Co-design of the Spinal Cord Injury Health Maintenance Tool to Support Self-Management: A Mixed-Methods Approach

Background

There is a lack of consumer-friendly tools to empower and support people living with spinal cord injury (SCI) to self-manage complex health needs in community. This article describes the co-design process of the new SCI Health Maintenance Tool (SCI-HMT).

Methods

Co-design of the SCI-HMT using a mixed-methods approach included a rapid review, e-Delphi surveys with range of multidisciplinary health care professionals (n = 62), interviews of participants with SCI (n = 18) and general practitioners (n = 4), focus groups (n = 3 with 7, 4, and 4 participants with SCI, respectively), design workshops with stakeholders (n = 11, 8), and end-user testing (n = 41).

Results

The SCI-HMT (healthmaintenancetool.com) was developed based on participatory research with data synthesis from multiple sources. Five priority health maintenance issues for bladder, bowel, skin, pain, and autonomic dysreflexia were originally covered. Best practice recommendations, red flag conditions, referrals, and clinical pathways were agreed on through an e-Delphi technique. Qualitative analysis identified six broad key concepts for self-management, including early symptom recognition, role of SCI peers, knowledge sharing with primary care, general practitioners as gatekeepers, and shared decision-making and highlighted a need to place much stronger emphasis on mental health and well-being. Design workshops and end-user testing provided key insights about user experience, functionality, and content for the SCI-HMT.

Conclusion

The co-design process engaging end users, including people with SCI and general practitioners, enabled a shared understanding of the problem and identification of important needs and how to meet them. Informed by this process, the SCI-HMT is a freely accessible resource supporting SCI self-management, shared decision-making, and early problem identification.

Longitudinal effects of time since injury and age at injury on outcomes of people with spinal cord injury in Queensland, Australia

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVES

To investigate the longitudinal effects of time since injury and age at injury on outcomes of quality of life, physical function, secondary conditions and participation, in people with traumatic spinal cord injury (SCI).

SETTING

Community resident people with spinal cord injury in Queensland, Australia.

METHODS

A baseline sample of 270 people with SCI was recruited. Telephone surveys on measures of quality of life (WHOQOL-Bref), secondary conditions (Secondary Conditions Surveillance Instrument, subset), physical functioning (Functional Independence Measure motor subscale) and participation (Community Integration Measure) were conducted each year between 2004 and 2008, and again in 2018. Random-effect within-between models were used to determine the effect of time since injury and age at injury on each outcome variable. Inverse probability-of-censoring weights were used to correct for selection bias.

RESULTS

There was an effect of time since injury on secondary conditions, with a one-year change associated with 9% higher odds of having worse Secondary Conditions Surveillance Instrument scores (odds ratio = 1.09, 95% confidence interval = 1.02, 1.17; p = 0.006). We did not find any evidence of a time since injury effect on quality of life, physical function, or participation. Similarly, we did not find any evidence of an age at injury effect on any outcome variable.

CONCLUSIONS

Secondary conditions may increase with longer time since injury among people with SCI, suggesting appropriate formal and informal supports are required to minimise the impact of these emerging health problems as individuals age.

Methodology and study population of the second Swiss national community survey of functioning after spinal cord injury

STUDY DESIGN

Descriptive study of the second community survey of the Swiss Spinal Cord Injury Cohort Study (Survey 2017) conducted between 03/2017 and 03/2018.

OBJECTIVES

To describe the methodology, recruitment results, characteristics of participants and non-participants, and non-response of the Survey 2017.

SETTING

Community.

METHODS

Description of the sampling strategy and sampling frame. Recruitment results and characteristics of participants and non-participants of the two Survey 2017 questionnaire modules were analyzed using descriptive statistics. Determinants of survey participation were examined using multivariable logistic regression, and the impact of non-response bias on survey results was evaluated using inverse-probability weighting.

RESULTS

Out of 3959 persons who met the eligibility criteria, 1530 responded to module 1 (response rate 38.6%) and 1294 to module 2 (response rate 32.7%) of the Survey 2017. Of the 4493 invited persons, 1549 had participated in the first SwiSCI community survey conducted in 2012/2013. Of these, 1332 were invited to the Survey 2017 and 761 participated in module 1 (response rate 58.9%) and 685 in module 2 (response rate 53.1%). The majority of module 1 participants were male (71.2%, 95% CI: 68.9, 73.5), with a median age of 57 (IQR: 46.0, 67.0) years and incomplete paraplegia (41.9%, 95% CI: 39.3, 44.5). Survey non-response was higher in the oldest age group, among females, and those with tetraplegia.

CONCLUSIONS

The design of the Survey 2017 was successful in recruiting a substantial proportion of the SCI source population in Switzerland. To counteract survey non-response, survey weights may be applied to subsequent analyses.

SPONSORSHIP

none.

Changes in health-related quality of life among older adults aging with long-term spinal cord injury

STUDY DESIGN

Cross-sectional and longitudinal.

OBJECTIVES

To (i) describe health-related quality of life (HRQoL) and changes over 6 years in older adults aging with long-term spinal cord injury (SCI) and (ii) investigate how changes in HRQoL are associated with age, gender, and injury characteristics.

SETTING

Community in southern Sweden.

METHODS

From the initial 123 participants (years 2011-2012) in the Swedish Aging with Spinal Cord Injury Study (SASCIS), 77 individuals (32% women, C1-L3, AIS A-D, median age 66 years, median time since injury 31 years, 30% complete injuries) were assessed 6 years later. HRQoL was rated with the Spinal Cord Injury Quality of Life Questionnaire (SCI QL-23). Associations were investigated using multivariable linear regression analyses.

RESULTS

The median rating of global QoL (scale range 0-100) was relatively high at both assessments (67 and 83, respectively). There was a large variability in all HRQoL-domains and no significant changes over 6 years. As compared to an AIS D injury, a tetraplegia AIS A-C injury and tetraplegia and paraplegia AIS A-C injuries were associated with positive change in depressive symptoms and global QoL, respectively.

CONCLUSIONS

Older adults aging with long-term SCI show large variations in all HRQoL-domains and have the potential to maintain a high and stable level of HRQoL over time. Persons with AIS D injuries may need increased attention to mitigate negative changes in depressive symptoms and global QoL. Further studies are needed to identify modifiable factors associated with changes in HRQoL in older adults aging with long-term SCI.

Patients' Perspectives on the Usability of a Mobile App for Self-Management following Spinal Cord Injury

With decreasing inpatient lengths of stay following spinal cord injury (SCI), newly injured patients may be discharged into the community without the self-management skills needed to prevent secondary conditions. A mobile app was developed to facilitate self-management skills following SCI in the inpatient rehabilitation and early community settings. The objective of this study was to explore patients' perspectives on the usability of this self-management app. A mixed-methods study design was implemented. The app was trialed at a local rehabilitation centre with 20 inpatient participants who experienced a SCI. They received mobile app training sessions throughout their inpatient rehabilitation. A thematic analysis was performed on qualitative data from post-discharge exit questionnaires and researchers' field notes. Quantitative data (in the form of participants' tool usage data and self-reported system usability scale scores) were collected at discharge and 3 months post-discharge. Three main themes emerged from the qualitative analysis: (1) being accessible to users (i.e., being easy to adopt and compatible with assistive technologies), (2) being intuitive to navigate (i.e., incorporating a simple app layout and a system of alert notifications), and (3) offering users flexibility (i.e., providing users with control over their data). The mobile app received above average mean system usability scale scores, both at discharge (78.1/100) and 3 months post-discharge (71.6/100). Given that participants found the app acceptable for use in inpatient rehabilitation and following discharge into the community, further testing is warranted to explore its efficacy in preventing secondary complications.

Development of a Self-Management App for People with Spinal Cord Injury

With decreasing inpatient rehabilitation lengths of stay, there may be a greater risk of spinal cord injury (SCI) populations being discharged into the community without the self-management skills needed to prevent secondary complications. Recent advancements in mobile health has made mobile apps a feasible method of delivering population-based, self-management interventions to address SCI-specific secondary complications. The objective of this study is to describe stakeholder perspectives on the development of a functional mobile app to facilitate self-management skills needed to prevent secondary complications following recent SCI during inpatient rehabilitation. A user-centered design approach was used that involved an evolving mobile app and the collection of prospective qualitative data. Stakeholders from three groups were enrolled in the study: individuals admitted for rehabilitation following SCI (n = 20) and informal (n = 7) and formal (n = 48) caregivers. Iterative feedback was gathered from rehabilitation inpatients during ongoing interactions and via post-discharge exit questionnaires, from informal caregivers via one-on-one interviews, and from formal caregivers via series of focus groups at various phases throughout the design process. Three main themes emerged from the analysis: (1) being individualized and user friendly (i.e., developing an app that is simple and easy to use to facilitate universal uptake), (2) targeting goals to promote self-management (i.e., adopting self-management skills relative to personal goals and confidence), and (3) increasing participation and support-seeking to facilitate lifestyle change (i.e., encouraging leisure activities to facilitate community integration). Key stakeholder perspectives contributed to the development of a self-management mobile app that will be evaluated in future research.

Early Colostomy Formation Can Improve Independence Following Spinal Cord Injury and Increase Acceptability of Bowel Management

Background: Colostomy formation can solve complications of bowel management following spinal cord injury (SCI). Newly injured patients at this spinal unit have chosen colostomy as a preferred option for bowel management. Objectives: To discover the reasons patients choose colostomy formation early following SCI and make comparison with those choosing it later, and to establish whether early colostomy is safe and advisable. Methods: Medical and nursing records of patients with SCI who chose to have a colostomy during the period 2005-2016 were examined retrospectively. Data were gathered concerning reasons for choosing a colostomy, early and later complications, the need for further surgery, and independence with bowel care before and after surgery. Patients were divided into two groups: those who chose a colostomy "early" during inpatient rehabilitation and those who chose it "later" as is traditional. Results: Reasons for choosing colostomy differed. Reducing reliance on caregiver and independence were of more importance to the early group; the later group chose colostomy to solve bowel care problems. Early complication rates in both groups were low. Longer term complications were higher in the early group, with the most common complication being rectal discharge. Parastomal hernia rates were low in both groups, as was the need for further surgery. Colostomy formation led to 20.8% of all patients gaining independence with bowel care. Conclusion: This study found colostomy to be a safe and effective option when performed early after SCI and demonstrates colostomy can be a means of gaining independence and making bowel care easier and more acceptable to the newly injured patient.

Improving Self-Management Skills Among People With Spinal Cord Injury: Protocol for a Mixed-Methods Study

Background

Most people with spinal cord injury will develop secondary complications with potentially devastating consequences. Self-management is a key prevention strategy for averting the development of secondary complications and their recurrence. Several studies have shown that self-management programs improve self-management behaviors and health outcomes in individuals living with chronic conditions such as asthma, diabetes, hypertension, and arthritis. Given the burgeoning health care costs related to secondary complications, we developed an alternative electronic health–based implementation to facilitate the development of self-management skills among people with spinal cord injury.

Objective

This study aims to evaluate the efficacy of a self-management app in spinal cord injury populations. The primary outcome is attainment of self-selected, self-management goals. Secondary outcomes include increases in general and self-management self-efficacy and reductions in self-reported health events, health care utilization, and secondary complications related to spinal cord injury. This study also aims to explore how the intervention was implemented and how the app was experienced by end users.

Methods

This study will employ a mix of qualitative and quantitative methods. The quantitative portion of our study will involve a rater-blinded, randomized controlled trial with a stepped wedge design (ie, delayed intervention control group). The primary outcome is successful goal attainment, and secondary outcomes include increases in self-efficacy and reductions in self-reported health events, health care utilization, and secondary conditions related to spinal cord injury. The qualitative portion will consist of semistructured interviews with a subsample of the participants.

Results

We expect that the mobile self-management app will help people with spinal cord injury to attain their self-management goals, improve their self-efficacy, reduce secondary complications, and decrease health care utilization.

Conclusions

If the results are positive, this study will produce credible new knowledge describing multiple outcomes that people with spinal cord injury realize from an app-based self-management intervention and support its implementation in clinical practice.

Trial Registration

ClinicalTrials.gov NCT03140501; http://clinicaltrials.gov/ct2/show/NCT03140501 (Archived by WebCite at http://www.webcitation.org/73Gw0ZlWZ)

International Registered Report Identifier (IRRID)

PRR1-10.2196/11069

Participation restriction and assistance needs in people with spinal cord injuries of more than 40 year duration

Study design

Prospective observational.

Objectives

Examine changes in participation restriction and assistance needs in a sample of people with long-standing spinal cord injuries (SCIs).

Setting

Two British spinal centres.

Methods

The sample consisted of British ageing with SCI study participants who were seen at baseline (1990 or 1993) and in the final follow-up (2010). Outcome measures were the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) and interview questions about assistance needs.

Results

Eighty-five Ageing study participants took part in 2010; their mean age was 67.65 years and the mean time since injury was 46.26 years. The mean CHART-SF physical independence subscore decreased from 97.44 in 1990 to 91.26 in 2010, mobility from 95.58 to 82.10, occupation from 86.82 to 64.49 and social integration from 96.29 to 88.68 (all p < 0.05). Increasing assistance needs were reported by 10.1% of participants in 1990, by 36.6% in 2010 (p < 0.05) and by 62.4% over the entire 20-year study period. Persons requiring more assistance were older and injured longer, had a more severe SCI and lower self-reported quality of life and life satisfaction (p < 0.05). In the multivariate logistic regression, the strongest predictor of needing more assistance was injury severity (p < 0.05).

Conclusions

An increase in participation restriction and in assistance needs was reported over the 20 year follow-up in persons injured more than 40 years ago. SCI severity was the main risk factor for needing more assistance. Clinical awareness of how participation changes with age may help provide timely intervention and offset declines.

Long-term bladder and bowel management after spinal cord injury: a 20-year longitudinal study

STUDY DESIGN

Prospective observational.

AIM

The aim of this study was to analyse changes in bladder and bowel management methods in persons with long-standing spinal cord injury (SCI).

SETTING

Two spinal centres in UK.

METHOD

Data were collected through interviews and examinations between 1990 and 2010 in a sample of persons injured more than 20 years prior to 1990.

RESULTS

For the 85 participants who completed the 2010 follow-up, the mean age was 67.7 years and the mean duration of injury was 46.3 years, 80% were male, 37.7% had tetraplegia AIS grade A, B, or C, 44.7% paraplegia AIS A, B, or C, and 17.6% an AIS D grade regardless of level. In all, 50.6% reported having changed their bladder method, 63.1% their bowel method, and 40.5% both methods since they enroled in the study. The reasons for change were a combination of medical and practical. In men, condom drainage remained the most frequent bladder method, and in women, suprapubic catheter replaced straining/expressing as the most frequent method. The use of condom drainage and straining/expressing bladder methods decreased, whereas the use of suprapubic and intermittent catheters increased. Manual evacuation remained the most frequent bowel management method. The percentage of participants on spontaneous/voluntary bowel emptying, straining and medications alone decreased, whereas the use of colostomy and transanal irrigation increased over time.

CONCLUSIONS

More than half the sample, all living with SCI for more than 40 years, required change in their bladder and bowel management methods, for either medical or practical reasons. Regular follow-ups ensure adequate change of method if/when needed.

"To Work Just Like Anyone Else"-A Narrative from a Man Aging with Spinal Cord Injury

People aging with spinal cord injury (SCI) develop medical problems commonly associated with the aging process at a younger age than the general population. However, research about how the life story changes and how meaning will be experienced in occupations is lacking. The aim was to describe and offer an explanation of how a man experienced meaning in everyday occupations while aging with an SCI. Four narrative interviews were performed over a four-year period, with a man in his fifties, who lived with SCI for 39 years. The narrative analysis generated an overall plot, named “To Work Just Like Anyone Else,” and gives a picture of his experiences, thoughts, and reflections about meaning in occupations, from when he became injured to the present, and in relation to his future. His life story is characterized by secondary health complications, and his experiences of negotiating with the aging body and making choices to continue working. Further, how occupational risk factors, e.g., imbalance, alienation, and deprivation, occur as a result of lack of rehabilitation and support from social systems is addressed. Future research should explore how rehabilitation and social systems can support people aging with SCI to experience meaning in everyday occupations and to have balance in everyday life.

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.

Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review

STUDY DESIGN

Scoping review.

OBJECTIVES

To gain a better understanding of the prevalence, course and association with age of secondary health conditions in individuals with spinal cord injury (SCI).

SETTING

Seattle, Washington, USA.

METHODS

We performed searches of electronic databases for studies published from 1986-2011 that provided information regarding the prevalence, course or associations with age and duration of secondary health conditions in individuals with SCI.

RESULTS

Ninety-two studies were included. The findings indicate that: (1) individuals with SCI experience a number of secondary health conditions, many of which occur at a higher rate in those with SCI than the normative population; (2) the most common conditions or symptoms are pain, bowel and bladder regulation problems, muscle spasms, fatigue, esophageal symptom and osteoporosis; (3) a number of conditions, including cardiovascular disease, diabetes, bone mineral density loss, fatigue and respiratory complications or infections, occur with higher frequency in older individuals or those with longer SCI duration, relative to younger individuals or those with shorter SCI duration; and (4) there is a marked lack of longitudinal research examining the natural course of health conditions in individuals aging with SCI.

CONCLUSIONS

The findings support the conclusion that individuals with SCI show signs of 'premature aging' in different organ systems. Longitudinal research is needed to understand when problems are most likely to emerge, and to develop and test the efficacy of interventions to prevent these health conditions and their negative impact.

An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life

STUDY DESIGN

Systematic review.

OBJECTIVES

To identify changes in subjective quality of life (QoL) as one ages with a spinal cord injury (SCI).

SETTING

Vancouver, Canada.

METHODS

Electronic databases were searched for studies reporting on age-related QoL changes over time. Data from relevant studies were transcribed into data extraction forms and analyzed by years post injury (YPI) and chronologic age. Each study was assigned a level of evidence based on a modified Sackett scale.

RESULTS

In all, 21 studies, each with a low level of evidence, were included for review. The results indicated that regardless of chronologic age, individuals with relatively new SCI have the potential to improve their QoL. Among individuals with advanced YPI, overall QoL is consistently reported as good or excellent over time, however, with variations in different QoL domains.

CONCLUSION

The QoL of individuals aging with a SCI has the potential to improve, and remain high and stable over time. As the identified studies provide low levels of evidence, more longitudinal research with greater methodological and measurement rigor is needed to corroborate the findings and conclusions of this review.