Spinal cord injury medicine. 4. Optimal participation in life after spinal cord injury: physical, psychosocial, and economic reintegration into the environment

Traumatic spinal cord injury

Traumatic spinal cord injury (SCI) has devastating consequences for the physical, social and vocational well-being of patients. The demographic of SCIs is shifting such that an increasing proportion of older individuals are being affected. Pathophysiologically, the initial mechanical trauma (the primary injury) permeabilizes neurons and glia and initiates a secondary injury cascade that leads to progressive cell death and spinal cord damage over the subsequent weeks. Over time, the lesion remodels and is composed of cystic cavitations and a glial scar, both of which potently inhibit regeneration. Several animal models and complementary behavioural tests of SCI have been developed to mimic this pathological process and form the basis for the development of preclinical and translational neuroprotective and neuroregenerative strategies. Diagnosis requires a thorough patient history, standardized neurological physical examination and radiographic imaging of the spinal cord. Following diagnosis, several interventions need to be rapidly applied, including haemodynamic monitoring in the intensive care unit, early surgical decompression, blood pressure augmentation and, potentially, the administration of methylprednisolone. Managing the complications of SCI, such as bowel and bladder dysfunction, the formation of pressure sores and infections, is key to address all facets of the patient's injury experience.

Serum lipid profile in subjects with traumatic spinal cord injury

Background and Aims

Few large studies have examined the relationship between spinal cord injury (SCI) and lipid profile. We studied serum lipid concentrations in subjects with traumatic SCI in relation to the degree of neurological involvement and time since injury, and compared them with values from a reference sample for the Spanish population (DRECE study).

Materials and Methods

A retrospective cohort was built from 177 consecutive cases with traumatic SCI admitted to the SCI unit of the Miguel Servet Hospital in Aragon (Spain). Outcome measures (cholesterol, triglycerides, HDL-c and LDL-c levels) were analyzed according to the ASIA Impairment Scale (AIS), neurological level of injury (involvement of all limbs vs. only lower limbs), and time since injury. All analyses were adjusted for age and sex.

Results

Cases without preserved motor function (AIS A or B) had lower total and HDL cholesterol than the others (-11.4 [-21.5, -1.4] mg/dL total cholesterol and -5.1 [-8.8, -1.4] mg/dL HDL-c), and cases with all-limb involvement had lower total, HDL, and LDL cholesterol than those with only lower-limb involvement (-14.0 [-24.6, -3.4] mg/dL total cholesterol, -4.1 [-8.0, -0.2] mg/dL HDL-c, and -10.0 [-19.7, -0.3] mg/dL LDL-c) (all p<0.05). No association was found between lipid concentrations and time since injury. Concentrations of lipid subfractions and triglycerides in SCI subjects were lower than in sex- and age-stratified values from the reference sample.

Conclusion

A high degree of neurological involvement in SCI (anatomically higher lesions and AIS A or B) is associated with lower total cholesterol and HDL-c.

Disability and the built environment: an investigation of community and neighborhood land uses and participation for physically impaired adults

PURPOSE

There is a need for empirical support of the association between the built environment and disability-related outcomes. This study explores the associations between community and neighborhood land uses and community participation among adults with acquired physical disability.

METHODS

Cross-sectional data from 508 community-living chronically disabled adults in New Jersey were obtained from among participants in national Spinal Cord Injury Model Systems database. Participants' residential addresses were geocoded to link individual survey data with Geographic Information Systems data on land use and destinations. The influence of residential density, land use mix, destination counts, and open space on four domains of participation were modeled at two geographic scales-the neighborhood (i.e., half mile buffer) and community (i.e., five mile) using multivariate logistic regression. All analyses were adjusted for demographic- and impairment-related differences.

RESULTS

Living in communities with greater land use mix and more destinations was associated with a decreased likelihood of reporting optimum social and physical activity. Conversely, living in neighborhoods with large portions of open space was positively associated with the likelihood of reporting full physical, occupational, and social participation.

CONCLUSIONS

These findings suggest that the overall living conditions of the built environment may be relevant to social inclusion for persons with physical disabilities.

Do risk perceptions explain sex differences in community integration and participation after Spinal Cord Injury?

OBJECTIVE

To describe how men and women with spinal cord injury (SCI) rate the risks posed by a set of everyday activities measured using the Risk Inventory for persons with Spinal Cord Injury (RISCI), and to examine whether sex differences are related to community integration and participation.

DESIGN

Cohort study.

SETTING

Metropolitan Detroit.

PARTICIPANTS

One hundred and forty community-dwelling white and African-American men and women with SCI.

OUTCOME MEASURES

RISCI scores, community integration, and level of and satisfaction with community participation.

RESULTS

Study participants were just over age 40 years, and had been living with SCI for 10.8 years. One-third were women and 40% were African-American. Results showed women with SCI had higher RISCI scores (perceived more dangers) on every item on the RISCI Scale (P < 0.001). The items perceived to hold greatest risk were revealing personal information to others, going on a blind date, and going for a roll ("walk") alone after dark. Women with higher RISCI scores reported lower community integration (P < 0.05) and lower levels of and lower satisfaction with community participation (P < 0.01). For men, however, RISCI scores were mainly unrelated (except for community integration) to participation measures.

CONCLUSION

More research is needed to determine whether the levels of risk perceived by women are warranted and whether a sense of vulnerability for women with SCI is unnecessarily limiting their chances at "a good life" after injury.

Active LifestyLe Rehabilitation interventions in aging spinal cord injury (ALLRISC): a multicentre research program

BACKGROUND

With today's specialized medical care, life expectancy of persons with a spinal cord injury (SCI) has considerably improved. With increasing age and time since injury, many individuals with SCI, however, show a serious inactive lifestyle, associated with deconditioning and secondary health conditions (SHCs) (e.g. pressure sores, urinary and respiratory tract infections, osteoporosis, upper-extremity pain, obesity, diabetes, cardiovascular disease) and resulting in reduced participation and quality of life (QoL). Avoiding this downward spiral, is crucial.

OBJECTIVES

To understand possible deconditioning and SHCs in persons aging with a SCI in the context of active lifestyle, fitness, participation and QoL and to examine interventions that enhance active lifestyle, fitness, participation and QoL and help prevent some of the SHCs.

METHODS

A multicentre multidisciplinary research program (Active LifestyLe Rehabilitation Interventions in aging Spinal Cord injury, ALLRISC) in the setting of the long-standing Dutch SCI-rehabilitation clinical research network.

RESULTS

ALLRISC is a four-study research program addressing inactive lifestyle, deconditioning, and SHCs and their associations in people aging with SCI. The program consists of a cross-sectional study (n = 300) and three randomized clinical trials. All studies share a focus on fitness, active lifestyle, SHCs and deconditioning and outcome measures on these and other (participation, QoL) domains. It is hypothesized that a self-management program, low-intensity wheelchair exercise and hybrid functional electrical stimulation-supported leg and handcycling are effective interventions to enhance active life style and fitness, help to prevent some of the important SHCs in chronic SCI and improve participation and QoL.

CONCLUSION

ALLRISC aims to provide evidence-based preventive components of a rehabilitation aftercare system that preserves functioning in aging persons with SCI.

Community reintegration of spinal cord-injured patients in rural south India

STUDY DESIGN

Cross sectional follow-sup survey.

OBJECTIVE

To ascertain the factors influencing community reintegration, of individuals with spinal cord injury living in rural environment, and to suggest measures to enhance community participation.

SETTING

Bangalore, Karnataka, India.

METHODS

Thirty-five individuals who were admitted under Physical Medicine and Rehabilitation Department of St Johns Medical College Hospital and rehabilitated to their functional level based on their level of injury; individuals living in rural environment were included in the study. The study was conducted by means of a standardized questionnaire and environmental and home assessments carried out during follow-up home visits after 12 months of discharge from the hospital. The main outcome measures were Craig Handicap Assessment and Reporting Technique (CHART) and Craig Hospital Inventory of Environmental Factors (CHIEF). The home visits and assessments were carried out by a rehabilitation team, which consisted of community-based rehabilitation worker, medico-social worker, physiotherapist and occupational therapist, and headed by a physiatrist.

RESULTS

The findings of the study indicate a general decline in community re integration in terms of physical independence, mobility, occupation and social integration. Mobility issues were the greatest perceived barrier and economic issues also significantly influenced the community participation.

CONCLUSION

Our study showed significant decline in community reintegration in subjects living in rural south India. Architectural and environmental barriers, poor socio-economic status and comorbidities significantly affected the level of community participation.

Outpatient spinal cord injury rehabilitation: Managing costs and funding in a changing health care environment

PURPOSE

To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

METHOD

Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

RESULTS

There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

CONCLUSIONS

A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.

Osteoporotic fractures and hospitalization risk in chronic spinal cord injury

Osteoporosis is a well acknowledged complication of spinal cord injury. We report that motor complete spinal cord injury and post-injury alcohol consumption are risk factors for hospitalization for fracture treatment. The clinical assessment did not include osteoporosis diagnosis and treatment considerations, indicating a need for improved clinical protocols.

INTRODUCTION

Treatment of osteoporotic long bone fractures often results in lengthy hospitalizations for individuals with spinal cord injury. Clinical features and factors that contribute to hospitalization risk have not previously been described.

METHODS

Three hundred and fifteen veterans > or = 1 year after spinal cord injury completed a health questionnaire and underwent clinical exam at study entry. Multivariate Cox regression accounting for repeated events was used to assess longitudinal predictors of fracture-related hospitalizations in Veterans Affairs Medical Centers 1996-2003.

RESULTS

One thousand four hundred and eighty-seven hospital admissions occurred among 315 participants, and 39 hospitalizations (2.6%) were for fracture treatment. Median length of stay was 35 days. Fracture-related complications occurred in 53%. Independent risk factors for admission were motor complete versus motor incomplete spinal cord injury (hazard ratio = 3.73, 95% CI = 1.46-10.50). There was a significant linear trend in risk with greater alcohol consumption after injury. Record review indicated that evaluation for osteoporosis was not obtained during these admissions.

CONCLUSIONS

Assessed prospectively, hospitalization in Veterans Affairs Medical Centers for low-impact fractures is more common in motor complete spinal cord injury and is associated with greater alcohol use after injury. Osteoporosis diagnosis and treatment considerations were not part of a clinical assessment, indicating the need for improved protocols that might prevent low-impact fractures and related admissions.

Barriers to providing dual energy x-ray absorptiometry services to individuals with spinal cord injury

To assess barriers to bone mineral density testing in individuals with chronic spinal cord injury, a cross-sectional study of 20 individuals with spinal cord injury was conducted with assessment of physical and logistical barriers to dual energy x-ray absorptiometry scanning. We identified several barriers, including scanner design and configuration in the scanning room that limited accessibility, increased typical scanning time, and made additional staff necessary. For dual energy x-ray absorptiometry to become a routine component of ongoing care in spinal cord injury medicine, we recommend the following changes: (1) install ceiling-mounted hydraulic lifts and grab bars to facilitate transfers in the scanning room; (2) increase staffing during scans; (3) increase time allotment for scans; (4) install the scanner in an adequately-sized room; and (5) partner with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury.

Home aids and personal assistance 10-45 years after spinal cord injury

OBJECTIVE

Assessment of home aids, adaptations and personal assistance received after traumatic spinal cord injury (SCI).

SETTING

Clinic for Spinal Cord Injuries, Denmark. Uptake area, 2.5 million inhabitants.

STUDY DESIGN AND METHODS

Cross-sectional follow-up with retrospective data from medical files.

MATERIALS

Individuals with traumatic SCI before 1 January 1991, still in regular follow-up and with sufficient medical record. In all, 279 were included, and 236 answered the questionnaire (193 men and 43 women), with a response rate of 84.6%. Mean age at follow-up was 50.5 years, and mean follow-up time, 24.1 years. One hundred and twenty-six were paraplegic and 110, tetraplegic. Responders and non-responders were comparable.

RESULTS

Most common aids or adaptations reported were commode/shower chair on wheels or a seat (69%), grab bar by the toilet (41%), electrical bed (44%), special mattress (28%), lift/hoist (20%), computers (39%) and kitchen tools or cutlery with special handles (14%). In all, 7.6% of the participants reported no aids. Eighty-two percent answered 'Yes' to the question 'Have the aids, you currently or previously needed, been available to you?' The majority reported that their source of information about aid had been various journals and magazines. Twenty-one percent had personal helpers, with 60 h per week in median (range 2-168). Thirty-three percent received domestic help with 2.5 h per week in median (range 0.5-37). Eight percent had a home nurse. A total of 98.7% were living in their own homes.

CONCLUSIONS

This is the first study of a representative SCI population giving information on home aids. Individuals with SCI in Denmark seem to be sufficiently supplied with aids and personal assistance.

The impact of spinal cord injury on sexual function: concerns of the general population

STUDY DESIGN

Secure, web-based survey.

OBJECTIVES

Obtain information from the spinal cord injured (SCI) population regarding sexual dysfunctions, with the aim of developing new basic science and clinical research and eventual therapies targeting these issues.

SETTING

Worldwide web.

METHODS

Individuals 18 years or older living with SCI. Participants obtained a pass-code to enter a secure website and answered survey questions. A total of 286 subjects completed the survey.

RESULTS

The majority of participants stated that their SCI altered their sexual sense of self and that improving their sexual function would improve their quality of life (QoL). The primary reason for pursuing sexual activity was for intimacy need, not fertility. Bladder and bowel concerns during sexual activity were not strong enough to deter the majority of the population from engaging in sexual activity. However, in the subset of individuals concerned about bladder and/or bowel incontinence during sexual activity, this was a highly significant issue. In addition, the occurrence of autonomic dysreflexia (AD) during typical bladder or bowel care was a significant variable predicting the occurrence and distress of AD during sexual activity.

CONCLUSION

Sexual function and its resultant impact on QoL is a major issue to an overwhelming majority of people living with SCI. This certainly constitutes the need for expanding research in multiple aspects to develop future therapeutic interventions for sexual health and SCI.

Aging with spinal cord injury

The years after SCI may be associated with acceleration of the aging process because of diminished physiologic reserves and increased demands on functioning body systems. Clinicians with expertise in the treatment and prevention of SCI-specific secondary complications need to collaborate with gerontologists and primary care specialists and need to invest in the training of future physicians to ensure a continuum of accessible, cost-effective, and high-quality care that meets the changing needs of the SCI population. Managed care payers often do not adequately cover long-term disability needs to prevent secondary SCI-specific complications. In this era of increasing accountability, evidence-based clinical practice guidelines are needed to document scientific evidence and professional consensus to effectively diagnose, treat, and manage clinical conditions; to reduce unnecessary testing and procedures; and to improve patient outcomes. Longitudinal research is needed to minimize cohort effects that contribute to misinterpretation of cross-sectional findings as representative of long-term changes in health and functioning. However, longitudinal studies confound chronologic age, time since injury, and environmental change. Thus, time-sequential research, which controls for such confounding effects, is essential, as is research on the effects of gender,culture, and ethnicity. If we consider how much progress has been made over the past 50 years with respect to SCI mortality related to infectious disease, we can expect to achieve even greater progress against the effects of aging in the next 50 years. Recent developments in molecular biology regarding growth and neuro-trophic factors are bringing us closer to the goal of repairing the damaged spinal cord. The challenge remains for rehabilitation professionals to provide the most comprehensive and holistic approach to long-term follow-up, with an emphasis on health promotion and disease prevention, to postpone functional decline and enhance QOL.

Case management in the undergraduate curriculum

The redesign of an undergraduate curriculum at one baccalaureate nursing program resulted in adoption of a required course on case management for chronic illnesses. The course is structured around rehabilitation standards and medical-surgical and community health principles of nursing care. A service-learning model was used to develop the clinical experience, which involved student nurses visiting the homes of individuals with chronic illnesses. These visits were made in collaboration with personnel from community-based agencies or programs. This article discusses the design of the course and some of the content areas and clinical activities.