on finding, maintaining, and deciding to leave employment. Conclusions: Individuals with SCI who are successfully employed after injury must learn how to perform necessary behaviors to manage health and function in a work environment. The decision to leave employment often appears to be associated with secondary complications and other conditions that occur as persons with SCI age.

SCI Longitudinal Aging Study: 40 Years of Research

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Participation and Life Satisfaction in Aged People with Spinal Cord Injury: Does Age at Onset Make a Difference?

BACKGROUND

Few studies have reported on outcomes in samples of elderly people with SCI and the impact of the age at onset of SCI is unclear.

OBJECTIVE

To study levels of participation and life satisfaction in individuals with SCI aged 65 years or older and to analyze differences in participation and life satisfaction scores between individuals injured before or after 50 years of age.

METHODS

This cross-sectional survey included 128 individuals with SCI who were at least 65 years old. Age at onset was dichotomized as <50 or ≥ 50 years of age. Participation was measured with the Frequency scale of the Utrecht Scale for Evaluation-Participation, and life satisfaction was measured with 5 items of the World Health Organization Quality of Life abbreviated form.

RESULTS

Participants who were injured before 50 years of age showed similar levels of functional status and numbers of secondary health conditions but higher participation and life satisfaction scores compared to participants injured at older age. In the multiple regression analysis of participation, lower current age, higher education, and having paraplegia were significant independent determinants of increased participation (explained variance, 25.7%). In the regression analysis of life satisfaction, lower age at onset and higher education were significant independent determinants of higher life satisfaction (explained variance, 15.3%).

CONCLUSIONS

Lower age at onset was associated with better participation and life satisfaction. This study did not reveal indications for worsening participation or life satisfaction due to an accelerated aging effect in this sample of persons with SCI.

Measuring positive affect and well-being after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Positive Affect and Well-being bank and short form

OBJECTIVE

To develop an item response theory (IRT)-calibrated spinal cord injury (SCI)-specific Positive Affect and Well-being (PAWB) item bank with flexible options for administration.

DESIGN

Qualitative feedback from patient and provider focus groups was used to expand on the Neurological Disorders and Quality of Life (Neuro-QOL) positive affect & well-being item bank for use in SCI. New items were created and revised based on expert review and patient feedback and were then field tested. Analyses included confirmatory factor analysis, graded response IRT modeling and evaluation of differential item functioning (DIF).

SETTING

We tested a 32-item pool at several rehabilitation centers across the United States, including the University of Michigan, Kessler Foundation, Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital and the James J. Peters/Bronx Department of Veterans Affairs hospital.

PARTICIPANTS

A total of 717 individuals with SCI answered the PAWB questions.

RESULTS

A unidimensional model was observed (Confirmatory Fit Index=0.947; Root Mean Square Error of Approximation=0.094) and measurement precision was good (reliability in theta of -2.9 to 1.2 is roughly equivalent to classical reliability of 0.95 or above). Twelve items were flagged for DIF, however, after examination of effect sizes, the DIF was determined to be negligible and would have little practical impact on score estimates. The final calibrated item bank resulted in 28 retained items

CONCLUSIONS

This study indicates that the Spinal Cord Injury--Quality of Life PAWB bank represents a psychometrically robust measurement tool. Short form items are also suggested and a computer adaptive test is available.

Predictors of subclinical atherosclerosis in women with spinal cord injury

BACKGROUND

Chronic spinal cord injury (SCI) is associated with an increase in risk factors for cardiovascular disease (CVD). In the general population, atherosclerosis in women occurs later than in men and usually presents differently. Associations between risk factors and incidence of CVD have not been studied in women with SCI.

OBJECTIVE

To determine which risk factors for CVD are associated with increased carotid intima-media thickness (CIMT), a common indicator of atherosclerosis, in women with SCI.

METHODS

One hundred and twenty-two females older than 18 years with traumatic SCI at least 2 years prior to entering the study were evaluated. Participants were asymptomatic and without evidence of CVD. Exclusion criteria were acute illness, overt heart disease, diabetes, and treatment with cardiac drugs, lipid-lowering medication, or antidiabetic agents. Measures for all participants were age, race, smoking status, level and completeness of injury, duration of injury, body mass index, serum lipids, fasting glucose, hemoglobin A1c, and ultrasonographic measurements of CIMT. Hierarchical multiple linear regression was conducted to predict CIMT from demographic and physiologic variables.

RESULTS

Several variables were significantly correlated with CIMT during univariate analyses, including glucose, hemoglobin A1c, age, and race/ethnicity; but only age was significant in the hierarchical regression analysis.

CONCLUSIONS

Our data indicate the importance of CVD in women with SCI.

Cardiometabolic changes and disparities among persons with spinal cord injury: a 17-year cohort study

BACKGROUND

Cardiometabolic syndrome in individuals who are aging with spinal cord injury (SCI) increases the risk of cardiovascular disease and diabetes. Longitudinal research is needed on the natural progression of cardiometabolic syndrome in SCI.

OBJECTIVE

To identify the magnitude of changes in biomarkers of cardiometabolic syndrome and diabetes over time in people aging with SCI, and to discern how these biomarkers relate to demographics of race/ethnicity and sex.

METHODS

This cohort study was a follow-up of a convenience sample of 150 participants (mean age, 51.3; duration of SCI, 27.3 years) from a full cohort of 845 who participated in research in which physiologic and serologic data on cardiovascular disease had been prospectively collected (1993-1997). Inclusion criteria were adults with traumatic-onset SCI. Average years to follow-up were 15.7 ± 0.9. Assessments were age, race, level and completeness of injury, duration of injury, blood pressure, body mass index, waist circumference, serum lipids, fasting glucose, hemoglobin A1c, and medications used. Primary outcome was meeting at least 3 of the criteria for cardiometabolic syndrome.

RESULTS

The frequency of cardiometabolic syndrome increased significantly from 6.7% to 20.8% or 38.2% according to 2 definitions. It was significantly higher in Hispanics and apparently higher in women. Diabetes increased significantly by a factor of 6.7.

CONCLUSION

Our data indicate clinically important increases in the frequency of cardiometabolic syndrome, especially among Hispanic and female participants, and a similar increase in diabetes among individuals aging with SCI. Clinical practice guidelines need to be customized for women and Hispanics with SCI.

Predictors of changes in sentimental and sexual life after traumatic spinal cord injury

OBJECTIVE

To investigate changes and identify predictors in interpersonal functioning and sexual life after traumatic spinal cord injury (SCI).

DESIGN

Prospective, multicenter, follow-up observational study.

SETTING

Subjects at home, interviewed by phone during a 6-month period, 3.8 mean years after discharge from 24 centers participating in a previous epidemiologic prospective survey.

PARTICIPANTS

Subjects (N=403) with traumatic SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

DEPENDENT VARIABLES

satisfaction with sentimental life and satisfaction with sexual life compared with before the injury.

INDEPENDENT VARIABLES

demographic (age, sex, marital status, vocational status), SCI related (severity, level, bowel/bladder continence), car-driving ability, perceived quality of life (QoL), and impact of sentimental life, social integration, and vocational status on QoL.

RESULTS

Satisfaction with sentimental life was reportedly increased or the same as before SCI in 69% of the sample, but satisfaction with sexual life in only 31%. Lesser satisfaction with sexual life was reported by men than women (P=.002) and by married people than singles (P<.001). Significant predictors of sentimental life were perceived QoL and preserved driving ability (R(2)=.195). Bladder continence was positively associated with a better satisfaction with sexual life (R(2)=.368). Bowel continence did not remain a significant predictor of satisfaction with sexual life in multivariate analysis.

CONCLUSIONS

The challenge of a comprehensive rehabilitation of SCI, addressing the recovery of well-being including a satisfying sentimental and sexual life, requires identifying new issues that should be considered in up-to-date rehabilitation programs. The results indicate associations between driving ability and a better satisfaction with sentimental life. Further investigations are needed to explore whether the relationship is causative.