Spinal cord injury medicine. 5. Preserving wellness and independence of the aging patient with spinal cord injury: a primary care approach for the rehabilitation medicine specialist

A Primary Care Provider's Guide to Preventive Health After Spinal Cord Injury

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

The age factor in axonal repair after spinal cord injury: A focus on neuron-intrinsic mechanisms

Age is an important consideration for recovery and repair after spinal cord injury. Spinal cord injury is increasingly affecting the middle-aged and aging populations. Despite rapid progress in research to promote axonal regeneration and repair, our understanding of how age can modulate this repair is rather limited. In this review, we discuss the literature supporting the notion of an age-dependent decline in axonal growth after central nervous system (CNS) injury. While both neuron-intrinsic and extrinsic factors are involved in the control of axon growth after injury, here we focus on possible intrinsic mechanisms for this age-dependent decline.

Some Problems of the Lower Extremity in Patients with Spinal Cord Injuries

Spinal cord injury (SCI) is devastating, leaving patients wholly or partly paralyzed. Health care providers who care for SCI patients during the acute or chronic phases are faced with different phenomena in the lower extremities of these subjects. In this article, the authors review the relevant changes associated with SCI. Preventive measures of these medical complications are directed according to the specific cause. Early comprehensive rehabilitation carried out by a specialized team prevents complications while enhancing functional gains.

Evidence-Based Strategies for Preserving Mobility for Elderly and Aging Manual Wheelchair Users

Elderly and aging manual wheelchair (MWC) users have increased risk for accelerated loss of function and mobility that greatly limits independence and affects quality of life. This review paper addresses important issues for preserving function and mobility for elderly and aging individuals who use a MWC by presenting the current available evidence and recommendations. These include recommendations for maximizing function, by decreasing pain, improving the ability to self-propel, and prolonging mobility and endurance through ergonomics, individualized wheelchair selection and configuration, and adaptations for increasing the capacity to handle the daily mobility demands through training, strengthening, and exercise. Each recommendation is supported by current research in each relevant area.

Reliability and validity of using the Lokomat to assess lower limb joint position sense in people with incomplete spinal cord injury

Background

Proprioceptive sense (knowing where the limbs are in space) is critical for motor control during posture and walking, and is often compromised after spinal cord injury (SCI). The purpose of this study was to assess the reliability and validity of using the Lokomat, a robotic exoskeleton used for gait rehabilitation, to quantitatively measure static position sense of the legs in persons with incomplete SCI.

Methods

We used the Lokomat and custom software to assess static position sense in 23 able-bodied (AB) subjects and 23 persons with incomplete SCI (American Spinal Injury Association Impairment Scale level B, C or D). The subject’s leg was placed into a target position (joint angle) at either the hip or knee and asked to memorize that position. The Lokomat then moved the test joint to a “distractor” position. The subject then used a joystick controller to bring the joint back into the memorized target position. The final joint angle was compared to the target angle and the absolute difference was recorded as an error. All movements were passive. Known-groups validity was determined by the ability of the measure to discriminate between able-bodied and SCI subjects. To evaluate test-retest reliability, subjects were tested twice and intra-class correlation coefficients comparing errors from the two sessions were calculated. We also performed a traditional clinical test of proprioception in subjects with SCI and compared these scores to the robotic assessment.

Results

The robot-based assessment test was reliable at the hip and knee in persons with SCI (P ≤ 0.001). Hip and knee angle errors in subjects with SCI were significantly greater (P ≤ 0.001) and more variable (P < 0.0001) than in AB subjects. Error scores were significantly correlated to clinical measure of joint position sense (r ≥ 0.507, P ≤ 0.013).

Conclusions

This study shows that the Lokomat may be used as a reliable and valid clinical measurement tool for assessing joint position sense in persons with incomplete SCI. Quantitative assessments of proprioceptive deficits after neurological injury will help in understanding its role in the recovery of skilled walking and in the development of interventions to aid in the return to safe community ambulation.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-167) contains supplementary material, which is available to authorized users.

The person with a spinal cord injury: an evolving prototype for life care planning

The sequela of spinal cord injury (SCI) can provide a prototype for life care planning because the segmental design of the vertebrate body allows assessments to be quantitative, repeatable, and predictive of the injured person's impairments, self-care capabilities, and required assistance. Life care planning for patients with SCI uses a standard method that is comparable between planner, yet individualizes assessment and seeks resources that meet unique patient-centered needs in their communities of choice. Clinical care and rehabilitation needs organized with an SCI problem list promotes collaboration by the interdisciplinary team, caregivers, and family in efficient achievement of patient-centered goals and completion of daily care plans.

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.

Staying physically active after spinal cord injury: a qualitative exploration of barriers and facilitators to exercise participation

Background

While enhancing physical activity has been an essential goal of public health officials, people with physical impairments such as spinal cord injury (SCI) are more likely to live a sedentary lifestyle. Exercise has been shown to decrease the risk for many of the secondary conditions associated with SCI, including osteoporosis, cardiovascular disease, pressure ulcers, urinary tract infections, diabetes and arthritis, yet this population is rarely a target for health promotion efforts. This paper examines the self-reported exercise experiences of people with SCI using a qualitative-exploratory design.

Methods

We enrolled 26 individuals with SCI (15 self-described 'exercisers' and 11 'non-exercisers') from a non-random pool of survey responders. Semi-structured phone interviews were conducted to record participants' experiences with exercise pre/post injury, barriers and facilitators to being active and perceived health impact.

Results

Regardless of exercise status, all participants reported physical activity prior to injury and expressed interest in becoming active or maintaining an active lifestyle. Participants identified a range of both motivational and socio-environmental factors that were either facilitating or constraining of such a lifestyle. Non-exercisers identified barriers to exercise, including a perceived low return on physical investment, lack of accessible facilities, unaffordable equipment, no personal assistance and fear of injury. Exercisers identified facilitators, including personal motivation, independence, availability of accessible facilities and personal assistants, fear of health complications, and weight management. Exercisers associated a greater range of specific health benefits with being active than non-exercisers.

Conclusion

Despite motivation and interest in being exercise active, people with SCI face many obstacles. Removal of barriers coupled with promotion of facilitating factors, is vital for enhancing opportunities for physical activity and reducing the risk of costly secondary conditions in this population.

A latent variable structural path model of health behaviors after spinal cord injury

BACKGROUND/OBJECTIVE

To develop a latent behavioral model by identifying and confirming the factor structure of health behaviors of people with spinal cord injury (SCI) and their relationships with biographic, injury, and educational characteristics.

RESEARCH DESIGN

Survey data were collected from 1388 adults with traumatic SCI of at least 1 year duration.

MAIN OUTCOME MEASURES

Selection of health behaviors was based on a bidimensional behavioral risk model. Behaviors were measured by core item sets from the Behavioral Risk Factor Surveillance System and supplemented by an alcohol screening measure, select fitness proxies, and the SCI Health Survey.

RESULTS

Latent variable structural equation modeling was used to identify underlying factors and their relationship with participant characteristics. Seven specific factors were identified by exploratory factor analysis and were cross-validated using confirmatory factor analysis. They included: (a) healthy nutrition, (b) unhealthy nutrition, (c) fitness, (d) smoking, (e) alcohol use, (f) psychotropic prescription medications, and (g) SCI healthy activities. Two higher-order dimensions were also identified, including a risk dimension (b, d, e) and a protective dimension (a, c, g). Participant characteristics were associated with the domains. For instance, participants with the most severe injuries scored lower on smoking and alcohol but higher on psychotropic medications; age was positively correlated with healthy nutrition and negatively correlated with alcohol and tobacco use but also negatively correlated with fitness.

CONCLUSION

Behaviors can be meaningfully combined into underlying dimensions to more efficiently use them as predictors of secondary conditions.

A guideline-driven assessment of need for cardiovascular disease risk intervention in persons with chronic paraplegia

OBJECTIVE

To examine percentages of persons with chronic paraplegia who qualify for lipid-lowering therapeutic lifestyle intervention (TLI) as assessed by authoritative guidelines.

DESIGN

Cross-sectional.

SETTING

Academic medical center.

PARTICIPANTS

Forty-one subjects (mean age +/- standard deviation, 34+/-11 y) with motor-complete paraplegia (American Spinal Injury Association grade A or B) at T6-L1 levels for greater than 2 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percentages of subjects qualifying for TLI were independently assessed and then compared using National Cholesterol Education Project Adult Treatment Panel (ATP) II (1994) and ATP III (2002) Guidelines.

RESULTS

A total of 34.1% of subjects qualified for intervention based on the ATP II Guidelines and 63.4% based on ATP III (chi1(2) test=4.53; 2-tailed, P=.003). Seventy-six percent (31/41) of study participants had high-density lipoprotein cholesterol levels below the high-risk criterion of 40 mg/dL established by ATP III. Almost one third of subjects had hypertension, and 34.1% satisfied criteria for diagnosis of the metabolic syndrome.

CONCLUSIONS

A high percentage of young, apparently healthy people with chronic paraplegia are at risk for cardiovascular disease and qualify for lipid-lowering TLI. Updated guidelines of the ATP III have increased the urgency for early risk assessment and intervention.

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.

Use of the ICF conceptual framework to interpret hand function outcomes following tendon transfer surgery for tetraplegia

STUDY DESIGN

Clinical commentary

OBJECTIVE AND SETTING

This paper is a clinical commentary based on the Round Table discussion on Assessment and Outcomes at the 7th International Conference on Tetraplegia: Surgery and Rehabilitation, Bologna, Italy 6-8 June, 2001. It refers specifically to the 10-year re-review undertaken in 2001 at the Spinal Unit, Burwood Hospital, Christchurch, New Zealand.

SUBJECTS

In all, 24 tetraplegic persons at a minimum of 12 years and up to 18 years following bilateral forearm tendon transfer surgery.

METHOD

The data were interpreted using the International Classification of Functioning, Disability, and Health (ICF) conceptual framework as the basis of interdisciplinary understanding of the participation dimension.

RESULTS

The results of the study outlined confirm that outcome measurement at more than one level of functioning is desirable to determine the functional effects beyond grip strength levels and activities of daily living, to consider the dimension of participation.

CONCLUSIONS

Use of the ICF as a theoretical framework for interpretation of the results enhanced the clinical applicability of the outcome measures used in the 10-year re-review undertaken in New Zealand in 2001.